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«Sara Zoeterman Submitted in partial fulfillment of the Requirements for the degree of Doctor of Philosophy Under the Executive Committee of The ...»

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In the Moment: Prenatal Mindful Awareness and its Relationship to Depression, Anxiety,

and Birth Experience

Sara Zoeterman

Submitted in partial fulfillment of the

Requirements for the degree of

Doctor of Philosophy

Under the Executive Committee of

The Graduate School of Arts and Sciences

COLUMBIA UNIVERSITY

2014

© 2013

Sara Zoeterman

All rights reserved

ABSTRACT

In the Moment: Prenatal Mindful Awareness and its Relationship to Depression, Anxiety, and Birth Experience Sara Zoeterman The transition into motherhood has long been conceptualized as a time of psychological upheaval. However, when examining rates of postpartum psychopathology, it appears that more women adapt well to this change than do not. In keeping with research in the fields of positive psychology and resilience, it appears that naturally occurring protective factors may aid a woman through this transition. This dissertation proposes the idea that qualities of mindfulness, while typically cultivated through training, may be naturally protective against psychopathology during times of adjustment and development.

Specifically, this paper examines the transition from pregnancy into the post-partum period. I examine pregnant women’s levels of mindful, momentary awareness and analyze how these levels predict the self-reported emotional experience of giving birth, as well as post-partum levels of anxiety and depression. Future directions and limitations are discussed.

TABLE OF CONTENTS

List of Tables…………………………………………………………………….ii Introduction……………………………………………………………………….1 Methods………………………………………………………………………….14 Results……………………………………………………………………………20 Discussion……………………………………………………………………….26 Tables…………………………………………………………………………….31 References………………………………………………………………………..44 Appendices……………………………………………………………………….51 Appendix A: Measures…………………………………………………...51 Appendix B: Informed Consent Form……………………………………55 Appendix C: IRB Approval………………………………………………57 Appendix D: Additional Analyses………………………………………..58

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Table 1: Descriptive Statistics for all variables……………………………………..31 Table 2: Correlations of all variables……………………………………………….32 Table 3: Regression Analysis: Time 1 Act Aware predicting Time 2 Depression…33 Table 4: Regression Analysis: Time 1 Act Aware predicting Time 2 Anxiety…….34 Table 5: Regression Analysis: Time 1 Act Aware predicting Negative Emotional Birth Experience…………………………………………………………………………..35 Table 6: Regression Analysis: Time 1 Act Aware predicting Positive Emotional Birth Experience…………………………………………………………………………..36 Table 7: Regression Analysis: Negative Birth Experience predicting Time 2 Depression…………………………………………………………………………..37 Table 8: Regression Analysis: Negative Birth Experience predicting Time 2 Anxiety………………………………………………………………………………38 Table 9: Regression Analysis: Positive Birth Experience predicting Time 2 Depression…………………………………………………………………………...39 Table 10: Regression Analysis: Positive Birth Experience predicting Time 2 Anxiety………………………………………………………………………………40 Table 11: Regression Analysis: Interaction of T1 ActAware x Negative Birth Experience predicting T2 Depression………………………………………………..41 Table 12: Regression Analysis: Interaction of T1 ActAware x Positive Birth Experience predicting T2 Depression……………………………………………….42 Table 13: Factor Structure of Birth Experience Variables…………………………..43

–  –  –

This dissertation was made possible by The Motherhood Project, which was conceived of, designed, and implemented by Aurelie Athan and Jeanette Sawyer-Cohen. I am grateful to have had full access to their data as the foundation of this project.

–  –  –

This dissertation is dedicated to my three guides. Each was essential in his way.

Thank you, To George, for helping me up when I was down and out, something that often goes under acknowledged yet is invaluable in life.

To Ezra, for very quickly teaching me more about mindfulness and motherhood than any scholarly endeavor ever could.

Finally, of course, to Isaac, for everything. You make all things possible.

–  –  –





Mindfulness has been implicated in the effective treatment of a wide range of psychiatric disorders not limited to but including depression, generalized anxiety, substance abuse, and borderline personality disorder (Segal, Williams, & Teasdale, 2002; Evans, Fernando, Findler, Stonewell, Smart, & Haglin, 2008; Witkiewitz, Marlatt, & Walker, 2005; Linehan, 1993). As a result, interventions that target mindfulness-related psychological processes have gained significant ground as a therapeutic tool both explicitly in the form of mindfulness-based therapies (e.g., Kabat-Zinn et al., 1992), and less directly as mindfulness-based therapeutic techniques are integrated as “active ingredients” in larger effective treatments such as Dialectical Behavior Therapy (Linehan, 1993). The application of these techniques has been expanded beyond treatments of psychiatric pathology to include the promotion of healthy psychological adaptation in the face of life stress in non-clinical populations. Mindfulness-based techniques, which purport to increase individual levels of empathy, compassion, and a focus on the present moment, have been shown to both improve coping with stress as well as encourage lasting psychological health in response to diverse set of stressors such as job-related stress, interpersonal difficulties, and parenthood (Klatt, Buckworth, & Malarkey, 2009; Barnes, Brown, Krusemark, Campbell, & Rogge, 2007; Duncan, Coatsworth, & Greenberg, 2009).

The focus of research in mindfulness to date has primarily been on the application of mindfulness-based techniques for individuals with deficits in coping or functioning rather than attempting to understand mindfulness as a common factor that may aid in the need for adaptation. This perspective suggests that mindfulness is common and that mindfulness-based therapies may be effective because they focus on a deficit that exists in individuals who are unable to cope well with adversity. In the current study, I will attempt to examine mindfulness as 1 a positive psychological factor that allows for coping among new mothers, as the transition to motherhood is a unique developmental time in a woman’s life that presents a significant opportunity for positive change or poor adaptation.

Stress and Motherhood Having a child has long been observed to result in upheaval in the lives of new parents (LeMasters, 1957). In particular for women gestating and giving birth to a child, symptoms of depression and anxiety have been shown to commonly emerge in response to pregnancy and new motherhood (Heron, O’Connor, Evans, Golding, & Glover, 2004). The etiology of these symptoms remains highly varied, from biological causes, such as fluctuations in the hormonal milieu, to social factors, such as family support or income (Kendall-Tackett, 2009).

During pregnancy as well as throughout the weeks and months following childbirth, new mothers are at risk for developing pathology, highlighting the psychological risks associated with the transition to motherhood. Approximately 7-15% of women develop depression in late pregnancy (Dietz et al., 2007), while around 10% of women develop non-psychotic postpartum depression following delivery (Bledsoe & Grote, 2006). In new mothers, some studies find a prevalence rate of up to 15% (O'Hara, 1997). Estimates of the prevalence of postnatal maternal anxiety range widely from 3% to 43% (Glasheen, Richardson, & Fabio, 2010). Research has shown that 4% of postpartum mothers had co-morbid anxiety and depression, while 16% had anxiety alone (Matthey, Barnett, & Howie, 2003). While depressive episodes have appeared to be more common, and thus the focus of research has been on depression in pregnant women and the post-partum period, some studies suggest that postpartum anxiety is more common than postpartum depression (Wenzel, Haugen, Jackson, & Brendle, 2005). However, it does appear that anxiety and depression are strongly linked, in that prenatal anxiety has been shown to be 2 predictive of postnatal depression, even when controlling for prenatal depression levels (Heron, O’Connor, Evans, Golding, & Glover). Anxiety and depressive disorders have been shown consistently to be highly comorbid in both during pregnancy and in the postpartum period (Stuart, Couser, Schilder, O’Hara, 1998; Andersson, Sundstrom-Poromaa, Wulff, Astom, & Bixo, 2010).

Having examined the rates of common pathology in pregnant women and new mothers, it becomes apparent that while these stages pose a challenge to women, more adapt well than do not. Despite the popular focus on pathology in pregnancy and new motherhood, it seems that most developing mothers are able to cope with the complicated mix of demands both internal and external, psychological and contextual, without developing symptoms that reach a clinical range. Our culture’s prevailing – and inaccurate – view seems to be that pregnancy and new motherhood represent a pathological time in a woman’s life. Rather, this developmental period simply poses complex psychological and practical challenges to the individual, and thus can be conceptualized as a major life event that presents a significant amount of stress and thus requires adaptation. As such, it may be valuable to understand how individuals adapt to stressful life events generally to better understand convergence and divergence with adaptation to motherhood.

Adaptation to stressful events The idea that most women cope well with the stressful life event of developing into a new mother (pregnancy and postpartum periods) is consistent with research on responses to other life stressors, where the modal outcome is healthy adaptation. The literature on resilience – the psychological concept wherein individuals are able to maintain stable functioning over time, particularly in the face of major stressors – has been important in the field’s thinking about 3 responses to stress (Bonanno, 2004). For example, after experiencing a potentially traumatic event, many individuals not only do not develop PTSD, the majority cope well and completely, while a smaller group sees a short disruption in functioning and then fairly quickly returns to preevent functioning levels (Bonanno, 2004). This response holds true for a number of other stressful life events such as becoming unemployed (Galatzer-Levy, Bonanno, & Mancini, 2010), losing a spouse (Bonanno, 2009), the birth of a child (Galatzer-Levy, Mazursky, Mancini, & Bonanno, 2011), as well as significant disease and physical injury (deRoon-Cassini, Mancini, Rusch, & Bonanno, 2010; Lam, Shing, Bonanno, Mancini, & Fielding, 2012). The research on responses to major life stressors has consistently demonstrated that individuals follow a number of patterns of response that are unique from one other in terms of course and outcome, but that the most common response is healthy adaptation (deRoon-Cassini, Mancini, Rusch, & Bonanno, 2010; Galatzer-Levy et. al., 2010, Bonanno, 2004).

The transition to new motherhood, in theory, should not be any different than any of those stressful life events. Theoretically, women who do not fall into the roughly 10-15% experiencing pathological symptom levels are likely to be coping well. These 85-90% are adapting well enough in the face of a stressful life event that they are not reporting pathological levels of symptomatology. What helps an individual cope with the stress of significant life events? Or, to paraphrase William James in his 1909 presidential address to the American Psychological Association (Froh, 2004), how can we understand the ability of an individual to cope and even grow throughout difficult developmental periods? Though such questions have been long standing in psychology, only recently have broad attempts been made to understand positive outcomes and healthy adaption in responses to significant life stressors, rather than maintaining a singular focus on negative or pathological outcomes of such experiences.

4 Positive Psychology Traditionally, psychology has been interested primarily in compiling and understanding diagnoses, reducing symptoms, and alleviating suffering. As a relatively new branch of western psychology, positive psychology has gained traction from a shared sense by some researchers and clinicians that examining psychology primarily from a deficits perspective is lacking.

Positive psychology, which finds its roots in phenomenology, existentialism, and humanistic psychology (Froh, 2004), takes the perspective that if we are only attempting to “fix what is broken”, we are only advancing the field – or helping the individual – from one direction.

Rather, what is emphasized in positive psychology is an examination of the factors that might allow individuals to cope, grow, and flourish through regular life experiences (Fredrickson, 2001; Seligman & Csikszentmihalyi, 2000; Gable & Haidt, 2005). In the fledgling stages of the life of positive psychology, it gained ground primarily as a philosophical shift to bringing a strengths-based, phenomenological perspective to the field’s thinking, as an attempt to balance out the prevailing deficits- or pathology-based perspective (Seligman & Csikszentmihalyi, 2000).



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