telling the birth story cbs

Susan Dowd Stone, LCSW Susan Dowd Stone, LCSW

Telling the Birth StoryTelling the Birth Story The role of a The role of a

mother’s support mother’s support group in the group in the identification and identification and amelioration of amelioration of high risk factors high risk factors in post partum in post partum womenwomen


Primary PreventionPrimary Prevention

“…“…Prevention is the great Prevention is the great challenge of postnatal illness challenge of postnatal illness because this is one of the few because this is one of the few areas of psychiatry in which areas of psychiatry in which primary prevention is feasible…”primary prevention is feasible…”

Hamilton & Harberger (1992)Hamilton & Harberger (1992)


The Obstetric NetworkThe Obstetric Network It is essential to integrate a It is essential to integrate a

psychiatric dimension into this psychiatric dimension into this network to break the vicious network to break the vicious circle of mood disorders that circle of mood disorders that women experience during women experience during pregnancy and motherhoodpregnancy and motherhood

- Harris, Bryan (2002)- Harris, Bryan (2002)


The efficacy of post partum The efficacy of post partum support groupssupport groups

A psychoeducation group for women with low post A psychoeducation group for women with low post partum mood can significantly reduce depressive partum mood can significantly reduce depressive symptomssymptomsHoney, J.L, Bennett, P, Morgan M. (2002)Honey, J.L, Bennett, P, Morgan M. (2002)

A program of supportive group therapy for post partum A program of supportive group therapy for post partum mothers can significantly lower or eliminate mothers can significantly lower or eliminate depressive episodesdepressive episodesLane, B., Roufeil, M.M., Williams, S., Tweedie, R..(2001)Lane, B., Roufeil, M.M., Williams, S., Tweedie, R..(2001)

Post partum mothers attending a group integrating Post partum mothers attending a group integrating supportive educational and cognitive behavioral supportive educational and cognitive behavioral components yielded significant reductions in symptom components yielded significant reductions in symptom frequency and intensity after 4 – 6 weeks.frequency and intensity after 4 – 6 weeks.Chabrol, H., Teissedre, F., Saint Jean, M., Teisseyre, N., Sistac, C, Chabrol, H., Teissedre, F., Saint Jean, M., Teisseyre, N., Sistac, C, Michaud, C., Roge, B.(2002)Michaud, C., Roge, B.(2002)


Undetected depressive illness Undetected depressive illness despite despite

antenatal screening attemptsantenatal screening attempts Premorbid undiagnosed mood disordersPremorbid undiagnosed mood disorders Inaccurate self-reportInaccurate self-report Fear of involvement of child protection Fear of involvement of child protection

agenciesagencies Ability to mask symptoms especially if Ability to mask symptoms especially if

highly functionalhighly functional Motherhood mythMotherhood myth Severe life eventsSevere life events


Post Partum Post Partum ContinuumContinuum

Post Partum Responses

Healthy Rebound “Baby Blues” Post Partum Depression

Post Partum Psychosis


Who comes to a mother’s Who comes to a mother’s support group - risk support group - risk

factorsfactors Post Partum ContinuumPost Partum Continuum Difficult conception/amniotomyDifficult conception/amniotomy Caesarian/birth traumaCaesarian/birth trauma Multiple birth mothersMultiple birth mothers Isolated, lack of support/cross cultural pressuresIsolated, lack of support/cross cultural pressures Marital issues/financial difficulties/intimacyMarital issues/financial difficulties/intimacy Breastfeeding issuesBreastfeeding issues Difficult child/bonding issuesDifficult child/bonding issues Unexpressed feelings/anger/ sense of inadequacy/ griefUnexpressed feelings/anger/ sense of inadequacy/ grief Sense of self/professional moms/motherhood mythSense of self/professional moms/motherhood myth Nutritional concernsNutritional concerns Histories of abuseHistories of abuse Self or caregiver identified depressionSelf or caregiver identified depression Substance AbuseSubstance Abuse Psychiatric HistoryPsychiatric History


Additional issuesAdditional issues Adoptive parentAdoptive parent Gay parentGay parent Single parentSingle parent Premature babiesPremature babies Multiple young childrenMultiple young children Unwanted pregnancyUnwanted pregnancy


Difficult conceptionDifficult conception Unsuccessful attempts to Unsuccessful attempts to

conceive are accompanied by conceive are accompanied by significant psychological distress significant psychological distress – Little, B.B.; Yonkers, K.A.(2001)Little, B.B.; Yonkers, K.A.(2001)


CaesarianCaesarian Caesarian mothers used to stay in the Caesarian mothers used to stay in the

hospital up to ten dayshospital up to ten days Recovery from major surgeryRecovery from major surgery Support of nursing staffSupport of nursing staff Longer period of modelingLonger period of modeling Not prepared/residual angerNot prepared/residual anger If mother remained in hospital longer, If mother remained in hospital longer,

separations from baby less likely during separations from baby less likely during this important maternal sensitive periodthis important maternal sensitive period


Birth TraumaBirth Trauma

Protracted unexpected delivery Protracted unexpected delivery experiences during laborexperiences during labor

Severe pregnancy complications Severe pregnancy complications may increase the severity of may increase the severity of postnatal depressive symptoms by postnatal depressive symptoms by acting as acute or chronic stressorsacting as acute or chronic stressors..

--Veroux, H., Sutter, A., Glatigny, E., Minisini A. Veroux, H., Sutter, A., Glatigny, E., Minisini A. (2002)(2002)


Premature or ill babiesPremature or ill babies May not be available to mother May not be available to mother

during maternal sensitive periodduring maternal sensitive period Ill/premature babies more at risk Ill/premature babies more at risk

for maternal rejection, failure to for maternal rejection, failure to thrive and battering.thrive and battering.

Mourning the idealized childMourning the idealized child


Multiple birthsMultiple births Associated high risk Associated high risk

factor for PPDfactor for PPD Trauma related to Trauma related to

difficult conceptiondifficult conception Raised possibility of Raised possibility of

low birth low birth weight/health weight/health problemsproblems

Heightened Heightened exhaustion for careexhaustion for care

Difficulty breast Difficulty breast feedingfeeding


IsolationIsolation Woman’s perception of self as not Woman’s perception of self as not

supportedsupported Family lives far away/cross Family lives far away/cross

cultural issuescultural issues Cut off from friends, no longer has Cut off from friends, no longer has

commonalities with friendscommonalities with friends Difficulties with spouseDifficulties with spouse Afraid of judgmentsAfraid of judgments


Marital issuesMarital issues “…“…Many patients report Many patients report

that marital stress is an that marital stress is an important aspect of their important aspect of their illness. Nevertheless, in illness. Nevertheless, in the usual patient the usual patient oriented and child oriented and child oriented regimes of oriented regimes of treatment the husband treatment the husband (partner) receives scant (partner) receives scant attention…”attention…”– Hamilton & Harbinger, Hamilton & Harbinger,

(1992(1992))


Support for partnersSupport for partners Ongoing demands to Ongoing demands to

run the house, care run the house, care for the new baby the for the new baby the mother and other mother and other children children

JealousyJealousy “…“…Marital problems Marital problems

which appear to which appear to have emanated from have emanated from PPD often persist PPD often persist long after symptoms long after symptoms are abated…” are abated…” - - Hickman, (1982)Hickman, (1982)


Family support Family support “…“…I know I could have I know I could have

and should have done and should have done more. We as a family did more. We as a family did not want to accept not want to accept mental illness in our lives. mental illness in our lives. Because of this stigma, Because of this stigma, Sharon suppressed her Sharon suppressed her feelings after Garrett’s feelings after Garrett’s birth. Had we ever birth. Had we ever imagined infanticide or imagined infanticide or suicide might result, suicide might result, something would have something would have been done…”been done…”– Glenn Comitz, husband of a Glenn Comitz, husband of a

woman imprisoned for woman imprisoned for infanticide (Comitz, 1988, infanticide (Comitz, 1988, Beyond the Blues)Beyond the Blues)


Financial DifficultiesFinancial Difficulties The cost of childbirth and The cost of childbirth and

aftercare already high, but aftercare already high, but psychiatric interventions may be psychiatric interventions may be excluded due to costexcluded due to cost

Find inexpensive activities Find inexpensive activities outings for familiesoutings for families

Financial burdens fall to working Financial burdens fall to working partnerpartner


Restoration of Restoration of IntimacyIntimacy ““Sex and affection were absent Sex and affection were absent

during that time. Not tonight, not during that time. Not tonight, not tomorrow night, not next week, tomorrow night, not next week, not ever!” not ever!” – A post partum husband complains In Post A post partum husband complains In Post

Partum Psychiatric Illness (R. Hickman, Partum Psychiatric Illness (R. Hickman, 1992)1992)

Persistent discomfortPersistent discomfort


Breastfeeding Breastfeeding DifficultiesDifficulties Sense of failureSense of failure Caesarian mothers more at riskCaesarian mothers more at risk Convenience and guiltConvenience and guilt Psychotropic medicationsPsychotropic medications


Motherhood – the Motherhood – the expectationexpectation


Difficult Child/Bonding Difficult Child/Bonding


Technology and Technology and Attachment Theory Attachment Theory

LiteratureLiterature UltrasoundsUltrasounds Mother’s capacity to form Mother’s capacity to form

relationshipsrelationships Baby’s capacity to respondBaby’s capacity to respond Early separationsEarly separations Sensitive/critical periodSensitive/critical period


Unexpressed FeelingsUnexpressed FeelingsAnger – in conjunction with or irrespective of Anger – in conjunction with or irrespective of depressed mooddepressed moodGraham, J.E., Lobel, M. DeLuca, R.S.Graham, J.E., Lobel, M. DeLuca, R.S.

FrustrationFrustrationHelplessnessHelplessnessFearFearGuiltGuiltGriefGriefAnxietyAnxietyEmbarrassmentEmbarrassmentExhaustionExhaustion


Lack of feelingsLack of feelings “…“…Mothers are supposed to love Mothers are supposed to love

their babies! I don’t have any their babies! I don’t have any feelings toward mine. I just feel feelings toward mine. I just feel numb. What’s wrong with me?...”numb. What’s wrong with me?...”– support group participant (Harberger P.N, support group participant (Harberger P.N,

Berchtold, N.G. & Honikman, J.I.(1992)Berchtold, N.G. & Honikman, J.I.(1992)


Sense of Sense of self/professional moms self/professional moms

vs. stay at home vs. stay at home Motherhood Myth Motherhood Myth Sandwich Sandwich

generationgeneration Multi-taskingMulti-tasking


Nutritional Concerns – Nutritional Concerns – Eating DisordersEating Disorders Baby wellnessBaby wellness Return to pre-pregnancy weightReturn to pre-pregnancy weight Nutritional consults for the Nutritional consults for the

mothermother The role of diet/exercise in The role of diet/exercise in

alleviating mild symptoms of PPDalleviating mild symptoms of PPD


Eating Disorders Eating Disorders Negative Body ImageNegative Body Image

Patient’s offspring may be Patient’s offspring may be seriously at risk seriously at risk

May seem normal; often May seem normal; often overlookedoverlooked

Bingeing and purging not as Bingeing and purging not as evident, could be seen as evident, could be seen as “pregnancy cravings” or morning “pregnancy cravings” or morning sicknesssickness


Histories of abuseHistories of abuse ShameShame FearFear Breaking the cycleBreaking the cycle


Self or caregiver Self or caregiver identified identified

depression/anxietydepression/anxiety Can’t “snap out of it”Can’t “snap out of it” Constant fears about baby/selfConstant fears about baby/self Unrealistic attributionsUnrealistic attributions


Case StoriesCase Stories Linda older mom with previous Linda older mom with previous

successful career, difficulty conceiving, successful career, difficulty conceiving, first child, cross cultural issuesfirst child, cross cultural issues

Paula mother of twins, financial Paula mother of twins, financial difficulties, marital issues, abuse difficulties, marital issues, abuse history, poor relationship with motherhistory, poor relationship with mother

Laura difficult conception and birth Laura difficult conception and birth antenatal depression, small birth antenatal depression, small birth weight, bonding issuesweight, bonding issues


Goals of a Goals of a mother/baby support mother/baby support

groupgroup Information clearing houseInformation clearing house Professional feedback/role playing Professional feedback/role playing Non judgmental support systemNon judgmental support system Observational and clinical review of maternal/child Observational and clinical review of maternal/child

relationshiprelationship Relaxation Relaxation Dispel motherhood myth of the maternal instinctDispel motherhood myth of the maternal instinct Strengthen marital supportStrengthen marital support Mobilize additional support systemsMobilize additional support systems Reduce environmental stressReduce environmental stress Rearrange prioritiesRearrange priorities Encourage networking/socializationEncourage networking/socialization Amelioration of symptomsAmelioration of symptoms Identify needs for additional treatmentIdentify needs for additional treatment


Engaging the mothersEngaging the mothers

Referrals from physician’s offices Referrals from physician’s offices or in hospital after birth: Inviting a or in hospital after birth: Inviting a new mother new mother

Visiting in rooms prior to Visiting in rooms prior to dischargedischarge

Emphasizing the socialization part Emphasizing the socialization part of the groupof the group


Group FormatGroup Format

Convenient Facility, parkingConvenient Facility, parking Ease of access, timingEase of access, timing Confidentiality assuredConfidentiality assured Sliding scale to increase access to Sliding scale to increase access to

help but may be billed to help but may be billed to insurance companyinsurance company


Postpartum Group Postpartum Group Psychotherapy FormatPsychotherapy Format Group meets for one hour weeklyGroup meets for one hour weekly Facilitated by licensed professional Facilitated by licensed professional

social worker with training in social worker with training in antenatal mood disordersantenatal mood disorders

If needed, participants may be If needed, participants may be referred for individual counseling referred for individual counseling or medication managementor medication management


Community ReferralsCommunity Referrals

The importance of establishing The importance of establishing antenatal allianceantenatal alliance

Encourage attendance ASAPEncourage attendance ASAP Extension of your area Obstetrical Extension of your area Obstetrical

TeamTeam


Mother-baby groupMother-baby group Marketed as socialization groupMarketed as socialization group Women more likely to attend if no Women more likely to attend if no

stigmastigma Opportunity to eye-ball new mothersOpportunity to eye-ball new mothers May offer interdisciplinary May offer interdisciplinary

participationparticipation Meets weekly for one hourMeets weekly for one hour Day care may be providedDay care may be provided


Excerpts from “Her Eyes are Excerpts from “Her Eyes are Wild”Wild”

- - William Wordsworth 1798William Wordsworth 1798“…“…Sweet babe, they say that I am madSweet babe, they say that I am mad

But nay, my heart is far too glad But nay, my heart is far too glad And I am happy when I singAnd I am happy when I sing

Full many a sad and doleful thing…Full many a sad and doleful thing…A fire was once within my brainA fire was once within my brain

And in my head, a dull, dull painAnd in my head, a dull, dull painAnd fiendish faces, one, two, threeAnd fiendish faces, one, two, three

Hung at my breast and pulled at meHung at my breast and pulled at meSuck little babe, oh suck againSuck little babe, oh suck again

It cools my blood, it cools my brainIt cools my blood, it cools my brainThy lips I feel them baby, theyThy lips I feel them baby, they

Draw from my heart the pain away…”Draw from my heart the pain away…”

Soundbite Beethoven’s Symphony #9Soundbite Beethoven’s Symphony #9

telling the birth story cbs

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