IPT for postnatal depression incorporating the mother-child relationship: Integrating attachment work into IPT

Dr Carolyn Deans Victoria University, Australia

Dr Rebecca ReayAustralian National University, Australia

ISIPT Conference, London 2015

Acknowledgements

• Prof Anne Buist, University of Melbourne, Australia

• Prof Scott Stuart, University of Iowa, USA• Joan* (name changed to protect confidentiality)

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Postnatal depression• PND a prevalent condition amongst mothers with

negative long-term outcomes (Buist et al. 2008)

• Women with poor social and partner support are at greater risk of PND (Bilszta et al, 2008;; O’Hara & Swain, 1996)

• Effective treatments are available to treat depressed mothers:– Medication (see O’Hara 2009 for review)– Cognitive Behavioural Therapy (Milgrom et al. 2005; Morrell et al 2009)

– Interpersonal Psychotherapy (Brandon et al. 2012; Grote et al 2004, 2008;; Miller et al. 2008;; O’Hara et al. 2000;; Spinelli & Endicott, 2003)

– Group IPT (Reay et al. 2010; Mulcahy et al. 2010 )

• PND is known to have negative outcomes for children: behavioural, social, psychological and cognitive (Burke, 2003; Fihrer McMahon & Taylor 2009)

• Infants are exposed to negative maternal affect and behaviours e.g. hostility, withdrawal, inconsistent parenting (Goodman & Brumley, 1990; Downey & Coyne, 1990; Gelfand & Teti, 1990; Lovejoy et al. 2000)

• Maternal sensitivity has been shown to mediate the relationship between PND and insecure attachment styles in children (Coyl et al. 2002)

• A ‘sensitive window of opportunity’ - the first 4 months of life (Moehler et al 2006; Pickens & Field, 1993)

Impact of postnatal depression on infant

Childbearing is a critical period for the potential transmission of mental health problems from one

generation to the next.

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Simply targeting depression may not be sufficient to improve parent-child outcomes (Forman et al. 2007; Muzik et al. 2009)

Long term f/u of participants in RCT of IPT (N=120) • IPT treatment associated with:

– significant reduction in symptoms – meeting recovery criteria– improvement in their marital relationships. – reduction in their parenting stress

• No significant improvement in the mothers’ view of: – child’s temperament, – behavioural problems, and significantly,– Attachment security (18 mths post Rx)

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WHAT ABOUT INTERVENTIONS THAT TARGET MI RELATIONSHIP?

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Treating the mother-infant relationship

• Mother-infant therapy treats mother and infant as a single dyadic relationship (Galbally et al., 2006)• Watch, Wait, and Wonder (Cohen 1999)

• Toddler-parent psychotherapy (Toth et al, 1996; 2006; Cicchetti et al. 2000)

• Circle of Security (Hoffman, Marvin, Cooper & Powell, 2006)

• Videotape feedback (Kalinauskiene et al, 2009)

• Intensive combined therapies (Clark, Tluczek, & Brown, 2008)

• Some address mental health symptoms, none show strong evidence of addressing PND (Kersten-Alvarez et al. 2011; Nylen et al. 2006)

Rationale for targeting MI relationship in IPT

• IPT already addresses relationships as a key precipitator, maintainer, and protective factor in PND

• Many mothers bring up relationship with baby during IPT treatment for PND … normally not directly addressed

• Targeting and improving the MI relationship may assist the mother in her recovery from PND

Options:• Include the infant in IPT sessions (Clark, Wenzel, Tluczek, 2003) • Sequential treatment: IPT (individual or group) + MI therapy• Traditional IPT modified to assist parents to focus on infant

(Grigoriadis and Ravitz, 2007).

IPT FOR POSTNATAL DEPRESSION INCORPORATING THE MOTHER-INFANT RELATIONSHIP

A group approach

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Group IPT

• Group IPT- small groups of mothers diagnosed with PND

• Modify traditional IPT strategies to include infant relationship

• Two specific sessions focused on mother-baby relationship

• Influenced by maternal sensitivity framework (Stayton, Hogan, & Ainsworth 1971; Nicholls & Kirkland, 1996):

• Mothers perceive and interpret baby’s emotional states and needs

• Responsive to baby’s cues and needs (i.e. joy, comfort, guidance, room for exploration)

• Communication with her child that is developmentally appropriate, non-intrusive, and consistent (clear and unambiguous).

Joan*• Referred for treatment of PND 6 weeks postpartum• 32 y.o. married woman, two children: 6 weeks and 3 y.o.• Past history of mental health problems (C&A)• Poor relationship with mother• Past history of PND when first baby was 6 mths, • Told to “play with her baby” by psychologist• Bright smile, few close friends• “Good” relationship with husband• Problems: >>loneliness and not enjoying role

» preoccupied with housework» managing toddler tantrums

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Group outline

Pre A Clinical assessment

Pre B Individual session

1 Introduction and psycho-education

2 - 3 Role transitions – for mother and for baby

4 - 5 Communicating with baby (interpersonal incidents)

Mid Partner session

6 - 8 Communicating with partner, social support

9 - 10 Consolidating progress and farewells

husband

Babytoddler

Good friends x 4,

brother-in-law

mums quite commonly

do this!

siblings

work colleaguesOther

friends

Choir group

Mother’s group

mum

dad

Role Transition – for motherBEFORE CHILDREN (AND PARTNER) AFTER CHILDREN (AND PARTNER)

POSITIVE ASPECTS

(things that were comforting, rewarding, enjoyable meaningful, productive, felt good about myself)

- Sleeping (in)!- Hobbies & Leisure activities- Time to myself- Work (gives something to do, money that was

my own to spend, a reason to get dressed up, effort was appreciated by someone)

- Freedom- Free to socialise with who I wanted, go

where I wanted, do what I wanted- No family commitments or family decision

making

- Watching a little human being grow, learn, experience

- Watching how baby makes other people happy (I made that!)

- Something that I ACHIEVED- Gained some confidence in myself

NEGATIVE ASPECTS

(challenging, frustrating, saddening, or difficult)

- Lacking direction or fulfilment?- Lacking ‘something to love’ or ‘something

that was mine alone’

- No sleep- Hard work and relentless work, - Little control over what I have to do- Monotony (same thing every day)- Conflicts & dissatisfaction over roles- Lost confidence in myself- Isolation from other people (even other mums

as hard to find convenient times to be together)- Can’t understand what baby wants

sometimes- No independence (have to do everything for

baby’s survival)

Role Transitions – for babyBEFORE BIRTH (IN THE WOMB) AFTER BIRTH (IN THE WORLD)

POSITIVE ASPECTS

(things that were comforting, peaceful, enjoyable, helped me develop)

- Was rocked, moved, swung most of the day- Sensations and tastes from mum’s food- Hearing mum’s heartbeat all the time, - the soothing rhythm of womb- It was dark and calm- Constant food supply- Predictable, no shocks, no-one suddenly

grabbing me or putting me places

- Can hear different things- Can touch, experience new sensations- Can bond with mum/dad through

physical touch and feeding- Can explore the world- Can communicate more with mum

(through crying, then smiling, screaming, babbling)

- Can meet new people, including dad

NEGATIVE ASPECTS

(challenging, frustrating, saddening, or difficult)

- Going through the labour and birth- Bit cramped towards the end (would push on

mum’s tummy to tell her I’m cramped)

- Don’t understand how to use my body- Some of my body doesn’t work

properly yet (reflux, gas, bowels)- No control over my life - Little control over my emotions- Open to good and bad experiences,

will learn how to react to things based on what mum teaches me

- Can’t express what I want, have to hope mum understands

- No independence (dependent on parents to do everything for my survival)

Joan’s Themes during IPT-G:

• Realises her expectations of her toddler to manage strong emotions alone were unrealistic. “she’s just going to have frustrations each day, I just have to accept that and help her with it”

• More aware of the need to attend to baby cues and be less distracted by needing to clean house. “I thought ‘of course I communicate with my baby’... but now I see what you were saying”

• Challenge of communicating my needs to husband for emotional support “I need to get better at telling him I don’t want him to take over (when I’m frustrated with girls)- without screaming at him”

• Pattern of withholding her feeling and struggles from others for fear of rejection- began to open up to members of her mothers groups with good results.

Joan’s outcome measures

Significant reduction in: • Depression scores (BDI)• Parenting Stress (PSI-SF)

Significant improvement in: • Social support (SAS-SR)• Bonding (Maternal Attachment Inventory) • Perception of infant’s temperament: (ICQ)

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Joan’s outcome measures

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Future directions:

• Randomised control trial with a Treatment As Usual comparison group;

• Individual and group conditions?

• Incorporation of the relationship with the toddler?

• What are the mechanisms of change from an attachment perspective?

Thank you & questions

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• Dr Carolyn DeansVictoria University, Australia carolyn.deans@vu.edu.au

• Dr Rebecca ReayAustralian National University, Australia Rebecca.reay@act.gov.au

• Professor Anne BuistUniversity of Melbourne, Australia

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