Cognitive Behavioural Therapy as an Intervention for New Mothers Postpartum Depression - Research Proposal Example

Cognitive Behavioral Therapy As an Intervention for New Mothers’ Postpartum Depression and Difficulties with Attachment to Their Newborns This study aims to test if Cognitive Behavioral Therapy (CBT) will be effective in helping women to deal with post partum depression (PPS) and attachment with their newborn infants. Thirty (30) women in the first trimester of gestation will be recruited from a local clinic to participate in this study. They will be randomly assigned to a control group and an experimental group. All the subjects will answer the Edinburgh Post Natal Depression Scale (EPDS) and the Beck Depression Inventory- II (BDI-II) before and after they give birth and the Mother-Infant Attachment Scale (MIAS) as an additional post test after they give birth. The only difference will be that the experimental group will undergo CBT session once a week. Results will be compared to validate if CBT has been instrumental in helping the experimental group manage their PPS and attachment issues or not. Introduction This study purports to answer the research question: To what extent does Cognitive Behavioral Therapy (CBT) help women with postpartum depression and difficulty with attachment to their infant as compared to women who do not receive CBT? Postpartum depression (PPT) affects a growing number of new mothers and its consequences for both mother and infant can be damaging. It usually occurs within four weeks after the birth of the infant (O’Hara, 1997), and affects one in every seven new mothers, reflecting a prevalence rate of 13% (Wisner et al., 2006; O’Hara & Swain, 1996). The seriousness of the impact of PPD has been alarming, making it an important public health problem (Cuijpers et al., 2008). To prevent PPS, Cognitive Behavior Therapy (CBT) has been known to be an effective intervention. It is a psychotherapeutic approach of training an individual to think of positive things instead of dwelling on the negative. Thus, it may provide significant impact on women with postpartum depression and difficulties with attachment to their infants. CBT can help the new mothers to understand how their thinking and behaviour affect their emotional state and this in turn affects their feelings and ability to attach to their babies. Review of Literature Depression Depression is associated with “feelings of extreme sadness” which not only last for long periods of time, but it is also recurrent and may further develop into suicidal tendencies (NHS, 2010). It is usually manifested with negative behaviors stemming from negative emotions. Sometimes, the person experiencing it is not even aware that he or she is undergoing depression. Its concept as a serious and debilitating illness, one which has had great impact globally, has become recognised within general medicine and the public eye in more recent times (NHS, 2010). In 1996, the World Bank published a report on the global burden of disease implicating the importance for the realisation that the impact of depression worldwide is vast. In 1990, 11 million sufferers of depression were identified in the US alone (Scott et al, 2003) . Cognitive Behavior Therapy Aaron Beck, one of the proponents of Cognitive Behavior Therapy (CBT), agrees that much of our psychological problems are caused by “cognitive distortions” due to our acknowledged human fallibility. Individuals who undergo depression have belief systems or assumptions that may have developed from their negative early experiences which were not resolved well. Thus the negative experiences may have lead to the development of dysfunctional beliefs about the world, which may easily be triggered certain events (Field, 2000). Beck (1987) came up with the concept of “negative cognitive triad” that describes the pattern that triggers depression. In the first component of the triad, the client exhibits a negative view of himself. He is convinced that he is to blame for whatever pathetic state he is currently in because of his personal inadequacies. Secondly, the client shows negative view of the world, hence, a tendency to interpret experiences in a negative manner. He nurtures a subjective feeling of not able to cope with the demands of the environment. Third and lastly, the client projects a gloomy vision of the future. He can only anticipate failure in the future. Beck (1975) developed a model to treat depression. He writes that, in the broadest sense, “cognitive therapy consists of all of the approaches that alleviate psychological distress through the medium of correcting faulty conceptions and self-signals” (p. 214) Specifically, it goes to the root of depressive self-schemata. “Depressive self-schemata have been defined as maladaptive cognitive structures, consisting of networks of information about the self, formed through developmental processes and social learning experiences, that negatively bias information processing and emotional and behavioral responding” (Beck, 1987; Brewer & Nakamura, 1984; Derry & Kuiper, 1981; Kovacs & Beck, 1978; Segal, 1988 as mentioned in Pace and Dixon, 1993, p.288). Stallard (2003) contends that the aim of CBT assessment is to develop a cognitive formulation of the problem and establish the relationship between environmental factors and internal features. He enumerates the aims of CBT intervention as follows: to increase the client’s self-awareness; to facilitate a better understanding of himself and to improve his self-control by developing more appropriate cognitive and behavioural skills. The therapist uses a variety of therapeutic strategies depending on what he decides will work on his particular client. He also delegates responsibility to his client by expecting him to do homework outside the therapy sessions. Homework or Task Assignment is aimed at positive behavior that brings about emotional and attitudinal change (Corey, 2005). Therapy for depressed clients focuses on their specific problem areas and involves doing activities to deeply process the problem and probable solutions. This can result not only in a client feeling better but also behaving in more effective ways. Clients feel overwhelmed with all their responsibilities and their inability to attend to all the details of their lives lead them to be depressed. The therapist usually needs to take the lead in helping clients make a list of their responsibilities, set priorities and develop a realistic plan of action. Because carrying out such a plan is often inhibited by self-defeating thoughts, it is well for therapists to use Cognitive Rehearsal techniques in both identifying and changing negative thoughts. If clients can learn to combat their self-doubts in the therapy session, they may be able to apply their newly acquired cognitive and behavioral skills in real-life situations (Corey, 2005, p.291) After undergoing intensive CBT, relapse prevention is essential. All throughout treatment, clients are encouraged to integrate the techniques they have learned in therapy in their daily lives with the goal of keeping CBT effective even when therapy ends (Roth, Eng and Heimberg, 2002). However, clients are also warned that they might still encounter difficult times in the future even after successful treatment but their newly acquired skills at dispelling negative thoughts and reactions must be at their disposal to use whenever they would need them and maintain the belief that a single difficult event is not a failure on their part. “An important goal of therapy should be to ensure that clients can apply cognitive and behavioral techniques on their own, with less reliance on the therapist over time, thus facilitating relapse prevention efforts.” (Roth, Eng and Heimberg, 2002, p. 453) Pace and Dixon (1993) have done a study to confirm that brief individual cognitive therapy, as compared with a no-treatment control condition, was effective in reducing depressive symptoms and the number of negative self-referent judgments. for mildly and moderately depressed college students. Depressed people appear to be more likely than non-depressed people to actively distort information about the self in negative ways that are consistent with the depressive features of their self-schemata (Haaga et al., 1991). Cognitive Behavior Therapists admit that Cognitive Behavior Therapy places central emphasis on the client’s cognition and behavior, but does not ignore emotions in the therapy process, rather, it is considered a by-product of cognition and behavior (Corey, 2005). Post Partum Depression Not all women are joyous and relieved after giving birth to their infants. Some mothers may be disengaged from their babies, talk less, have less facial expressions and touch their infants less frequently (Field et al., 2007). These women may resent having given birth as they realize that they do not own their lives anymore and are now responsible for their babies (Paris, Bolton & Weinberg, 2009). Research has shown that PPD has been found to result in the following: an increased risk of marital stress, and sometimes ending in divorce (Holden, 1991); increased incidences of child abuse and neglect (Buist, 1998), and reported cases of maternal suicide and infanticide (Sit et al., 2006). The children of the women experiencing PPD may suffer negative consequences such as increased risk of impaired mental and motor development, development of difficult temperament, poor self-regulation, low self-esteem and long-term behaviour problems (Beck 1999, Goodman & Gotlib 1999, Orvaschel et al. 1988,Wisner et al. 2006). Children may also manifest insecure attachment, difficulties in social interaction and cognitive difficulties which can interfere with their expressive language development (Hipwell et al., 2000; Dennis, 2004, Wiffen & Gotlib, 1989; Cox et al., 1987). Infants of women who are under Post Partum Depression may suffer disruption in the mutual regulatory interchange they share with their mothers, straining attachment processes. This also causes impairment in their social-relational learning and development as well as their ability to regulate their physiological, affective and interactional states (Brockington 2004; Teti 2000; Sokolowski et al. 2007). Studies have shown that the quality of early mother-infant relationship may be predictive of how a child would develop. Poor relationships may lead to development of diverse forms of psychopathology, behaviour problems and cognitive deficits (Feldman and Eidelman 2009; Lyons-Ruth 2008; Milgrom et al. 2004; Righetti-Veltema et al. 2003). Muñoz et al. (2010) recommend that pregnant women be routinely screened for possible depression and if they qualify to be at risk, they should receive preventive measures to reduce the likelihood of the depression developing into a clinical case during the pregnancy and after giving birth. They contend that pregnancy, postpartum and the early years of life are considered critical developmental stages when the health of both mother and child should be considered top priorities. They suggest the accessibility of mood management training, parent education, nutritional counselling, early childhood education and economic support for new parents and their families (Muñoz et al., 2010). Attachment Meredith Small (1999) reports that mothers are biologically predisposed to care for their infants. Nine long months in the womb, the fetus affects the mother and its dependence on her likewise affects her. For example, a stressed mother can hinder the normal brain processes of brain masculinization of her unborn child. T. Berry Brazelton, a prominent child psychologist claims, in a good interaction mother and baby synchronize with each other from the beginning, and that the pathways may be set up in intrauterine life ready to be entrained, especially by the mothers, immediately after birth" Infants given the opportunities to form attachments, be they secure or insecure ones, become attached to the person very familiar to them. Most of the time, it is their mothers. Children remain attached to their mothers or significant caregiver even if their attachment becomes insecure due to abuse or battering (Small, 1999). Attachment behaviors include sucking, clinging, crying, following, and smiling. Suomi (1978) believes that such responses reflect the infant’s effort to get and maintain physical contact or proximity with the mother. When they get separated, the infant reacts in such a way that manifests his separation anxiety. The infant, predisposed to the essence and presence of his mother, somehow knows her interaction pattern. In an experiment by Murray and Trevarthen (1986), mother and child interact over a life-size, closed-circuit television. The nine-month old baby exhibited attachment behaviors as he cooed and gurgled to his responsive live mother on the screen. However, when it is the tape-recorded mother’s interaction that was shown, the baby lost interest because the same mother was no longer responsive to his attachment behaviors. When the live mother was on again, the baby cheered up again. It can be assumed from this experiment that babies can not be fooled with mere models of their real mothers and shows that strong attachments boost familiarity and imprinting of her image and presence in his mind. A sensitive mother helps her child feel secure and a less attentive mother engenders insecurity. In the first few years of life, a child with a secure attachment can learn how to balance separation and reunion. He is unafraid when he gets separated from her, trusting that she will be back for him. On the other hand a child with an insecure attachment to his mother manifests panic, anger and a desperate search for her, thinking that she will never come back. When the mother returns, a host of responses may be observed of the child. Some children would be delighted and warmly embrace the parent; others would appear to be indifferent, withdrawn, hostile, uncertain or confused. The kind of response the child had led the psychological observers to develop the attachment categories of secure, avoidant, ambivalent and disorganized (Benoit, 2004). For the babys well being, secure attachments must then be combined with other basic competencies of parenting such as knowing when to feed, to comfort, and hold the baby, and the threats to the infants surviving. Smith (2006) claims that whatever the biological forces, parenting style is more influenced by other factors. Inexperienced mothers may not necessarily know how to care for their newborn infants automatically, but can learn it from observation of other mothers caring for their young. Biological connections between mother and child if present at birth may or may not be sustained. If mothers and infants are physically distanced, then this connection is disrupted. A child’s well-being is dependent on secure attachments combined with basic competencies in parenting like reading a baby’s signals for food, comfort, need to be held or worse, need for medical intervention (Smith, 2006). Biological studies indicate that when human babies are born, their brains are underdeveloped, hence are highly dependent and in constant need of care and nurturance from their mothers. Unlike other mammals like horses or cows whose offspring can stand on their own minutes after their birth, human biology draws both mother and newborn towards each other to ensure the survival of the infant (Smith, 2006). Some factors that may disrupt the synchronicity of a mother and child may be mismatches between the temperaments of mothers and infants. Clashing temperaments may create tension in the bond between mother and child.  “Temperament is a biological predisposition towards behaving in certain characteristic ways.  The mixture of the disposition of mother and child then is where biology and experience interconnect.” (Small, 2006, p. 58). Another source of tension or ambivalence in the mother-child bond is a mother’s inconsistency in giving due attention to her child. When a crucial change takes place such as the birth of a sibling or a mother’s return to employment, a child reacts by seeking the attention he used to enjoy constantly. Since children are not pleased with the change in their mother’s treatment of them, they resort to attention-seeking behaviors that almost always are not pleasant, hence, ensuing stress and tension in the mother-child relationship (Small, 2006). Methodology From the foregoing literature, the possible impact of the onset of PPD is likely to result in negative outcomes for both mother and infant. In order to prevent PPD, this study suggests the employment of Cognitive Behavior Therapy (CBT) during pregnancy and after birth. A randomized control study will be followed, using two subgroups of pregnant women randomly selected from a clinic. The experimental group will undergo CBT before giving birth while the control group will not. Both groups will complete both a pretest on their first trimester and a post test after giving birth. The test will be a questionnaire asking them mood questions that could determine if they are at risk for PPD. Sampling Thirty pregnant women in their first trimester will be randomly selected by a computer program to participate in this study. The program will likewise assign them to the group they will belong. These women go to the local clinic which provides obstetrical and gynaecological services. Research Design This research proposal seeks to answer: To what extent does Cognitive Behavioral Therapy (CBT) help women with postpartum depression and difficulty with attachment to their infant as compared to women who do not receive CBT? The chosen design was selected as it uses a control group a randomized assignment of the subjects to permit a fair comparison of the both groups. Randomized control study allows the researcher to observe the experimental group prior to treament and post treatment to further analyze how the independent variable has influenced the experimental group. It allows the researcher compare posttests of both the experimental and control groups. The design helps answer the research question by permitting the comparison of both groups. The experimental group will receive Cognitive Behavioral Therapy once per week and the control group will not receive CBT treatment. Each subject in the experimental group will complete a pre test and a post test to measure the benefit of the Cognitive Behavioral Therapy in the fist trimester of gestation and then again after birth. The pre test questionnaire will address mood and attachment related questions; such as if they have been experiencing any type of mood changes during the first trimester. In the case of attachment issues, they will be asked history of previous children, family dynamics, etc. The control group will also complete the pre-test/post-test to measure if there are any changes after birth again. Again the control group will be asked mood and attachment related questions to monitor if there are any changes after birth. According to Engel & Schutt (2010), internal validity is described as a criterion necessary to demonstrate causality; it is the ability to rule out all other alternative explanation. In the case of randomized control study there are no threats to internal validity because the assignment of subjects in the study is random and provides all samples the same opportunity to participate in the research. Campbell and Stanley proposed that “External validity asks the question of generalizability: To what populations, settings, treatment variables and measurement variables can this effect be generalized?” (Campbell & Stanley, 1966). The issues of external validity are related to the generalization and whether the results obtained from a small sample group selected to participate in the study can be generalized and can make predictions in regards to the entire population. In this study the sampling can be a representation of the entire population because there are only two characteristics required to participate; gender and pregnancy in the first trimester. Randomized control study in this research is an important representation of external validity because the samplings are being randomly selected and assigned to the experimental and control group, allowing a representation of the entire population in the selection. Measurement and Data Collection The instruments to be used in this study that will determine the likelihood of PPD are The Edinburgh Post Natal Depression Scale (EPDS), the Beck Depression Inventory- II (BDI-II) and the Mother-Infant Attachment Scale (MIAS) which will be administered to the mothers after delivering their babies to measure their attachment. Vivilaki et al. (2009) describe the EPDS as an effective screening instrument that detects depressive symptoms early as well as a sensitive instrument that determines major depression. The BDI-II complements the EPDS to measure depression. The EPDS is a 10-item self-report scale that describes symptoms of depression which include: inability to laugh and look forward to things with enjoyment, blaming oneself unnecessarily, anxious or worried, scared or panicky, inability to cope, difficulty to sleep, sad or miserable, crying and thoughts of harming oneself. Each question has four possible answers, graded depending on the severity or duration of each symptom. The questions are as follows: 1. I have been able to laugh and see the funny side of things. 2. I have looked forward with enjoyment to things. 3. I have blamed myself unnecessarily when things went wrong. 4. I have been anxious or worried for no good reason. 5. I have felt scared or panicky for no very good reason. 6. Things have been getting on top of me. 7. I have been so unhappy that I have had difficulty sleeping. 8. I have felt sad or miserable. 9. I have been so unhappy that I have been crying. 10. The thought of harming myself has occurred to me. On the other hand, the BDI-II is a 21-item self-report scale that measures the presence and intensity of depressive symptoms on a 4-pt. scale. The most recent version deleted the symptoms of weight loss, body image change, work difficulty, and somatic preoccupation and replaced it with four symptoms of agitation, worthlessness, concentration difficulty, and loss of energy (Vivilaki et al., 2009). This is the version that will be used in this study. 1. Sadness: I am sad all the time 2. Pessimism: I feel my future is hopeless and will only get worse 3. Past Failure: As I look back, I see a lot of failures 4. Loss of Pleasure: I cant get any pleasure from the things I used to enjoy. 5. Guilty Feelings: I feel quite guilty most of the time. 6. Punishment Feelings: I feel I am being punished. 7. Self-Dislike: I am disappointed in myself. 8. Self-Criticalness: I blame myself for everything bad that happens. 9. Suicidal Thoughts or Wishes: I would like to kill myself. 10. Crying: I feel like crying, but I cant. 11. Agitation: I am so restless or agitated that its hard to stay still. 12. Loss of Interest: Its hard to get interested in anything. 13. Indecisiveness: I have much greater difficulty in making decisions than I used to. 14. Worthlessness I dont consider myself as worthwhile as useful as I used to. 15. Loss of Energy I dont have enough energy to do very much. 16. Changes in Sleep Pattern I sleep most of the day. 17. Irritability I am irritable all the time. 18. Changes in Appetite My appetite is much greater than usual. 19. Concentration Difficulty I find I cant concentrate on anything. 20. Tiredness or Fatigue I am too tired or fatigued to do a lot of the things I use to do. 21. Loss of Interest in Sex I have lost interest in sex completely. To measure attachment between the mothers and their infants, the Mother-Infant Attachment Scale (MIAS) will also be used. It is a 15-item scale describing mothers’ feelings of attachment to their infants and rated with a 5-pt. Likert scale ranging from Strongly Agree, Agree, Undecided, Disagree and Strongly Disagree. The split half reliability was found to be 0.83 and there was high internal consistency. It has high face and construct validity. The English version of the items translated from the original Hindi scale are as follows (Bhakoo et al., 1994). 1. I feel that this child does not love me 2. I love this child so much that I can not bear to be away from him (her) even for a short time 3. This child is difficult to bring up 4. I am extremely proud of this child 5. When this child is out of my sight I always worry that some thing may happen to him (her) 6. I am annoyed by this child 7. It seems that this child has great fortune 8. It seems that this child obeys me 9. This child has troubled me a lot 10. This child is of my expectation 11. This child has increased our difficulties 12. I feel angry with this child 13. This child is much affectionate to me 14. This child seems to be a promising child 15. This child has a lot of patience Data Analysis and Statistics In this study, the constructs to be dealt with are post partum depression and attachment between mothers and their infants. Both are the dependent variables to the independent variable of CBT. This study intends to find out if CBT will have an effect on the subjects’ PPS and attachment to their infants once they give birth using the instruments of EPDS, BDI-II and MIAS as mentioned in the previous portion. Wainer and Braun (1988) explain that in quantitative research, construct validity begins with an initial concept, notion, question or hypothesis which determines which data is to be sought and the methodology that must be used to gather it. Such construct is made to interplay with the data in order to ‘validate’ the investigation, usually by the application of a test or some other process that manipulates variables. Cronbach and Meehl (1995) clarifies that the data yielded can either support or reject the construct which can now be elevated as a theory or a further hypothesis. Descriptive Statistics Heiman (2002) defines a variable as “any measurable aspect of a behavior or influence on a behavior that may change”. In this case, the variable that may influence behaviour or change is the CBT, which serves as the independent variable for the study. What is to be measured to determine change are the dependent variables of PPS and Attachment to the Infants of the pregnant women who will serve as subjects in this study. PPS will be measured by the EPDS and BDI-II tests while Attachment will be measured by the MIAS. Comparison shall be made from the results of the pre-test (before giving birth/ pre-natal) and the post test (after giving birth/ post-natal). Comparing the statistical data for this study may be done easily by filling out results in the following chart. Descriptive characteristics (including means, standard deviations, frequencies and percentages) will be calculated for each test and inputted in the chart. One chart will be for the control group (no CBT) and another chart will be for the experimental group (with CBT) Participants Results for EPDS Results for BDI-II Results for MIAS Pre-Natal Post-Natal Pre-Natal Post-Natal Post-Natal 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Inferential Statistics To the research question: “To what extent does Cognitive Behavioral Therapy (CBT) help women with postpartum depression and difficulty with attachment to their infant as compared to women who do not receive CBT?”, the following hypotheses are made for this study. It would be more practical to divide the research question into the dependent variables to be studied to see if the independent variable of CBT will have an effect on them. For the dependent variable of Post Partum Depression: Ho: Subjects who will receive CBT before and after childbirth will have the same level of post partum depression (PPS) as the subjects who will not receive CBT. H1: Subjects who will receive CBT before and after childbirth will have NOT have the same level of post partum depression (PPS) as the subjects who will not receive CBT. To test out this hypothesis, the results for the pre and post tests using the EPDS and BDI-II will be compared. If the subjects in the experimental group will yield lower scores that mean lower depression in the post test, it may imply that the CBT they have undergone had a positive effect on them, thus, the null hypothesis (Ho) will be rejected and the alternative hypothesis (H1) will be accepted. For the dependent variable of attachment: Ho: Subjects who will receive CBT before and after childbirth will have the same level of attachment to their infants as the subjects who will not receive CBT. H1: Subjects who will receive CBT before and after childbirth will have NOT have the same level of attachment to their infants as the subjects who will not receive CBT. To test out this hypothesis, the results for the post tests of the control and experimental groups using the MIAS will be compared. If the subjects in the experimental group will yield higher scores that mean higher attachment to their infants, it may imply that the CBT they have undergone had a positive effect on their attachment to their infants. Thus, the null hypothesis (Ho) will be rejected and the alternative hypothesis (H1) will be accepted. Conclusions and Recommendations for Future Research Post partum depression (PPS) has been gaining much attention lately since its prevalence among new mothers has reached proportions that would be considered a public health problem. One recommended intervention to prevent PPS is Cognitive Behavior Therapy (CBT). It is a psychological therapeutic approach that trains individuals to think of more positive thoughts and not dwell on negative beliefs, thus, positive behaviors will follow and the outcome would be more positive feelings. In the case of new mothers, undergoing CBT implies that they would have more optimistic dispositions towards motherhood, and in effect, PPS would be eliminated or at least well-managed, in case it surfaces after childbirth. Since PPS may also affect the mothers’ attachment to their infants, CBT is likewise meant to help new mothers form healthy attachments to their infants. This study attempts to test the effectiveness of CBT in reducing the likelihood of PPS in new mothers. Although it will only be use a small number of subjects, it will serve as a seed research study for further and larger-scaled research. It is recommended for replication with a larger number of subjects including cross-cultural research to determine if culture has an effect with PPS. Some cultures have more built-in support for new mothers while other cultures have none, or very little. It is also recommended that more instruments that measure PPS and mother-infant attachment will be developed and tested in future researches. References Beck, A.T. (1975) Depression: Cause & Treatment. Philadelphia: University of Pennsylvania, Press. Beck, A. T. (1978). Maladaptive cognitive structures in depression. American Journal of Psychiatry, 135, 525-533. Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quarterly, 1, 5-57. 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