© Springer International Publishing AG 2018
Maria Muzik and Katherine Lisa Rosenblum (eds.)Motherhood in the Face of TraumaIntegrating Psychiatry and Primary Carehttps://doi.org/10.1007/978-3-319-65724-0_1313. Survivor Mom’s Companion: A Population-Level Program for Pregnant Women Who Are Survivors of Childhood Maltreatment: The Need for a Public Health Approach to Addressing Unresolved Maternal Trauma
(1)
School of Social Work, University at Buffalo/State University of New York, Buffalo, NY, USA
(2)
School of Nursing, University of Michigan, Ann Arbor, MI, USA
Abstract
Childhood maltreatment trauma is a key determinant in intergenerational patterns of maltreatment and psychiatric vulnerability in the U.S. and globally. These cycles of maltreatment and vulnerability intersect during the childbearing year, when unresolved maternal trauma from maltreatment adversely affects a woman’s perinatal mental health and offspring development. We can recognize unresolved maternal trauma in the form of posttraumatic stress disorder (PTSD) and symptomatology, and its complex forms or comorbidities. The childbearing year presents unique clinical realities in addressing the traumatic-stress related mental health needs of women, principally among them is the lack of available trauma-informed and PTSD-specific interventions. Consequently, we must develop and implement approaches that circumvent barriers to access and address these clinical realities. Ideal characteristics of such approaches for expanding mental health service delivery have been defined and include reach, scalability, and affordability. Approaches that have the promise of addressing the needs of survivors of childhood maltreatment and sexual trauma will also need to be positioned in trauma-informed environments, and be trauma-specific in nature. One targeted approach that is trauma-specific and which has the characteristics of being a promising novel approach to delivering perinatal mental health care is the Survivor Moms’ Companion (SMC). The SMC is a fully manualized, self-study, and structured-listening psychoeducational program for women who are survivors of childhood maltreatment and who are pregnant (“survivor moms”). The goal of the SMC program is to improve women’s obstetric, postpartum, and early parenting experiences, and enhance psychological functioning.
One in five women has a maltreatment history (Pereda et al. 2009; Stoltenborgh et al. 2011; World Health Organization 2014). The effects on the lives of women and their families, communities, and society have now been well characterized and have been portrayed in studies of mother-infant attachment, traumatic stress, neurobiology, and epigenetics. Together these provide evidence that childhood maltreatment trauma is a key determinant in intergenerational patterns of maltreatment and psychiatric vulnerability in the USA and globally. The Adverse Childhood Experiences (ACE) study demonstrated a profound “toxic stress” effect of abuse, neglect, and parental mental illness on life course health (Felitti et al. 1998). This level of population health adverse impact calls for augmenting clinical responses with frontline public health interventions that do not require diagnosis and individualized treatment.
Adversity brings significant costs. The WHO estimates that child maltreatment is responsible for almost a quarter of mental health disorders. Costs are on a par for all noncommunicable diseases (including cancer, obesity, diabetes, heart and respiratory diseases) (Sethi et al. 2013). In the USA, annual cost in relation to chronic illness is estimated at $80–$100 billion (Wang and Holton 2007; Gelles and Perlman 2012). In addition, US studies show that abused or neglected individuals have more neurodevelopmental deficits (Skowron et al. 2011), psychological and behavioral problems (Lansford et al. 2002), and involvement with child welfare services and the juvenile justice system; and, when adults, higher rates of sexual assault and domestic violence victimization (Hetzel and McCanne 2005), homelessness (Stein et al. 2002), and criminality (Widom 1989), as well as increased odds of perpetrating maltreatment or failing to protect (Thornberry and Henry 2013). Preventing maltreatment and breaking these intersecting cycles is thus a public health priority.
These cycles of maltreatment and vulnerability intersect during the childbearing year, when unresolved maternal trauma from maltreatment adversely affects bothher perinatal mental health (Seng et al. 2009) and her process of becoming a mother(Mercer 2004). We can recognize unresolved maternal trauma in the form of post-traumatic stress disorder (PTSD) symptomatology and through its complex forms or comorbidities. Having a maltreatment history carries a 12-fold risk for PTSD during pregnancy (Seng et al. 2009). PTSD overall is nearly twice as high during pregnancy (7.9%) (Seng et al. 2009) as for women generally (4.6%) (Resnick et al. 1993), with sociodemographic factors including younger maternal age, being African-American, living in poverty, lower levels of educational attainment, and higher levels of exposure to crime (Seng et al. 2009) potentiating risk. Sexual trauma, including childhood sexual maltreatment, appears to be a particularly salient trigger for active PTSD during pregnancy (Wosu et al. 2015). The process of becoming a mother can also be more difficult for women from families of origin where abuse, neglect, or impairment of the parents results in poor models to follow(Fraiberg et al. 1975). Although childhood maltreatment and sexual trauma occur at similar rates across the social gradient, women in low-resource perinatal settings experience PTSD in pregnancy at nearly fourfold higher rates (13.9 vs 2.9%) compared to more advantaged settings (Seng et al. 2008, 2009). This constitutes a health disparity that is addressable.
Attention to trauma and PTSD during pregnancy is clinically important for several reasons. First, PTSD is associated with behaviors that increase risk to mothers and babies such as substance misuse, inadequacy of engagement in prenatal care, and excessive weight gain (Morland et al. 2007). It is associated with low birth weight and shorter gestation (Seng et al. 2011a; Shaw et al. 2014; Yonkers et al. 2014), postnatal PTSD and depression, and impaired maternal-infant bonding (Seng et al. 2013; Muzik et al. 2013). Maltreatment history may also be associated with less sensitive parenting (Muzik et al. 2013, 2017), having a dysregulated infant (Feldman et al. 2009; Schore 2003), and greater risk of protective service involvement (Kim et al. 2014). Last, but certainly not least, past and current trauma are implicated in the risk for pregnancy-associated suicide and homicide, each of which accounts for more deaths than many of the obstetric complications commonly screened for in the course of routine prenatal care (Palladino et al. 2011; Romero and Pearlman 2012; Mokdad et al. 2004; Muzik et al. 2016).
Given such pervasive effects, it could be argued that trauma/toxic stress is akin to a contagion, one that we are ill-equipped to treat. To date, much of our efforts at containment are reactive rather than proactive, particularly when it comes to childhood maltreatment (Zimmerman and Mercy 2010). We have developed no immunization for this epidemic. Authors of a 2014 report for the US Substance Abuse and Mental Health Services Administration (SAMHSA) argue that “…behavioral health is the linchpin for the next era of public health” and that the science on toxic stress and trauma “…is as convincing as the germ theory was when the public hygiene movement began” (Shern et al. 2016). Our current reliance on individual psychotherapy to reactively address the effects of childhood maltreatment is one which is being called into question for a couple of important reasons. First, rates of mental health needs in general in the USA are high and cannot possibly be met using the current paradigm (Kazdin and Blase 2011). Unmet need for mental health services is widespread in the USA, representing over 7 million people and disproportionately affecting women and children and persons with low income (Roll et al. 2013). Second, there are many reasons people do not receive mental health treatment, due to issues of access and resource constraint, stigma, and cultural obstacles (Kazdin and Blase 2011). Both structural barriers (e.g., the inability to afford the cost of treatment and not knowing where to go for treatment) and attitudinal barriers (e.g., thinking one can handle the problem without treatment or that treatment would not help) have been identified among adults with mental illness and perceived unmet needs for treatment (Roll et al. 2013).
Specific to the childbearing year, there are several clinical realities that affect our ability to address the traumatic stress-related mental health needs of women. First, there are low rates of identification of depression, anxiety, and stress during the childbearing year and concurrently low rates of treatment uptake (Goodman and Tyer-Viola 2010; Kelly et al. 2001). Second, although exposure-based cognitive-behavioral therapies have an extensive evidence base for working with post-traumatic stress disorder sequelae, there are remaining questions about their use during pregnancy, due to a dearth of data regarding use in pregnancy (Arch et al. 2012), and inconclusive findings for effectiveness for trials to date (Madigan et al. 2015). Third, due to concerns about the advisability of psychiatric medication usage in pregnancy given the possibility of teratogenic and infant withdrawal effects, many women prefer non-pharmaceutical treatments (Battle et al. 2013).
In response to these clinical realities stated above, we, as clinicians, are tasked to develop approaches that have promise to circumvent barriers to access, feasibility, and acceptance. Kazdin and Blase suggest that we need “a portfolio of models” with “overlapping reach that can cover the swath of individuals in need of services,” which might include web- and phone-based interventions, providing treatment in everyday settings, using nontraditional providers, promoting self-help approaches, and use of media to communicate prevention and intervention messages (Kazdin and Blase 2011).
13.1 Ideal Characteristics of Novel Approaches to Meet This Large-Scale Need
A subset of characteristics has been suggested by Kazdin and Rabbitt as essential components for novel approaches that have promise for expanding models of service delivery and addressing the mismatches and gaps between need and provision of mental health care (Kazdin and Rabbitt 2013). These include reach, scalability, affordability, expansion of nonprofessional workforce, expansion of settings where services are provided, and flexibility and feasibility of intervention delivery (Kazdin and Rabbitt 2013). Reach refers to the capacity to reach people who have not been typically reached by traditional service delivery methods; scalability refers to the capacity for a model to be applied on a large scale; and affordability means that the cost of the model is comparatively low to usual models of care. Other essential components for novel approaches include expansion of the nonprofessional workforce to increase the number of providers who can offer interventions and expansion of settings where services are provided to bring interventions to locales and everyday settings where people are likely to participate or attend already. Lastly, feasibility and flexibility are necessary components for ensuring that interventions can be implemented and adapted to a variety of conditions and for diverse groups.
Kazdin and Rabbitt’s list of characteristics (Kazdin and Rabbitt 2013) is well aligned with the focus in population health interventions, where the emphasis is on “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,” also stated as aiming to improve health and health equity at the population level (Kindig and Stoddart 2003). Directing population-level health initiatives toward childbearing women is practical due to the frequency of antenatal and postnatal visits, which provide multiple opportunities for clinical contacts. Midwives and other perinatal team members have capacity to provide integrated frontline interventions. Pregnancy is an ideal time to focus on addressing trauma and toxic stress because there is the potential for primary prevention as well as improving lifespan maternal and infant outcomes. Public health resources already are strongly geared toward redressing inequity in perinatal outcomes for vulnerable populations, and the idea of universal and targeted services being balanced to optimize outcomes is already well established. Examples of public health initiatives in obstetrical care, for instance, include recommendation of folic acid supplementation to prevent neural tube defects (Williams et al. 2015) and the Back to Sleep campaign to prevent sudden infant death syndrome (Trachtenberg et al. 2012). A meta-analysis of 36 separate systematic reviews of public health interventions suggests that there is a wide variety of such interventions that could be readily conducted by midwives (McNeill et al. 2012).
Many interventions that align with a public health approach and also the Kazdin and Rabbitt recommendations (Kazdin and Rabbitt 2013) for optimal characteristics for novel psychotherapeutic approaches are psychoeducational in nature. Psychoeducation has been defined as the provision of information, together with skill building, and emotional support, and is a fairly widespread mental health-care strategy (Lukens and McFarlane 2004; Mechanic 2002). Psychoeducation is one of the most effective of evidence-based practices for both clinical trials and community settings (Lukens and McFarlane 2004). Psychoeducation is an excellent way to promote mental health literacy (knowledge and beliefs about mental health) (Jorm 2012) and has been identified as a key facilitator to formal help seeking among young adults (Taylor-Rodgers and Batterham 2014).
13.2 Need for a Targeted Trauma- and PTSD-Specific Intervention for Maternity Care
Approaches that have the promise of addressing the needs of survivors of childhood maltreatment and sexual trauma will also need to be positioned in trauma-informed environments and be trauma-specific in nature. The SAMHSA’s National Center for Trauma-Informed Care (NCTIC) defines a trauma-informed environment as one that realizes the widespread impact of trauma, recognizes the signs and symptoms of trauma, responds by fully integrating knowledge about trauma at all levels, and seeks to actively resist re-traumatization (National Center for Trauma-Informed Care an Alternatives to Seclusion and Restraint (NCTIC) 2015a). Being trauma informed is not a “treatment” per se, but rather a set of guiding principles that can be used across multiple settings. Trauma-specific interventions differ in that they are “interventions or treatments designed specifically to address the consequences of trauma and to facilitate healing;” many such interventions are described on the NCTIC website (NCTIC 2015b).
The process of translating trauma-informed care into perinatal settings is beginning (Seng and Taylor 2015), and having a trauma-specific intervention widely available would be a useful catalyst for moving forward. Lack of broad availability of manualized interventions with published efficacy or effectiveness studies represents an important barrier to assessing for trauma in perinatal settings. Health-care workers who are providing pregnancy care are reluctant to ask about trauma exposure if there are not readily available corresponding resources to offer women. Furthermore, women are understandably reluctant to disclose their history of traumatic exposure if they perceive that the environment does not stand ready to provide such resources (Seng et al. 2008). Unfortunately, this means that the needs of women with abuse-related traumatic sequelae frequently are not coming to the attention of maternity care providers (Seng et al. 2008). In the absence of trauma-informed care, the predominant collective focus has been on depression, which overlaps with PTSD but does not capture all the manifestations of trauma-related disorders, and which is often addressed as an endogenous rather than a trauma-related disorder. Furthermore, due to the absence of attention to trauma and PTSD in pregnancy, we as clinicians are only just beginning to measure and understand the impact of pregnancy PTSD on perinatal outcomes and population health.
At this time perinatal professions are beginning to renew their focus on psychosocial needs among pregnant women (Renfrew et al. 2014; National Institute for Health and Care Excellence 2014), and pediatric professionals are strongly focusing on preventing and redressing traumatic and toxic stress among young children. The rest of this chapter focuses on one trauma-specific psychoeducational intervention for women during pregnancy.
13.3 Description of the Survivor Moms’ Companion and Its Beginning Evidence Base
One targeted intervention that is trauma specific and which has the characteristics of being a novel and promising approach to delivering perinatal mental health care is the Survivor Moms’ Companion (SMC). The SMC is a pregnancy intervention that fills a frontline services gap in perinatal health by addressing maltreatment-related traumatic stress sequelae and maternal role development needs in tandem. The SMC is a fully manualized, self-study and structured-listening psychoeducational program for women who are survivors of childhood maltreatment and who are pregnant (survivor moms). The SMC possesses the ideal characteristics outlined by Kazdin and Rabbitt (2013) as being recommended for novel approaches to provision of mental health care. It was designed to be offered via primary health-care settings by nurses, social workers, or potentially outreach workers as a means for addressing the needs of pregnant women who have experienced sexual trauma and who may be experiencing symptoms of post-traumatic stress disorder; in this way, there is potential to reach the target population and expand the nonprofessional workforce. The intervention can be delivered via in-person or telephone sessions and could articulate well with home-visiting programs; in this way it has the potential to expand the types of settings where services are provided. The SMC’s frontline approach is congruent with the concept of an integrated primary mental health-care (IPMHC) model (Cheng 2000); embedding the intervention in the context of integrated care carries with it the possibility of scalability. It is affordable in comparison with usual specialty care for mental health treatment. The intervention is designed to broadly meet the needs of women with abuse history, whether or not they meet any formal diagnostic criteria for a mental disorder, yet, consistent with the IPMHC model, also provides case finding and treatment engagement for the estimated 10–15% of women who might also benefit from referral for treatment with one-on-one psychotherapy and/or psychiatric medication. In this way, the SMC is flexible, and pilot testing shows that it is feasible to deliver in low-resource settings (Sperlich et al. 2011).
The SMC’s psychoeducation content is informed by the developers’ clinical experiences as midwives working with women who have survived sexual abuse and is responsive to several issues raised by women through extensive qualitative research on the part of the developers (Seng et al. 2002; Sperlich and Seng 2008). Women shared that they struggled with being “triggered” into intrusive re-experiencing of trauma during pregnancy, including during medical procedures and labor. They shared that they often used dissociative coping or experienced emotion dysregulation, often in the form of anger and hopelessness. Many women shared their interpersonal struggles in the context of their maternity care relationships—they reported being slow to trust, fast to anger, and easily re-traumatized by aspects of the maternity care experience. These themes from the early studies underpinning the SMC were affirmed in a recent meta-synthesis (Montgomery 2013). The format was also based on this intervention development research (Seng et al. 2002; Sperlich and Seng 2008). Women desired a safe relationship with a consistent person but generally were not willing to use psychotherapy. They wanted help to develop social support outside their family, flexibility in addressing past trauma versus staying present focused, and choices about disclosing details of their history versus speaking in generalities. Many expressed a desire for their trauma-related concerns to be addressed in the context of their maternity care. Importantly, many women had no words for what they were experiencing. Taken together, this suggested that a present-focused, psychoeducational intervention would be acceptable, especially if there was an option to practice skills in vitro with avatars in lieu of personalizing the skills practice to their in vivo situation. The role women seemed to prefer was that of a “tutor” who helped with learning and skills practice rather than a therapist whose focus would be to help with treating clinical distress and impairment. The SMC is a ten-module self-study program designed to be completed during pregnancy. Rather than being diagnosis based, it is population based, meaning that women with a history of childhood maltreatment or sexual trauma who do not meet criteria for PTSD diagnosis may self-refer to the program. Women can also be referred to the program through their maternity care provider. The SMC has the standard features of other psychoeducation in that it focuses on information giving, skills training, and addressing emotional support needs. The woman reads the weekly self-study modules, which begin with an orienting set of questions, learning objectives, and written information on various topics related to trauma, PTSD, and childbearing. Skills building takes the form of problem-solving in relation to vignettes of other women’s experiences who have survived abuse, based on characters created for the program who typify various issues related to traumatic sequelae, including PTSD symptomatology. There are questions that allow the woman to personalize the skills practice to her own situation if she so chooses. Each module ends with questions designed to help the woman structure the focus of her subsequent interactions with her assigned SMC “tutor.”
Related posts:
Mental Health Problems Among Childbearing Women: Historical Perspectives and Social Determinants
Enhancing Emotion Regulation: The TARGET Approach to Therapy with Traumatized Young Mothers
Project BRIGHT: An Attachment-Based Intervention for Mothers with Substance Use Disorders and Their Young Children
The Effects of Intimate Partner Violence on the Early Caregiving System
Trauma Exposure: Consequences to Maternal and Offspring Stress Systems
The Slippery Slope of Birth Trauma
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