Self-Compassion and Mental Self-Compassion and Mental Distress Among Mothers of Distress Among Mothers of Hospitalized Preterm InfantsHospitalized Preterm Infants

Lois C. Howland, DrPH, MS, RNLois C. Howland, DrPH, MS, RNNancy Jallo, PhD, RNNancy Jallo, PhD, RNRita Pickler, PhD,RNRita Pickler, PhD,RN

Cynthia D. Connelly, PhD, RNCynthia D. Connelly, PhD, RNDale Glaser, PhD, RNDale Glaser, PhD, RN

AcknowledgmentsAcknowledgments Funding and collaborative support: Funding and collaborative support:

Faculty Incentive Award, Hahn School of Faculty Incentive Award, Hahn School of Nursing, University of San DiegoNursing, University of San Diego

Center for Biobehavioral Clinical Research (P30 Center for Biobehavioral Clinical Research (P30 NR011403, R. Pickler, Principal Investigator), NR011403, R. Pickler, Principal Investigator), School of Nursing, Virginia Commonwealth School of Nursing, Virginia Commonwealth UniversityUniversity

Neonatal Intensive Care Unit,Neonatal Intensive Care Unit,Sharp Mary Birch Hospital for Women and Sharp Mary Birch Hospital for Women and NewbornsNewborns

BackgroundBackground Incidence of preterm birth remains high at ~550,000 Incidence of preterm birth remains high at ~550,000

annually annually (Mathews, et al., 2011)(Mathews, et al., 2011)

Mothers of preterm infants have high levels of postpartum Mothers of preterm infants have high levels of postpartum mental distress (stress, anxiety, depression) mental distress (stress, anxiety, depression) (Vigod, et al., (Vigod, et al., 2010, Lefkowitz, Baxt, & Evans, 2010)2010, Lefkowitz, Baxt, & Evans, 2010)

Perinatal stress and anxiety linked to postpartum Perinatal stress and anxiety linked to postpartum depressiondepression (Drewett, et al., 2004) (Drewett, et al., 2004)

High levels of maternal postpartum distress can impair a High levels of maternal postpartum distress can impair a mother’s ability to care of her infant (mother’s ability to care of her infant ((Kingston, Tough, & (Kingston, Tough, & Whitefield, 2012)Whitefield, 2012)

Higher levels of self-compassion have been associated Higher levels of self-compassion have been associated with lower levels of depression, and better well-being with lower levels of depression, and better well-being (Allen (Allen & Leary, 2010)& Leary, 2010)

Defining Self-CompassionDefining Self-Compassion

“Self-compassion….entails three basic components: (1) extending kindness and understanding to oneself rather than harsh self-criticism and judgment; (2) seeing one’s experiences as part of the larger human experience rather than as separating and isolating; and (3) holding one’s painful thoughts and feelings in balanced awareness rather than over-identifying with them…..can be viewed as useful emotional self-regulation strategy…” (Neff, 2003)

Study AimsStudy Aims

To evaluate the relationship of reported self-To evaluate the relationship of reported self-compassion level with:compassion level with: Maternal mental distress measures: stress, anxiety, Maternal mental distress measures: stress, anxiety,

and depressive symptoms and depressive symptoms Maternal-infant responsiveness Maternal-infant responsiveness Sleep qualitySleep quality Amount of RGI intervention exposureAmount of RGI intervention exposure

Data Source: Data Source: The Maternal Relaxation Study The Maternal Relaxation Study

Theoretical framework: Theoretical framework: psychoneuroimmunology (PNI)psychoneuroimmunology (PNI)

Design: non-randomized, repeated measures Design: non-randomized, repeated measures intervention studyintervention study

Number of participants: 20Number of participants: 20 Number of study visits: 3 visits over 8 weeksNumber of study visits: 3 visits over 8 weeks Recruitment: recruited between April and Recruitment: recruited between April and

September, 2010September, 2010 Location of study visit: private area adjacent to Location of study visit: private area adjacent to

NICU, at the infantNICU, at the infant’’s bedside, or in the s bedside, or in the participantparticipant’’s home by preference of the mothers home by preference of the mother

Participant EligibilityParticipant Eligibility

Inclusion criteriaInclusion criteria >> 18 years old 18 years old One or more neonates currently in NICUOne or more neonates currently in NICU Infant gestational age 23-32 weeksInfant gestational age 23-32 weeks

Exclusion criteriaExclusion criteria Unable to read/write EnglishUnable to read/write English Current use of systemic steroidsCurrent use of systemic steroids Current treatment for chronic illness Current treatment for chronic illness Current treatment for psychiatric disorders (not Current treatment for psychiatric disorders (not

including postpartum depression)including postpartum depression) Currently using GI techniquesCurrently using GI techniques

Study ProceduresStudy Procedures

Data collection:Data collection: Completion of 6 questionnaires at each visitCompletion of 6 questionnaires at each visit Last visit includes interview on motherLast visit includes interview on mother’’s opinion of GI s opinion of GI

plus a self-reported measure of maternal-infant plus a self-reported measure of maternal-infant responsivenessresponsiveness

Compensation: Compensation: $20 cash or gift card for Visits 1 and 2, $40 cash or $20 cash or gift card for Visits 1 and 2, $40 cash or

gift card for last visit, keeps CD and CD playergift card for last visit, keeps CD and CD player

Self-Reported Behavioral MeasuresSelf-Reported Behavioral Measures

Intervention ProceduresIntervention Procedures

Relaxation guided imagery interventionRelaxation guided imagery intervention Mind-body intervention using mental images to Mind-body intervention using mental images to

produce a relaxed mental state produce a relaxed mental state

Daily listening to 20-minute RGI recordingDaily listening to 20-minute RGI recording

Set of 3 CD tracks that focus on specific outcomes:Set of 3 CD tracks that focus on specific outcomes: RelaxationRelaxation Working with difficult feelingsWorking with difficult feelings Increasing feelings of self-compassionIncreasing feelings of self-compassion

Change CD tracks every 2 weeks for 6 weeks then Change CD tracks every 2 weeks for 6 weeks then whichever CD track preferred for remainder of studywhichever CD track preferred for remainder of study

Measurement of InterventionMeasurement of Intervention

Weekly scripted phone call to mother to capture average Weekly scripted phone call to mother to capture average number of times she used the CDnumber of times she used the CD

Weekly averages from the 8 weeks on study were Weekly averages from the 8 weeks on study were aggregated to establish an overall aggregated to establish an overall ““average listening average listening frequencyfrequency”” Mean # times RGI used per week = 4.46 (SD = 1.77, Mean # times RGI used per week = 4.46 (SD = 1.77,

range 1.7-7.4)range 1.7-7.4)

Study Sample (N=20)Study Sample (N=20) Mean maternal ageMean maternal age = 27.3 years (SD 6.38, range 18-37) = 27.3 years (SD 6.38, range 18-37)

Race/ethnicityRace/ethnicity = 60% white, 50% Hispanic = 60% white, 50% Hispanic

Education levelEducation level = 100% HS grad or above (4/20 > college grad) = 100% HS grad or above (4/20 > college grad)

Marital statusMarital status = 50% not married = 50% not married

Family incomeFamily income = 50% <$40,000/year = 50% <$40,000/year

ParityParity = 35% one or more children = 35% one or more children

Breast-feeding statusBreast-feeding status = 100% breastfeeding at baseline = 100% breastfeeding at baseline

Mean infant LOSMean infant LOS = 62.3 days (SD 22.3, range 26 - 99) = 62.3 days (SD 22.3, range 26 - 99)

Mean GAMean GA = 29.2 weeks (SD 4.1, range 23-35) = 29.2 weeks (SD 4.1, range 23-35)

Mean Neonatal Morbidity Index scoreMean Neonatal Morbidity Index score = 4 (SD 1.1, range 2-5) = 4 (SD 1.1, range 2-5)

Self-Report MeasuresSelf-Report Measures

Variable Week 0µ (SD)

Cronbach’s α

Week 8µ (SD)

Cronbach’s α

Self-compassion 16.99 (3.51) .881 18.01 (3.10) .960

Perceived Stress 19.55 (5.75) .845 17.79 (5.80) .787

Depressive Symptoms

18.45 (11.89) .918 14.61 (11.79) .930

State Anxiety 42.05 (13.40) .950 39.42 (12.79) .944

Social Support 34.05 (5.39) .845 33.74 (8.69) .960

Sleep quality 9.75 (0.87) .725 7.68 (3.51) .734

Maternal-infant responsiveness

- - - - 91.47 (11.64) .877

Pearson correlations of self-compassion score with Pearson correlations of self-compassion score with biobehavioral outcomes and weekly RGI use biobehavioral outcomes and weekly RGI use

Variable mean score Mean self-compassion scale score

Week 0(N = 20)

Week 8(N = 18)

Perceived stress -.636** -.721**Depressive symptoms -.703** -.633**State anxiety -.739** -.409Sleep quality -.380 -.248Maternal-infant responsiveness -- .289Functional social support .592** .512*Weekly average RGI use -- .411*p-value 0.05 level **p-value 0.01 level

Summary of ResultsSummary of Results Lower self-compassion scores Lower self-compassion scores at Week 0 and Week 8 at Week 0 and Week 8

associated with higher scores in reported:associated with higher scores in reported: Stress Stress AnxietyAnxiety Depressive symptomsDepressive symptoms Sleep quality (poorer) Sleep quality (poorer)

Higher self-compassion scores Higher self-compassion scores at Week 8 positively at Week 8 positively correlatedcorrelated Greater RGI useGreater RGI use Higher maternal-infant responsiveness. Higher maternal-infant responsiveness.

Study ImplicationsStudy Implications Mothers of hospitalized preterm Mothers of hospitalized preterm

infants can experience high levels of infants can experience high levels of mental distress and lower levels of mental distress and lower levels of self-compassionself-compassion

Identifying effective strategies to Identifying effective strategies to enhance self-compassion in mothers enhance self-compassion in mothers of preterm infants may reduce of preterm infants may reduce mental distress, enhance sleep mental distress, enhance sleep quality, and improve the mother-quality, and improve the mother-infant relationshipinfant relationship

Study LimitationsStudy Limitations

Missing data: incomplete self-report data on two Missing data: incomplete self-report data on two participants for Week 8participants for Week 8

Overall sample size smallOverall sample size small No control comparison groupNo control comparison group Intervention fidelity – self-reportIntervention fidelity – self-report Varying infant medical conditions and length of stay (i.e., Varying infant medical conditions and length of stay (i.e.,

varying stress levels over time)varying stress levels over time) Intervention not available for mothers not fluent in Intervention not available for mothers not fluent in

EnglishEnglish

With appreciation to our study participants With appreciation to our study participants and….and…. NICU nurse sub-investigators:NICU nurse sub-investigators:

Sara Peterson, RNSara Peterson, RN Kathryn Sondreal-Evans, RNKathryn Sondreal-Evans, RN Catheline Seigmund, ALS, RNCatheline Seigmund, ALS, RN Anna Rickel, RNAnna Rickel, RN

SMBHWN Study CoordinatorSMBHWN Study Coordinator: : Kathy Arnell, RNCKathy Arnell, RNC

USD research assistantsUSD research assistants Heather Warlan, MSN, RNHeather Warlan, MSN, RN Linda Schaffer, PHD, RNLinda Schaffer, PHD, RN Elizabeth Light, BSN, RNElizabeth Light, BSN, RN