Postpartum Depression and Trauma History: Healing past relationships while contributing to present healthy attachments

February 25, 2015

Jen Perfetti, LPC, IMH-E(IV)(In Collaboration with Roseanne Clark, PhD)UW Department of PsychiatryAddressing PPD in WI Home Visiting Programs

The Impact of Postpartum Mental Health on

Mother-Infant Relationships

Still Face Video

• Impaired ability to be involved in child’s physical care and play and to meet child’s normal needs for attention

• Difficulty bonding with baby and resulting feelings

of guilt and inadequacy

• Anxiety about doing psychological or physical harm towards baby (Weissman et al., 1979)

Possible Impact of PPD on Parenting

Possible Impact of PPD on Parenting•Depressed moms more often match negative affective/behaviorial states and less often match positive affective/behavioral states (Field et al., 1990; Murray, Fiori-Cowley, Hooper & Cooper, 1996)

•Depressed mothers hold more negative views of their interactions with their infants, and show more anger in interactions with their infants than non-depressed mothers (Weinberg & Tronick, 1998)

Interactions of Depressed Mothers with their Infants have been characterized as:

Withdrawn, Under-involved

or

Intrusive, Controlling

(Field et al, 1990)

Bi-Directional Effects in Depressed Mother-Infant Interactions• Infants imitate a variety of adult

facial expressions as early as 2-3 weeks after birth

• Mother’s depressed mood may induce a depressed state in the infant

• Infant’s subsequent distress and unresponsiveness are likely to maintain and perhaps increase the severity of the mother’s depression

(Field et al., 1982; Meltzoff & Moore, 1977; Meltzoff, 1990)

Early Relationships and Emotion Regulation• Experience of positive

emotion helps infants to organize their experience

• Infant-caregiver relationships provide the context for the socialization of emotion regulation - particularly in the context of face-to-face interactions

(Cole, Michel & Teti, 1994; Demos, 1986)

Consequences of maternal depression for infant/child development and problems in regulation

• Infants of depressed mothers show less interest, more anger and sadness and more fussiness than infants of non-depressed mothers (Tronic & Reck, 2009; Weinberg & Tronick, 1998)

• Clinical observations of infants: Sober, sad or flat affect, regulation difficulties, poor attention & eye contact, fewer vocalizations, and limited exploration of the environment (Clark et al., 2008; Clark et al., 1994)

Consequences of PPD for Infant & Child Behavior & Development

Maternal depression during the first year of life has been found to contribute to risk for developmental delays and disturbances in young children (Goodman & Gotlib, 2002)

• Lower levels of mental and motor development in infants at 1 year of age (Lyons-Ruth, et al., 1986)

• Lower IQ among pre-school age boys, controlling for general behavior problems, birth weight, etc. (Sharp, Hay, Pawlby, Schmucker, Allen, & Kumar, 1995)

• Teacher reports of behavior problems in kindergarten, especially among low SES boys (Sinclair & Murray, 1998)

Infants of Postpartum Depressed Mothers: Research

• Biological Factors (Goodman & Gotlib, 2002) Heritability of depression

• Impairments to the mother-infant relationship More insecure infant attachment

(Murray 1992; Murray et al 1996) Less optimal mother-infant interactions

(Weinberg & Tronick, 1998)

Transmittal Mechanisms of Risk to Child

• Course/timing of depression – Chronicity • Mothers’ degree of sensitivity in parent-child

interactions• Mothers’ personality, co-morbid conditions &

relationship history• Availability of fathers/other caregivers• Characteristics of the child – temperament &

gender

(Clark, Hyde, Essex, & Klein, 1997; Lyons-Ruth et al., 1986; NICHD Early Child Care Research Network, 1999; Weinberg & Tronick, 1996)

Factors that May Mitigate Risk to Infants

Dads May be Depressed, too!

• Depression in about 7-10% of fathers

• Rates are higher in the 3-6 month postpartum period and when the mother is depressed

• Effects on parenting:• 1/2 as likely to read to

their 1 year olds and 4 times as likely to spank them.

Paulson, 2010

• Co-occurs with Anxiety

• Relationship between mental health diagnosis and maltreatment as a child (Edwards, et.al, 2003)

• Disruption in early attachment relationships can lead to ongoing disrupted relational patterns, often diagnosed as Personality Disorders

Postpartum Depression is Seldom ONLY Depression

Types of Trauma Exposure

• Community Violence• Complex Trauma (Multiple or Prolonged Events)• Domestic Violence• Early Childhood Trauma (age 0-6)• Medical Trauma• Natural Disasters• Neglect• Physical Abuse• Refugee and War Zone Trauma• School Violence• Sexual Abuse• Terrorism• Traumatic Grief

(The National Child Traumatic Stress Network website, 2015)

The Trauma Lens

• Consider what the child has been exposed to

• Consider what the parent has been exposed to

• It is the experience of the event, not the event itself, that is traumatizing

• If we don’t acknowledge trauma we end up chasing behaviors and limiting possibilities for change

• The behavioral and emotional adaptations one makes to cope with trauma are brilliant and adaptive, and personally costly

• If you don’t ask, they won’t tell

• What is not integrated is repeated(The National Child Traumatic Stress Network website, 2015)

Maternal Attachment, Trauma History and Quality of Mother-Infant

Relationships • Greater Unresolved Trauma and Fear of Loss (AAI)

Less improvement in maternal caregiving quality Less improvement in infant dysregulation & irritability

following treatment

• Unresolved Trauma and Fear of Loss Important moderator of treatment efficacy for further

studySuggests this aspect of maternal state of mind may be

an important port of entry for interventionClinical experience also shows early loss among women

experiencing PPD seems to impede their capacity to recognize and contain their anxiety and anger and respond sensitively & consistently to their infants.

Clark et al 2008

Screening with the EPDS and ACES

Screening Allows You To…

Have an ongoing conversation about mental health and emotional well-being over time

Look together at relationship history and current relationships

Engage her in looking with you at the experience/issue

“Prevention planning” together if risk is elevated -- put supports in place early

Supportive Communication

• Listening is a skillful, active intervention• Understanding must precede action

• Don’t underestimate the healing power of supportive listening & empathy for mother

• Don’t assume mother has others in her life to provide this type of emotional support

“People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

~ Maya Angelou

Common Factors in Relationships that are Therapeutic (Wampold 2011)

Effective Relationships are characterized by:“a partnership between two allies working in a

trusting relationship toward a mutual goal “It is the client’s perception of this relationship

that facilitates positive changeHope

The optimism that things will improveAttention

Openly acknowledging a problem and focusing on it together

Corrective Relational ExperienceWith Home Visitor

Consistency and predictabilityRupture/RepairCompassionate interactions

With OneselfHolding self in mindSelf acceptance and understanding

With Their ChildBecoming the “protective shield”Seeing their child’s valueUnderstanding their child’s motivations, needs and

fears

Opportunities in HV Relationship

Consistency

Presence/showing up

Slowing down (stepping out of crisis, pausing, dropping in)

Awareness of triggers/reactions

Meaning of child’s behavior

Creating a Safe Space in the Home

Respectfully structure the environmentAsk to turn off TV or loud musicAsk for cell phones to be put away

Boundaries and PrivacyAsk who is home (may not see someone in another

room)Schedule sensitive visits in Program Office (eg.

ACES interview) – without kids or program support for childcare

Model respect for privacy and ask if there is a private place to talk

Screening Can Also Offer…

Awareness of own reactions and compassion for self (FAN: Mindful Self-Regulation)

Not just a cognitive telling of story, but getting in touch with emotional experience

“What was not remembered was the associated affective experience” ~Selma Fraiberg

Getting in touch with felt experience is most important for not repeating abuse

Following birth of baby…Ask about Mother’s Birth Experience

• Perceived negative birth experience can be a risk factor for PPD (Bland, 2009)

• Be open to her subjective experience without pre-conceived notions

• A disempowering birth experience can impact a woman’s sense of competence as a mother

• Retelling birth story can help integrate her experience

• If she seems to be experiencing posttraumatic symptoms, such as nightmares or flashbacks, refer her to a mental health provider.

Introducing the EPDS• Let your client know that you use this in your visits

with all mothers, at the same points in time• Communicate that you value this assessment as a

way of looking together with her at her emotional experience during pregnancy/postpartum time

• Responses should be about only the past week• Let her know that after she takes a few moments to

fill it out, you will talk about it together

Discussing Screening Results• “Your answers indicate that you have

been experiencing some symptoms of depression. How does that fit with what you’ve been feeling?”

• “Your score isn’t in the range for likely clinical depression, but it sounds like you’re struggling right now. Let’s talk about what kinds of support would feel helpful.”

Discussing Screening Results• Notice especially high items and use as

discussion starter• “You marked___could you tell me more

about that? Could you tell me about a time when you felt that way?”

• Always check the last item - thoughts of harming herself

EPDS Screening Frequency

• Pregnancy – once per trimester

• Postpartum – once between 2 wks and 60 days

• Repeated screening is beneficial as a woman’s experience can change rapidly over the course of the postpartum year

• Ideal postpartum schedule: 1, 3, 6, 9, 12 mos.

• Conduct screening even if already receiving mental health services

EPDS Across Settings• In our work together, I’d really like to

be able to talk about how you are feeling, your sense of well-being and how I can best support you

• May be different levels of trust in different settings

• What was the outcome of that screening? Were any referrals made?

Introducing the ACES Interview• Communicate that you value this interview as a way

of looking together at past experience that can impact her relationships

• Should be done as an interview, not a checklist• Foreshadow that these questions can be difficult to

answer, invite her to let you know if she needs to take a break

• Watch for shutting down (dissociation)• Do not do interview at end of visit - make sure there

is time to debrief, move into another activity, change tone, and/or assess her state before ending visit

Providing Referrals• Mental health parity/insurance

• Mental health treatment reimbursed at same rate as physical healthcare

• Be prepared to assist with finding transportation and childcare options for mothers to receive a mental health evaluation, diagnosis and treatment

• Transport mothers to first appointment• Become familiar with mental health providers with

specific training in perinatal mood and anxiety disorders• Maternal Child Health Hotline –

www.referweb.net/mchh

Barriers to Referral Follow UpStigma of mental illnessMedia portrayal - sensationalizing

Andrea Yates (often do not differentiate between severe postpartum depression and postpartum psychosis)

Fear of mental health or child welfare system

Minimizing or normalizing symptomsInfluence of motherhood mythsLack of energy or motivation are

symptoms of depression

Involve Her Partner and Family

• Ask Mother about discussing results with her partner or family member

• Wonder with partner about his/her concerns

• Provide and review DHS More than Just the Blues Brochure

• PSI website (www.postpartum.net) and Federal booklet

mchb.hrsa.gov/pregnancyandbeyond/depression/index.html

info and video for Dads/Partners and Family Members

Provider Barriers

• Boundaries/Scope of PracticeYou are not responsible for managing or treating

symptoms of PPD, but you can facilitate a connection to a mental health professional and provide a supportive relationship

• First make sure the discomfort felt with the mother/family is not your own discomfortReflect on your own feelings and preconceptions

about mental healthPractice your responses. Learn from each

encounter.

Questions to consider in your follow-up discussion with Mom…

1.What do you want to know more about? (follow up on specific items and examples of her experience, especially suicidal ideation)

2. Wonder with Mom about how her mood might impact her experience of mothering and her time with her baby?

3. What supportive interventions might you offer (individual, mother-baby and family)?

4. What referral opportunities might you suggest (mental health evaluation and treatment, mother-baby groups, child care or respite care)?

Therapeutic Approaches with Mother-Infant Dyads

Promote Self Care

• Women often focus or feel they should focus far more on the care of others than themselves

• Encourage and give permission to mothers to incorporate self-care into their daily routines as a means of preventing PPD & anxiety, as well

as coping with it

Implications for Supportive Relational Interventions

• Depression alone• Increase positive affect• Increase sensitivity and responsiveness

• Depression and Anxiety• Reduce stress• Increase feelings of competence

• Depression and BPD• Provide structure, clear treatment goals• Increase distress tolerance and emotion regulation

capacities• Increase ability to see child as a separate individual

Supporting family relationships in the context of maternal depression in Home Visiting?

Be attuned to the stressed and depressed mother

Wonder with her how she is doing

Listen, validate and provide hope

Interact with a range of affect, especially positive

Support her in responding to her child’s positive behaviors as well as his needs for emotional availability and scaffolding

Address the questions and concerns of the woman’s partner and enlist his/her assistance in supporting her instrumentally and emotionally

Support the Mother/Infant Relationship• Suggest using part of visit to “just be with”

baby in one-to-one ‘special time’• Developmentally appropriate play• Soothing activities (massage, cuddling/lullaby)• Singing/music• Making daily tasks playful• Face to face interaction• Smiling, even when you don’t feel like it

• When fussy, vocalizing or reaching out, wonder with mom about what baby is needing or trying to communicate

• Support/reinforce her positive efforts toward reading baby’s cues & providing support

(Clark, 2006)

Support Mother-Infant Relationship

• “Speak for baby” to highlight cues & reactions to mom’s efforts

• Amplify baby’s initiatives toward mom

• Model gentle handling & responsivity toward baby

• Non-judgmental developmental guidance

• Dispel myths about spoiling young babies

(Clark, 2006)

Attachment Styles

• Secure Attachment• Mothers responsive, emotionally available and loving• Babies able to seek proximity and utilize mother for

comfort when distressed; ability to explore environment

• Insecure-Avoidant• Mothers ignored, rejected, and spoke in negative

terms about baby; reject or punish baby’s distress• Baby played independently, no distress at mother’s

absence, upon return actively ignored her and showed blank or restricted affect

(Ainsworth, 1978)

Attachment Styles

• Insecure-Anxious/Ambivalent• Mothers inconsistently responsive to attachment-

seeking behavior• Limited exploration of environment, heightened

distress upon separation, both seek and resist contact post-reunion

Insecure-Disorganized (Main & Solomon, 1990)

• Frightening parental behavior, such as abuse - source of security is also source of fear

• Conflicting response, such as reaching for parent while looking away or smiling while appearing afraid

(Ainsworth, 1978)

Kauai Study of Resilience and Recovery (Emmy Werner, 2005)

• Effects of adverse childhood experiences had previously been reconstructed retrospectively from a clinical population

• Among children exposed to multiple stressors, only a minority develop serious emotional disturbances or behavioral problems

• Of children with 4 or more ACEs (n=698), two-thirds had learning/behavior problems by 10 yrs. and delinquency/mental health issues by 18 yrs.

• BUT… one-third did not; they were successful across multiple areas of life

Factors of Resilience (Emmy Werner, 2005)

• Protective Factors within the Individual

Infant/Toddler: Agreeable, cheerful temperament; advanced motor and language development and self-help skills

Age 10: Higher problem solving scores and better readers; had a skill they were proud of and readily assisted others who needed help

Age 18: Belief in own effectiveness and ability to problem solve; more realistic education and vocational plans and higher expectations for their future

Factors of Resilience (Emmy Werner, 2005)

• Protective Factors in the Family Close bond with at least one competent, emotionally

stable person who was sensitive to their needs Boys: households with structure and rules, male figure

as model of identification, encouragement of emotional expressiveness

Girls: families that combined an emphasis on independence with reliable support from a female caregiver

Families held religious beliefs that provided some stability and meaning in their lives

• Protective Factors in the Community Support from adults such as teacher, neighbor, friend’s

parent, coach, HOME VISITOR!

Recovery in Adulthood (Emmy Werner, 2005)

• By adulthood (ages 32 & 40) most of youth who had developed serious coping problems in adolescence had staged a recovery by the time they reached midlife

More true for girls than boys Majority of survivors had no serious coping problems in adult life

• Factors that Opened Opportunities with no planned intervention: Continuing education at community colleges and adult high schools Educational and vocational skills acquired during service in the

armed forces Marriage to a stable partner Active participation in a “community of faith,” Recovery from a life-threatening illness or accident Psychotherapy (to a much lesser extent)

• Those who did not achieve recovery: Less exposed to positive interactions with caregivers in infancy and

early childhood More externalizing, versus internalizing, behaviors as young child Parents with chronic mental health and/or alcohol abuse issues

Vicarious Trauma/Secondary Traumatic StressSigns

Physiological Reactions – agitation, sleep disturbances, fatigue, headaches/stomachaches, low immunity

Emotional Reactions – Irritability, helplessness, anxiety, anger, numbness, sadness, boredom, feeling incompetent

Cognitive Reactions – difficulty concentrating, intrusive traumatic imagery, preoccupation with other’s trauma

Behavioral Reactions – impatience with others, nightmares, startle response, hypervigilance, use of negative coping

Spiritual Reactions – sense of meaningless, loss of purpose, questioning prior beliefs, pervasive hopelessness

Interpersonal Reactions – Withdrawing/isolating, decrease interest in intimacy, mistrust, impact on parenting, intolerance of other’s behavior

(The National Child Traumatic Stress Network website, 2015)

Vicarious Trauma/Secondary Traumatic StressPotential Impact on Clients

Silencing ClientsChanging the SubjectAvoiding the TopicFake Interest or Fake Listening

Being angry/sarcastic with clients

Pat answers

Wishing they would “get over it”

Poor decision making or poor boundaries with clients

(The National Child Traumatic Stress Network website, 2015)

Secondary Traumatic Stress (STS)– Organizational Strategies

Clinical SupervisionReflective SupervisionTrauma Case Load BalanceEnhance the Physical Safety of StaffWorkplace Self-Care GroupsFlextime SchedulingTrainings on Secondary Traumatic Stress Create External Partnerships with STS ProvidersTrain Organizational Leaders and Non-Clinical Staff of

STSProvide Ongoing Assessment of Staff Risk and

Resiliency(The National Child Traumatic Stress Network website, 2015)

Secondary Traumatic Stress (STS)– Individual Strategies

Use Supervision to Address STSIncrease Self-Awareness of STSMaintain Healthy Work-Life BalanceExercise and Good NutritionPractice Self-CareStay ConnectedDevelop and Implement Plans to Increase Personal

Wellness and ResilienceContinue Individual Training on Risk Reduction and Self-

CareUse Employee Assistance Programs or Counseling Services

as NeededParticipate in a Self-Care Accountability Buddy System

(The National Child Traumatic Stress Network website, 2015)