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Helen Kim, MD Director, HCMC Mother Baby Program and Hennepin Women ’ s Mental Health Program Department of Psychiatry Hennepin County Medical Center www.mnwomensprogram.org helen.kim@hcmed.org. Minding the mother and restoring natural rhythms to support the mother-baby relationship.

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Minding the mother and restoring natural rhythms to support the mother baby relationship

Helen Kim, MD

Director, HCMC Mother Baby Program and

Hennepin Women’s Mental Health Program

Department of Psychiatry

Hennepin County Medical Center

www.mnwomensprogram.org

helen.kim@hcmed.org

Minding the mother and restoring natural rhythms to support the mother-baby relationship


Outline

Definitions: mind, mindsight, mentalizing

What interferes with mindsight?

Psychiatric illness as brain/mind disorders that include disruptions in energy and biological rhythms

The role of psychiatrists and medication

Functional or integrative medicine as a lens to interpret mind/body symptoms


Mission:

To support families by strengthening the emotional health and parenting capacity of mothers


Mission:

To support families by strengthening the emotional health and parenting capacity

MINDSIGHT of mothers



Definition of mind by daniel siegel md
Definition of Mindby Daniel Siegel, MD

Mind: “an embodied and relational process that regulates the flow of energy and information. ”

“An emergent process that arises from energy and information flow within you and between you and others”


Mindsight

  • the ability to reflect on the mind or mental states of oneself and others.

  • emerges from within attachment relationships that foster such processes.

  • essential in healthy relationships

  • a learnable skill

  • “I am sad” vs “I feel sad”


Mindsight is a kind of focused attention that allows us to see the internal workings of our own minds. It helps us to be aware of our mental processes without being swept away by them, enables us to get ourselves off the autopilot of ingrained behaviors and habitual responses, and moves us beyond the reactive emotional loops we all have a tendency to get trapped in…The focusing skills that are part of mindsight make it possible to see what is inside, to accept it, and in the accepting to let it go, and, finally, to transform it.”Dan Siegel, MD


Mindsight -- seeing the mind

1) Insight into oneself

2) Empathy for others

3) Integration within you and your nervous system and between you and others

Intepersonal Neurobiology -- the study of mindsight


Mentalize

Mentalize

To be aware of mental states (desires, needs, feelings, reasons, beliefs) that drive reactions and behaviors of ourselves and others

To feel and think about feeling at the same time

A psychological skill that allows one to understand the internal state of oneself and another

Occurs on intellectual/conscious level

Occurs on a gut/intuitive level

An old idea --- Descartes, Theory of Mind, Fonagy (mentalizing in the context of attachment relationship, Arietta Slade (mentalizing in context of parenting; reflective functioning)


Mindsight - noun

Mentalize - verb

  • Nonjudmental curiosity, acceptance, compassion

  • Mindfulness of the mind of self and others;

  • Mind mindedness, reflective functioning, psychological mindedness

  • Empathy for self and others


Mentalizing as a Compass for Treatment

Jon G. Allen, PhD, Efrain Bleiberg, MD, and Tobias Haslam-Hopwood, PsyD, The Menninger Clinic

http://www.menningerclinic.com/education/clinical-resources/mentalizing

  • Mentalizing as conceptual compass to help patients understand how staff approach treatment

  • Shared understanding and shared goals as foundation for sense of “we’re in this together”


Why is mentalizing important
Why is mentalizing important?

  • Self-awareness: to reflect on and communicate our feelings/thoughts

  • Self-agency: Understanding that behavior doesn’t just happen but is based on mental states.

    “I am responsible for my behavior”

  • Self-regulation: “I feel angry” vs “I am angry”

    “I am not my feelings”

  • Relationships: feeling felt by another provides sense of connectedness/security;

    promotes understanding, intimacy

  • Finding meaning from suffering and hope

  • Resilience

Mentalizing as a Compass for Treatment

Jon G. Allen,


Why is mindsight or mentalizing important
Why is mindsight or mentalizing important?

Responsibility

Regulation

Relationships

Resilience


"The whole idea of thinking about thinking is that we learn about ourselves through being understood by other people. Babies learn about their feelings by having their feelings understood by someone else." ~ David Wallin


What interferes with mentalizing? about ourselves through being understood by other people. Babies learn about their feelings by having their feelings understood by someone else."

  • Strong emotions: shame, anger, fear ---> flight/fight/freeze

  • Defense strategies: repression, denial, avoidance, suppression

  • Apathy/indifference: “I don’t care” what’s in my mind or yours

  • “Psychiatric illness”: depression, anxiety, substance use, mania, psychosis


Psychiatric illness as disruptions in biological rhythms and energy

  • Maternal depression or anxiety

    • inhibit mindsight and/or the ability to mentalize

    • disrupt biological rhythms and energy

  • Stabilizing a mother’s biological rhythms is essential before she can synchronize with her baby’s rhythms.

  • Parents as brain scientists or curators of the mind:

    • Compassionate stance

    • Non-judgmental curiosity

    • Awe and wonder


Depression is the number one complication of childbirth wisner nejm 2001
energyDepression is the number one complication of childbirth”(Wisner, NEJM 2001)

Perinatal Depression: 10% in general population 25% in high risk groups

Perinatal Anxiety: 7-10%

Gestational Diabetes: 5% pregnancies


Women have 1.5-2.5 x rate of depression vs. men energyLifetime prevalence: 21.3% women and 12.7% men

Kessler RC, et al. J Affect Disorders 1993;29:85-96


Psychosis energy



Risks of untreated depression anxiety
Risks of Untreated Depression/Anxiety pregnancy

  • Poor self care, nutrition, and prenatal compliance.

  • Increased smoking, alcohol, drugs

  • Increased ob/neonatal complications, such as preterm delivery

  • Increased attachment and behavioral problems

  • More pediatric visits for behavioral problems and injuries


Maternal depression and risk to early parenting
Maternal Depression and Risk to Early Parenting pregnancy

Children 0-3 years old are most vulnerable to risks of maternal depression due to rapid brain development and sole reliance on caregiver


Maternal Depression and Risk to Children pregnancy

Children’s Defense Fund of Minnesota. (2011). Zero to Three Research to Policy: Maternal Depression and Early Childhood. www.cdf-mn.org


Cost of untreated maternal depression pregnancy

for mother and baby

Wilder Research, Oct 2010

  • Total annual cost of not treating 1 mother with depression = $22,647

  • Cost of not treating the mother = $7,211

  • Cost attributable to a child born to a depressed mother = $15,323


Brain/Mind Science vs “Behavioral Health” pregnancy

  • Waiting until behavior is a problem is not early detection/early intervention

  • Psychiatric illness -- disorders of the brain/mind that can manifest in behavior changes*

  • Mind behind the behavior as the target

  • Early intervention starts prenatally and with parents/children

*Thomas Insel, MD, NIMH http://www.ted.com/talks/thomas_insel_toward_a_new_understanding_of_mental_illness


Are psychiatrists just prescribers and behavioral health providers
Are psychiatrists just “prescribers” and “behavioral health providers”?

“You need to see a psychiatrist” = “You need meds”


STRESS health providers”?


Stress affects mind body and ability to mentalize
STRESS affects mind/body and ability to mentalize health providers”?

Difficulty sleeping

Headaches, body or joint aches

Poor energy

Poor concentration

Altered appetite

Digestion problems

Heart problems

High blood pressure

Irritability/anger/depression


Stress depression and anxiety through a functional medicine lens
Stress, Depression and Anxiety health providers”?through a Functional Medicine lens


Personalized medicine that deals with primary prevention and underlying causes instead of symptoms for serious chronic disease. Based on these principles:-Biochemical individuality-Patient-centered medicine -- "patient care" vs "disease care”-Web-like interconnections of physiological factors -Health as a positive vitality not merely the absence of disease

What is Functional Medicine? www.functionalmedicine.org


Some clinical imbalances underlying chronic medical conditions:

  • Hormone and neurotransmitter imbalances

  • Energy, mitochondria, and oxidative stress

  • Detoxification imbalances

  • Immune and inflammation imbalances

  • Gut and digestive health

  • Mind-body dysrhythms


Chronic Inflammation: conditions:

the common final pathway to chronic disease


Is depression an inflammatory condition? conditions:

  • Acute inflammatory response necessary for trauma or infection

  • Overactive immune or inflammatory response harmful: autoimmune disorders, RA, IBS, asthma, allergies, MS, celiac, thyroid

  • Chronic inflammation drives some chronic diseases: heart disease, obesity, diabetes, and depression

  • Pro-inflammatory cytokines cause physical and psychological symptoms (malaise, low mood, low energy, sleep disturbance) called “sickness behavior” which resembles depression

  • Neurotransmitter-focused theories of depression have been limited

  • Depression’s connections to inflammation and immune dysregulation offer other treatment options

  • Psychoneuroimmunology: the study of the CNS and immune system


What causes chronic inflammation? conditions:

  • Stress

  • Toxins

  • SAD diet

  • Lack of exercise

  • Hidden allergens/infections


What do you need to thrive
What do you need to thrive? conditions:

  • Safety

  • Sleep

  • Healthy Foods/Healthy Digestion

  • Light, water, air

  • Movement

  • Love, community, connection

  • Purpose


Sleep
Sleep conditions:


Sleep1
SLEEP conditions:

Average sleep in 1900 --- 9 hours

Study of 669 middle-aged adults found people sleep much less than they should, and even less than they think. (Am J Epi, 2006)

White women 6.7 hrs/night

White men 6.1 hrs/night

Black women 5.9 hrs/night

Black men 5.1 hrs/night

Poor sleep less than wealthy.


National sleep foundation sleep in america poll 2003
National Sleep Foundation conditions:Sleep in America Poll 2003:

% reporting <7 hrs

slept/weeknight

Ages 18 to 54 41

Ages 55-64 38

Ages 65-85 32


Sleep deprivation: the costs conditions:

  • Inhibits mentalizing (mind-blindedness)

  • Irritability

  • Poor concentration

  • Increased inflammation

  • Makes you fat

  • Increased risk of accidents



Standard American Diet (SAD) conditions:

  • High sugar

  • High processed food -- think Twinkie’s

    nutrient poor, high calorie

  • High in animal fats

  • High in unhealthy fats: saturated, hydrogenated

  • Low in fiber

  • Low in complex carbohydrates

  • Low in plant-based foods


Food Rules conditions: by Michael Pollan

1) What should I eat? -- Eat food

2) What kind of food should I eat? -- Mostly plants

3) How should I eat? -- Not too much

NAD: Real food, fresh fruits and vegetables, lean protein, moderate amounts of healthy fat, adequate fiber

Standard American Diet to New American Diet:

From SAD to NAD


Healthy Digestion conditions:

  • Bacterial balance: Healthy gut has 3 pounds of good bacteria that digest your food, help regulate hormones, excrete toxins.

  • Immune system protected by thin layer that lines the gut. If barrier damaged, can set off immune and and inflammatory reactions


Gut = the “second brain” conditions:

  • Enteric nervous system

  • 100 million neurons line the gut (more than the spinal cord)

  • Butterflies, pit in your stomach, gut feeling

  • 95% of the body’s serotonin is in the gut

  • Irritable bowel syndrome

  • Bidirectional connection between gut and brain (pit in your stomach can be result or cause of anxiety)

  • Neurogastroenterology


What sabotages healthy digestion? conditions:

  • SAD diet

  • Overuse of medications (NSAIDS, antibiotics, H2 blockers)

    > 200 over-the-counter (OTC) remedies for digestive disorders (GERD, irritable bowel, bloating, heartburn, ulcers)

  • Chronic low-grade infections or gut imbalances with overgrowth of bacteria in the small intestine, yeast overgrowth, parasites

  • Toxins

  • Digestive enzyme dysfunction – such as from acid blocking meds or zinc deficiency.

  • Stress -- alters the gut nervous system, contributes to leaky gut and changing the normal bacterial flora in the gut.


Stabilizing a mother s biological rhythms to help her synchronize with her baby s rhythms

Stabilizing a mother conditions:’s biological rhythms to help her synchronize with her baby’s rhythms.


Mind body strategies
Mind-Body Strategies conditions:

Relax: breathing, yoga, meditation, prayer

Sleep

Address the stressors

Gut health: Pollan’s “Food Rules”

Get moving!

Purposeful, meaningful activity

Tend and Befriend

Community


How to engage psychiatrist or other medical provider: conditions:

  • Imagine with the patient the hoped for outcome of appointment

  • Encourage a family member to accompany the patient

  • Send a note with your patient --- concise and specific (e.g. help with restoring sleep)

  • State what you are working on in therapy, such as “We are working on mindsight” or “We are working on mentalizing” and define what those terms are.

  • State your understanding of the priorities:

    • Safety

    • Sleep/wake and daily routines

    • Urgent needs/concerns

    • Regulation, relationships, responsibility, resilience

    • Long-term plan for addressing underlying destabilizing factors


Integrative health resources
Integrative Health Resources conditions:

Institute for Functional Medicine

www.functionalmedicine.org

Dr Mark Hyman: www.drhyman.com

Ultramind Solution or Ultrasimple Diet

Dr. Christiane Northrup: www.drnorthrup.com

Women's Bodies, Women's Wisdom

Dr Margaret Christiansen: christensencenter.com

Other Books:

Henry Emmons (Chemistry of Joy; Chemistry of Calm)

Michael Pollan (Food Rules, Omnivore’s Dilemma)

James Hollis (Finding Meaning in the 2nd Half of Life)

Articles of interest:

Limitations of acute care approach to chronic conditions and a call for medical education reform (Holman H. JAMA 2004;292:1057-1059)


Recovery from depression is a family affair conditions:

  • CBT in depressed teens was effective, but not if they had a parent who was currently depressed (JAMA. 2009;301(21):2215-2224)

  • Treatment of depression in children not effective unless addressing needs of parents


Mother baby model of care

Mother-Baby Model of Care conditions:

Provide treatment for maternal psychiatric disorders while maintaining and supporting MB relationship

Specialized intensive outpatient/inpatient programs for

pregnant women or mothers and babies

Incorporates baby into mother’s mental health treatment

Eliminates childcare barrier

Eliminates separation from baby and disruption in breastfeeding

Supports a healthy attachment relationship


Mother-Baby Model of Care conditions:

Staffed by psychiatrists and other mental health providers who specialize in perinatal and infant mental health

Include expertise in meds for preg and nursing women

Peer support

Reduces stigma

Assessment of MB relationship


Mother-Baby Programs in UK, Australia, US conditions:

  • Australia: 4 MB inpt units just in Melbourne, Australia (15-27 night stay)

    United Kingdom: 20 MB units that offer both outpt and inpt

  • United States:

    Outpatient MB Programs:

    • Women and Infants Day Hospital Program, Rhode Island (2000)

    • El Camino Hospital MOMS Program, San Francisco, CA (2008)

    • Pine Rest Mother-Baby Partial Hospital, Michigan (2013)

    • HCMC Mother-Baby Program, Minneapolis, (2013)

      Inpatient Perinatal Program:

      -- UNC Perinatal Psychiatric Inpatient Unit, (2012)


Hcmc mother baby program
HCMC Mother-Baby Program conditions:

  • Partial hospital program for pregnant and postpartum mothers

  • Fills gap in service for perinatal women with moderate-severe depression or anxiety

    • Goal of treatment: to support mentalizing/mindsight capacity in mothers and promote positive parenting practices

  • 4 hours/day, 4 days/week, for 3 weeks

  • Services:

    • Group psychotherapy

    • Medication evaluation and management

    • On-site nursery for babies up to 1 year old

    • Lactation consultation


Stories
Stories conditions:

  • Range of backgrounds:

    • Higher income mom overwhelmed with sleep deprivation and fear driven by undiagnosed bipolar disorder

    • Low income, single mom homeless with 3 kids under 4 and struggling with depression

    • Low income immigrant mom with baby in foster care after she tried to kill herself

  • I didn’t know that:

    • My baby needs me to feel safe

    • My baby needs me to talk to her

    • My baby is not needy or greedy


Circle of security

Circle of Security conditions:

Kent Hoffman, Glen Cooper, and Bert Powell

Relationship based early intervention program designed to enhance attachment security between parents and children

http://www.youtube.com/watch?v=cW2BfxsWguc&feature=plcp


Shark music conditions:


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