Botella, L. 1 Belles, L. 1 Pinheiro, R.T. 2 Herrero, O. 1 da Silva, R.A. 2 Pinheiro, K.T. 2

1. Process and Outcome of Constructivist and Cognitive Therapy for Postpartum Depression:A Randomized Pilot Study Botella, L.1 Belles, L.1 Pinheiro, R.T.2 Herrero, O.1 da Silva, R.A.2 Pinheiro, K.T.2 Martí, A.1 1 Ramon Llull University. Barcelona. Spain. 2 Universidade Católica de Pelotas.Brasil SPR Annual Conference. Madison, 2007.

2. Postpartum Depression • Relevant public health problem impairing mother and child well-being, development, and mental health.

3. Postpartum Depression • Persistent dysphoria, feelings of guilt, sleep disorders, suicidal ideation, fear of hurting the newborn, reduced appetite and libido, reduced mental functioning, and obsessive ideation.

4. Postpartum Depression • Prevalence between 10% and 20%

5. Postpartum Depression • The disorder appears usually within the first four weeks after childbirth, and it reaches its highest intensity within the first six months.

6. Postpartum Depression Metaanalytic results indicate that: • Psychotherapy is effective in the short term. • Effectiveness is not affected neither by setting nor by seriousness of symptoms. • Some therapies seem to be effective also in a long term basis, but studies are too premature to be conclusive.

7. Postpartum Depression Metaanalytic results indicate that: • The dropout index is very high. • Counseling and Interpersonal Psychotherapy appear more effective than Cognitive Behavior Therapy in short term studies--not replicated in longer-term studies. • More research is needed comparing different therapeutic approaches.

8. Goal of the study • To compare (a) a manualized format of individual Cognitive Therapy (CT) with (b) an also manualized format of individual Relational Constructivist Integrative Therapy (RCIT).

9. Invalidation Fragmentation Helplesness Alienation Guilt

10. Specific Hypotheses • (1) Differential process hypothesis: Since CT and RCIT are based on different conceptual basis, they operate through different psychotherapeutic processes. • (2) Process-outcome hypothesis: The reconstructive process specifically fostered by RCIT is related to symptomatic improvement.

11. Participants • 30 women from the city of Pelotas, Brazil, (mean age=29; min.=18; max.= 41; SD=7) • Diagnostic criteria for postpartum depression using psychiatric clinical interviews and scoring 12 or above in the BDI and the EPDS.

12. Outcome measures • Beck Depression Inventory (BDI). • Beck Anxiety Inventory (BAI). • Edinburgh Post-Natal Depression Scale (EPDS).

13. Process measures Derived from Personal Construct Grid

14. Constructs (right pole) Elements Constructs (left pole) Scorings 1= Very much like the left pole 7= Very much like the right pole

15. Constructs (right pole) Elements Constructs (left pole) Process measures: (a) Cognitive complexity (b) Intensity (c) Polarized construing

16. Procedure • Participants were randomly assigned to one of the two psychotherapeutic treatments being compared: CT (n=12) and RCIT (n=18). • All therapists had been intensively trained in both manuals.

17. Results • Cognitive Complexity. There were no significant changes in patient’s cognitive complexity as a result of psychotherapeutic treatment in general. • Also, there were no significant changes in this particular cognitive process index as a differential result of the type of therapy (CT or RCIT).

20. Results • Intensity. There were no significant changes in the patient’s grids intensity as a result of psychotherapeutic treatment in general. • Also, there were no significant changes in this particular cognitive index as a differential result of the type of therapy (CT or RCIT) assigned to every patient in the study.

23. Results • Polarized construing. There was a significant decrease (p=.005) in the patient’s polarized construing as a result of psychotherapeutic treatment in general. • Such an effect was common to both types of therapy in the study. Effect size of the comparison between the outcome of both types of therapy in terms of polarized construing were small (.304).

26. Results • Inter-Element Distances. In order to test the effect of psychotherapy over the more relevant self-referential elements (i.e., “Myself before having the baby”, “Myself now”, “Ideal woman”, and “Ideal mother”) Euclidean distances between each one of these elements before and after therapy and for each participant in the study were calculated.

27. Results • In the case of RCIT changes pre-post in the element “Myself now” (p=0.001) were significantly greater than the ones in any other element—“Ideal woman” (p=.004), “Ideal mother” (p=.036) and “Myself before having the baby” (p=.055). • However, in the case of CT even if changes pre-post in the element “Myself before having the baby” were lower than those in the element “Myself now”, this difference was not statistically significant (p=.518).

28. Results • In CT, the reduction in the distance between the elements “Myself now” and “Ideal woman” after therapy was lower than among patients in RCIT. • The same was true for the reduction between elements “Myself now” and “Ideal mother”.

29. Results • Patients satisfaction with their role as women after having the baby, and their satisfaction with their role as mothers after having the baby were both very significantly correlated to the three measures of symptomatic improvement used in this study (i.e., BDI, BAI, and EPDS). • None of the other inter-element distances was significantly correlated to any symptom measure.

31. Discussion • There were no significant changes in patient’s cognitive complexity neither as a result of psychotherapeutic treatment in general nor as a differential result of the type of therapy—CT or RCIT. This was also the case with patient’s grid intensity index. The absence of conclusive studies demonstrating the effect of psychotherapy on these particular cognitive indices in the case of depressive clients made this results not altogether surprising.

32. Discussion • There was a significant decrease in the patient’s polarized construing as a result of psychotherapeutic treatment in general. Such an effect was independent of the type of therapy. This result is coherent with evidence that “depressive individuals tend to make polarised judgements on construct scales, at least when these are applied to the self” and, thus, successful psychotherapy with depressive patients should decrease high levels of polarised construing.

33. Discussion • RCIT fostered a greater amount of changes in the element “Myself now”, and it also made it closer to “Ideal woman” and “Ideal mother” than CT. This effect is likely to be due to RCIT incorporating self awareness and self reconstruction as an explicit goal almost from the first session, while CT focuses more on identifying and modifying cognitive processes of biased thinking.

34. Discussion • Patients satisfaction with their role as women after having the baby, and their satisfaction with their role as mothers after having the baby were both very significantly correlated to the three measures of symptomatic improvement used in this study (i.e., BDI, BAI, and EPDS).

35. Discussion • This result supports the connection between role adjustment and symptomatic amelioration—i.e., that role adjustment is related to improvement in depression and anxiety.

36. Thank you for your attention!