Minding the mother and restoring natural rhythms to support the mother-baby relationship

1. Helen Kim, MD Director, HCMC Mother Baby Program and Hennepin Women’s Mental Health Program Department of Psychiatry Hennepin County Medical Center www.mnwomensprogram.org helen.kim@hcmed.org Minding the mother and restoring natural rhythms to support the mother-baby relationship

2. Outline Definitions: mind, mindsight, mentalizing What interferes with mindsight? Psychiatric illness as brain/mind disorders that include disruptions in energy and biological rhythms The role of psychiatrists and medication Functional or integrative medicine as a lens to interpret mind/body symptoms

3. Mission: To support families by strengthening the emotional health and parenting capacity of mothers

4. Mission: To support families by strengthening the emotional health and parenting capacity MINDSIGHT of mothers

5. MIND

6. Definition of Mindby Daniel Siegel, MD Mind: “an embodied and relational process that regulates the flow of energy and information. ” “An emergent process that arises from energy and information flow within you and between you and others”

7. Mindsight • the ability to reflect on the mind or mental states of oneself and others. • emerges from within attachment relationships that foster such processes. • essential in healthy relationships • a learnable skill • “I am sad” vs “I feel sad”

8. “Mindsight is a kind of focused attention that allows us to see the internal workings of our own minds. It helps us to be aware of our mental processes without being swept away by them, enables us to get ourselves off the autopilot of ingrained behaviors and habitual responses, and moves us beyond the reactive emotional loops we all have a tendency to get trapped in…The focusing skills that are part of mindsight make it possible to see what is inside, to accept it, and in the accepting to let it go, and, finally, to transform it.”Dan Siegel, MD

9. Mindsight -- seeing the mind 1) Insight into oneself 2) Empathy for others 3) Integration within you and your nervous system and between you and others Intepersonal Neurobiology -- the study of mindsight

10. Mentalize To be aware of mental states (desires, needs, feelings, reasons, beliefs) that drive reactions and behaviors of ourselves and others To feel and think about feeling at the same time A psychological skill that allows one to understand the internal state of oneself and another Occurs on intellectual/conscious level Occurs on a gut/intuitive level An old idea --- Descartes, Theory of Mind, Fonagy (mentalizing in the context of attachment relationship, Arietta Slade (mentalizing in context of parenting; reflective functioning)

11. Mindsight - noun Mentalize - verb • Nonjudmental curiosity, acceptance, compassion • Mindfulness of the mind of self and others; • Mind mindedness, reflective functioning, psychological mindedness • Empathy for self and others

12. Mentalizing as a Compass for Treatment Jon G. Allen, PhD, Efrain Bleiberg, MD, and Tobias Haslam-Hopwood, PsyD, The Menninger Clinic http://www.menningerclinic.com/education/clinical-resources/mentalizing • Mentalizing as conceptual compass to help patients understand how staff approach treatment • Shared understanding and shared goals as foundation for sense of “we’re in this together”

13. Why is mentalizing important? • Self-awareness: to reflect on and communicate our feelings/thoughts • Self-agency: Understanding that behavior doesn’t just happen but is based on mental states. “I am responsible for my behavior” • Self-regulation: “I feel angry” vs “I am angry” “I am not my feelings” • Relationships: feeling felt by another provides sense of connectedness/security; promotes understanding, intimacy • Finding meaning from suffering and hope • Resilience Mentalizing as a Compass for Treatment Jon G. Allen,

14. Why is mindsight or mentalizing important? Responsibility Regulation Relationships Resilience

15. "The whole idea of thinking about thinking is that we learn about ourselves through being understood by other people. Babies learn about their feelings by having their feelings understood by someone else." ~ David Wallin

17. What interferes with mentalizing? • Strong emotions: shame, anger, fear ---> flight/fight/freeze • Defense strategies: repression, denial, avoidance, suppression • Apathy/indifference: “I don’t care” what’s in my mind or yours • “Psychiatric illness”: depression, anxiety, substance use, mania, psychosis

18. Psychiatric illness as disruptions in biological rhythms and energy • Maternal depression or anxiety • inhibit mindsight and/or the ability to mentalize • disrupt biological rhythms and energy • Stabilizing a mother’s biological rhythms is essential before she can synchronize with her baby’s rhythms. • Parents as brain scientists or curators of the mind: • Compassionate stance • Non-judgmental curiosity • Awe and wonder

19. “Depression is the number one complication of childbirth”(Wisner, NEJM 2001) Perinatal Depression: 10% in general population 25% in high risk groups Perinatal Anxiety: 7-10% Gestational Diabetes: 5% pregnancies

20. Women have 1.5-2.5 x rate of depression vs. menLifetime prevalence: 21.3% women and 12.7% men Kessler RC, et al. J Affect Disorders 1993;29:85-96

21. Psychosis

22. 50% of women with PPD have depressive symptoms during pregnancy

23. Risks of Untreated Depression/Anxiety • Poor self care, nutrition, and prenatal compliance. • Increased smoking, alcohol, drugs • Increased ob/neonatal complications, such as preterm delivery • Increased attachment and behavioral problems • More pediatric visits for behavioral problems and injuries

24. Maternal Depression and Risk to Early Parenting Children 0-3 years old are most vulnerable to risks of maternal depression due to rapid brain development and sole reliance on caregiver

25. Maternal Depression and Risk to Children Children’s Defense Fund of Minnesota. (2011). Zero to Three Research to Policy: Maternal Depression and Early Childhood. www.cdf-mn.org

26. Cost of untreated maternal depression for mother and baby Wilder Research, Oct 2010 • Total annual cost of not treating 1 mother with depression = $22,647 • Cost of not treating the mother = $7,211 • Cost attributable to a child born to a depressed mother = $15,323

30. Brain/Mind Science vs “Behavioral Health” • Waiting until behavior is a problem is not early detection/early intervention • Psychiatric illness -- disorders of the brain/mind that can manifest in behavior changes* • Mind behind the behavior as the target • Early intervention starts prenatally and with parents/children *Thomas Insel, MD, NIMH http://www.ted.com/talks/thomas_insel_toward_a_new_understanding_of_mental_illness

32. Are psychiatrists just “prescribers” and “behavioral health providers”? “You need to see a psychiatrist” = “You need meds”

35. STRESS

36. STRESS affects mind/body and ability to mentalize Difficulty sleeping Headaches, body or joint aches Poor energy Poor concentration Altered appetite Digestion problems Heart problems High blood pressure Irritability/anger/depression

37. Stress, Depression and Anxiety through a Functional Medicine lens

39. Personalized medicine that deals with primary prevention and underlying causes instead of symptoms for serious chronic disease. Based on these principles:-Biochemical individuality-Patient-centered medicine -- "patient care" vs "disease care”-Web-like interconnections of physiological factors -Health as a positive vitality not merely the absence of disease What is Functional Medicine? www.functionalmedicine.org

41. Some clinical imbalances underlying chronic medical conditions: • Hormone and neurotransmitter imbalances • Energy, mitochondria, and oxidative stress • Detoxification imbalances • Immune and inflammation imbalances • Gut and digestive health • Mind-body dysrhythms

42. Chronic Inflammation: the common final pathway to chronic disease

44. Is depression an inflammatory condition? • Acute inflammatory response necessary for trauma or infection • Overactive immune or inflammatory response harmful: autoimmune disorders, RA, IBS, asthma, allergies, MS, celiac, thyroid • Chronic inflammation drives some chronic diseases: heart disease, obesity, diabetes, and depression • Pro-inflammatory cytokines cause physical and psychological symptoms (malaise, low mood, low energy, sleep disturbance) called “sickness behavior” which resembles depression • Neurotransmitter-focused theories of depression have been limited • Depression’s connections to inflammation and immune dysregulation offer other treatment options • Psychoneuroimmunology: the study of the CNS and immune system

45. What causes chronic inflammation? • Stress • Toxins • SAD diet • Lack of exercise • Hidden allergens/infections

46. What do you need to thrive? • Safety • Sleep • Healthy Foods/Healthy Digestion • Light, water, air • Movement • Love, community, connection • Purpose

48. Sleep

49. SLEEP Average sleep in 1900 --- 9 hours Study of 669 middle-aged adults found people sleep much less than they should, and even less than they think. (Am J Epi, 2006) White women 6.7 hrs/night White men 6.1 hrs/night Black women 5.9 hrs/night Black men 5.1 hrs/night Poor sleep less than wealthy.

50. National Sleep Foundation Sleep in America Poll 2003: % reporting <7 hrs slept/weeknight Ages 18 to 54 41 Ages 55-64 38 Ages 65-85 32