Becoming a Mindful MotherAppLying acceptance and commitmenttherapy to maternaL mentaL heaLth

hexaflexThere are 6 core principles in ACT:

Commitment & Behaviour Change Process

Occupational therapist Jo Adams, (currently on parental leave fromher role in a community mental health centre in Hamilton), works inperinatal mental health and general adult mental health teams. She hasworked in a variety of health settings in New Zealand, Asia and theUnited Kingdom. Jo is part of the New Zealand Act training team,providing training workshops in acceptance and commitment therapy

In the December 2012 edition of OT Insight, the first of a series ofarticles on acceptanceand commitment therapy (ACT) was

instigated by occupational therapist, Esthe Davis. In this first article,Esthe described the premise of third wave psychotherapy anddiscussed its relevance to occupational therapy practice. To review,ACT teaches skills to reduce the impact of automatic thoughts andunpleasant emotions/sensations on behaviour, promotingpsychological flexibility (Hayes, 2005) ACT focuses on an individual'sresponse to private experiences (thoughts, feelings, sensations,urges), and how these responses affect overall vitality, or suffering.That is, the functional context and workability of these experiencesare more significant than their accuracy, frequency or other suchattributes (Davis, 2012)

In this subsequent article, wenow apply ACT to a specificoccupational therapy role;working with clients in amaternal/perinatal mental healthservice. The perinatal phase isdefined as the period relating tothe beginning of pregnancy untilone year following the birth. It isunderstood that during thisperiod, women are at risk ofexperiencing a reoccurrence oronset of psychiatric illnesses, at anestimated level of 15% of allpregnancies (Ministry of Health,2012). Given their efficacy andlack of side effects for motherand baby, one of therecommended treatments forperinatal anxiety and mooddisorders is brief psychologicalintervention (New ZealandGuidelines Group, 2008). Aspreviously described, ACT fits well with occupational therapyphilosophy and foundations. As a form of therapy, it is well matchedto this client group, who are generally eager to engage and moveforward.

Although all parts of the ACT hexaflex (see Figure 1) can be utilisedin any given session-and in any chosen order-client presentationguides where to begin, and where to place emphasis. With theperinatal client group, an identified need is for being present/mindfulness. Mindfulness is defined as, 'paying attention in aparticular way; on purpose, in the present moment, nonjudgmentally'(Kabat Zinn, 1994, pA) and is not unique to ACT.

With high levels of anxiety, a perceived lack of control, and roleadjustment issues vying for attention, women are often not in touchwith what is happening 'in the now'. Their energy ISconsumed with

Joon an adventure at TunnelBeach,Dunedin

trying to make thoughts and feelings 'go away', rather thanexperiencing them for what they are: natural, passing internal .experiences. (This is conceptualised as experiential avoidance InACT, the solution for which is acceptance).

Learning the skill of bringingattention to the present momentat any time when default copingmethods are adding to (ratherthan alleviating) suffering, canenhance emotional well-beingand help mothers to moveforward - in line with their values.Sessions include formal trainingof mindfulness techniques andlearning to apply the concepts toeveryday life. For this clientgroup, who often need to haveeyes and ears open to the needsof children, we use mindfulnessexercises that are designedaround everyday tasks - doingthe dishes or taking a shower.Slowing an activity down, such asa very slow walk on grass, createsthe possibility of being mindful.Focussing on the present

moment, for example, when completing pleasant baby-care tasks, isused therapeutically to encourage a healthy maternal-infantrelationship and to expand awareness of the variety of emotionspresent at these times.

A pilot study of a group of pregnant women participating in amindfulness-based cognitive therapy group over 8 weeks found thatall participants continued to use mindfulness in their everydaylives up to several months following completion (Dunn, et al.,2012). likewise, maternal mental health clients were observedto integrate mindfulness quickly into their lives and maintaininformal practice beyond therapist intervention. When anindividual is practicing mindfulness regularly, they are reminded thateach experience can be survived and is often different to h?w theymight have imagined it, thus adding to a person's adaptivestrategies for coping with stress (Duncan & Bardacke, 2010).

acceptance

being present/mindfulness

defining valueddirections

cognitvede-fusion

self as context

Mindfuiness & Acceptance Process

Figure 1.

12 Vol.34 No.3 May 2073

committedaction

Learning to develop contact with the present moment enhancesself-awareness and provides a platform for working on other aspectsof the hexaflex, such as cognitive defusion When working withMs B, a woman who was pregnant with her second child andexperiencing health anxiety in relation to her and her children, aseries of mindfulness exercises were introduced and demonstrated insession, She was taught to scan through her body to noticesensations in detail. Changes in temperature, pressure, comfort,discomfort and numbness were noted, Subsequent thoughts, urges,memories and feelings were also noted, An attitude of willingness toexperience these things with non-judgement was encouraged,Rather than fearing the experience of 'feeling anxious', and trying to

avoid it completely, Ms B learnedto be present with the experience,and was able to observe in moredetail the coming and going ofeach specific sensation, thoughtand urge (looking at one'sthoughts, rather than from one'sthoughts), This was significant toMs B as she was then able toparticipate in valued activities inthe community with her toddler,such as swimming, despite havingdistressing internal experienceswhen doing so,

Psychoeducation in ACT ofteninvolves the use of metaphors andexperiential exercises (Smout,2012). For example, the metaphorused to convey the concept ofacceptance (the willingness tohave thoughts/feelings/sensations)for Ms B is that of quicksand, Ifwe get stuck in quicksand, thenatural inclination is to struggle tomove quickly out of it. However,that is exactly what you shouldn'tdo - the struggle makes you sinkfurther and faster, Paradoxically,the best thing to do in quicksand islie down and spread your weightover the greatest area, Similarly,when encountering a distressingthought, feeling, sensation orurge, the best way through it isnot to fight and struggle, but to letit be there (Hayes & Smith, 2005),Ms B personalised this metaphor

by relating it to teaching her son to float at the pool, 'when he'sscared, he struggles in the water, but if he relaxes he can float, andhe feels quite differently about the water',

Values are clarified via discussions and imagery exercises, (eq,What kind of mother would you like to be?), and form the guidingpath for the setting of goals, Maternal mental health clientsrespond well to the ACT approach of asking, 'What's the next stepyou could take to live more like the way you want to in the area of(relationships, work, recreation, health)' and to check on progresssession by session (Smout, 2012),

ACT fits well with occupational therapy philosophy and is aneffective form of therapy for maternal mental health clients, who areadjusting to the changes and challenges of pregnancy, birth andparenting,

Further reading and learning is accessible via internet sources andlocally run courses,

All ACT therapeuticprocesses are for thepurpose of anindividual living a lifemore in line with theirchosen values:focussed on anindividual's value systemand their inherent drive

_to act in line with theirvalues,

Rather than aimingfor symptom reduction(struggling to reducesymptoms and distressingthoughts or feelings),ACT encourages aflexible, responsiveapproach to one's daily,human experience.

References

Davis, E, (2012), Towards Psychological Flexibility, OTlnsight, 33(8), 8-9,

Duncan, L.G. & Bardacke, N, (2010), Mindful-based childbirth and parenting

education: Promoting family mindfulness during the perinatal period, Journal of Childand Family Studies, 19:190-202,

Dunn, c.. Hanieh, E" Roberts, R, & Powrie, R, (2012). Mindful pregnancy and

childbirth: effects of a mindfulness-based intervention on women's psychologicaldistress and well-being in the perinatal period, Archives of Women's Mental Health,15(2): 139-43,

Hayes, 5, & SrnithS. (2005) Get out of your mind & into your life: The newacceptance & commitment therapy. Oakland: New Harbinger.

Kabat-Zinn, J. (1994), Wherever you go, there you are: Mindfulness meditation ineveryday life, New York: Hyperion.

Ministry of Health. (2011), Health Beginnings, Developing perinatal and infantmental health services in New Zealand. Wellington: Ministry of Health,

New Zealand Guidelines Group, (2008), New Zealand Guidelines Group,

Identification of Common Mental Disorders and Management of Depression in PrimaryCare, An Evidence-based Best Practice Guideline, Wellington: New Zealand Guidelines

Group,

Smout, M. (2012). Acceptance and commitment therapy: Pathways for generalpractitioners, Australian Family Physician, 41(9), 672-6.

Recommended Reading

Kabat-Zinn, M, & J, (1997), E~eryday Blessings: The Inner Work of Mindful

Parenting, New York: Hyperion.

Resources on: www.contextualpsychology.org

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Change Table comes complete with mattress.Cot sides, head & footboards, and padding are optional extras.

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Vol.34 No.3 May 2013 13