Telling the Birth Story Implementing a Facility Based PPD program Susan Dowd Stone, MSW, LCSW Managing Director Blue Skye Consulting, LLC The role of a mother’s support group in the identification and amelioration of high risk factors in post partum women

The role of a mother’s support group in the identification and amelioration of high risk factors in post partum women

Primary Prevention “… Prevention is the great challenge of postnatal illness because this is one of the few areas of psychiatry in which primary prevention is feasible…” Hamilton & Harberger (1992)

“… Prevention is the great challenge of postnatal illness because this is one of the few areas of psychiatry in which primary prevention is feasible…”

Hamilton & Harberger (1992)

The Obstetric Network It is essential to integrate a psychiatric dimension into this network to break the vicious circle of mood disorders that women experience during pregnancy and motherhood - Harris, Bryan (2002)

It is essential to integrate a psychiatric dimension into this network to break the vicious circle of mood disorders that women experience during pregnancy and motherhood

- Harris, Bryan (2002)

The efficacy of post partum support groups A psychoeducation group for women with low post partum mood can significantly reduce depressive symptoms Honey, J.L, Bennett, P, Morgan M. (2002) A program of supportive group therapy for post partum mothers can significantly lower or eliminate depressive episodes Lane, B., Roufeil, M.M., Williams, S., Tweedie, R..(2001) Post partum mothers attending a group integrating supportive educational and cognitive behavioral components yielded significant reductions in symptom frequency and intensity after 4 – 6 weeks. Chabrol, H., Teissedre, F., Saint Jean, M., Teisseyre, N., Sistac, C, Michaud, C., Roge, B.(2002)

A psychoeducation group for women with low post partum mood can significantly reduce depressive symptoms

Honey, J.L, Bennett, P, Morgan M. (2002)

A program of supportive group therapy for post partum mothers can significantly lower or eliminate depressive episodes

Lane, B., Roufeil, M.M., Williams, S., Tweedie, R..(2001)

Post partum mothers attending a group integrating supportive educational and cognitive behavioral components yielded significant reductions in symptom frequency and intensity after 4 – 6 weeks.

Chabrol, H., Teissedre, F., Saint Jean, M., Teisseyre, N., Sistac, C, Michaud, C., Roge, B.(2002)

Undetected depressive illness despite antenatal screening attempts Premorbid undiagnosed mood disorders Inaccurate self-report Fear of involvement of child protection agencies Ability to mask symptoms especially if highly functional Motherhood myth Severe life events

Premorbid undiagnosed mood disorders

Inaccurate self-report

Fear of involvement of child protection agencies

Ability to mask symptoms especially if highly functional

Motherhood myth

Severe life events

Post Partum Continuum Post Partum Responses Healthy Rebound “ Baby Blues” Post Partum Depression Post Partum Psychosis

Who comes to the mother’s support group Post Partum Continuum Difficult conception/amniotomy Caesarian/birth trauma Multiple birth mothers Isolated, lack of support/cross cultural pressures Marital issues/financial difficulties/intimacy Breastfeeding issues Difficult child/bonding issues Unexpressed feelings/anger/ sense of inadequacy/ grief Sense of self/professional moms/motherhood myth Nutritional concerns Histories of abuse Self or caregiver identified depression Substance Abuse Psychiatric History

Post Partum Continuum

Difficult conception/amniotomy

Caesarian/birth trauma

Multiple birth mothers

Isolated, lack of support/cross cultural pressures

Marital issues/financial difficulties/intimacy

Breastfeeding issues

Difficult child/bonding issues

Unexpressed feelings/anger/ sense of inadequacy/ grief

Sense of self/professional moms/motherhood myth

Nutritional concerns

Histories of abuse

Self or caregiver identified depression

Substance Abuse

Psychiatric History

Additional issues Adoptive parent Gay parent Single parent Premature babies Multiple young children Unwanted pregnancy

Adoptive parent

Gay parent

Single parent

Premature babies

Multiple young children

Unwanted pregnancy

Difficult conception Unsuccessful attempts to conceive are accompanied by significant psychological distress Little, B.B.; Yonkers, K.A.(2001)

Unsuccessful attempts to conceive are accompanied by significant psychological distress

Little, B.B.; Yonkers, K.A.(2001)

Caesarian Caesarian mothers used to stay in the hospital up to ten days Recovery from major surgery Support of nursing staff Longer period of modeling Not prepared/residual anger If mother remained in hospital longer, separations from baby less likely during this important maternal sensitive period

Caesarian mothers used to stay in the hospital up to ten days

Recovery from major surgery

Support of nursing staff

Longer period of modeling

Not prepared/residual anger

If mother remained in hospital longer, separations from baby less likely during this important maternal sensitive period

Birth Trauma Protracted unexpected delivery experiences during labor Severe pregnancy complications may increase the severity of postnatal depressive symptoms by acting as acute or chronic stressors . - Veroux, H., Sutter, A., Glatigny, E., Minisini A. (2002)

Protracted unexpected delivery experiences during labor

Severe pregnancy complications may increase the severity of postnatal depressive symptoms by acting as acute or chronic stressors . - Veroux, H., Sutter, A., Glatigny, E., Minisini A. (2002)

Premature or ill babies May not be available to mother during maternal sensitive period Ill/premature babies more at risk for maternal rejection, failure to thrive and battering. Mourning the idealized child

May not be available to mother during maternal sensitive period

Ill/premature babies more at risk for maternal rejection, failure to thrive and battering.

Mourning the idealized child

Multiple births Associated high risk factor for PPD Trauma related to difficult conception Raised possibility of low birth weight/health problems Heightened exhaustion for care Difficulty breast feeding

Associated high risk factor for PPD

Trauma related to difficult conception

Raised possibility of low birth weight/health problems

Heightened exhaustion for care

Difficulty breast feeding

Isolation Woman’s perception of self as not supported Family lives far away/cross cultural issues Cut off from friends, no longer has commonalities with friends Difficulties with spouse Afraid of judgments

Woman’s perception of self as not supported

Family lives far away/cross cultural issues

Cut off from friends, no longer has commonalities with friends

Difficulties with spouse

Afraid of judgments

Marital issues “… Many patients report that marital stress is an important aspect of their illness. Nevertheless, in the usual patient oriented and child oriented regimes of treatment the husband (partner) receives scant attention…” Hamilton & Harbinger, (1992 )

“… Many patients report that marital stress is an important aspect of their illness. Nevertheless, in the usual patient oriented and child oriented regimes of treatment the husband (partner) receives scant attention…”

Hamilton & Harbinger, (1992 )

Support for partners Ongoing demands to run the house, care for the new baby the mother and other children Jealousy “… Marital problems which appear to have emanated from PPD often persist long after symptoms are abated…” - Hickman, (1982)

Ongoing demands to run the house, care for the new baby the mother and other children

Jealousy

“… Marital problems which appear to have emanated from PPD often persist long after symptoms are abated…”

- Hickman, (1982)

Family support “… I know I could have and should have done more. We as a family did not want to accept mental illness in our lives. Because of this stigma, Sharon suppressed her feelings after Garrett’s birth. Had we ever imagined infanticide or suicide might result, something would have been done…” Glenn Comitz, husband of a woman imprisoned for infanticide (Comitz, 1988, Beyond the Blues)

“… I know I could have and should have done more. We as a family did not want to accept mental illness in our lives. Because of this stigma, Sharon suppressed her feelings after Garrett’s birth. Had we ever imagined infanticide or suicide might result, something would have been done…”

Glenn Comitz, husband of a woman imprisoned for infanticide (Comitz, 1988, Beyond the Blues)

Financial Difficulties The cost of childbirth and aftercare already high, but psychiatric interventions may be excluded due to cost Find inexpensive activities outings for families Financial burdens fall to working partner

The cost of childbirth and aftercare already high, but psychiatric interventions may be excluded due to cost

Find inexpensive activities outings for families

Financial burdens fall to working partner

Restoration of Intimacy “Sex and affection were absent during that time. Not tonight, not tomorrow night, not next week, not ever!” A post partum husband complains In Post Partum Psychiatric Illness (R. Hickman, 1992) Persistent discomfort

“Sex and affection were absent during that time. Not tonight, not tomorrow night, not next week, not ever!”

A post partum husband complains In Post Partum Psychiatric Illness (R. Hickman, 1992)

Persistent discomfort

Breastfeeding Difficulties Sense of failure Caesarian mothers more at risk Convenience and guilt Psychotropic medications

Sense of failure

Caesarian mothers more at risk

Convenience and guilt

Psychotropic medications

Motherhood

Difficult Child/Bonding

Technology and Attachment Theory Literature Ultrasounds Mother’s capacity to form relationships Baby’s capacity to respond Early separations Sensitive/critical period

Ultrasounds

Mother’s capacity to form relationships

Baby’s capacity to respond

Early separations

Sensitive/critical period

Unexpressed Feelings Anger – in conjunction with or irrespective of depressed mood Graham, J.E., Lobel, M. DeLuca, R.S. Frustration Helplessness Fear Guilt Grief Anxiety Embarrassment Exhaustion

Anger – in conjunction with or irrespective of depressed mood

Graham, J.E., Lobel, M. DeLuca, R.S.

Frustration

Helplessness

Fear

Guilt

Grief

Anxiety

Embarrassment

Exhaustion

Lack of feelings “… Mothers are supposed to love their babies! I don’t have any feelings toward mine. I just feel numb. What’s wrong with me?...” support group participant (Harberger P.N, Berchtold, N.G. & Honikman, J.I.(1992)

“… Mothers are supposed to love their babies! I don’t have any feelings toward mine. I just feel numb. What’s wrong with me?...”

support group participant (Harberger P.N, Berchtold, N.G. & Honikman, J.I.(1992)

Sense of self/professional moms vs. stay at home Motherhood Myth Sandwich generation Multi-tasking

Motherhood Myth

Sandwich generation

Multi-tasking

Nutritional Concerns Baby wellness Return to pre-pregnancy weight Nutritional consults for the mother The role of diet/exercise in alleviating mild symptoms of PPD

Baby wellness

Return to pre-pregnancy weight

Nutritional consults for the mother

The role of diet/exercise in alleviating mild symptoms of PPD

Eating Disorders Negative Body Image Patient’s offspring may be seriously at risk May seem normal; often overlooked Bingeing and purging not as evident, could be seen as “pregnancy cravings” or morning sickness

Patient’s offspring may be seriously at risk

May seem normal; often overlooked

Bingeing and purging not as evident, could be seen as “pregnancy cravings” or morning sickness

Histories of abuse Shame Fear Breaking the cycle

Shame

Fear

Breaking the cycle

Self or caregiver identified depression/anxiety Can’t “snap out of it” Constant fears about baby/self Unrealistic attributions

Can’t “snap out of it”

Constant fears about baby/self

Unrealistic attributions

Goals of a mother/baby support group Information clearing house Professional/peer feedback/role playing Non judgmental support system Observational and clinical review of maternal/child relationship Relaxation Dispel motherhood myth of the maternal instinct Strengthen marital support Mobilize additional support systems Reduce environmental stress Rearrange priorities Encourage networking/socialization Amelioration of symptoms Identify needs for additional treatment

Information clearing house

Professional/peer feedback/role playing

Non judgmental support system

Observational and clinical review of maternal/child relationship

Relaxation

Dispel motherhood myth of the maternal instinct

Strengthen marital support

Mobilize additional support systems

Reduce environmental stress

Rearrange priorities

Encourage networking/socialization

Amelioration of symptoms

Identify needs for additional treatment

Engaging the mothers Referrals from physician’s offices or in hospital after birth: Inviting a new mother Visiting in rooms prior to discharge Emphasizing the socialization part of the group

Referrals from physician’s offices or in hospital after birth: Inviting a new mother

Visiting in rooms prior to discharge

Emphasizing the socialization part of the group

Telling the Birth Story Group Format Convenient Facility, parking Ease of access Babies and younger children welcome at some meetings Confidentiality assured Free of charge or sliding scale to increase access to help

Convenient Facility, parking

Ease of access

Babies and younger children welcome at some meetings

Confidentiality assured

Free of charge or sliding scale to increase access to help

Community Referrals The importance of establishing antenatal alliance Encourage attendance ASAP Extension of your area Obstetrical/Pediatric Team

The importance of establishing antenatal alliance

Encourage attendance ASAP

Extension of your area Obstetrical/Pediatric Team

Excerpts from “Her Eyes are Wild” - William Wordsworth 1798 “… Sweet babe, they say that I am mad But nay, my heart is far too glad And I am happy when I sing Full many a sad and doleful thing… A fire was once within my brain And in my head, a dull, dull pain And fiendish faces, one, two, three Hung at my breast and pulled at me Suck little babe, oh suck again It cools my blood, it cools my brain Thy lips I feel them baby, they Draw from my heart the pain away…” Soundbite Beethoven’s Symphony #9

“… Sweet babe, they say that I am mad

But nay, my heart is far too glad

And I am happy when I sing

Full many a sad and doleful thing…

A fire was once within my brain

And in my head, a dull, dull pain

And fiendish faces, one, two, three

Hung at my breast and pulled at me

Suck little babe, oh suck again

It cools my blood, it cools my brain

Thy lips I feel them baby, they

Draw from my heart the pain away…”

Soundbite Beethoven’s Symphony #9

Susan Dowd Stone, MSW, LCSW President, Postpartum Support International Facilitated PPD program at HUMC Contributor, Government PPD Educational Webinar Chair, PSI International Conference June ’06 “ Perinatal Mental Health: Community Solutions, Interventions and Treatment Options” Contributing author on PPD treatment NJ State Certified Instructor on PPD programs Managing Director, Blue Skye Consulting 560 Sylvan Avenue, NE, Englewood Cliffs, NJ 07632 201-567-5596 www.blueskyeconsulting.org [email_address]

Facilitated PPD program at HUMC

Contributor, Government PPD Educational Webinar

Chair, PSI International Conference June ’06

“ Perinatal Mental Health:

Community Solutions, Interventions and Treatment Options”

Contributing author on PPD treatment

NJ State Certified Instructor on PPD programs

Managing Director, Blue Skye Consulting

560 Sylvan Avenue, NE, Englewood Cliffs, NJ 07632

201-567-5596

www.blueskyeconsulting.org

[email_address]