Developing Systemic Therapies in a Specialist Perinatal Mental Health Service using an Attachment Narrative Therapy Approach

2 June 2025

Abstract:

This paper describes the development of systemic therapies in a Specialist Perinatal Mental Health Service (SPMHS) that developed Attachment Narrative Therapy (ANT) specifically for families in the perinatal stage of the family life-cycle. ANT offers a good fit in the perinatal period, integrating systemic family therapy, narrative therapy, and attachment theory. From pregnancy to the child being two is a family life-cycle stage of great change and reorganisation. This involves opportunities and challenges for attachments and relationships between parents, the baby and wider family/carers. Attending to cross generational narratives and attachments are important in ensuring the perinatal stage is navigated successfully. Peri-ANT, a semi-structured version of ANT, was developed as a manualised approach. It can be flexibly adapted to the unique circumstances of each family. The paper describes the perinatal context, service needs and priorities, and the development of Peri-ANT including construction of the manual and how it was delivered.

Keywords:

Attachment, narrative therapy, systemic family therapy, perinatal, infant mental health

Authors:

Elaine Farrer, Karen Seal, Ruth O’Shaughnessy, Rudi Dallos

Cheshire and Mersey Specialist Perinatal Service, Mersey Care NHS Trust and Cheshire and Wirral Partnership NHS Trust

Biographies:

Karen Seal is the Lead Family Therapist (job share with Elaine Farrer) for the Cheshire and Merseyside Perinatal Service. She has worked in the NHS for over 15 years in a variety of mental health teams and leadership roles as a psychologist and family therapist.

Elaine Farrer is the Lead Family Therapist (job share with Karen Seal) for the Cheshire and Merseyside Perinatal Service. She combines this post with being the Programme Lead for the CYP IAPT PGDip course in Systemic Family Practice in Manchester. Elaine has a 30-year clinical background working in mental health, CYP services and in leadership roles developing the CYP workforce.

Ruth O’Shaughnessy is a Consultant Clinical Psychologist and Co-Clinical Lead for the Cheshire and Merseyside Specialist Perinatal Service. She has published numerous articles and book chapters in the field of attachment, perinatal, and parental mental illness.

Rudi Dallos is Emeritus Professor of Clinical Psychology at the University of Plymouth and works as a family therapist in private practice. He is the author of several books.

Acknowledgements:

With thanks to all the families we worked with and from whom we have learned so much.

Thank you to all the systemic staff within the Cheshire and Merseyside Perinatal teams for your hard work, support and willingness to go with us on this journey.

Setting the Scene

This paper describes the rationale for developing an integrated systemic - attachment - narrative therapy in a perinatal clinical context and it details the manualised approach (Peri-ANT) that was created. The approach is still in the initial implementation stage in the service so the paper will focus on the rationale for the approach but will offer some reflections on our experiences so far.

Perinatal services can be one of the most rewarding services in which systemic practitioners may work. It can also be emotionally challenging, especially given the connection practitioners have with this life stage and the memories and feelings that may be triggered of our own experiences of childhood and how we were parented. It can be distressing to see young infants already starting to show distress and problematic reactions to dangers in their families. It is rewarding to see positive changes because of our work with families and realise that pathways to more serious problems later in children’s lives may have been averted.

Whilst perinatal services fall under the umbrella of adult services in the NHS, parent-infant, couple and family psychological interventions are central to the NHS Long Term Plan ambition for perinatal mental health (NHSE, 2019; NHSE 2022). Perinatal services are thus uniquely positioned to intervene early as the life of the child begins, delivering interventions that have the potential to change transgenerational patterns and family trajectories. Becoming a parent is a window of opportunity for both personal emotional growth and relational growth. This “both/and” approach fits well with the systemic principle of working with multiple family members across the age span. We know that interaction cycles start to evolve early, escalate and become maintained as increasingly adaptive or maladaptive patterns in families (Main, Hesse and Kaplan, 2005; DeWolff and IJzendoorn, 1997). There is wide recognition of how narratives, past trauma and experiences can shape these interactions (Fraiberg, Adelson and Shapiro 1975). In other services we may only be able to speculate about historical events that may have contributed to the genesis of problems that present in services. But in perinatal services we can be there at the start to support and hopefully intervene in positive ways.

Pregnancy and new parenthood are a time for looking backwards as well as forwards, and many new parents find themselves remembering all sorts of things they may not have thought about for years. Some describe the experience as a sort of ‘appraisal’ or ‘stock-taking’ of life up to now. Most prospective parents find themselves remembering and thinking about their own childhoods. These memories and stories are important; they are part of the information about how they want or don’t want to parent their own baby; how they want to support one another as partners, and what kind of family they want to be. These narratives, in the form of scripts, get replicated or revised during the time of new parenthood. The changes we see in the perinatal stage of the family life cycle is a re-shaping of these narratives, scripts and the accompanying attachments and relationships.

Becoming a parent is a time for conflicting feelings and burgeoning responsibility as families get ready to welcome new life into the world. It’s easier and natural for parents-to-be to focus on the birth and not life after birth and as a parent. But in terms of life after the baby has been born there are many things to consider. How do parents adjust to each other, no longer just partners, but with this third person to care for together? During the perinatal period there are two families with different histories and values converging about their shared ideas of parenting and hopes for the future. How can parents share their personal dreams, hopes, fears and childhood memories? Supporting parents to talk about this is part of shaping family life and future relationships. This is where the power of systemic intervention in the perinatal period lies.

The Service Context: Specialist Perinatal Mental Health Services in the NHS

The evidence-base for a perinatal adaptation of Attachment Narrative Therapy is set against a backdrop of established NICE guidance for the treatment of a wide range of presentations using Systemic Family Therapy and practice (AFT, 2016). We are at a junction point in the evolution of developmentally informed approaches to perinatal and transgenerational mental health. The evidence base is relatively ‘new’ and the next step is to better understand what works for whom from the perspective of transdiagnostic and cross-modality approaches in perinatal mental health. Considering these issues, the need for evidence-informed practice or practice-based evidence, drawing on different levels and types of evidence, is key to building the evidence-base in perinatal mental health.

The involvement of systemic thinking in perinatal services is relatively new but is strongly supported nationally at a political and strategic level (NHSE, 2022; Darwin et al, 2021). NHS England and NHS Improvement commissioned a good practice guide to support professionals and commissioners in understanding how to support and involve partners and other family members of mothers accessing specialist services, in line with the NHS Long Term Plan (Darwin et al, 2021). Drawing on this, the NHS transformation programme for perinatal services promotes three core principles, the first one being “Think Family” as a golden thread throughout clinical service provision. The second is an invite to think specifically about the needs of multiple family members in the perinatal period (“the perinatal frame of mind”) and the third is to be inclusive by “staying curious”. All three lean into systemic ways of thinking and practice, and support the development of a tailored intervention model such as Peri-ANT. We would contend that blending systemic, narrative and attachment ways of working supports all three principles, and the resulting therapeutic offer supports the delivery of the national transformation programme.

Alongside systemic theories, attachment theory is also highly relevant and widely applied in perinatal services since one of its primary points of focus is on the emotional connections and bonds that are developing between babies and parents. Bowly (1988) and Ainsworth et al (1978) described how the ties between the infant and parent can function well to provide nurture and care for the infant. But they also described patterns where this bonding was insecure leading to potential extremes where the baby and mother could be at risk. In our service we find that there are many families where the parents have themselves experienced ruptures, traumas or dangers in their own childhoods. These can re-emerge to trigger traumatic memories and states of mind which disrupt their attachment and relationships with their own children. This is often not a thought through process, with traumas silently playing out through parent-baby bonding difficulties, replicated scripts of trauma or harmful parenting and parental conflict.

Building on the important foundations of attachment theory and contributions to child development and mental health (Dallos, 2007; Dallos and Vetere 2009), Attachment Narrative Therapy extends clinical theory and practice by:

Extending the traditional dyadic focus of attachment to triads and diverse family structures. We are aware of the importance of considering other relationships, especially the triad of mother - father - child, but also other key family members, such as grand-parents, siblings and others.
Focussing on the clinical applications of attachment theory to promote change in relationships and mental health.
Enhancing a focus on strengths and solutions, away from problem saturated narratives which risk creating blame and shame (especially for the mother).

ANT: Attachment Narrative Therapy

ANT is an approach that integrates concepts and techniques from systemic family therapy, narrative therapy and attachment theory (Dallos, 2023, Dallos and Vetere, 2009). It was initially developed in the context of work in eating disorder services (Dallos, 2004) and subsequently a manualised version was developed in work with families with a child with a diagnosis of autism (Dallos et al, 2022). Though it is described as integrating these different approaches it recognises the fundamental systemic connections between them. For example, Bowlby’s conceptualisation of attachment was that it was a ‘goal directed’, self – corrective system based on based on feedback. Like systemic therapy he utilised concepts from systems theory and cybernetics to describe how the attachment system functions with a feedback loop to maintain a ‘comfortable’ state of connection between the child and parent. Likewise, in his concept of the ‘working model’ we can see a connection with narrative approaches in that the working model can be seen as narratives that the child and parents develop about themselves, each other and their relationship. Waters and Roisman (2019) refers to the ‘secure base script’ as a narrative that the child comes to develop based on their experiences. This secure script features an expectation that if and when they experience danger they will be able to seek comfort and protection from an attachment figure and this person will reliably provide this. However, many children hold ‘insecure scripts’ featuring expectations that attachment figures will be unavailable or unreliable and that they should only rely on themselves or alternatively need to escalate their distress in order to be attended to. Likewise, parents hold from their own childhoods a reciprocal model of parenting narratives and scripts. Secure scripts help parents to confidently manage and sooth their baby (Bowlby,1979; Ainsworth et al, 1978). In contrast insecure scripts can promote a sense of inadequacy, incompetence and anxiety, resulting in an emotional withdrawal from the baby. Parents may experience powerful feelings of frustration, anger and a need to control or even compete with their baby (Crittenden, 2017; Grey and Farnflield, 2017; Ainsworth et al,1978). In some instances it can be a confusing mixture of both insecure scripts along with powerful trauma driven feelings of flight/fight responses towards their baby.

A core premise underpinning ANT is that predictable and repetitive patterns encapsulating problems in families can be understood to be driven by underlying attachment insecurities. Problematic cycles can be seen as fuelled by processes of negative emotional arousal which interfere with productive problem solving leading to apparently ‘stuck’ and failing attempted solutions. For example, a mother without a secure parenting script from her own childhood may become increasingly distressed as her attempts to soothe her crying baby appear not to be working. Her baby cries and screams more as she energetically tries to calm him by bouncing him on her knees. She becomes less able to slow down, speak warmly and softly to her baby and continues an agitated rocking of the baby which she does not realise is distressing not calming him down. This can perhaps culminate in a ‘rescue’ attempt by her partner, friend or mother which, if the baby calms down, can unfortunately have the consequence of her feeling a failure as a mother and disconnected from her baby alongside feeling a sense of shame at others witnessing the perceived failure. An unfortunate and potentially worrying dynamic may start to be set up that may be initially characterised by emotional withdrawal from her baby and culminating in depression or trauma for mother and baby.

A further core principle of ANT is that it is essential to promote and establish a ‘secure’ base in work with families before creative thinking and change can effectively occur. An important aspect of this in perinatal work is to help mitigate feelings of failure, shame, humiliation and anger by making clear from the outset that our work with parents will not be judgemental but sympathetic and collaborative. However, it also recognised that the construction of the ‘secure base’ needs to be adapted to the characteristic self-protective attachment patterns that family members have developed. For some people with dismissing attachment strategies focussing on emotions initially may be experienced as too threatening. In contrast for parents with pre-occupying patterns, focussing on explanations and understandings may seem disconnected from their need for their emotions to be expressed and acknowledged. Establishing a secure base in therapy is therefore a delicate, collaborative process, individual to each therapy system.

ANT makes an important connection with the constructivist aspects of narrative therapies. In particular it builds on Byng-Hall’s (1985) concept of corrective and replicative intentions to explore how parents are not simply hostages to their past histories but also make ‘choices’ about what aspects of their childhood experiences they wish to alter and which to continue. This offers an existential thread to ANT in recognising that our working models are used to make predictions and anticipations which serve as a guide for the choices we make. Examples include what kinds of parents we want to be; what we have learnt from observing our own parents, and what we wish to change. In ANT we focus on the positive intentions behind what the parents are trying to do rather than what is going wrong.

Finally, ANT also extends these ideas by recognising the importance of wider systems and moving ‘beyond the dyad’ to consider how attachment connections occur not only, or predominantly in, dyadic relationships but in triads. So, a child is seen to have an attachment relationship not just with each parent but also their parents’ relationship as a couple. Furthermore, our working models go beyond the dyad, recognising the representations of our parents’ relationships where we play a part in the dynamics between our parents. For example, patterns of triangulation where we may have been drawn into take sides in their conflicts or alternatively more benign patterns where we were invited to join in to care for or comfort the other parent, a pattern commonly observed in the case of parental mental health difficulties. In our practice we have noticed a cooling in emotional atmosphere with conflicted parents when they are asked to think about how their child perceives their couple relationship. Externalising the relationship appears to help parents to think about their interactions from a different lens, not just what is happening between them as a dyad but widening to include their children’s thoughts and feelings in response. Deepening these conversations further to think about scripts of couple relationships they want to pass onto their children further aids this triadic element of ANT.

Peri-ANT

Peri-ANT was developed from ANT which was initially formulated in the context of working with eating disorders (Dallos, 2004). Dallos became curious about what the early relationships relating to food might have been like between parents and their babies. Babies can be fractious and distressed around mealtimes and parents must combine an ability to sooth the baby, so she is able to take in milk comfortably. In this work we could only speculate about what early relational patterns around soothing and comforting had been established. In perinatal work these patterns are being played out currently. This offers a hopeful framework - that assisting these patterns to become more effective can perhaps prevent later serious conditions such as anorexia developing.

Exploring patterns is a central feature of Peri-ANT and is a core skill in systemic therapy. This can include an exploration of the sequences of actions involved between different family members, understandings and explanations held by them and their feelings at the time and subsequently. This three-fold focus (actions, understandings and feelings) also represents a core conceptual and therapeutic feature of Peri-ANT. It draws on the idea of representational systems (Crittenden, 2017; Bowlby, 1988; Dallos, 2007) to emphasise that families are seen to be engaged with each other simultaneously at these multiple levels. In the perinatal context this is also clearly highly relevant since infants do not yet have language and parents need to be able to try to interpret their feelings and needs from their actions. Importantly, parents need to be able to reflect on how their own actions impact are experienced by their baby.

Born from this thinking, our formulation in Peri-ANT has a triadic focus and revolves around three core concepts:

Past and current attachment experiences shape how parents cope with difficulties and manage distress, including the ability to place these experiences into words to tell the stories of their experience.
The meanings parents attribute to these attachment narratives are crucial. Changes in these meanings can help parents to think about themselves, their relationships with each other and their baby. These in turn can change their family’s future in different ways.
The narratives that parents and families hold take place in a wider socio-political, cultural context which includes ideas and beliefs about parenting (e.g. how to be a ‘good’ parent) and child-rearing (e.g. the ‘best’ way to raise a child; parent responsibilities and gender roles; cultural differences in parenting practises).

The Perinatal Journey:

In the perinatal phase, narratives form around pregnancy, birth and the early days of parenting. In each of these stages, attachment and relational changes occur that may challenge the relationship between the couple. Central to attachment theory is a consideration of the way in which families support each other when faced with danger, threat, and anxiety. For some parents their perinatal journey may not have gone to plan or as hoped, and they may have experienced unanticipated danger and threat. How parents respond, as we described, falls back to their own attachments and responses may be either aligned or complementary, i.e. avoidant (cognitive with less emotion) or pre-occupied (emotional with less thought). Each parent may be drawn to using a different, contrasting strategy to the other parent. This leaves the child with what Mary Main (1991) describes as a ‘mixed model’. The child must try and develop different strategies to adjust to each parent which can be highly challenging for a young baby. For couples where these patterns are understood between them, they work well together to offer a complementary pattern so that the parenting journey flows more easily. Conversely, if couples are less aware of their patterns or hold contradictory patterns, parenting smoothly can be more challenging. Parents being aware of their attachment differences may stimulate their baby to develop more flexible and sophisticated understandings of relationships.

Pregnancy

The perinatal journey begins with planning for (or not) and conceiving the baby. Perinatal services usually commence after conception, but it is important to consider and incorporate the whole pregnancy narrative into the formulation. Mixed feelings are common during pregnancy which can bring a range of physical and psychological anxieties for both parents (Butterworth, O’Shaughnessy, and Galbraith 2019). Pregnancies can be unexpected, planned and/or long awaited. Finding out about the pregnancy comes with an array of emotions including surprise, relief, joy, and fear. Couples may worry about relationship and life changes as they negotiate how to make room for another person. For first time parents, a new family life cycle stage is about to begin. For all couples the family life cycle stages may overlap, with competing challenges of elderly parents, losses and life changes.

The Birth Experience

For some families in the perinatal period, the story of their child’s birth can dominate. Childbirth sometimes goes to plan; sometimes it does not. Where mothers have a history of trauma, the experience of being out of control, exposed, vulnerable, having things ‘done to them’ and feeling invalidated, can be re-traumatising. It is not uncommon for birth partners to have a related but independent traumatic response to the birth process, perhaps having feared for the life of their partner and/or baby, and often having felt excluded or powerless. Whilst the process of birth may be shared, the experiences for each person can be very different. This is another moment where the couple’s own attachments and responses can either fit and flow or misalign and create tension and misunderstandings. This takes many forms and there is a spectrum of severity. For example, at the mild end, a partner may try to help and support following a difficult birth in ways that are irritating to the mother; the mother may expect the partner to understand what she has been through because the partner was present at the birth and feel disappointed when they don’t. At the severe end, there can be a total breakdown of understanding as both parents struggle in different ways to come to terms with the birth trauma. The differences then drive a further wedge between them as they feel increasingly misunderstood and isolated in their distress.

Following Birth

Some parents feel an instant bond or connection with their baby. It may start to develop during pregnancy; it can hit like an overwhelming emotional wave in the first moments with their baby. For others it can take longer and grows over time. Though these variations are entirely natural and normal, many parents worry when these feelings are not immediate. This can lead to shame, distress, and a feeling of failure, particularly in the aftermath of a traumatic birth for mum and/or for dad or partner. This may be further complicated where the baby is born developmentally or physically fragile or perhaps needing a neonatal admission. Here there is the added complex task of adjusting from the anticipated image of how they hoped their child to be, to the reality of the situation. The early moments after birth come with a collection of “first time” experiences; the first time they hold their baby, the first feed, the first separation and so on. Each of these firsts will help to form the narratives of the postnatal period and as first-time events, they will have dominance in the process of narratives forming.

Through the perinatal life stage, the process of becoming a parent involves the reactivation of childhood memories. We carry our past with us and having a baby stirs up feelings and embodied experiences from one’s own infancy and childhood (Fraiberg, Adelson and Shapiro, 1975). This can bring back happy memories but can reactivate childhood adversity. Adverse Childhood Experiences (ACEs) are highly stressful, and potentially traumatic, events or situations that occur during childhood and/or adolescence (Young Minds 2018). In a 2014 UK study on ACEs, 47% of people experienced at least one ACE with 9% of the population having 4+ ACES (Bellis et al, 2014). They can have a lasting impact on people’s mental health, wellbeing and how they function in life. These experiences influence people’s attachments and powerful stories are formed around them that shape people’s beliefs and behaviours. These memories are then drawn on when parents are shaping their new narratives and they influence how the experiences of the perinatal stage are interpreted in the forming of narratives. In turn, these then influence the new relationship with the baby and the changing relationships between couples and with the wider system.

Tragically for some parents, rather than experiencing the joy of bringing a baby home, they experience the devastating loss of their baby in either pregnancy, birth or the post-natal period. People often experience significant psychological distress, as well as feelings of shame and inadequacy. Couples may come together in this or experience differences in how they respond, and how they grieve. Loss forms a specific and powerful contextual factor for how parents care for subsequent babies. Themes of over protectiveness, parental fear, and parenting through grief processes can dominate the subsequent experiences of caring for a baby and bringing up a child.

The Peri-ANT Framework: an Overview

Phase 1: Co-Creating a Secure Base ¹Interventions focus on building the therapeutic relationship and therapeutic safety. ²Engagement, Attachment and Cultural Genograms, Tracking, PDI, Assessment techniques. ³SCORE, SRS	Phase 2: Mapping Perinatal Stories ¹Interventions focus on developing a systemic attachment formulation to determine the direction for change. ²Building a formulation, sculpting, LUUUUT, mapping scripts, Tracking (the problem), PDI. ³SRS. SCORE at session 4 or multiples of.
Phase 3: Contemplating and Attempting Change ¹Interventions shift to focus on the creation of change. ²Refining the formulation, sculpting changes over time, LUUUUT, mapping script changes, Tracking change as it occurs. ³SCORE at session 4 or more. SRS	Phase 4: Maintaining Changes and Endings ¹Ending processes and relapse prevention. ²Strengthening changes that have occurred. Relapse prevention, future planning, reflexive ending conversations, ending processes. ³Final SCORE, SRS
Key: Black: The phase and it’s descriptor Red¹: The aims for therapy in this phase	Blue²: Open list of examples of interventions Purple³: Measures used to gather outcome data

A joint initiative between: Cheshire and Wirral Partnership and Mersey Care NHS Foundation Trusts

Cheshire and Merseyside Perinatal Service 2024

The Peri-ANT model consists of the four phases described in ANT (Dallos, 2007, 2023). Families access between 6-16 sessions on average. These have then been adapted to the perinatal context:

Phase 1: Co-constructing a secure base with families:

For many families, attending Family Therapy can be an anxiety provoking situation, perhaps involving fears of being judged and blamed, for parents and other members of the family. The focus on creating a sense of safety runs through the Peri-ANT programme. Phase 1 focusses on engagement, building a trusting therapeutic relationship, building a safe and trusted space for therapy and the family and therapist getting to know each other. This is vital to the therapeutic endeavour, particularly for families who have good reason to be cautious and mistrustful of professionals and services. Building trust involves transparent consent seeking for the work with clarity about what is to be offered. The collaborative nature of the therapy is not only explained but modelled and demonstrated in the initial appointment through the use of curiosity, respectful enquiry and the therapists holding Karl Tomm’s (1987a, 1987b) interventive interviewing theory in mind. By recognising that every interaction and question will have a potential therapeutic impact, the relational trust is steadily built between therapist and family and a safe base is developed.

Phase 2: Engaging in collaborative exploration of difficulties and strengths:

Once a secure base is achieved and a safe, therapeutic space is established, therapy can explore their areas of strength, resilience and problematic areas in more detail to create a robust formulation in readiness for change. Careful exploration and assessment techniques guide the therapist through the formulation process towards a robust and collaborative formulation. It is recognised that this exploration can be stressful, challenging and may provoke intense feelings. Interventions which may seem benign such as mapping a genogram can, especially in the perinatal period, deliver a powerful emotional kick if not managed with skill and care. It is important to check with families that the content and pace of this exploration is comfortable for them. Consistent with core systemic principles this exploration is also seen as promoting change in that parents come to be able develop richer and more coherent narratives based on remembering unnoticed, forgotten or dismissed information from the past and from their recent interactions.

Broadly the exploration moves between a focus on the past, attachment histories, key events (perpetuating and precipitating events) alongside a focus on current relational dynamics in the families (perpetuating factors). Also key to the exploration is a focus on protective factors: individual and relational resilience, positive intentions, strengths and corrective and replicative scripts.

Phase 3: Moving together to contemplate changes and engage in experimentation.

In this phase the therapist’s approach is guide the parents as they experiment with different ways of approaching problems. The aim of this phase is to offer interventions that create lasting desired change within the family relationships and attachments. Change is more likely to be effective in therapy when the family are engaged and feel safe with their therapist and the therapist is working from a robust and thoughtful formulation informing the interventions. Ensuring the family have a safe and effective journey through phase 1 and 2 before starting is paramount. We recognise that change involves some risk and sometimes steps into the unknown. We hold relational risk taking in mind (Mason 2005) as we offer interventions that support useful therapeutic risk taking and learning. Alongside this is a continual thread of reflexivity with the option to move back into phase 1 or 2 if needed. ANT uses tasks and ‘homework’ for parents to try different ways of acting, thinking and feeling with each other as a way of safely experimenting with change. This may also involve revisiting ideas that they had previously tried but did not persevere with because they lacked confidence that they would eventually work.

Phase 4: Thinking about the future, consolidating changes, continuing sources of support whilst managing a healthy relational ending process in therapy.

Stabilising change in important if it is to be sustainable. Families need to be confident that they can maintain the change and relapse prevention helps to plan for times of challenge that might lie ahead. Navigating a thoughtful ending to therapy is especially important in attachment work, particularly so for families who have experienced multiple adversities. For every effort we make as therapists to engage a family, an equal effort is required to separate and say goodbye in a way that helps create lasting positive change from the therapeutic encounter. It is also important to note that many people access therapy at more than one time in their lives, especially when they have experienced trauma. Our ending processes are important to ensure there is a positive legacy for any therapy that comes after us. To that end, we try to plan endings and manage them collaboratively, giving choice and agency to the family about the ending they choose to have with us. Ending processes can last a number of sessions. They may also be quicker than we would wish at times as we adapt to the family’s style of ending that might be more abrupt than we would choose. The fit for the family and the sustainability of the change are the key driving factors in this phase.

Supervision

To support Peri-ANT practice, a network of supervision was put into place including one to one individual supervision and group network meetings, all supervised by systemically qualified supervisors. During our discussions we noticed that practitioner preference varied. Some started with a desire understand what they were doing and why. Some wanted to read the manual and absorb it as a first step into trying something new. Others were happy to pick up some of the techniques and interventions that were a fit for them and start there then build. We came to recognise that this fits with Burnham’s Approach, Method and Technique (AMT) idea (1992). Therapists can come at Peri-ANT from any angle and grow their practice. This was a key idea in supervising the team as we acknowledged different staff needed to feel validated in their own way of approaching a new way of working. As one family therapist put it, “TAM is just as valid as AMT.”

The Parent Development Interview (PDI)

The parents are invited separately to engage in the PDI interview which explores their own childhood attachment experiences and also their relationship with their child. Clinicians explain that this is to help us understand their background and to try and to help ensure that Peri-ANT is geared to their needs. Families are also advised that they will be sent a brief summary of their interview and that, with their consent we will refer to parts of it in the sessions. Clinicians emphasise that a particularly relevant part will be what they have learnt from their early experiences and what they wish to repeat or change (corrective and replicative intentions). The use of the PDI is actively being shaped by our systemic backgrounds and we envisage this will be something in the future that will change as the model of Peri-ANT grows and develops.

Multi-family group sessions

These consist of groups of parents meeting to work together, to share experiences, such as the challenges they face and ways of coping. The session has a strength based, solution focussed emphasis with parents acting as ‘consultants’ to other parents, to connect with other families, share experiences and overall to foster their engagement in Peri-ANT as ‘consultants’ to each. The initial session encourages them to share and explore each other’s experiences, challenges of parenting and share ideas and techniques for managing difficulties. The combination of both family and group sessions brings a rich variety to the therapy. During the pilot stage of Peri-ANT, there were logistical barriers for running groups from the start. The group element was therefore built into the programme once the model’s initial establishment in the service was embedded.

Single Family Therapy Sessions

Fortnightly single-family sessions are offered, delivered by qualified Systemic Family Practitioners (SFPs) and/or Family Therapists all of whom have completed additional Peri-ANT training. We acknowledge that many services do not have a systemic team to deliver in this way, but we also hold that view that to deliver systemic interventions with skill, efficacy and to avoid unintentional harm, practitioners need to be trained and qualified in what they do. Much harm can be caused by well-meaning practitioners thinking they can deliver a therapy because the interventions look easy. Genograms are complex, sculpts take skill and the holding of a therapeutic, systemic framework with curiosity, collaboration and self-reflexivity is a specialist competency within the systemic field. The method of delivery for the family sessions include sessions with an individual systemic clinician, joint work, or a family therapy team. Non-systemic staff trained in ANT may be involved in joint or clinic delivery but every offer of therapy and every session had the direct input of a systemically qualified clinician. The clinicians working with the families are in turn supported by monthly ANT/systemic clinical supervision. Continual monitoring and feedback is built in so Routine Outcome Measures (ROMs) and measures are used to track change and effectiveness. This information is discussed with families and employed to adjust sessions to their needs. It is also collated and fed back into the perinatal service. Families are asked if they would welcome suggestions for activities, adapted to each phase of therapy e.g., observing their patterns of interacting, keeping a diary to track successful/problematic episodes, or thinking further about their family genograms.

Peri-ANT in Practice

To illustrate some of our experiences so far we offer two brief vignettes:

Simon, Kate and Connor

Connor is 18 months old and lives with his parents Kate and Simon. The referral to perinatal services sought help with Kate’s experience of post-natal depression. Assessment highlighted this was related to relationship difficulties between Kate and Simon in the context of Simon using high levels of alcohol. The alcohol was causing problems in their parenting of Connor and was impacting on the early relationship he was developing with both parents. Through phase 2, the mapping of attachments and childhood narratives, we identified that Kate was keen to step away from her childhood pattern of being a carer. However, Simon’s drinking to excess was creating care needs and the pattern was replicating, impacting on her mood. Simon recognised the need in others for him to stop drinking but genogram work and sculpting helped them both to recognise that he would find it hard to stop due to the powerful family history of alcohol misuse and his relationship with it. In phase 3, these new understandings were used to think through their relationship, and they chose to separate but to remain as active co-parents. Couples rarely separate so mindfully but they were able to have very careful conversations about Connor’s care and his safety. Importantly, Simon identified that his childhood experiences meant he links being a “fun father” to alcohol and risk taking. (i.e. his father, when drunk, would allow him to play with fire and on one occasion he remembers thinking his father would set him alight. This account was told with laughter and as an example of a fun time with his dad.) Both parents left the work with a recognition that this was a pattern that they could now see and would actively work to prevent it repeating. The following outcomes were observed:

A couple’s issue of alcohol use had been considered from a triadic, systemic perspective which had positive impact on their parenting of Connor.
The couple had navigated an amicable separation with calm, safe co-parenting arrangements and parents who remained friends.
The reduction and prevention of safeguarding risks related to Simon’s history of being parented by a father who drinks heavily.
Kate’s mood improved and she was discharged from the perinatal service at the end of Peri-ANT with no need for further interventions.

Olivia, Luke and Robin

Robin is 12 months old and lives with his mother, Olivia and father, Luke. The family were referred to perinatal services because of Olivia’s diagnosis of OCD, which had been around prior to becoming pregnant, but intensified after Robin was born. Luke was being increasingly drawn into rituals and described feeling more of a carer than partner at times. They felt they were getting tangled in the same argument again and again and it was leaving them feeling distant from one another. The couple engaged with tracking as part of ANT. They spoke about the OCD rituals often being a trigger, with Luke feeling frustrated at being directed to do tasks he felt were “silly” but also feeling it was quicker and easier to just do the task and they could move on. Olivia spoke about feeling torn in asking for support, then feeling guilty as Luke became cross and would storm out. They both spoke about Robin witnessing Olivia tearful and Luke cross, and not wanting this to be the model of a couple relationship they wanted to give to him. They spoke of Robin starting to cry when tensions were high, and neither parent feeling successful in then soothing him as they were both upset themselves. Repair would happen eventually after some time apart, with Luke making the approach and apologising as he was left feeling like a “bad partner and father”. Adding a layer of meaning around intentions to the tracking, as well as exploring intergenerational patterns at times of stress helped Olivia to see that Luke’s storming out was about him needing some space as opposed to her greatest fear of him leaving the family with some finality. They both recognised different patterns of wanting to solve conflict, with Olivia noting that in her family growing up, arguments would blow up and then calm quickly, while Luke spoke of his family just not talking about things, so finding it very difficult to speak about how he was feeling with Olivia. They both started to understand the pattern differently and were able to make suggestions about points in the cycle they could attempt changes. Luke spoke of reassuring Olivia that him leaving the room did not mean he did not love her and he would be back, and Olivia recognising that difficult interactions often started at a point when Luke was feeling burnt out with OCD tasks. Thinking about what Robin was observing helped the couple to take a further step back and connect to the scripts they wanted to take forwards of themselves as parents. At the end of therapy, the following outcomes were observed:

Olivia and Luke were able to consider Robin’s perspective and view on patterns they were tangled in and on their relationship, and consider the “couple” script they wanted him to observe. This gave them a shared sense of agency in making changes.
Olivia was able to separate the OCD from her relationship, and Luke was recruited less and less into rituals, and Luke spoke of feeling less like a carer and more like a partner.
They were able to see and stop patterns of withdrawal sooner or understand the intention of this being a way of coping as opposed to not caring. This stopped difficulties from escalating.
Olivia’s OCD symptoms had reduced and she was discharged from perinatal services.
The team were able to see the benefit of thinking about OCD from a systems perspective and the impact of including partner and child perspectives on the situation in addition to the referred mum’s.

Discussion

The Peri-ANT model offers a structured integrative model for working in the complex and challenging context of perinatal clinical services. It is specifically tailored to the perinatal stage of the family life cycle which is a unique opportunity for intervention, being the point where a new person and often a new generation joins the family structure. The manual framework consists of number of phases and activities for the sessions; it also allows a flexibility in its application. Central to the approach is the focus on helping to co-create with families a sense of trust and safety- a secure base from which positive change becomes possible. As we have shown in the case vignettes, families will present with different needs and issues. If we are to be effective, it is essential that we respond to these and adapt our planning and delivery of sessions to incorporate each family’s circumstances and needs. Each session starts with a check-in to explore life changes since the last session, the participants current emotional position, and current concerns. If needed, the focus of a session may need to lean into these, setting aside planned techniques to ensure the secure base is maintained. For example, a family who arrive having just argued, may need the therapist to adapt and set aside sculpting plans in favour of exploring their experience of how ruptures in their relationship are repaired. This illustrates that the activities in each stage and also the stages themselves can flex back and forth to track the needs of the family. It is also key to the peri-ANT approach that the sessions are collaboratively steered with all family members present and the therapist having a voice. Thus the approach, whilst manualised, is not directive but maintains a collaborative ethos of family and therapist working together to achieve the desired outcomes.

The implementation of peri-ANT has also prompted some fundamental re-thinking for us of some of the core concepts of attachment and systemic theories. It is apparent that for some families, their own experiences of being parented has left them with a working model of parenting that does not enable them to work together in ways they might wish. Hence peri-ANT is also mapping some clinically important and theoretically exciting areas in our understanding of ‘working models’ and scripts in the perinatal period. The work has also highlighted just how important it is to hold a triadic perspective on attachment. The impact of the “other” parent on each dyad – no matter which dyad is being considered – fundamentally changes the dynamic within the dyadic relationship. Once triads are considered, it leaves the dyadic perspective feeling thin at best and at worst, it offers a binary perspective prone to blaming one parent. In contrast, the triadic, systemic perspective offers a rich multi-dimensional way of considering attachment patterns. From the systemic side, bringing attachment into systemic practice brings a new perspective to how we work across generations. Attachment theory adds something to every conversation about genograms, narrative or family scripts, bringing an added dimension to our cross generational work with families.

Finally

This article provides an outline of the Peri-ANT model. The full manual and appendices for Peri-ANT are available by contacting the authors and consists of the following:

1: The Peri-ANT Guide

2: Shared Exploration of Attachment

3: Collaborative Formulation

4: Formats for Exploration

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