!aamft book 2 part

Clinical Updates for
Family Therapists:
Research and Treatment
Approaches for Issues Affecting
Today’s Families
American Association for Marriage and Family Therapy The American Association for Marriage and Family Therapy promotes andadvances the common professional interests of Marriage and FamilyTherapists.
The American Association for Marriage and Family Therapy112 South Alfred StreetAlexandria, VA 22314703-838-9808www.aamft.org 2005 American Association for Marriage and Family Therapy. All rightsreserved. Printed in the United States of America. No part of this publica-tion may be reproduced, stored in a retrieval system, or transmitted, in anyform or by any means, electronic, mechanical, photocopying, recording, orotherwise, without the prior written permission of the publisher.
We are pleased to present Volume 2 of Clinical Updates for Family Therapists: Research and Treatment Approaches for Issues Affecting Today’sFamilies. Since 1999, the AAMFT has produced a new Clinical Update article every two months, to coincide with the publication of Family TherapyMagazine. This volume includes the 18 Clinical Updates that were originally pub-lished from 2002 through 2004. (Refer to the back of the book for a list of topicsincluded in Volume 1.) The articles have been reviewed by the authors and revisedto include the most up-to-date research and resources.
Clinical Updates are digests of the latest information about a topic, with refer- ences for more in-depth study. Clinicians find the Clinical Updates particularly use-ful when faced with a clinical issue they rarely see. Students of family therapy findthem an invaluable primer on the array of issues likely to be presented by clients.
My hope is that you will reach for it often, and that it will benefit both you andyour clients.
When each Clinical Update was originally published, a companion CON- SUMER Update on the same topic was published in the form of a brochure. TheConsumer Update brochures offer a way to inform clients about the topic andlearn how family therapy may help them. Further, the Consumer Update brochuresserve the clinician as a marketing tool to reach out to potential clients and referralsources, and let them know that the therapist is available to assist with the particu-lar problem discussed in the brochure. The Consumer Update brochures are stillavailable from the AAMFT. We invite you to consider purchasing some of thebrochures to market your expertise and your availability to the public.
We extend thanks to the authors of the Clinical Update chapters, both for their authorship of the original article as well as their review and update in preparationfor this publication. Your work continues to be a valued resource for the field.
Karen Gautney, M.S.
Deputy Executive DirectorAmerican Association for Marriage and Family Therapy TABLE OF CONTENTS
Postpartum Depression
Adolescent Self-Harm
Premarital Assessment
Caregiving for the Elderly
Panic Disorder
Alzheimer’s Disease
Adoption Challenges
Debbie Riley, M.S., and Ellen Singer, M.S.W.83 Bipolar Disorder
Borderline Personality Disorder
Obsessive Compulsive Disorder
Childhood Onset Mental Illness
Elisabeth R. Crim, Ph.D., and JoAnn C. Fitzpatrick, M.A. .139 Substance Abuse and Intimate Relationships
Intrafamilial Childhood Sexual Abuse
Mary Jo Barrett, M.S.W., and Terry S. Trepper .165 Juvenile Sexual Offenders
Sexual Minority Youth
Linda Stone Fish, Ph.D., and Rebecca G. Harvey, M.A. .197 Body-focused Repetitive Behaviors:
A Subgroup of Impulse-Control Disorders
Fred Penzel, Ph.D. .209
Treating Anger in Therapy
Key Aspects of Asperger’s Syndrome
Postpartum Depression
A CLOSER LOOK: UNDERSTANDING POSTPARTUM MOOD DISORDERS“M y baby had been crying for an hour. I felt nauseous. I had a four-year-old in the next room, a screaming baby and I feltmyself unraveling away from my backbone. I started to shake. The quivering came from the deepest part of my soul, a place that you’re onlyaware of when you’re about to die. I needed to throw up, but I couldn’t get outof bed. I tried to sit up, but my eyes couldn’t see and I was dizzy. I felt scared. Ithought I had made a horrible mistake. I didn’t want to take care of this baby.” In recent years, there has been increasing public awareness and growing concern about the necessity to educate and inform women and their familiesabout their risks for a mood disorder during pregnancy and/or postpartum.
Research indicates that women are more vulnerable for developing a moodor anxiety disorder in the months surrounding birth than at any other timein their life (O’Hara, 1999). Fifty percent to 80% of mothers will experiencesome change in their mental health within the first year after delivery.
Approximately 10% to 15% of these women are at risk for postpartumdepression with potentially serious consequences for themselves, their fami-lies and their newborns—the most devastating being suicide and infanticide.
There is a critical need for early assessment and effective treatment.
When ignored, the symptoms of a postpartum depression are far more likelyto exacerbate, to become treatment-resistant and cyclical in nature withdeleterious repercussions for the developing attachment relationshipbetween mother and child.
Additionally, there is growing evidence that a mother’s ongoing depres- sion may impair a child’s cognitive and social development (Murray, 1997).
With proper screening and risk assessment during pregnancy and in theearly months of the postpartum period, postpartum mood disorders arevery treatable and even preventable.
Marriage and family therapists (MFTs) are frequently called upon to Originally Published as Clinical Update January/February 2002 help families cope during tenuous periods along the lifecycle. The birth of ababy is a life cycle event of dramatic proportions. A physically and emotion-ally taxing experience, childbirth involves a renegotiation of family roles inorder to create a space for the newest member.
Stress in the postpartum period is a predictable developmental crisis that disturbs the equilibrium of the family system. For some women, a postpar-tum mood disorder is a maladaptive response to the normal and appropriatefeelings of loss that surround the birth of a child.
Shrouded in cultural myths and expectations, new parents tend to revel in the ideals that society promotes about motherhood and childbirth with-out accounting for the psychological, environmental, and biological stressesthat this normally joyful event brings to the family. As a result, new parentsoften fail to prepare themselves for the enormous emotional changes andphysical demands that occur after a baby’s birth, particularly during the firstyear. This lack of preparation leaves some women much more susceptible tothe hormonal and chemical changes that occur during pregnancy and afterchildbirth.
A woman may believe that mothering is an instinctive phenomenon that requires no outside training or influence, or that the bond with her babywill be immediate and intense. As she comes face to face with the contrastbetween her expectations and the reality, guilt and fear may interfere withany expression of conflicted feelings.
Because MFTs are privy to so much of a family’s biological and psycho- logical history, they are also in an excellent position to assess a woman’s riskfor postpartum depression even before she becomes pregnant. With anunderstanding of the emotional process and dynamic shifts that occur duringthe first year after birth, clinicians can help families create psychological sup-ports in advance of the postpartum period, as well as in the early months fol-lowing delivery, while normalizing this developmental transition for families.
DIAGNOSIS AND ASSESSMENT
What is postpartum depression?
Postpartum depression is a biological illness caused by changes in brain
chemistry that can occur following the birth of a child. During pregnancy,
hormonal levels elevate dramatically, particularly progesterone, estrogen,
and cortisol, falling rapidly within hours to days after childbirth. In addi-
tion, the amount of endorphins produced by the placenta during pregnancy
drops significantly after delivery.
Female reproductive hormones assist in maintaining the balance of neu- rotransmitters that regulate the chemical activity of the brain. A disruptionin that activity with a corresponding fluctuation in the normal levels of sero-tonin, norepinephrine, dopamine, and/or acetylcholine can lead to depres-sion, panic, and even psychosis. Even the thyroid gland can be affected bythe enormous chemical shifts associated with pregnancy and childbirth,leaving women more vulnerable to a depressive episode.
The literature on postpartum mood disorders makes a distinction American Association for Marriage and Family Therapy between postpartum depression and postpartum psychosis. Traditionally, the“baby blues,” was an umbrella term used to describe any postpartumdepression regardless of symptoms or severity. However, the blues is nowconsidered a part of normal postpartum adjustment because so manywomen, as many as four out of five, experience mild changes in their mentalhealth following childbirth. Characterized by tearfulness, irritability, anxiety,and feelings of being overwhelmed, the baby blues usually surface by daythree or day four postpartum. These symptoms are transitory, and generallydiminish by day 14 without any need for medical and/or psychologicalintervention. Because, however, some women go on to develop a majorpostpartum depression, women at risk should be monitored during this ini-tial period. Symptoms that persist or intensify beyond two weeks should beevaluated immediately to determine whether medical and/or psychologicalsupport is indicated.
Postpartum psychosis, a potentially life-threatening medical emergency is biochemical in origin. Approximately one to two out of every thousandwomen who give birth will experience a psychosis. If ignored, postpartumpsychosis can prove costly to both mother and child with suicide rates atapproximately 5% and the risk of infanticide at 4% (Bennett & Indman,2002). Notable about psychosis is its abrupt onset anywhere from 3 to 14days after childbirth. Significant confusion, disorientation, and rapid moodcycling often accompanied by auditory hallucinations and delusional think-ing are the predominant features of this illness. Mothers with postpartumpsychosis frequently have intrusive and obsessive thoughts about harmingtheir infant and/or themselves. Personal and family histories of women withpsychosis indicate a higher incidence of mood disorders, particularly bipolardisorder and schizophrenia.
At least 1 out of 10 women who give birth will develop a major depres- sive disorder with postpartum onset. Among the characteristic symptomslisted in diagnosis are dysphoric mood accompanied by sleep and appetitechanges, psychomotor disturbance, fatigue, excessive guilt, and suicidalideation. In addition, women with pronounced postpartum depressionexperience feelings of confusion and disorientation (they describe it as“being in a fog”) that is sometimes accompanied by memory impairment.
The singular feature that seems to distinguish postpartum disorders fromthe normal and appropriate stressfulness of the initial postpartum period isthe inability to sleep, despite exhaustion. What is especially striking andmost touching about a woman’s experience with postpartum depression isher own awareness that she is having difficulty engaging with her infant, yetfeeling immobilized to act on her intuitive sense. Some women describethemselves as “going through the motions” of caring for their newborn,but feeling emotionally detached.
While most of the symptoms of postpartum depression are generally akin to the DSM-IV’s (APA, 1994) diagnostic criteria for a major depressivedisorder, women with postpartum depression are especially prone to feelingsof guilt, anxiety and maternal inadequacy with accompanying distortions intheir thinking. They often feel frightened about being left alone with grave American Association for Marriage and Family Therapy concerns that they will be unable to cope with the overwhelming demandsof caring for an infant. Many women in the throes of this depression believequite genuinely that their infant would do better in the care of a differentmother, and they see themselves as replaceable. These overpowering feelingsof maternal inadequacy and incompetence surface with debilitating conse-quences for the new mother, resulting in her painful sense of helplessnessagainst seemingly unexplainable physiological and psychological forces.
Most often, new mothers find their depressive symptoms intensified by overwhelming feelings of anxiety that potentially can interfere with day-to-functioning, especially around caring for their infant. It is not uncommon,however, for postpartum depression to coexist with another diagnostic com-ponent such as a postpartum panic reaction or post-traumatic stress reac-tion. For others, the compelling feature of their depression is an obsessive-compulsive reaction in which they are plagued by spontaneously occurring,but repetitive and disturbing thoughts or images, usually having to do withharming their baby. Womens’ fears about acting on their thoughts usuallygenerates behaviors designed to reduce anxiety, like hiding knives, or ceas-ing to hold their infants for fear of dropping them. The obsessive compul-sive sub-type of postpartum depression can also involve repetitive behaviors,like diaper counting, or checking on the baby’s breathing many times dur-ing the infant’s sleep. Generally, these clinical varieties of postpartum mooddisorders originate with some family and/or personal history of anxiety dis-order, panic attacks, or obsessive-compulsive behaviors. Because childbirthis so physically and emotionally stressful, it frequently restimulates sensa-tions and memories of an earlier traumatic event for women diagnosed withpost-traumatic stress disorder.
Although the time frame for postpartum depression is the first four to six weeks following childbirth, any woman who has given birth within thepast year is vulnerable. Weaning a baby from the breast and the return ofthe menses are significant events that also affect the timing of a depression.
Many women frequently delay in asking for medical and therapeutic help out of shame, guilt, and mistaken beliefs that a “good mother” shouldbe content and capable of handling the overwhelming adjustment of caringfor a new baby with little or no need for her own care. Too often, familymembers and health care providers fail to recognize the symptoms of apostpartum depression, attributing a mother’s complaints instead to thestressful adjustment of caring for a new baby.
Who is at risk?
Although there is no exact way to predict the occurrence of a postpartum
depression, it is possible to identify the psychosocial factors that increase
risk. Isolating the numerous biological, environmental, and psychological
stressors that contribute to onset helps to determine the focus of treatment.
The most important risk factor for postpartum depression is a personal and/or family history of depression and/or bipolar disorder. In fact, morethan 50% of women who have had a previous postpartum depression are atrisk of a recurrent depression following a subsequent birth. Women are also American Association for Marriage and Family Therapy more vulnerable if they have been depressed during their pregnancy or havea history of premenstrual dysphoric disorder.
Stressful situations that include marital tension, health problems with the baby, a complicated pregnancy and/or delivery, and a lack of social sup-port also place a woman at increased risk for postpartum depression.
Among the psychological factors that set the stage for a postpartum mooddisorder are an early history of sexual abuse or trauma, chemical dependen-cy in the family of origin, ambivalent or negative feelings about the preg-nancy, and ambivalence about the maternal role.
Other issues that may have an impact on a woman’s mental health dur- ing the postpartum period are previous fertility problems and unresolvedlosses, such as miscarriage and stillbirth. It is not uncommon for delayedgrieving to date as far back as childhood experiences of loss, like divorce orthe death of a parent, and be restimulated by the birth of a child.
There are several screening tools used to detect postpartum depression, including the “Postpartum Depression Predictors Inventory” (Beck, 1998)and the “Antepartum Questionnaire” (Posner, 1997). The “EdinburghPostnatal Depression Scale” (Cox, Holden, & Sagovsky, 1987) has been themost widely used screening tool to assess for postpartum depression. Thisself-assessment scale consists of 10 short statements, each with four possibleresponses, designed to help the new mother report to the practitioner howshe has been feeling over a seven-day period. Responses are scored accord-ing to the increased severity of symptoms and receive a rating of 0, 1, 2, or3. Mothers who receive a total score above 12/13 are likely to be sufferingfrom a depressive illness.
The Postpartum Depression Screening Scale (Beck & Gable, 2002) tar- gets specific symptom areas like sleeping/eating disturbances, anxiety/inse-curity, mental confusion, and loss of self. The PDSS uses a 35-item Likert-type scale to assess for the severity of a woman’s depression within a two-week period. Both the Edinburgh and the PDSS are designed to identifypossible depression and not intended to replace clinical judgment.
TREATMENT OPTIONSDecisions about treatment for postpartum mood disorders vary according tothe severity of symptoms. Professional consensus, however, seems to supportthe use of antidepressant medications in combination with either interper-sonal or cognitive behavioral psychotherapy. Group psychotherapy has alsobeen found to alleviate some symptoms by reducing the feelings of isolationthat many women feel after childbirth and during a depression. The moresevere the depression, the more experts usually recommend the use of med-ication. Women who present a personal and/or family history of psychiatricillness tend to be good candidates for antidepressants or mood stabilizers.
Since the feelings associated with postpartum blues tend to ameliorate by two weeks, most women with “the baby blues” do quite well with addedrest and extra help caring for their infant, along with reassurance and emo-tional support that their feelings are normal and temporary. For the mother American Association for Marriage and Family Therapy with severe symptoms, such as suicidal or psychotic thoughts, hospitaliza-tion may be necessary to protect her and her child while the depression isbeing stabilized. Other symptoms that suggest the need for emergencytreatment include rapid weight loss without intentional dieting, refusal toeat, and sleep deprivation of more than 48 hours duration. In those extremecases when a mother is not responding to trials of medication or has a psy-chotic depression with postpartum onset, she may benefit from a course ofelectroconvulsive therapy. ECT or electroshock therapy involves the induc-tion of a series of brain seizures under anesthesia as a way of treating thedepression.
For women with depression that intensifies and persists beyond the time frame of the blues, psychotherapy provides a supportive framework in whichpsychosocial stressors can be addressed. At a psychological level, postpartumdepression is a reflection of profound feelings of loss that are left unex-pressed. Concurrent with the overwhelming demands of caring for an infantis a loss of time with one’s spouse, the loss of adult companionship, loss of apreviously known freedom and a departure from the way things were. Thestruggle for most families is their wish to return to that which is familiarand the conflicted feelings inherent in knowing that their lives will neveragain be the same.
A woman’s partner may have his own reactions to the birth of their child as he experiences the loss of time with his spouse or worries about hisnew role as a provider for the family. When a postpartum illness occurs, hemay have additional concerns about his wife’s health and fear that their livesare deteriorating as a result of her depression. Interestingly, most men whofind themselves caring for a partner with a postpartum mood disorder arenot strangers to depression themselves. History-taking frequently revealstheir personal knowledge of depressive illness, either because they have suf-fered from depression themselves or have experience with a family memberwho was challenged by some type of mood disorder. Their earlier experi-ence often heightens their emotional reactivity to the current situation.
Systemic Considerations
Whereas traditional treatment identified the woman as the patient, more
recent practice recognizes that the birth of a baby reverberates throughout
the family system and treatment goals must address the experience of the
entire family, particularly that of the marital couple. As family members
struggle with their own unspoken expectations of how things should be,
guilt and fear often interfere with a family’s comfort in talking about the
ambivalent feelings that are absolutely normal and appropriate during this
time.
Instability in the marital relationship is one of the key risk factors in the onset of a postpartum depression. Therefore, the initial therapeutic workshould strive to normalize the reactions of both partners and their individ-ual feelings of frustration, uncertainty, anger, and sadness that may createdistance between them. As MFTs assist the family in this reorganization ofroles, it may also be significant to explore with them ways in which they American Association for Marriage and Family Therapy BIOMEDICAL ISSUESA variety of antidepressant drugs are used to treat postpartum depression. Theseinclude the tricyclics, like Norpramin (desipramine) and Pamelor (nortriptyline), as wellas the SSRIs, of which the most commonly used are Prozac and Zoloft. Effexor andCelexa, two other drugs in the SSRI family of antidepressant medications, are also beingprescribed. The most frequent side effects associated with SSRIs are headache, anxiety,insomnia, nausea, and sexual dysfunction. Patients who use TCAs often complain aboutdry mouth and blurred vision. Less commonly used because of their deleterious sideeffects, but nonetheless effective in treatment resistant depressions, are the MAOinhibitors, i.e., Nardil and Parnate.
The most dangerous side effect of the MAOs is a hypertensive reaction, which, although reversible with medication, can be life threatening. This reaction is caused byan interactive effect between the drug and the absorption of large amounts of tyra-mine, a substance found in certain foods. Consequently, patients who take MAOs mustfollow a tyramine-restricted diet and avoid foods such as aged meats and cheeses,wine, and beer. Another disadvantage of MAO inhibitors is harmful interactions withother drugs such as Demerol, nasal decongestants, and certain asthma inhalers.
In some cases, depending on the antidepressant that is being used, mothers who begin a course of treatment need to be informed that it may take between three to sixweeks before they begin to feel better so that they don’t become quickly discouragedand quit taking their medication if they don’t feel more immediate results. Women alsoshould know that individual body chemistry and sensitivity to medication affects thetype and combination of drug choices. No single medication is effective for all women.
Because anxiety and agitation are often a component of postpartum depression, anti-anxiety drugs such as Ativan or Xanax may be used in conjunction with an antide-pressant to provide added symptom relief. In cases of more severe depression or apostpartum psychosis, lithium is sometimes given to counteract the uncomfortableeffects of rapid mood cycling. Thyroid medication also seems to alleviate depressivesymptoms in women with an underactive thyroid. Subsequently, therapists shouldencourage clients to have a medical evaluation so that organic causes for her emotion-al state are ruled out.
One of the most controversial issues facing breastfeeding mothers receiving treat- ment for postpartum depression is the safety of medication for their nursing infant.
Recent studies endorse Zoloft (sertraline) and Paxil (paroxetine) as top choices forbreastfeeding moms with little or no medication detected in infants (Moline, et al 2001).
Celexa (citalopram) and Prozac (fluoxetine) do enter breast milk in small amounts butare considered acceptable choices when mothers are not responding to Zoloft or Paxil.
Although some of the older tricyclic medications may cause more side effects in themother than the SSRIs, drugs like Tofranil (imipramine) or Pamelor (nortriptyline) may bemore effective for some mothers and are recommended as alternatives.
For severe depressions with psychotic features, it is often necessary to combine an antidepressant with an antipsychotic like Haldol or a mood regulator like lithium (adrug which is contraindicated for breastfeeding moms). Haldol, a widely used antipsy-chotic medication, is usually chosen over some of the newer drugs like Risperdal orZyprexa primarily because as of date, the latter two have not been tested enough inbreastfeeding mothers and their babies.
American Association for Marriage and Family Therapy have dealt with change and loss in the past, as this will have a bearing ontheir current behavior.
Transition to Motherhood
Pregnancy and delivery gives rise to a psychological process as many women
struggle with their notions of what constitutes a “good mother.” The
advent of motherhood also reconnects women with their earliest memories
and sensations of their experiences as daughters, and the birth of a child
rekindles those images. Inevitably, the quality of a woman’s past relationship
with her own mother has an enormous impact on her current responses to
her baby as she takes on this new role of “Mommy.”
Most women rely on their knowledge of their own mothers as a role model for motherhood. A woman’s previously unsatisfactory relationshipwith her own mother may create ambivalence about the maternal role, andleave the new mother feeling isolated and inadequate about her copingskills. Women with postpartum depression tend to question their ability todevelop a secure attachment to their infant and a genuine concern that theymay not have the emotional stamina to be appropriately responsive, ade-quately attuned, and sufficiently nurturing to meet the ongoing demands oftheir newborn.
Treatment consists of helping women after birth and even during preg- nancy to gain emotional access to some of the negative and confusingbeliefs that influence their behavior, thoughts, and feelings. Failure to man- POSTPARTUM DEPRESSION AND ITS REPERCUSSIONS ON THEFAMILYSYSTEMA systems approach offers the view that the functioning of one person in the fami-ly cannot be understood out of context of the people closely involved. Althoughwomen with postpartum depression were formerly perceived as the “identifiedpatient,” current thinking acknowledges that the birth of a baby creates a dynamicreaction throughout the family system.
Bowenian theory takes the perspective that individuals usually marry at the same level of differentiation, which directly affects the level of emotional reactivityand anxiety in the marital dyad. The case example in the chart indicates that bothindividuals have a history of depression and significant loss in their respective fami-lies. As their roles shift from couple to parents, there is a parallel process regardingthe feelings of loss in response to the enormous changes after childbirth. Althoughthe mother with postpartum depression is the “presented patient,” it is clear thatboth spouses are reacting with intensity to the changes in their lives. For the father inthis case example, his current feelings of fear, anger, helplessness, and confusion maybe a restimulation of his earliest experience of fear, anger, loss, and powerlessness.
Systemic treatment helps to reestablish emotional intimacy within the relation- ship by looking at the family as “patient,” and exploring the emotional experienceof everyone involved. Family treatment opens communication channels andenables partners to respond to each other more objectively and not reactively.
American Association for Marriage and Family Therapy Figure 1. Case Example: Couple Experiencing Postpartum Depression
Therapeutic Issues of
Family History
Changes After Childbirth Postpartum Depression
age the psychological tasks of the postpartum period, an inherent part ofthe transition to motherhood, is implicated in the downward spiral of cog-nitive and emotional processes that result in maternal depression.
Preventive Strategies
For women at high risk of developing a major depression with postpartum
onset, much of the treatment can begin during pregnancy with a preventive
program that entails starting psychotherapy several months before the due
date and then adding an antidepressant at the appropriate time. It is also
vital that families use this time to put an adequate support plan in place. In
this way, the new mother will be assured of receiving enough help with
household responsibilities and infant care in the weeks and months follow-
ing delivery. This plan ensures sufficient rest for the new mother and
reduces feelings of being overwhelmed, a common experience of the post-
partum mother. In addition, a good social support network might even
include some kind of weekly psychotherapy group to lessen a new mother’s
feelings of isolation.
REFERENCESAmerican Psychiatric Association (1994). Diagnostic and statistical manual of men- tal disorders (4th ed.). Washington, D.C.: American Psychiatric Association.
Moline, M. L., Kahn, D. A., Ross, R. W., Altschuler, L. L., & Cohen, L. S. (2001).
Postpartum depression: A guide for patients and families. Expert ConsensusGuideline Series. White Plains: Expert Knowledge Systems.
A brief article that gives a concise explanation of symptoms, risk factors andbiomedical issues as relates to the development of postpartum mood disorders.
American Association for Marriage and Family Therapy Murray, L., & Cooper, P. J. (Eds.) (1997). Postpartum depression and child develop- ment. New York: Guilford Press.
An informative and highly-referenced collection of clinical papers thatexplore the sociocultural and psychological impact of postpartum depres-sion on women and their families with a focus on the repercussions for themental health of the developing infant.
O’Hara, M. W., & Stuart, S. (1999). Pregnancy and postpartum. In R. G.
Robinson, & W. R. Yates (Eds.), Psychiatric treatment of the medically ill. NewYork: Marcel Dekker.
Research article that addresses assessment and treatment issues duringpregnancy and the postpartum period.
Screening Tools
Beck, C., & Gable, R. K. (2002). Postpartum Depression Screening Scale. Western
Psychological Services: Los Angeles.
Beck, C. T. (1998). A checklist to identify women at risk for developing postpar- tum depression. Journal of Obstetric, Gynecological, & Neonatal nursing, 27 (1),39-46.
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depres- sion: Development of the 10-item Edinburgh postnatal depression scale. BritishJournal of Psychiatry, 150, 782-786.
Posner, N. A., Unterman, R. R., Williams, K. N., & Williams, G. H. (1997).
Screening for postpartum depression: An antepartum questionnaire. Journal ofReproductive Medicine, 42 (4), 207-215.
RESOURCES FOR PRACTITIONERS
Books
In addition to the preceding books:
Bennett, S., & Indman, P. (2002). Beyond the blues: Prenatal and postpartum
depression. San Jose: Moodswings Press.
A treatment manual for the professional and non professional which offersinformation on assessment and treatment in a user friendly and concisemanner.
Burt, V. K., & Hendrick, V. C. (1997). Concise guide to women’s health. Washington, DC: American Psychiatric Press.
A thorough guide to assessing and managing psychiatric conditions inwomen with an emphasis on the biological, psychological and socioculturalfactors that influence a woman’s mental health.
Dunnewold, A., & Sanford, D. G. (1995). Postpartum survival guide. Oakland: A practical and comprehensive guide that addresses the range of postpar-tum adjustment problems. Good choice for clients, as well.
Hamilton, J. A., & Harberger, P. N. (Eds.) (1992). Postpartum psychiatric illness: a picture puzzle. Philadelphia: University of Pennsylvania Press.
One of the foremost works towards an understanding of postpartum mooddisorders, this book presents research and treatment considerations with anemphasis on the organic components of postpartum illness.
Kleiman, K. (2005). What am I thinking: Having a baby after postpartum depres- American Association for Marriage and Family Therapy Kleiman, K. (2000). The postpartum husband: practical solutions for living with post- partum depression. Xlibris Corporation.
Contains information and specific recommendations to help partners copewith the impact of depression after the birth of a baby.
Miller, L. J. (Ed.) (1999). Postpartum mood disorders. Washington, DC: American This is a comprehensive, well-organized and recent overview of all aspectsof postpartum mood disorders, including the effects of postpartum disor-ders on child-rearing.
Stern, D. N., Bruschweiler-Stern, N., & Freeland, A. (1998). The birth of a mother: How the motherhood experience changes you forever. New York: Basic Books.
An in-depth and sensitive look at the psychological processes involved aswomen move towards motherhood.
Organizations
Postpartum Support International
927 N. Kellogg Avenue
Santa Barbara, CA 93111
805-967-7636
www.postpartum.net
The purpose of the organization is to increase awareness among public andprofessional communities about the emotional changes that women oftenexperience during pregnancy and after the birth of a baby.
Depression After Delivery, Inc.
91 East Somerset Street
Raritan, NJ 08869
1-800-944-4773 (4PPD)
www.depressionafterdelivery.com
Depression After Delivery, Inc. is a national, non-profit organization thatprovides support for women with ante and postpartum depression. Itsfocus includes education, information, support groups, telephone supportand referral for women and families coping with mental health issues asso-ciated with childbearing, both during pregnancy and postpartum.
ABOUT THE AUTHOR
Diana Lynn Barnes, Psy.D., LMFT specializes in women’s health concerns and life
cycle changes, particularly those involving issues of pregnancy and birth. Dr. Barnes
is a frequently interviewed trainer and internationally recognized writer and presen-
ter on the subject of postpartum mood disorders. She has received acclaim as the
consultant for MSNBC’s “A Mother’s Confession” and Discovery Health
Channel’s “Medical Diary.” Dr. Barnes has appeared on CNN, Fox News, and
Lifetime Television, and is a frequent consultant for the print media. She is the past
president of Postpartum Support International, a Clinical Member of the AAMFT,
and CAMFT. She started The Center for Postpartum Health in Woodland Hills,
California in order to address the needs of pregnant and postpartum women and
their families. (www.postpartumhealth.com).
American Association for Marriage and Family Therapy

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