CHANGE, CHOICE, AND CONTROL

A model for helping parents to manage stress in the

transition to parenthood

Carrie Cornsweet Barber, Ph.D.

University of Waikato, School of Psychology

Perinatal Mental Health New Zealand Trust

A LONG AND WINDING ROAD TO RESEARCH IN

PERINATAL MENTAL HEALTH IN NEW ZEALAND

PARENTING SUPPORTS AND NEEDS

2007-2008: being a parent in Hamilton

2009-2011: being pregnant with

complications

2011: PMHNZ founded

2012--…: How to help?

Interactive self-help: mobile app

Information and support: group workshop

Resources and strategies: primary care

Pregnancy is change

Changes in

Body

Relationships

Roles

Identity

Perspective on the world

PREGNANCY AND STRESS

PREGNANCY AND STRESS

Change = stress

Stress is disequilibrium

Cannon (1926)—Stress: external factors that

disrupt homeostasis

Things that happen—bad and otherwise

Stress

Depres-sion Anxiety

STRESS AND DISTRESS: WHAT’S THE

DIFFERENCE?

Stuff happens

Can I cope?

Resources balance stress Stress>resources

Distress

On alert Exhausted and helpless

Everyone has stress, and they (mostly) all survive… Yes, most pregnant women are more anxious than

non-pregnant women

15-20% have clinical levels of anxiety Especially…

Those with medical problems

Those with history of pregnancy loss

Those with less social support

5-11% have clinical levels of depression

Especially… Those with a history of depression

Those with extra high levels of stress

Those with less social support

WHY BOTHER?

When anxiety and/or depression is high in

pregnancy…

Unhealthy coping/health behaviours

Chronic physiological arousal

Risk of PTL and LBW

Risk of asthma and maybe ADHD in child

Differences in neonate behaviour

Effects on relationships

Irritability

Isolation

Effects on confidence in parenting

Increased risk of postnatal depression

WHY BOTHER?

Excessive stress or distress during pregnancy has an impact

On the foetus Preterm delivery

Low birthweight

Brain development

Cardiovascular health

Behavioural problems

On the mother (less evidence for causality) Risk for depression

Risk for anxiety

STRESS MATTERS

Animal studies (one of many): Offspring of stressed mother mice

(Champagne, 2013)

Less exploration (=anxiety)

Less preference for sugar water

(=depression)

More aggression (=irritability/anger)

Effects vary by sex and genetic strain

STRESS IN PREGNANCY: HOW DO WE KNOW?

Human studies: most stressors are not randomly assigned, but… Project Ice Storm: follow up to age 11 ½

Significant effects in physical, cognitive, and behavioural areas

Women pregnant during 9/11 attacks IU growth restricted by first trimester exposure

Gestational age most reduced by mid-pregnancy exposure But these effects are small—most women are resilient

Women with Arabic names post 9/11 in the US More general, social stress

Higher risk for poor birth outcomes

Prenatal bereavement Increased risk for ADHD in male children

Queensland flood study: Maternal PTSD sx assoc with infant fine motor skills at 16

mo

STRESS IN PREGNANCY: HOW DO WE KNOW?

Even if it’s not ‘clinical’ distress, knowing

some strategies may help

Decrease anxiety

Increase self-confidence

Improve health and well-being

Modelling coping skills

Reduce risk of postnatal depression

WHY BOTHER?

Low stress High stress

High distress

Low distress

WHAT TIPS THE BALANCE?

Resources, e.g.

Social support

Coping strategies

Overall health

Stress load

Pile-up

History of trauma

Cognitive factors (perspective)

Locus of control/sense of control

Self-efficacy

WHAT TO DO?

We can’t avoid/prevent all stress

Decrease the impact…

INTERVENTIONS: EVIDENCE

Psychotherapy (for moderate to severe

depression and maybe anxiety)

Interpersonal Therapy (IPT)

Structured, short term (8-12 sessions)

Focused on relationship disputes, role changes, grief, and

interpersonal sensitivity

best studied for clinical depression in pregnancy

Cognitive Behaviour Therapy (CBT)

Focus on more realistic, adaptive thoughts and behaviours

Well studied with positive outcomes postnatally

Less clear prenatally, but some positive results

Both of these have been adapted for group or

individual

INTERVENTIONS: EVIDENCE

Medication (for moderate to severe

depression)

No RCT of medication for antenatal

depression

Effects of medication on foetus are not clear

No firm evidence of negative effects

But many methodological problems

Effects of depression on the foetus and

mother are well-documented

A tricky decision

INTERVENTIONS: BITS OF EVIDENCE

Interventions for stress management

and relaxation

Massage (and training partner in

massage)

Exercise (aqua exercise)

Yoga/Qi exercise

Music

Guided imagery/relaxation training

Mindfulness (Mindful Motherhood, MCBT)

Bibliotherapy with support

Biofeedback-assisted mindfulness

training…

SO MANY CHOICES?

‘There are lots of things you could do to help

with your stress’

More choice is better, right?

Choice = control?

CONTROL

Feeling out of control magnifies effects of

stress

Many women feel out of control in pregnancy

Especially with medical complications

How can we help them regain a sense of

control?

Realistic?

CONTROL IS COMPLICATED

Control is in the eye of the beholder

Locus of control

Internal

Powerful other (human)

Fate/divine/luck

What is healthy? What is true?

The dark side of internal LOC

Desire for Control

People vary…

VIGNETTE

Sarah, 26 yo, married, Pakeha, 30 weeks

Working full time

Moving house in two weeks

Grandmothers circling

Anxious, high-strung

Migraines, GI complaints

Seems overwhelmed and tearful

What do you do?

SARAH

Ask:

What do you think is causing all this? Is there anything you’re worried

about?

If she says…(guess the LOC beliefs)

You’re the doctor/you tell me

I think I just need to do X better

I don’t know, I guess it’s just how my life is…

Locus of control

• Internal

• Powerful other

(human)

• Fate/divine/luck

SARAH: ACKNOWLEDGING AND RESPONDING

Reflect

It sounds like you’ve got a lot going on right now

Normalize/making sense

So much is changing—that can be really stressful. Pregnancy is a huge transition, and that can throw people off kilter

Empower

What usually helps you to manage stress?

Different things work for different people. What have you tried before? Some of these things may be off the list at the moment

Would you like some ideas?

SARAH: STYLES OF RESPONSE

Internal

Offer choices, and reality testing

Powerful other

Offer solutions, model decision-making

Fate

Acknowledge what can’t be changed, ask what

helps to deal with it

REMEMBER

It’s about what works for them

It’s easy to lean toward your own style

As long as it’s safe, it’s ok

Empirically supported is a start…

But what works for THEM is what matters

RESOURCES AND STRATEGIES

Handout: a self-assessment tool and covert message about

choice

Self-help: Apps, e.g. Mind the Bump app (mindfulness for

pregnancy)

Books, e.g., The Pregnancy and Postpartum Anxiety Workbook (Wiegartz & Gyoerkoe, 2009)

Social support: find a group, any group? Positively pregnant groups

Brief psychotherapy Can provide perspective and reflection

Low stress High stress

High distress

Low distress

IPT/CBT

Medication? IPT/CBT

Group/social support

Psychoeducation/parent training

Relaxation/meditation/biofeedback

Exercise/yoga

Massage

Music

Journaling

Laughing

Whatever works

…

MORE STEPS TO HELPING DE-STRESS IN

PREGNANCY

Perspective: what is changing?

Psychoeducation about stress and life transitions

Information about pregnancy and parenting …but, limit information overload

Inventory:

Stressors (what is happening?)

Resources (support, strengths)

Coping strategies (what do you enjoy? What helps?)

STEPS TO HELPING DE-STRESS IN PREGNANCY

Plan

Self-care

Connecting with others

Planning for change

Regaining/maintaining self-efficacy and control

Finding the joy

SOMEDAY SOON…

REALLY SOON

Posit ively Pregnant 4-week group workshop for pregnant women

and partner or support person

Learn to

Identify your strengths and resources

Manage stress

Enhance and maintain wellbeing

Plan for parenthood

Four Saturdays, 10-12

River Ridge East Birth Centre

Workshop leader:

Carrie Barber,

School of Psychology,

University of Waikato Limited spaces available

contact Carrie at 021728796 or

ccbarber@waikato.ac.nz

This workshop is part of a project

developing resources and programmes

for families during pregnancy. The

workshop is offered free to couples

during the pilot. Participants will be

asked for feedback on their experience,

and may participate in research on the

effects of the workshop if they wish.

PERINATAL MENTAL HEALTH NEW

ZEALAND TRUST

Vision:

To improve outcomes for families and whanau affected by mental illness related to pregnancy,

childbirth and early parenthood

Mission:

Supporting and linking the service providers who work with young families

Advocacy and awareness

Resources and professional development

Support and encouragement for new parents

PERINATAL MENTAL HEALTH NEW

ZEALAND TRUST

Website: pmhnz.org.nz

Seminar series 2015

Friday, 4 September Whangarei

Friday, 6 November Christchurch

Information and networking about antenatal and postnatal distress and loss

Perinatal Distress Awareness Week

31 October to 8 November, 2015

Buggy walks and picnics

ACKNOWLEDGEMENTS

Perinatal Mental Health New Zealand Trust

University of Waikato Faculty of Arts and Social Sciences

University of Waikato Perinatal Mental Health Research Group

Bridgette Masters-Awatere et al.

Maternal Journey and River Ridge East Birth Centre

Simone DiGiorgio

Midwives

Marissa Panettierre

Lindsay Fergusson

Clare Barnett

SELECTED REFERENCES

Barber, C.C. (2012). Prelude to parenthood: The impact of anxiety and depression during pregnancy. In Perinatal Depression, Maria Graciela Rojas Castillo (ed). InTech: Rijeka, Croatia.

Barber, C.C., Clark, M., Williams, S. & Isler, R. (2013). Relaxation and mindfulness to manage stress in pregnancy: initial studies of a computerized self-help programme. MIDIRS Midwifery Digest, 23, 449-454.

Beddoe, A.E. and Lee, K.A. (2008) Mind-body interventions during pregnancy. Journal of Obstetric Gynecological & Neonatal Nursing, 37, 165-175.

Glover, V. (2014). Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done. Best Practice and Research Clinical Obstetrics and Gynaecology, 28, 25-35.

Sandman, CA and Davis, EP (2010). Gestation stress influences cognition and behavior. Future Neurology, 5 (5) 675-690.

QUESTIONS?