Telling the Birth Story

1. Telling the Birth Story • The role of a mother’s support group in the identification and amelioration of high risk factors in post partum women Susan Dowd Stone, LCSW

2. 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) Susan Dowd Stone, LCSW

3. 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) Susan Dowd Stone, LCSW

4. 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) Susan Dowd Stone, LCSW

5. 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 Susan Dowd Stone, LCSW

6. Post Partum Continuum Susan Dowd Stone, LCSW

7. Who comes to a mother’s support group - risk factors • 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 Susan Dowd Stone, LCSW

8. Additional issues • Adoptive parent • Gay parent • Single parent • Premature babies • Multiple young children • Unwanted pregnancy Susan Dowd Stone, LCSW

9. Difficult conception • Unsuccessful attempts to conceive are accompanied by significant psychological distress • Little, B.B.; Yonkers, K.A.(2001) Susan Dowd Stone, LCSW

10. 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 Susan Dowd Stone, LCSW

11. 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) Susan Dowd Stone, LCSW

12. 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 Susan Dowd Stone, LCSW

13. 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 Susan Dowd Stone, LCSW

14. 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 Susan Dowd Stone, LCSW

15. 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) Susan Dowd Stone, LCSW

16. 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) Susan Dowd Stone, LCSW

17. 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) Susan Dowd Stone, LCSW

18. 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 Susan Dowd Stone, LCSW

19. 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 Susan Dowd Stone, LCSW

20. Breastfeeding Difficulties • Sense of failure • Caesarian mothers more at risk • Convenience and guilt • Psychotropic medications Susan Dowd Stone, LCSW

21. Motherhood – the expectation Susan Dowd Stone, LCSW

22. Difficult Child/Bonding Susan Dowd Stone, LCSW

23. Technology and Attachment Theory Literature • Ultrasounds • Mother’s capacity to form relationships • Baby’s capacity to respond • Early separations • Sensitive/critical period Susan Dowd Stone, LCSW

24. 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 Susan Dowd Stone, LCSW

25. 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) Susan Dowd Stone, LCSW

26. Sense of self/professional moms vs. stay at home • Motherhood Myth • Sandwich generation • Multi-tasking Susan Dowd Stone, LCSW

27. Nutritional Concerns – Eating Disorders • Baby wellness • Return to pre-pregnancy weight • Nutritional consults for the mother • The role of diet/exercise in alleviating mild symptoms of PPD Susan Dowd Stone, LCSW

28. 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 Susan Dowd Stone, LCSW

29. Histories of abuse • Shame • Fear • Breaking the cycle Susan Dowd Stone, LCSW

30. Self or caregiver identified depression/anxiety • Can’t “snap out of it” • Constant fears about baby/self • Unrealistic attributions Susan Dowd Stone, LCSW

31. Case Stories • Linda older mom with previous successful career, difficulty conceiving, first child, cross cultural issues • Paula mother of twins, financial difficulties, marital issues, abuse history, poor relationship with mother • Laura difficult conception and birth antenatal depression, small birth weight, bonding issues Susan Dowd Stone, LCSW

32. Goals of a mother/baby support group • Information clearing house • Professional 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 Susan Dowd Stone, LCSW

33. 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 Susan Dowd Stone, LCSW

34. Group Format • Convenient Facility, parking • Ease of access, timing • Confidentiality assured • Sliding scale to increase access to help but may be billed to insurance company Susan Dowd Stone, LCSW

35. Postpartum Group Psychotherapy Format • Group meets for one hour weekly • Facilitated by licensed professional social worker with training in antenatal mood disorders • If needed, participants may be referred for individual counseling or medication management Susan Dowd Stone, LCSW

36. Community Referrals • The importance of establishing antenatal alliance • Encourage attendance ASAP • Extension of your area Obstetrical Team Susan Dowd Stone, LCSW

37. Mother-baby group • Marketed as socialization group • Women more likely to attend if no stigma • Opportunity to eye-ball new mothers • May offer interdisciplinary participation • Meets weekly for one hour • Day care may be provided Susan Dowd Stone, LCSW

38. 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 Susan Dowd Stone, LCSW