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

2. Outline Definitions: mind, mindsight, mentalizing
4/14/2017
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
H. Kim, Hennepin Women's Mental Health Program 2

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 4

5. MIND

6. Definition of Mind by 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
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 14

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. 4/14/2017
“Depression is the number one complication of childbirth” (Wisner, NEJM 2001)
Perinatal Depression: 10% in general population % in high risk groups
Perinatal Anxiety: 7-10%
Gestational Diabetes: 5% pregnancies
H. Kim, Hennepin Women's Mental Health Program 19

20. 4/14/2017
Women have x rate of depression vs. men Lifetime prevalence: 21.3% women and 12.7% men
Kessler RC, et al. J Affect Disorders 1993;29:85-96
H. Kim, Hennepin Women's Mental Health Program 20

21. Psychosis

22. 50% of women with PPD have depressive symptoms during pregnancy
4/14/2017
50% of women with PPD have depressive symptoms during pregnancy
H. Kim, Hennepin Women's Mental Health Program 22

23. Risks of Untreated Depression/Anxiety
4/14/2017
4/14/2017
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
H. Kim, Hennepin Women's Mental Health Program
H. Kim, Hennepin Women's Mental Health Program 23 23

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.

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 26

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

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

35. 4/14/2017
STRESS
H. Kim, HWMHP 35 35

36. STRESS affects mind/body and ability to mentalize
4/14/2017
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
H. Kim, HWMHP 36 36

37. Stress, Depression and Anxiety through a Functional Medicine lens
4/14/2017
Stress, Depression and Anxiety through a Functional Medicine lens
H. Kim, HWMHP 37 37

38. 4/14/2017
H. Kim, HWMHP 38 38

39. What is Functional Medicine? www.functionalmedicine.org
4/14/2017
What is Functional Medicine?
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
H. Kim, HWMHP 39 39

40. 4/14/2017
H. Kim, HWMHP 40 40

41. Some clinical imbalances underlying chronic medical conditions:
4/14/2017
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
H. Kim, HWMHP 41 41

42. Chronic Inflammation: the common final pathway to chronic disease42

43. 4/14/2017
H. Kim, HWMHP 43 43

44. Is depression an inflammatory condition?
4/14/2017
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
H. Kim, HWMHP 44 44

45. What causes chronic inflammation?
4/14/2017
What causes chronic inflammation?
Stress
Toxins
SAD diet
Lack of exercise
Hidden allergens/infections
H. Kim, HWMHP 45 45

46. What do you need to thrive?
4/14/2017
What do you need to thrive?
Safety
Sleep
Healthy Foods/Healthy Digestion
Light, water, air
Movement
Love, community, connection
Purpose
H. Kim, HWMHP 46 46

48. 4/14/2017
Sleep
H. Kim, HWMHP 48 48

49. SLEEP Average sleep in 1900 --- 9 hours
4/14/2017
SLEEP
Average sleep in 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 hrs/night
White men hrs/night
Black women hrs/night
Black men hrs/night
Poor sleep less than wealthy.
H. Kim, HWMHP 49 49

50. National Sleep Foundation Sleep in America Poll 2003:
4/14/2017
National Sleep Foundation Sleep in America Poll 2003:
% reporting <7 hrs
slept/weeknight
Ages 18 to
Ages
Ages
H. Kim, HWMHP 50 50

51. 4/14/2017
H. Kim, HWMHP 51 51

52. Sleep deprivation: the costs
Inhibits mentalizing (mind-blindedness)
Irritability
Poor concentration
Increased inflammation
Makes you fat
Increased risk of accidents

53. Healthy Nutrition and Digestion
4/14/2017
Healthy Nutrition and Digestion
H. Kim, HWMHP 53 53

54. 4/14/2017
H. Kim, HWMHP 54 54

55. Standard American Diet (SAD)
4/14/2017
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
H. Kim, HWMHP 55 55

56. Standard American Diet to New American Diet:
4/14/2017
Standard American Diet to New American Diet:
From SAD to NAD
Food Rules by Michael Pollan
1) What should I eat? -- Eat food
2) What kind of food should I eat? -- Mostly plants
3) How should I eat? -- Not too much
NAD: Real food, fresh fruits and vegetables, lean protein, moderate amounts of healthy fat, adequate fiber
H. Kim, HWMHP 56 56

57. 4/14/2017
H. Kim, HWMHP 57 57

58. 4/14/2017
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
H. Kim, HWMHP 58 58

59. Gut = the “second brain”
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

60. What sabotages healthy digestion?
4/14/2017
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.
H. Kim, HWMHP 60 60

61. 4/14/2017
H. Kim, HWMHP 61 61

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

63. Mind-Body Strategies Relax: breathing, yoga, meditation, prayer Sleep
4/14/2017
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
H. Kim, HWMHP 63 63

64. How to engage psychiatrist or other medical provider:
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

65. Integrative Health Resources
4/14/2017
Integrative Health Resources
Institute for Functional Medicine
Dr Mark Hyman:
Ultramind Solution or Ultrasimple Diet
Dr. Christiane Northrup:
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: )
H. Kim, HWMHP 65 65

69. Recovery from depression is a family affair
CBT in depressed teens was effective, but not if they had a parent who was currently depressed (JAMA. 2009;301(21): )
Treatment of depression in children not effective unless addressing needs of parents

70. 4/14/2017
4/14/2017
H. Kim, Hennepin Women's Mental Health Program
H. Kim, Hennepin Women's Mental Health Program 70 70

71. 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

72. Mother-Baby Model of Care
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

73. Mother-Baby Programs in UK, Australia, US
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)

74. 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

75. 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

76. Circle of Security Kent Hoffman, Glen Cooper, and Bert Powell
Relationship based early intervention program designed to enhance attachment security between parents and children

78. Shark music