Helen Kim, MD Director, HCMC Mother Baby Program and Hennepin Women’s Mental Health Program...

Helen Kim, MDDirector, HCMC Mother Baby Program andHennepin Women’s Mental Health Program

Department of PsychiatryHennepin County Medical Center

www.mnwomensprogram.orghelen.kim@hcmed.org

Minding the mother and restoring natural rhythms to support the

mother-baby relationship

Outline I. Definitions: mind, mindsight, mentalizing

II. What interferes with mindsight?

III. Psychiatric illness as brain/mind disorders that include disruptions in energy and biological rhythms

IV. The role of psychiatrists and medication

V. Functional or integrative medicine as a lens to interpret mind/body symptoms

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

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

MIND

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”

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”

“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

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

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)

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

Mentalizing as a Compass for TreatmentJon 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”

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 TreatmentJon G. Allen,

Why is mindsight or mentalizing important?

• Responsibility

• Regulation

• Relationships

• Resilience

"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

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

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

“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

Kessler RC, et al. J Affect Disorders 1993;29:85-96

Women have 1.5-2.5 x rate of depression vs. menLifetime prevalence: 21.3% women and 12.7% men

Psychosis

50% of women with PPD have depressive

symptoms during pregnancy

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

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

Children’s Defense Fund of Minnesota. (2011). Zero to Three Research to Policy: Maternal Depression and Early Childhood.

www.cdf-mn.org

Maternal Depression and Risk to Children

• 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

Cost of untreated maternal depression for mother and baby

Wilder Research, Oct 2010

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

•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

Brain/Mind Science vs “Behavioral Health”

*Thomas Insel, MD, NIMH http://www.ted.com/talks/thomas_insel_toward_a_new_understanding_of_mental_illness

Are psychiatrists just “prescribers” and “behavioral health providers”?

“You need to see a psychiatrist” = “You need meds”

STRESS

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

Stress, Depression and Anxiety through a Functional Medicine lens

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

1) Hormone and neurotransmitter imbalances

2) Energy, mitochondria, and oxidative stress

3) Detoxification imbalances

4) Immune and inflammation imbalances

5) Gut and digestive health

6) Mind-body dysrhythms

Some clinical imbalances underlying chronic medical conditions:

Chronic Inflammation:

the common final pathway to chronic disease

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

What causes chronic inflammation?

• Stress

• Toxins

• SAD diet

• Lack of exercise

• Hidden allergens/infections

What do you need to thrive?•Safety

•Sleep

•Healthy Foods/Healthy Digestion

•Light, water, air

•Movement

•Love, community, connection

•Purpose

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Sleep

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.

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

Sleep deprivation: the costs

• Inhibits mentalizing (mind-blindedness)• Irritability • Poor concentration• Increased inflammation• Makes you fat• Increased risk of accidents

Healthy Nutrition and Digestion

Standard American Diet (SAD)

• High sugar• High processed food -- think Twinkie’s

nutrient poor, high calorie• High in animal fats• High in unhealthy fats: saturated, hydrogenated• Low in fiber• Low in complex carbohydrates• Low in plant-based foods

•Food Rules by Michael Pollan

1) What should I eat? -- Eat food2) What kind of food should I eat? -- Mostly plants3) How should I eat? -- Not too much

•NAD: Real food, fresh fruits and vegetables, lean protein, moderate amounts of healthy fat, adequate fiber

Standard American Diet to New American Diet:

From SAD to NAD

Healthy Digestion

• Bacterial balance: Healthy gut has 3 pounds of good bacteria that digest your food, help regulate hormones, excrete toxins.

• Immune system protected by thin layer that lines the gut. If barrier damaged, can set off immune and and inflammatory reactions

• Enteric nervous system

• 100 million neurons line the gut (more than the spinal cord)

• Butterflies, pit in your stomach, gut feeling

• 95% of the body’s serotonin is in the gut

• Irritable bowel syndrome

• Bidirectional connection between gut and brain (pit in your stomach can be result or cause of anxiety)

• Neurogastroenterology

Gut = the “second brain”

What sabotages healthy digestion?

• SAD diet

• Overuse of medications (NSAIDS, antibiotics, H2 blockers)> 200 over-the-counter (OTC) remedies for digestive disorders (GERD, irritable bowel, bloating, heartburn, ulcers)

• Chronic low-grade infections or gut imbalances with overgrowth of bacteria in the small intestine, yeast overgrowth, parasites

• Toxins

• Digestive enzyme dysfunction – such as from acid blocking meds or zinc deficiency.

• Stress -- alters the gut nervous system, contributes to leaky gut and changing the normal bacterial flora in the gut.

Stabilizing a mother’s biological rhythms to help her synchronize with her baby’s rhythms.

Mind-Body Strategies

• Relax: breathing, yoga, meditation, prayer• Sleep• Address the stressors• Gut health: Pollan’s “Food Rules”• Get moving!• Purposeful, meaningful activity• Tend and Befriend• Community

• Imagine with the patient the hoped for outcome of appointment• Encourage a family member to accompany the patient

• Send a note with your patient --- concise and specific (e.g. help with restoring sleep)

• State what you are working on in therapy, such as “We are working on mindsight” or “We are working on mentalizing” and define what those terms are.

• State your understanding of the priorities:• Safety• Sleep/wake and daily routines• Urgent needs/concerns• Regulation, relationships, responsibility, resilience• Long-term plan for addressing underlying destabilizing factors

How to engage psychiatrist or other medical provider:

Integrative Health Resources• Institute for Functional Medicine

– www.functionalmedicine.org• Dr Mark Hyman: www.drhyman.com

– Ultramind Solution or Ultrasimple Diet• Dr. Christiane Northrup: www.drnorthrup.com

– Women's Bodies, Women's Wisdom• Dr Margaret Christiansen: christensencenter.com• Other Books:

– Henry Emmons (Chemistry of Joy; Chemistry of Calm)– Michael Pollan (Food Rules, Omnivore’s Dilemma)– James Hollis (Finding Meaning in the 2nd Half of Life)

• Articles of interest:– Limitations of acute care approach to chronic conditions and a call for medical

education reform (Holman H. JAMA 2004;292:1057-1059)

•CBT in depressed teens was effective, but not if they had a parent who was currently depressed (JAMA. 2009;301(21):2215-2224)

•Treatment of depression in children not effective unless addressing needs of parents

Recovery from depression is a family affair

Mother-Baby Model of Care•Provide treatment for maternal psychiatric disorders while maintaining and supporting MB relationship

•Specialized intensive outpatient/inpatient programs for pregnant women or mothers and babies

•Incorporates baby into mother’s mental health treatment

•Eliminates childcare barrier

•Eliminates separation from baby and disruption in breastfeeding

•Supports a healthy attachment relationship

•Staffed by psychiatrists and other mental health providers who specialize in perinatal and infant mental health

•Include expertise in meds for preg and nursing women

•Peer support

•Reduces stigma

•Assessment of MB relationship

Mother-Baby Model of Care

• Australia: 4 MB inpt units just in Melbourne, Australia (15-27 night stay)

United Kingdom: 20 MB units that offer both outpt and inpt

• United States:

Outpatient MB Programs:– Women and Infants Day Hospital Program, Rhode Island (2000)– El Camino Hospital MOMS Program, San Francisco, CA (2008)– Pine Rest Mother-Baby Partial Hospital, Michigan (2013)– HCMC Mother-Baby Program, Minneapolis, (2013)

Inpatient Perinatal Program:

-- UNC Perinatal Psychiatric Inpatient Unit, (2012)

Mother-Baby Programs in UK, Australia, US

HCMC Mother-Baby Program• Partial hospital program for pregnant and postpartum mothers• Fills gap in service for perinatal women with moderate-severe

depression or anxiety• Goal of treatment: to support mentalizing/mindsight capacity in

mothers and promote positive parenting practices

• 4 hours/day, 4 days/week, for 3 weeks• Services:– Group psychotherapy – Medication evaluation and management– On-site nursery for babies up to 1 year old– Lactation consultation

Stories

• Range of backgrounds:– Higher income mom overwhelmed with sleep

deprivation and fear driven by undiagnosed bipolar disorder

– Low income, single mom homeless with 3 kids under 4 and struggling with depression

– Low income immigrant mom with baby in foster care after she tried to kill herself

• I didn’t know that:– My baby needs me to feel safe– My baby needs me to talk to her– My baby is not needy or greedy

Circle of Security

• Kent Hoffman, Glen Cooper, and Bert Powell• Relationship based early intervention program

designed to enhance attachment security between parents and children

• http://www.youtube.com/watch?v=cW2BfxsWguc&feature=plcp

Shark music