The Infant Crier

Month: October 2018

  • What’s Going On In There? The Developmental Work of Pregnancy

    What’s Going On In There? The Developmental Work of Pregnancy

    “The connection between the pregnant woman and her developing fetus is perhaps the most profound but enigmatic of all the human relationships.”  (DiPietro, 2010, p. 28).

    INTRODUCTION: It’s a story we sometimes overlook entirely. Even when we do ask parents about it, sometimes we don’t catch the drama, the power, and the meaning of it.  The story is about the beginning of life, and what is happening inside the three people who are having this most profound and unsettling experience.Of course, we’ve long known that pregnancy is anything but innocuous for the one most visibly affected — the mother — but even then, we can fall short in our wondering.We know how to look backward (“What happened in there?”) when there is, later, a problem with the baby, or with one or more of the relationships.What if we had a chance to back up (long before there are symptoms of a problem), slow down, and just wonder what sort of mental activity is brewing in there, and why? What’s the point of it all? Is it really a developmental progression?  What variables impinge on the progression?  How do the parts — mom’s state of mind, dad’s dreams, baby’s sense of self, mom’s imagination about who this baby is, and the everyday things going on around this trio — all fit together, while influencing each other?That’s the sort of wondering we get to do, in this article, the first in a series on the developmental paths of early life.I wish we had room to ponder dad’s inner work.  We know it’s happening, and we know it’s important.  We’ll have to consider it another time. To be clear:  It is wondering that we’re doing herein.  We’re not establishing rules for pregnancy, or even proposing an orderly set of stages.  We’re just proposing a way to think about it all, and to imagine some implications.

    EXAMPLE #1   A crisis in a little northern Michigan town is featured in the national news.  A Farm Bureau employee in the southern part of the state inadvertently mixes a fire-retardant chemical into cattle feed. The feed is shipped north and fed to unsuspecting cattle. Soon, I pass stacks of dead cows beside barns as I pull in for home visits.  Polybrominated biphenyls are discovered in the food chain.  Word in the nearby farming communities is that this little-understood chemical might wreak havoc in the brains of humans, including babies.  Soon it will appear in breast milk.  Mothers hear about it, although they are mostly terrified to talk about it.

    If Reva Rubin was right, in an article published about this time (Rubin, 1975), that one of the key developmental/psychological tasks of the pregnant woman is her seeking safe passage for her unborn child, then what does the PBB crisis mean to a pregnant mom in rural northern Michigan?  Has she — irrationally, perhaps, but no less profoundly — come to believe she is failing to protect her baby?  Will this unspoken belief influence her capacity to move forward into other developmental tasks of pregnancy, including those needed to promote a profound sense of maternal self-confidence and authority?  Will she be able to attach to a child she fears she has harmed? When father asks her why she seems so blue, so detached, will she be able to put any of it into words?

    EXAMPLE #2   A baby is born to a mom still silently grieving the death of a previous child. The second baby was conceived just days after the death of the first one. Neither mother nor father has ever spoken of their shared loss; as a result, it seems to not actually be shared by the two of them at all.  They press forward, in silence, as if nothing has happened. Can parents attach to an unborn baby when their hearts are broken — especially when they deny it is so?

    In her brilliant description of the maturational crises of pregnancy, Grete Bibring drew our attention to the “…intense object relationship to the sexual partner [which] leads to the event of impregnation, by which a significant representation of the love object becomes part of the self” (Bibring, 1961, p. 15).  The above mom now has two pieces of unconscious psychological/developmental work to accomplish: In a state of estrangement from her husband, she must still manage to internalize the impregnation, in which the “love object becomes part of the self” (Bibring, 1961, p. 15); and she must achieve sufficient resolution of her grief over the child who has just died, in order to access needed libidinal energy for her connection to the next pregnancy, the next baby.

    Perhaps it’s too much.  Perhaps something will stand in the way of mom connecting to the new baby — or even accepting that she’s pregnant. The mother to whom this happened fell mysteriously ill immediately after the birth of the second child. She moved far away for a “recuperation period,” leaving her new son in the care of a stranger. Mom seemed unfazed by the separation. She had, indeed, come to the end of the pregnancy without finishing essential internal work.  She could — quite literally — not “face” her newborn, who would live the rest of his life with the psychological residue of his mother’s detachment.

    After several weeks, a friend — horrified to discover that mother was making no moves to see her little boy — brought them together for a visit. Decades after that brief visit, in response to a request by this newborn as an adult and father-to-be, mother wrote to him of her memories of those moments of greeting: “I felt no inclination to sweep you into the embrace I’m sure all expected.  You looked very much as I expected you to look … and we examined one another with what I fancy was a quite neutral expression.”

    Such breakdowns in the developmental work of pregnancy are often reparable. Parents play catch-up, and something allows many to “fix” the detachment or the depression that threaten life with baby. This particular mom never found her way back to her boy.  He stumbled into my office three decades later while awaiting the birth of his own firstborn son.

    EXAMPLE #3  It’s not news when a mid-adolescent becomes pregnant.  We know something of the obvious risks — that she may go through the pregnancy alone and poor, that the normal narcissism of her own developmental status might deter her efforts to invest fully in the Other inside her — but what do we know about how this will all play out developmentally?

    Pregnancy is never an “accident.”  Despite the pretense of many parents that they were uninvolved in the timing, it’s never true.  When and why it happens always has meaning.

    For Becky, it was right after a family trip to see her grandmother in North Carolina. The trip immediately preceded not only the pregnancy, but a significant change in Becky’s school performance and mood.

    Becky barely knew the boy-father, who was disinterested in her, and went on to impregnate another girl. While he evidently had no special meaning to her, the child growing inside her did. Sent to a home for unwed mothers, it was assumed Becky would give up her baby.  But she didn’t, even after discovering he was a boy. Her distance from him, throughout the pregnancy, was evident. At the delivery, one of the nurses took note of Becky sucking in her breath and mumbling, “Oh, no…” when she saw her newborn’s penis, even before she noticed his face. Nobody seemed to understand why she wanted to keep him when she felt so distanced from him.

    I met her when she returned to our little town with her son in tow. She spoke often of her expectation that her son would leave her someday.  Males always did, or so her narrative maintained. Her father, I learned, had been a military man on the base near her grandmother’s house.  Becky’s mother had been a “townie.”  He showed little interest in the pregnancy for little Becky, and appeared to be relieved when he was shipped overseas right after Becky was born. Becky grew up in her grandmother’s house with her mom, but with no dad anywhere.It looked as if Becky might be repeating the pattern; another child would be born without a daddy nearby.

    While I could not see it at the time, Becky began her interruption of the pattern by relinquishing custody of her son to her mother and stepfather before Jeremy was a year old. Her next step was to get pregnant again, this time with a military man. He was ordered to basic training at the base where her father had been 18 years earlier, so she moved back into grandma’s house.  She wrote me that her boyfriend had received orders to ship out, coincidentally to the same European country where her dad had been sent so long before.  She had pleaded with the base commander to change his orders. The father of her baby would stay.  They would marry.

    In her very last letter, Becky said she had learned that her new baby would be a girl, and that it would “…all work out, this time.  I think you know what I mean.”

    Sometimes the dynamics of pregnancy are awfully complicated, with the developmental work of pregnancy not completed for some years.

    THE DEVELOPMENTAL WORK OF PREGNANCY

    It would be unreasonable to assume that a living being as sophisticated and complex as an adult woman would treat the entrance of a human body into the insides of her innocuously, without noticing and responding.  “Noticing” and “responding” then become the work of pregnancy. In a flash, an expectant mother’s attention is riveted.  She is shaken. She does not just sit there.  She has work to do.  It will be sequential — developmental — but not perfectly so.

    THE BEGINNING:  ACCEPTANCE OF THE FOREIGN BODY

    A key element of this early work is simply acceptance of the pregnancy.  This sounds easy enough, but it’s not automatic. It involves a developmental step.  It implies traversing a threshold into motherhood, which may be rife with worrisome meaning for some moms.  It implies an unfamiliar responsibility, the need to conserve emotional energy, and the acceptance of certain limits.

    Something has come into mother’s body that did not use  to be there.  A certain resistance (not altogether unlike the natural rejection response of one’s body to a newly transplanted organ) must be overcome.  Mom must take note, her body must take note, and she must give permission.

    For a young woman of rape, this may be a huge step. Already there was an intrusion of another kind.  Now she must somehow separate that intrusion (of the rapist’s body) from the part of himself he left behind.  She must find a way to reject the first while accepting the second.  This is a tall order.

    Even without the violent or controlling intrusion of rape, merely the intrusion of the foreign body of the baby may be enormous for a woman who has never felt much control over her own body.

    For a mom living in a war-torn part of the world, even allowing herself to consider that life is beginning inside may bring on anticipatory grief, as the likelihood is high that this new life will have a very short term indeed.

    Under circumstances in which the safety of the fetus is more-or-less assured, however, mom will move forward (albeit unconsciously) toward acceptance of the intrusion of this “foreign body” (Bibring, 1961, p. 15), and incorporate it into her own. Mom and baby become one. (For this reason, death of the unborn baby in this early part of pregnancy may feel to mom like the death of part of herself.)

    She will eventually reach through this haze of lack-of-identity and confusion and say, essentially, “Yes.” It’s an unconscious act, of course, this affirmation, this acceptance.  It’s not necessarily an act of acceptance of a person, yet, since little in the way of an identity is yet available.

    This mostly-unconscious act of saying “Yes” may not be a one-time thing; the unconscious “decision” may be revisited several times.  As Lederman’s research showed us, acceptance of the pregnancy is not the same as acceptance of the baby, or of motherhood (Lederman, 1984, p. 17).  But accomplishing this first, delicate, unconscious act means her body can go on (instead of working to eliminate the intruder), and her mind can go on (tucking the fetus within so there is really no difference between that-which-is-mother, and that-which-is-baby — the safest possible place for baby to be, unless it isn’t).

    A NOTE ON THE DIFFERENCE BETWEEN ACCEPTING THE FOREIGN BODY AND WANTING TO BE PREGNANT

    [box style=”rounded” border=”full”]We’ve always been eager to understand how a mother’s attitude toward her prenate affected his later development, and many of us entertained private theories, based on our clinical work, about such connections. But wantedness, per se, is not really the point of this description of mother’s developmental work of acceptance.  We’re not suggesting that the developmental work of pregnancy requires that all mothers reach a certain plateau of acceptance of the pregnancy, of the baby, and of motherhood.  There is reason to believe that these are separate kinds of acceptance, perhaps reached at different times, perhaps never equivalently in all mothers. Mothers are fully entitled to tons of ambivalence, mountains of giddiness and terror, and various acts of reliving the past and predicting the future through dreams and strange — but perfectly normal — flights of ideas.  Our purpose here is not to take the mystery out and find categories (much less diagnoses) for the normal work of getting ready.  Our purpose is to come to an appreciation of the nuance and complexity of what goes on inside. We’re not looking for pathology; we’re looking for an understanding of what this marvelous inner work usually is.[/box]

    THE MIDDLE: IMAGINING AND THE EMERGENCE OF IDENTITY

    Having moved through acceptance of the intrusion of the foreign body, mom is now free to picture her baby; such imagining will constitute much of the work of the next developmental stage. Romantic notions aside, creating an identity for the being(s) growing inside may be tough, confusing, dismaying, complicated … and magical.

    In this second developmental stage, the outlines of an identity begin to be formed in mother’s imagination. This may be an exhilarating time, as mother’s imagination infuses baby with the best-of-all-possible-characteristics from her own and her partner’s histories. For some moms, however, the door opens to worrisome thoughts:

    • “My mom demeaned me during my whole childhood for being fat. I think my baby is fat.  What will mom say when she looks at my baby?”
    • “I feel mad at him sometimes, even now. What if I just don’t like him?”
    • “What if he’s weird, like Uncle Joey?”

    On and on it goes, this powerful developmental dance.  Thoughts are inconsistent and sometimes illogical.  Dreams are all over the place.  Ever so slowly, however, the notion of a person emerges.  It used to be that this developmental step — this emergence of an otherness —began sometime after quickening, after the baby announced herself suddenly and profoundly with a kick. But the near-universal use of routine ultrasound now pushes this second developmental step earlier in the pregnancy.  It can be joyful and affirming and real. Whatever else it is, it’s certainly far from innocuous.

    THE END:  DIFFERENTIATION

    Could it possibly be that mothers are obligated to say “good-bye” before they have fully said “hello”? In a sense, the answer is yes.

    As moms traverse the winding and complicated road from being alone in their bodies to becoming mothers, it appears there are two acts of differentiation that — while usually accomplished with little effort or even conscious attention — seem, nonetheless, developmentally important:

    • The “…growth of the pregnant woman from the role of the ‘daughter of the mother’ to the ‘mother of her baby’” (Schroth, 2010, p. 4). In other words, mother separates herself from her own mother as part of her preparation to become the mother of her baby. It seems a significant and meaningful step. In order to feel her power as a woman and to create a new view of herself as an efficacious, capable, intentional mom in her own right, she must assert that she is no longer merely her mother’s child. She is a mother, herself, perhaps resembling her mom in some ways, but wholly distinct in others.
    • The shift from the unconscious perception of the baby as part of the Self to the perception of the baby as an Other. In other words, mother separates herself from the baby who was fused with her as part of her preparation to encounter him as a unique and distinct human being.  Attachment, by definition, relies on accomplishment of this developmental task; otherwise, we’re left with mother everlastingly confusing the baby with herself, while the baby remains confused about the boundaries between self and other.

    Psychoanalysts Jenoe Raffai in Hungary and Gerhard Schroth in Germany developed a systematic facilitation for this final developmental work (Raffai, 1995 and Schroth, 2010).  Offered during the last weeks of pregnancy, the facilitation supports moms conversing with their unborns in ways that acknowledge the differentiation while opening up lines of communication that may be helpful during delivery, and may feel familiar to both mom and baby as they later begin to attach during the first postpartum days.  Schroth suggests that a kind of empathic “mirroring” (Schroth, personal communication) by the mother may support the unborn baby’s sense of being seen and known before birth.

    Practical results of this facilitation showed up in outcome studies on deliveries in Hungary and Germany. In the first Hungarian cohort of 1,200 mothers who participated in such facilitations, the rate of premature birth dropped to 0.1% (compared to the average of 8%); the cesarean section rate dropped to 6% (compared to the average of 30%); and the rate of postpartum depression dropped to nearly zero (from the average of 15%) (Raffai, 1995 and Schroth, 2010).

    French child psychiatrist Miriam Szejer suggested, “By the end of the pregnancy… the fetus and the mother no longer live by the same rhythms” (Szejer, 2005, p. 69).  I’ve come to believe that this is as it should be.

    What a glorious conclusion to the amazing developmental/psychological work of pregnancy: to be able, at the end, to say “Goodbye” in the very service of saying “Hello.”

    BARRIERS TO ACCOMPLISHMENT OF THE DEVELOPMENTAL WORK

    No one would be surprised if a mom whose last baby died might delay the very first developmental step (acceptance of the intrusion of the foreign object), when such acceptance —or even acknowledgment — might cause so much pain.  She may barely have begun the
    “…reorganization of the survivor’s sense of self to find a new normal” (O’Leary and Warland, 2016, p. 3). A strong sense of her capacity to protect her unborn may now elude mom (as well as dad, in ways often invisible to most observers), which may lead to a disinclination to imagine that they are pregnant again. One researcher, with decades of experience interviewing and supporting families after prenatal or infant loss, reports that “…most parents entering a new pregnancy believe … that grief for the deceased child will diminish” (O’Leary and Warland, 2016, p. 6), only to discover that grief is actually resurrected by the new pregnancy. Understand that we’re not implying that a baby conceived after loss cannot be accepted, but only that the developmental work of acceptance may, quite naturally, encounter a bit of resistance.

    The developmental work of which we speak may be complicated by the loss of one baby — a “vanquished twin” — while the other one remains, lying inside.  Mom now has the work of grief and the work of acceptance all at the same time. Sometimes a mom simply cannot simultaneously do both.  So she may, without ever noticing what she is doing, turn over the work of grieving the lost twin to her partner, or delay it entirely. (The remaining/surviving baby is, of course, witness to it all.)

    Sometimes interference comes from the outside world. What if mom is preoccupied with a sense that she is physically at risk (due to domestic violence, for example)?  She needs emotional energy to do the developmental work of pregnancy, but that energy is being drained away.  She cannot revel in a focus on self (already — and normally — a bit muddled, with unclear boundaries between that-which-is-fetus and that-which-is-mother), because the context of ease and safety is missing. Essential self-indulgence feels absurdly inaccessible in this state of uncertainty and unease.

    And on it goes, through the entire pregnancy.  To notice these challenges is not to suggest psychopathology.  It is to acknowledge how complicated the work is, which makes it more than a little awe-inspiring that moms somehow navigate these unconscious waters so well.  The aim of such understanding need not be the elimination of all challenges.  Rather, the aim might be to support more of it becoming conscious, which then gives the family access to the narratives that naturally arise.  For example, dad might later be able to say to his son: “Your grandma got very sick while mom was carrying you inside.  Mom was sad about it.  She didn’t get to just think about herself, and about you. That’s why we’re making cupcakes for her, and for you, today.  Today is about nothing except the two of you being together, with no worries.”

    Or mom might explain this narrative to her pre-teen daughter: “You’ve always had to work extra hard to get me to let you go.  I know.  I’m sorry.  Believe it or not, we’ve been fussing about this since you were inside me.  You were ready to separate from me before I was ready to let you be your own little person. I heard you, but I couldn’t get myself ready to let you go. That’s probably why you were several days late in being born, and why I sometimes act goofy and scared when you want to try something on your own.  I get it. Sorry.”

    SUPPORTS IN THE ACCOMPLISHMENT OF THE DEVELOPMENTAL WORK

    Recent research teaches us that the growth of maternal self-efficacy (MSE) during pregnancy is an important inoculant against perinatal depression, and is a predictor of satisfaction with both the childbirth experience and with later parenting (Fulton, et al, 2012). Achievement of high levels of MSE does not result merely from being surrounded by cheerleaders, of course.* The formula for one’s perception of self-efficacy may include self-evaluation of one’s abilities in specific domains, but it may also include a range of internal perceptions, including long-standing self-narratives about one’s personal power and agency, and one’s “remembered care from their own parents” (Fulton, et al, 2012, p. 331). One of the joys of the developmental work that rests on delicious and healthy self-absorption is that these perceptions can be made conscious, can be mused upon, and can even be revised.  During some parts of pregnancy, some moms find themselves dreaming about events that haven’t been thought of in many years; calling family members from whom they have been estranged; asking their own parents surprising questions; looking at yearbooks and photo albums and otherwise digging into old memories and narratives — all part of a noble effort to pull together an efficacious sense of self.

    * It doesn’t hurt, of course, to have one’s attributes and capabilities highlighted during and after pregnancy. But one study of the relationship between social support and MSE turned up an interesting finding: “…partner support was unrelated to both maternal self-efficacy and depressive symptomatology” (Haslam, et al, 2006, p. 286), whereas higher levels of parental support were related to higher levels of MSE.

    Perhaps planning for the delivery, itself, can constitute a piece of developmental work.  We have seen mothers wrap themselves protectively around their bellies as they declare how they want the upcoming process to unfold.  Does maternal self-efficacy increase when a mother asserts herself in ways not previously associated with her personality?  Must we take note of the potential loss of self-efficacy when it does not go according to plan? French obstetrician Michel Odent affirms a truth felt by many women: “In the age of industrialized childbirth, the mother has nothing to do.  She is a ‘patient’” (Odent, 2002, p. 29).  Perhaps less scoffing at assertive women who are looking not only for a better start for their babies but for a greater sense of their own authority in the world might be in order.  As a mother prepares the way for birthing her unborn, maybe she’s also doing yet more developmental work.

    CONCLUSION

    It can be seen that the developmental work of pregnancy is not a one-off and may not be tidily sequential.  It builds on itself (thus the descriptor we’ve been using: developmental).  It may be messy and clumsy, moving in fits and starts, and it may be unnerving to partners, employers and extended family members (if not the mother herself).  But it has purpose and meaning. Decks are cleared, issues revisited (if not resolved), hopes investigated, fears aroused anew (perhaps so they can be put to rest — or, at least, put into storage for a bit). Mom gets a chance to greet herself, to re-invent herself, to meet parts of herself she had forgotten.  She gets a chance to feel integrated, even as she may worry that she’s falling apart.  She gets a chance to feel powerful, even in the face of so much inner challenge, with more to come.

    Guess who benefits from all of this?

    One final reminder: This clumsy, dramatic, mostly unconscious work is not being done in private. There is a witness.  Certainly it’s clever for evolution to work this way, with baby and mom communicating throughout the pregnancy about who she is, about life outside, about what the baby can expect. It means that — irrespective of her conscious intentions — mom “talks” to baby; if it’s not her words, it’s her endocrine system, giving information about her heart, her state of being, her reactions to things she’s seeing or thinking about or feeling.  The baby, of course, is a perceptive listener, retaining the messages (while undoubtedly getting the meaning of some of them all wrong).

    In the end, we see that there’s meaning in every last bit of this powerful, mostly unconscious developmental work of pregnancy.

    List of References, Suggested Reading and Study Questions:

    What’s Going On In There? The Developmental Work of Pregnancy – References and Study Questions

  • Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    Pathways to Parenting: Prenatal Bonding in Mothers and Fathers

    “In giving birth to our babies, we may find that we give birth to new possibilities within ourselves.”
    – Myla and Jon Kabat-Zinn, Everyday Blessings: The Inner Work of Mindful Parenting, 2014

    For many parents, pregnancy represents a time of reorganization that leads to psychosocial growth and the hope of new possibilities.  The coming of a new baby inspires shifts within the psychological worlds of the parents as their emotional ties to the infant begin to take shape. The development of these ties is critical because they are related to parents’ postnatal feelings about the baby (Vreeswijk, Maas, Rijk, & van Bakel, 2014), and they provide psychological fuel for the demanding work of postnatal infant care (Rapael-Leff, 2005).  Importantly, a parent’s prenatal thoughts and feelings about his or her infant are also associated with postnatal parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dubber, Reck, Muller & Gawlik, 2015; Hjelmstedt & Collins, 2008).  Just as the infant will ultimately develop an attachment to the parent, the parent develops a complementary caregiving system that provides motivation to protect and nurture the infant (Solomon & George, 1996), and this system comes online during pregnancy.

    To date, the majority of the research informing our understanding of prenatal parent-infant relationship development has been with mothers (Slade, Cohen, Sadler & Miller, 2009).  More recently, prenatal bonding in fathers has also been the subject of research. Across studies, accumulating evidence suggests that: one, pregnancy represents the beginning of the parent-infant relationship for both women and men (Vreeswijk et al., 2014), and two, the quality of this relationship is related to postnatal parenting for both mothers and fathers (Dubber et al., 2015; Hjelmstedt & Collins, 2008). Focusing exclusively on mothers, D.W. Winnicott put it this way:

    I suggest, as you know I do, and I suppose everyone agrees, that ordinarily the woman enters into a phase, a phase from which she ordinarily recovers in the weeks and months after the baby’s birth, in which to a large extent she is the baby and the baby is her. There is nothing mystical about this. After all, she was a baby once, and she has in her the memories of being a baby; she also has memories of being cared for, and these memories either help or hinder her in her own experiences as a mother.

    — Winnicott, 1966 (as cited in Winnicott, 1987)

    In the IMH field we take Winnicott’s words to heart every day in our work with parents and infants; we talk to parents explicitly about their own child rearing histories, and we help them make conceptual links between past and present.  Indeed, attachment theory argues that a parent’s own relational history, described as “memories” by Winnicott and as “Ghosts” or “Angels” by more contemporary authors (Fraiberg, Adelson, & Shapiro, 1975; Lieberman, Padron, Van Horn, & Harris, 2005), is influential in the formation of the parent-infant relationship. Extensive research in the attachment field supports this link (Mayseless, 2006), and our clinical work with families reinforces its importance.

    Pregnancy represents the first point in development when we have clinical access to the parent-infant relationship.  Therefore, whether we are working with expectant parents or helping parents reflect on their prior pregnancy and birth experiences, understanding the role of risk and resilience factors in pregnancy can extend the clinical window backward to the place where the parent-infant relationship first took shape.

    Risk and Resilience in the Lives of Expectant Mothers

    For women, pregnancy involves both physical and psychological processes that contribute to the deepening of the maternal-fetal bond over time (Yarcheski, Mahon, Yarcheski, Hanks, & Cannella, 2009; Slade, et al., 2009; Zeanah, Carr, & Wolk, 1990).  The quality of the mother’s physical health and psychological well-being during pregnancy is fundamentally tied to that of the fetus.  Prenatal risk factors that the mother is exposed to, therefore, have the potential to influence her own health, the health of the fetus and her psychological connection to her unborn baby.  Exposure to intimate partner violence (IPV), for example, increases the risk for infant mortality and morbidity (Sharps, Laughon, & Giangrande, 2007).  It also affects the mother’s psychological tie to the fetus.  IPV exposure during pregnancy is associated with less positive internal working models of the infant for mothers (Huth-Bocks, Levendosky, Theran, & Bogat, 2004), and is ultimately related to less sensitive early parenting behaviors (Dayton, Levendosky, Davidson & Bogat, 2010; Dayton, Huth-Bocks & Busuito, 2016).

    Symptoms of psychological distress including depression, anxiety and post-traumatic stress disorder (PTSD) can also influence the maternal-fetal bond (Dayton, Hicks, Goletz, Brown, 2017; Luz, George, Vieux & Spitz, 2017).  Estimated rates of clinical depression during pregnancy range from 10% to 30% for mothers (Ashley, Harper, Arms-Chavez, & LoBello, 2016), and untreated depression is associated with less optimal maternal-fetal bonding (Yarcheski, et al., 2009; Alhusen, Gross, Hayat, Rose, & Sharps, 2012). It is important to note, however, that much of this work has been conducted with married or cohabitating Caucasian parents from middle-income socioeconomic groups (Yarcheski, et al., 2009). In light of the economic and racial health disparities in pregnancy and birth outcomes (Lu & Halfon, 2003), more research that extends this work to economically and racially diverse samples of parents is needed.

    Protective factors for healthy and adaptive maternal-fetal bonding have also been identified. For instance, Yarcheski and colleagues (2009) conducted a meta-analytic review and found that, across many independent studies, increased levels of social support were associated with increases in the strength of the maternal-fetal bond.  From biological and psychological perspectives, this finding makes a lot of sense.  In relation to contextual stressors such as violence exposure, social connection has a countervailing influence on the human bio-behavioral regulatory system. Connection with trusted others is physically and psychologically calming and has important biological correlates such as lowering cortisol levels and initiating the release of oxytocin. These biological responses to social connection calm the nervous system and may thereby support the development of the maternal-fetal bond via increases in a mother’s sense of psychological and physical safety.

    Findings from this body of literature have important translational implications for the early parenting field.  IMH interventions during pregnancy that help women free themselves from violent relationships, process and heal from the violence they have been exposed to, and decrease their symptoms of psychological distress are clearly indicated.  Further, and consistent with the central aims of many IMH programs, increasing a mother’s social support network may help promote a positive bond with her unborn baby, ultimately leading to more positive birth outcomes and a healthier postnatal mother-infant relationship.

    The Father’s Prenatal Journey

    The meaning of fatherhood in the United States has changed in important ways over the past few decades (Lamb, 2010).  Men are now more actively involved in the daily lives of their children (Bianchi, 2011), and the importance of fathering to the social-emotional development of children is more frequently acknowledged (Lamb, 2010).  When fathers are involved very early in the lives of their children, they have the opportunity to form foundational and enduring relationships with them, and outcomes for mothers and babies are improved. The positive health effects associated with father involvement begin in pregnancy with improved prenatal, birth, and neonatal health outcomes and significantly lower per-infant healthcare costs (Alio, Salihu, Kornosky, Richman, & Marty, 2010; Salihu, Salemi, Nash, Chandler, Mbah, & Alio, 2013). In contrast, a lack of father involvement in pregnancy is associated with significantly higher infant mortality rates (Alio, Mbah, Kornosky, Wathington, Marty & Salihu, 2011).  Given these compelling findings, supporting the prenatal father-infant bond is an important target of intervention that has the potential to improve birth and relationship outcomes for fathers, mothers and infants.

    Though less is known about the factors that affect the development of the prenatal father-infant bond, preliminary research suggests that psychological distress in fathers, including depression and anxiety, may be one risk factor for lower levels of prenatal bonding (Luz, George, Vieux & Spitz, 2017; Dayton, et al., 2016). Preliminary work also suggests that, on average, fathers may experience higher levels of emotional distance from their unborn babies, relative to mothers (Vreeswijk et al., 2014).  Much of this research has involved samples of middle-class, Caucasian fathers, however. As a result, less is known about how risk factors such as violence and poverty exposure may affect the developing father-infant relationship in pregnancy.

    To address the relative paucity of prenatal studies of fathering in contexts of risk, ongoing research at the Motown Family Relationships laboratory located at Wayne State University’s Merrill Palmer Skillman Institute, is currently investigating prenatal relationship development in urban-dwelling fathers, with the goal of informing early interventions with fathers.  A central finding of this work is that a father’s belief in the importance of early fathering to the health and well-being of the infant is robustly associated with stronger prenatal bonding: Fathers who believe that early fathering is important tend to report experiencing stronger bonds with their unborn infants (Dayton, Hicks, Goletz, Brown, 2017). This is an important finding because fathers in low-income groups are exposed to social narratives that describe fathering primarily in economic terms, and poverty-exposed fathers are clearly disadvantaged in this respect. Furthermore, qualitative data from this study suggest that many fathers have a difficult time grasping their importance during infancy and tend to view their parenting role as more influential when their children are older (i.e., preschool aged and above) (Dayton, et al., 2016). Helping fathers understand the importance of their early relationship with their infant beginning in pregnancy can help shift the narrative from fathering as a mainly financial role to the importance of the early father-infant relationship in promoting the healthy development of the infant.

    These cumulative findings have significant implications for IMH work with fathers and their families.  Most important, there is a need for early intervention protocols that communicate to fathers the centrality of the early father-infant relationship as a foundation on which the long-term parent-child relationship is built.  IMH practitioners are ideally positioned to engage fathers in clinical work and to help fathers negotiate the barriers that may prevent them from full involvement with their infants.  However, it is important to acknowledge that the vast majority of IMH workers are women. As women, our own histories have likely resulted in feelings and beliefs about the relative importance of fathers in the lives of infants and young children.  To authentically engage with fathers, therefore, we must examine our own feelings and challenge our own biases.  A mother-centric approach has dominated the IMH field since its inception.  Shifting our individual and collective views about early fathering will help move the field toward a more balanced family-centric approach and, ultimately, improve the lives of the families we care so deeply about.

    References

    Alhusen, J. L., Gross, D., Hayat, M. J., Rose, L., & Sharps, P. (2012). The role of mental health on maternal‐fetal attachment in low‐income women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(6), E71-E81.

    Alio, A. P., Salihu, H. M., Kornosky, J. L. , Richman, A. M., & Marty, P. J. Feto-infant health and survival: Does paternal involvement matter? (2010).  Maternal and Child Health Journal, 14(6), 931-937.

    Alio, A. P., Mbah, A. K., Kornosky, J. L., Wathington, D., Marty, P. J, & Salihu, H. M. (2011).  Assessing the impact of paternal involvement on racial/ethnic disparities in infant mortality rates. Journal of Community Health: The Publication for Health Promotion and Disease Prevention, 36(1), 63-68.

    Ashley, J. M., Harper, B. D., Arms-Chavez, C. J., & LoBello, S. G. (2016). Estimated prevalence of antenatal depression in the US population. Archive of Women’s Mental Health, 19(2), 395-400.

    Bianchi, S, M. (2011). Family change and time allocation in American families. The ANNALS of the American Academy of Political and Social Science, 638, 21-44.

    Dayton, C. J., Levendosky, A. A., Davidson, W. S., & Bogat, G. A. (2010). The child as held in the mind of the mother: The influence of prenatal maternal representations on parenting behaviors. Infant Mental Health Journal, 31(2), 220-241.

    Dayton, C. J., Buczkowski, R. S., Muzik, M., Goletz, J., Hicks, L., Walsh, T., & Bocknek, E. L. (2016). Expectant fathers’ beliefs and expectations about fathering as they prepare to parent a new infant. Social Work Research: Special Issue on Social Work with Men and Fathers, 40(4), 225-236.

    Dayton, C. J., Huth-Bocks, A. C., & Busuito, A.  (2016). The influence of interpersonal aggression on maternal perceptions of infant emotions:  Associations with early parenting quality.  Emotion, 16(4), 436-448.

    Dayton, C. J., Hicks, L., Goletz, J., & Brown, S. (2017). Prenatal bonding and child abuse potential: Risk and resilience in vulnerable, pregnant mothers and fathers.  Oral presentation at the annual meeting of the Society for Social Work and Research. New Orleans, Louisiana.

    Dubber, S., Reck, C., Müller, M., & Gawlik, S. (2015). Postpartum bonding: the role of perinatal depression, anxiety and maternal–fetal bonding during pregnancy. Archives of Women’s Mental Health, 18(2), 187-195.

    Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387–422.

    Hjelmstedt, A., & Collins, A. (2008). Psychological functioning and predictors of father–infant relationship in IVF fathers and controls. Scandinavian Journal of Caring Sciences, 22(1), 72-78.

    Huth‐Bocks, A. C., Levendosky, A. A., Theran, S. A., & Bogat, G. A. (2004). The impact of domestic violence on mothers’ prenatal representations of their infants. Infant Mental Health Journal, 25(2), 79-98.

    Kabat-Zinn & Kabat-Zinn, (2014).  Everyday Blessings:  The Inner Work of Mindful Parenting. New York: Hachette Books.

    Lamb, M. E. (Ed.) (2010). The Role of the Father in Child Development (5th ed.). Hoboken, NJ: Wiley.

    Lieberman, A., Padrón, E., Van Horn, P., & Harris, W.W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26, 504–520.

    Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7(1), 13-30.

    Luz, R., George, A., Vieux, R., & Spitz, E. (2017). Antenatal determinants of parental attachment and parenting alliance: How do mothers and fathers differ? Infant Mental Health Journal, 38(2), 183-197.

    Mayseless, O. (Ed.). (2006).  Parenting representations: Theory, research, and clinical implications.  New York:  Cambridge University Press.

    Raphael-Leff, J. (2005). Psychological Processes of Childbearing. London: The Anna Freud Centre.

    Salihu, H. M., Salemi, J. L., Nash, M.C., Chandler, K., Mbah, A. K., & Alio, A.P. (2014). Assessing the economic impact of paternal involvement: A comparison of the generalized linear model versus decision analysis trees. Maternal and Child Health Journal, 18(6), 1380-1390.

    Sharps, P. W.,  Laughon, K.,  & Giangrande, S. K.  (2007).  Intimate partner violence and the childbearing year: Maternal and Infant Health Consequences.  Trauma, Violence & Abuse, 8(2), 105-116.

    Slade, A., Cohen, L. J., Sadler, L. S., & Miller, M. (2009). The psychology and psychopathology of pregnancy: Reorganization and transformation. In C. H. Zeanah, Jr. (Ed.), Handbook of Infant Mental Health (pp. 22-39). New York: Guilford Press.

    Solomon, J., & George, C. (1996). Defining the caregiving system: Toward a theory of caregiving. Infant Mental Health Journal, 17(3), 183-197.

    Vreeswijk, C. M. J. M.; Maas, A. J. B. M.; Rijk, C. H. A. M.; Braeken, J.; van Bakel, H. J. A. (2014).  Stability of fathers’ representations of their infants during the transition to parenthood.  Attachment & Human Development, 16(3), 292-306.

    Winnicott, D.W. (1987). Babies and their Mothers. New York: Addison-Wesley.

    Yarcheski, A., Mahon, N. E., Yarcheski, T. J., Hanks, M. M., & Cannella, B. L. (2009). A meta-analytic study of predictors of maternal-fetal attachment. International Journal of Nursing Studies, 46(5), 708-715.

    Zeanah, C.H., Carr, S., & Wolk, S. (1990). Foetal movements and the imagined baby of pregnancy: Ar

  • Integrated Health Care – Starfish’s Integrated Pediatric Approach

    Integrated Health Care – Starfish’s Integrated Pediatric Approach

    Jung Nichols, LLPC, Integrated Health Supervisor

    A great need for mental health services is recognized

    Many years ago, Starfish Family Services’ late CEO, Ouida Cash, and Oakwood Health Care (now Beaumont Health) submitted an application to the Health Resources & Services Administration (HRSA) to start a local Federally Qualified Health Center (FQHC) in Inkster, Michigan, which became Western Wayne Family Health Center.  Years after the clinic was established, the clinic staff realized there also was a great need for mental health resources, and the FQHC partnered with Starfish.  Initially, it began with a part-time therapist who worked in an office in the building.  They quickly learned that the outcomes they had hoped for were not being achieved. Transformation to a more integrated approach (as opposed to co-located model) began when Michelle Duprey from Starfish Family Services came on board around 2010 and worked closely with staff and with the support of the management.  They learned the valuable lesson that you can’t place a mental health professional into a medical clinic and think that integration will just happen because true integration requires change and transformation of culture, workflow, relationships and attitude.

    A unique and creative approach to meeting mental health needs

    About two years later, the Ethel and James Flinn Foundation granted funding, which was subcontracted to the Detroit Wayne Mental Health Authority, for Starfish to begin the Screening Kids in Primary Care Plus program.  This program was specifically designed to partner with pediatricians to embed a Pediatric Behavioral Health Consultant into their practice to provide screening, brief intervention, action plans, resources, referrals and consultation on children’s mental health issues. Although the grant ended years ago, the Detroit Wayne Mental Health Authority continues to support this important Wayne County initiative. During this time, the Authority also initiated the Pediatric Integrated Health Care Workgroup to ensure that work being done for the adult population was also being addressed for the pediatric population.  One result was the Wayne County Pediatric Integrated Health Care Concept Paper with Duprey as the lead author.  Starfish was awarded additional grants to continue integrated health care work and expanded to Integrated Infant Mental Health (I-IMH) with the help of a Flinn Foundation grant around 2013.

    A Comprehensive Team Approach

    Currently, the Starfish Integrated Health Care team has one director — Michelle Duprey, and two supervisors — Chy Johnson and Jung Nichols.  There are nine IMH therapists who provide specialized home-based Infant Mental Health therapy and are also embedded in OB/GYN settings (outpatient clinics and hospitals). This allows them to combine their specialized training with the OB/GYN team for optimal women’s health care.  The four full-time Behavioral Health Consultants and one Medical Care Coordinator, who are embedded in various medical settings including pediatrics, family medicine, and oncology, work alongside medical staff to provide behavioral health and community resource expertise.  Our staff are physically located right inside the medical setting.  This is the One Location, One Visit philosophy.

    This philosophy is described in the Pediatric Integrated Health Care Manual developed by Duprey, who is a national subject-matter expert on PIHC https://www.integration.samhsa.gov/integrated-care-models/children-and-youth

    One Location, One Visit

    One Location, One Visit ensures that the medical team has behavioral health expertise available on-site when patients come to see their doctor.  The goal is to treat the whole person, which means mind and body.  As behavioral health professionals, we know that social/emotional well-being impacts physical health and that physical well-being in return  impacts social emotional health.  Having a behavioral health professional on the medical care team allows the team to address the many concerns that may arise in various ways, including care coordination, referrals to specialty mental health treatment, and information about how to access community resources.  Families can also receive education and support about anything normative that comes up in primary care visits, such as child development, parenting/discipline, and educational needs.  This normalizes discussion about and awareness of behavioral health needs of their children, as well as knowing where to go for questions/concerns if they arise in the future.  We know that addressing emotional needs of families as early as possible can help with early detection and allows us to provide intervention before things develop into more serious conditions.  An added benefit is that the medical staff also receive education that allows them to become more aware of behavioral health and the impact on health behaviors and outcomes.

    Example #1: Intervention on behalf of a 5-year-old

    Cash, a 5-year-old boy, came to the primary care clinic for a Child Protective Services (CPS) physical following a referral from the school after Cash came to class with a gash on his head. When prompted, Cash told his teacher, “My mom gave me a whoopin’ with a belt.” The forehead mark was found to be from his 3-year-old brother, who threw a hammer at his head after Cash hit him with a broom. When Cash’s mom, Cheyanne, was interviewed by CPS, she admitted hitting him with a belt and leaving physical marks.

    Cash is in the Detroit Public Schools Head Start program. He has been suspended five times. He can no longer ride the bus because he jumped on a boy on the bus and started hitting him with his fist. He also tried to kick a female classmate down a flight of stairs. He is disruptive in class and frequently throws temper tantrums.

    Cheyanne is fed up, easily aggravated and worried. Cash’s little brother is reported to be “absolutely terrified of him.” His 7-year-old brother teases Cash and Cash reportedly gets easily angry and punches and spits on him. His biological father is only intermittently available to the family and Cheyanne worries because he has been diagnosed with bipolar disorder. Cash has an involved stepfather but he is not comfortable with discipline.

    An internal referral was made to Starfish and the family successfully enrolled in services.  For the past five months, they have been getting home-based services, which emphasize parenting/discipline and family relationships.  Cash is making progress and is no longer violently aggressive toward his brothers.

    Kelly Mainville, MS, LLPC

    Building relationships promotes health and wellness from the start

    A major component of Infant Mental Health Therapy (IMH) is to promote the health and wellness of a child through close, secure relationships and attachments with their caregivers. As an Integrated Infant Mental Health Therapist/Behavioral Health Consultant working in an OB/GYN clinic, I strive to promote and model close, secure relationships and attachments with patients so they can go on to promote that same relationship with their loved ones. I help the patient understand the importance of forming a secure relationship with their doctor to further promote health and wellness throughout their pregnancy and early post-partum period and get them in the good practice of relationship building. And while my role is most certainly to promote healthy mental well-being in patients, more than anything it is to help them feel supported and held during their visits to the clinic. My IMH training and expertise is the foundation of my work; I apply it to my interactions with the patients I see — pregnant or not. My focus is to build relationships, to promote health and wellness at any stage of reproductive health, and to support patients. I also do a lot of advocating for baby — before baby is even here — and educating the patient on the importance of forming a close, secure relationship with their unborn child.

    My work is slow but deliberate

    Like much of the work we do in Infant Mental Health Therapy, my work with patients is often slow, but deliberate, difficult at times, but so rewarding. To see a patient’s face light up because this is the first time someone has really asked “How are you doing?” and is willing to listen to her concerns and to support her, validates that this work is important. To have patients say “hello” or “I was hoping you would come see me today” means that the relationships I am building means something to them. A few weeks ago, I encountered a patient for the first time and when I described my role in the clinic, she started crying. Of course, I asked her if something was wrong and her response was “I’m just really happy that someone cares about us.” She stated that her hormones caused her to be overly emotional but she kept repeating how happy she was that someone was going to check in at each appointment and support her. Other patients have shared similar sentiments, shaking my hand or giving me a hug and telling me how grateful they are to feel supported during a mostly happy, incredibly transformational time in their lives.

    Example #2: Infant Mental Health Intervention with a Depressed Mom

    Recently, Rosa, a woman in her late 20s, came into the clinic for her 6-week post-partum checkup. It was apparent that she was exhausted — mentally, physically, and emotionally. She had made a few concerning comments to the medical assistant (MA) during her vitals check and the resident doctor about not being able to cope with the baby’s crying, feeling very sad, and feeling very isolated. Both the MA and the resident doctor conferred with me and together we decided that it would be beneficial if I could speak with her. I entered the room and immediately saw a woman who was struggling. She had showered, gotten dressed, and looked physically presentable, but I could see worry, fear, and trepidation in her eyes. Instead of my more formal introduction of what my role is in the clinic, I simply said “I’m Kelly and I’m here to see how you are doing.” The minute I said that I could see a shift; mom became tearful, but I saw relief wash over her, too. She began to tell me her story. She and her husband had decided that because of some health issues, they would have children soon after they married. Mom said,  “I’ve nannied before, but never for kids under 2. I didn’t realize how much babies cry and I can’t take the crying.” She also reported feeling alone and like a bad mom because she couldn’t figure out what was making her baby cry and because she couldn’t handle the crying. I spent about 20 minutes with her, reassuring her that what she was feeling was a feeling shared by many new moms, that she was doing her very best to meet her baby’s needs and keep him comfortable, and that while this seemed overwhelming right now, it would not last forever.  It was at this time that I realized what an amazing candidate this mom would be for Infant Mental Health Therapy. I explained the program to her and I could see even more relief wash over her. Unfortunately, I was unable to add her to my caseload, but I was able to place her with a teammate who is also a mom and someone I felt would be a great fit. I will now follow up with Rosa in the clinic at her next post-partum appointment (the resident and attending doctors both agreed she should come to at least one more to monitor her mental health) and check in with how IMH is working out for her. I have a lot of hope that this program will benefit her greatly and I am so happy that I could play such an integral role in getting her the support she needed. This family makes me further believe in the importance of having a trained infant mental health clinician working as a Behavioral Health Clinician in OB/GYN offices. I was able to provide immediate support, which facilitated her acceptance of a long-term intervention to ensure optimal mental well-being and a positive outcome for her and baby.

    Expanding the Model: Partnering with the University of Michigan

    Of course, I value and believe in my work within the OB/GYN clinic, as do many of the patients and clinic staff, but it’s about more than just one clinic believing in the Integrated Infant Mental Healthcare model. It’s about the importance of integrated health becoming a regular practice in all OB/GYN clinics state and nationwide. This is why we have partnered with the University of Michigan to conduct an Integrated Infant Mental Health study that will evaluate the effectiveness of the Integrated Infant Mental Health Model (I-IMH) on maternal and child outcomes, as well as estimating the cost for implementing and delivering the I-IMH intervention in OB/GYN clinics. The hope is to show that the Integrated Infant Mental Health Model is a worthwhile investment in OB/GYN clinics and that through its emphasis on relationship building and support, it can promote healthier maternal and child outcomes in the process. We are in the beginning stages of this study; recruiting patients and getting other clinics we are embedded in on board with participating is proving to be a challenge, but we are working hard to show that the Integrated Infant Mental Health Model works.