Telling the Birth StoryImplementing a Facility Based PPD programSusan Dowd Stone, MSW, LCSWManaging DirectorBlue Skye Consulting, LLC: 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


Primary Prevention: 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)


The Obstetric Network: 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)


The efficacy of post partum support groups: 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)


Undetected depressive illness despite antenatal screening attempts: 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


Post Partum Continuum: Post Partum Continuum


Who comes to the mother’s support group: 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


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


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


Caesarian: 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


Birth Trauma: 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)


Premature or ill babies: 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


Multiple births: 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


Isolation: 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


Marital issues: 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)


Support for partners: 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)


Family support : 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)


Financial Difficulties: 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


Restoration of Intimacy: 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


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


Motherhood: Motherhood


Difficult Child/Bonding : Difficult Child/Bonding


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


Unexpressed Feelings: 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


Lack of feelings: 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)


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


Nutritional Concerns: 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


Eating Disorders Negative Body Image: 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


Histories of abuse: Histories of abuse Shame Fear Breaking the cycle


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


Goals of a mother/baby support group: 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


Engaging the mothers: 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


Telling the Birth StoryGroup Format: 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


Community Referrals: Community Referrals 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: 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, MSW, LCSWPresident, Postpartum Support International: 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 susanstonelcsw@aol.com