1. Self-Compassion and Mental Distress Among Mothers of Hospitalized Preterm Infants Lois C. Howland, DrPH, MS, RN Nancy Jallo, PhD, RN Rita Pickler, PhD,RN Cynthia D. Connelly, PhD, RN Dale Glaser, PhD, RN

2. Acknowledgments Acknowledgments Funding and collaborative support: Funding and collaborative support: Faculty Incentive Award, Hahn School of Nursing, University of San Diego Faculty Incentive Award, Hahn School of Nursing, University of San Diego Center for Biobehavioral Clinical Research (P30 NR011403, R. Pickler, Principal Investigator), School of Nursing, Virginia Commonwealth University Center for Biobehavioral Clinical Research (P30 NR011403, R. Pickler, Principal Investigator), School of Nursing, Virginia Commonwealth University Neonatal Intensive Care Unit, Sharp Mary Birch Hospital for Women and Newborns Neonatal Intensive Care Unit, Sharp Mary Birch Hospital for Women and Newborns

3. Background Incidence of preterm birth remains high at ~550,000 annually (Mathews, et al., 2011) Incidence of preterm birth remains high at ~550,000 annually (Mathews, et al., 2011) Mothers of preterm infants have high levels of postpartum mental distress (stress, anxiety, depression) (Vigod, et al., 2010, Lefkowitz, Baxt, & Evans, 2010) Mothers of preterm infants have high levels of postpartum mental distress (stress, anxiety, depression) (Vigod, et al., 2010, Lefkowitz, Baxt, & Evans, 2010) Perinatal stress and anxiety linked to postpartum depression (Drewett, et al., 2004) Perinatal stress and anxiety linked to postpartum depression (Drewett, et al., 2004) High levels of maternal postpartum distress can impair a mother’s ability to care of her infant ( (Kingston, Tough, & Whitefield, 2012) High levels of maternal postpartum distress can impair a mother’s ability to care of her infant ( (Kingston, Tough, & Whitefield, 2012) Higher levels of self-compassion have been associated with lower levels of depression, and better well-being (Allen & Leary, 2010) Higher levels of self-compassion have been associated with lower levels of depression, and better well-being (Allen & Leary, 2010)

4. Defining 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)

5. Study Aims To evaluate the relationship of reported self- compassion level with: To evaluate the relationship of reported self- compassion level with: Maternal mental distress measures: stress, anxiety, and depressive symptoms Maternal mental distress measures: stress, anxiety, and depressive symptoms Maternal-infant responsiveness Maternal-infant responsiveness Sleep quality Sleep quality Amount of RGI intervention exposure Amount of RGI intervention exposure

6. Data Source: The Maternal Relaxation Study Theoretical framework: psychoneuroimmunology (PNI) Theoretical framework: psychoneuroimmunology (PNI) Design: non-randomized, repeated measures intervention study Design: non-randomized, repeated measures intervention study Number of participants: 20 Number of participants: 20 Number of study visits: 3 visits over 8 weeks Number of study visits: 3 visits over 8 weeks Recruitment: recruited between April and September, 2010 Recruitment: recruited between April and September, 2010 Location of study visit: private area adjacent to NICU, at the infant’s bedside, or in the participant’s home by preference of the mother Location of study visit: private area adjacent to NICU, at the infant’s bedside, or in the participant’s home by preference of the mother

7. Participant Eligibility Inclusion criteria Inclusion criteria > 18 years old > 18 years old One or more neonates currently in NICU One or more neonates currently in NICU Infant gestational age 23-32 weeks Infant gestational age 23-32 weeks Exclusion criteria Exclusion criteria Unable to read/write English Unable to read/write English Current use of systemic steroids Current use of systemic steroids Current treatment for chronic illness Current treatment for chronic illness Current treatment for psychiatric disorders (not including postpartum depression) Current treatment for psychiatric disorders (not including postpartum depression) Currently using GI techniques Currently using GI techniques

8. Study Procedures Data collection: Data collection: Completion of 6 questionnaires at each visit Completion of 6 questionnaires at each visit Last visit includes interview on mother’s opinion of GI plus a self-reported measure of maternal-infant responsiveness Last visit includes interview on mother’s opinion of GI plus a self-reported measure of maternal-infant responsiveness Compensation: Compensation: $20 cash or gift card for Visits 1 and 2, $40 cash or gift card for last visit, keeps CD and CD player $20 cash or gift card for Visits 1 and 2, $40 cash or gift card for last visit, keeps CD and CD player

9. Self-Reported Behavioral Measures Self-Reported Behavioral Measures

10. Intervention Procedures Intervention Procedures Relaxation guided imagery intervention Relaxation guided imagery intervention Mind-body intervention using mental images to produce a relaxed mental state Mind-body intervention using mental images to produce a relaxed mental state Daily listening to 20-minute RGI recording Daily 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: Relaxation Relaxation Working with difficult feelings Working with difficult feelings Increasing feelings of self-compassion Increasing feelings of self-compassion Change CD tracks every 2 weeks for 6 weeks then whichever CD track preferred for remainder of study Change CD tracks every 2 weeks for 6 weeks then whichever CD track preferred for remainder of study

11. Measurement of Intervention Weekly scripted phone call to mother to capture average number of times she used the CD Weekly scripted phone call to mother to capture average number of times she used the CD Weekly averages from the 8 weeks on study were aggregated to establish an overall “average listening frequency” Weekly averages from the 8 weeks on study were aggregated to establish an overall “average listening frequency” Mean # times RGI used per week = 4.46 (SD = 1.77, range 1.7-7.4) Mean # times RGI used per week = 4.46 (SD = 1.77, range 1.7-7.4)

12. Study Sample (N=20) Mean maternal age = 27.3 years (SD 6.38, range 18-37) Mean maternal age = 27.3 years (SD 6.38, range 18-37) Race/ethnicity = 60% white, 50% Hispanic Race/ethnicity = 60% white, 50% Hispanic Education level = 100% HS grad or above (4/20 > college grad) Education level = 100% HS grad or above (4/20 > college grad) Marital status = 50% not married Marital status = 50% not married Family income = 50% <$40,000/year Family income = 50% <$40,000/year Parity = 35% one or more children Parity = 35% one or more children Breast-feeding status = 100% breastfeeding at baseline Breast-feeding status = 100% breastfeeding at baseline Mean infant LOS = 62.3 days (SD 22.3, range 26 - 99) Mean infant LOS = 62.3 days (SD 22.3, range 26 - 99) Mean GA = 29.2 weeks (SD 4.1, range 23-35) Mean GA = 29.2 weeks (SD 4.1, range 23-35) Mean Neonatal Morbidity Index score = 4 (SD 1.1, range 2-5) Mean Neonatal Morbidity Index score = 4 (SD 1.1, range 2-5)

13. Self-Report Measures Variable Week 0 µ (SD) Cronbach’s α Week 8 µ (SD) Cronbach’s α Self-compassion16.99 (3.51).88118.01 (3.10).960 Perceived Stress19.55 (5.75).84517.79 (5.80).787 Depressive Symptoms 18.45 (11.89).91814.61 (11.79).930 State Anxiety42.05 (13.40).95039.42 (12.79).944 Social Support34.05 (5.39).84533.74 (8.69).960 Sleep quality9.75 (0.87).7257.68 (3.51).734 Maternal-infant responsiveness - 91.47 (11.64).877

14. Pearson correlations of self-compassion score with biobehavioral outcomes and weekly RGI use Variable mean scoreMean self-compassion scale score Week 0 (N = 20) Week 8 (N = 18) Perceived stress-.636**-.721** Depressive symptoms-.703**-.633** State anxiety-.739**-.409 Sleep quality-.380-.248 Maternal-infant responsiveness--.289 Functional social support.592**.512* Weekly average RGI use--.411 *p-value 0.05 level **p-value 0.01 level

15. Summary of Results Lower self-compassion scores at Week 0 and Week 8 associated with higher scores in reported: Lower self-compassion scores at Week 0 and Week 8 associated with higher scores in reported: Stress Stress Anxiety Anxiety Depressive symptoms Depressive symptoms Sleep quality (poorer) Sleep quality (poorer) Higher self-compassion scores at Week 8 positively correlated Higher self-compassion scores at Week 8 positively correlated Greater RGI use Greater RGI use Higher maternal-infant responsiveness. Higher maternal-infant responsiveness.

16. Study Implications Mothers of hospitalized preterm infants can experience high levels of mental distress and lower levels of self-compassion Mothers of hospitalized preterm infants can experience high levels of mental distress and lower levels of self-compassion Identifying effective strategies to enhance self-compassion in mothers of preterm infants may reduce mental distress, enhance sleep quality, and improve the mother-infant relationship Identifying effective strategies to enhance self-compassion in mothers of preterm infants may reduce mental distress, enhance sleep quality, and improve the mother-infant relationship

17. Study Limitations Missing data: incomplete self-report data on two participants for Week 8 Missing data: incomplete self-report data on two participants for Week 8 Overall sample size small Overall sample size small No control comparison group No control comparison group Intervention fidelity – self-report Intervention fidelity – self-report Varying infant medical conditions and length of stay (i.e., varying stress levels over time) Varying infant medical conditions and length of stay (i.e., varying stress levels over time) Intervention not available for mothers not fluent in English Intervention not available for mothers not fluent in English

18. With appreciation to our study participants and…. NICU nurse sub-investigators: NICU nurse sub-investigators: Sara Peterson, RN Sara Peterson, RN Kathryn Sondreal-Evans, RN Kathryn Sondreal-Evans, RN Catheline Seigmund, ALS, RN Catheline Seigmund, ALS, RN Anna Rickel, RN Anna Rickel, RN SMBHWN Study Coordinator: SMBHWN Study Coordinator: Kathy Arnell, RNC Kathy Arnell, RNC USD research assistants USD research assistants Heather Warlan, MSN, RN Heather Warlan, MSN, RN Linda Schaffer, PHD, RN Linda Schaffer, PHD, RN Elizabeth Light, BSN, RN Elizabeth Light, BSN, RN