“Maternal mental illness is a significant complication of pregnancy and the postpartum period. Depression and anxiety are common manifestations, with prevalence rates up to almost 20% during pregnancy and the first 3 months postpartum. As research and public awareness gains momentum, more attention is being placed on medical protocols, interventions and better access to treatment.
For many years now, Karen Kleiman has changed the face of maternal mental health for both clinicians and families. As a speaker reaching many through outlets such as The Oprah Winfrey Show and as an author, through her many books for families and clinicians, Karen is a pioneer in this field providing the mainstream community with an understanding of this devastating illness, validating the women who suffered and helping clinicians gain insight into the experience postpartum depression.
Karen and I first spoke several years ago when I called her out of the blue to brainstorm solutions. I, as an advocate in maternal metal health policy and systems change was combing the landscape to learn why women weren’t being screened, diagnosed and treated routinely by their physicians. I knew that Karen had developed one of the only training programs for clinicians in the U.S. at the time.
After speaking, Karen and I knew that more providers needed to be expertly trained so we could reach more women, augment recovery and improve outcomes. Since then my organization, 2020 Mom along with Postpartum Support International has launched web-based training to easily reach clinicians all over the U.S. and meet a growing demand to learn about this field. Though we have a long way to go, training is now available to more people than ever and Karen’s intensive postgraduate training program at The Postpartum Stress Center continues to produce expert clinicians and is recognized as a best-in-class training.
Recently the United States Preventive Services Task Force, the American College of Obstetrics and Gynecology, and the Council on Patient Safety in Women’s Health Care, joined in this mission and have highlighted the importance of screening and proper treatment of maternal depression. It is now more important than ever that we train providers.
Therapists in this highly specialized field often turn to Karen’s books for guidance when working with the perinatal population. The Art of Holding: An Essential Intervention introduces a novel strategy for treating women with postpartum depression and anxiety. At a time when we are finally paying attention to this widespread crisis in maternal mental health, this book provides a hands-on resource for therapists who are dedicated to making a difference in the lives of women seeking their help.
Clinicians, we need you now more than ever; moms and families are counting on you. Karen Kleiman, thank you for your extraordinary contributions to the field – without your work we would be several steps behind.”
Joy Burkhard, MBA
Founder and Director
Chair, The National Coalition for Maternal Mental Health
I wonder, now, why I have such conflicting thoughts about this place. A place I knew as my own sacred space before I was ready for the world or before the world was ready for me.
Warm, radiant, transparent plastic encloses the precious gap between me and life outside the box. It is, by design, both protective and isolating. A womb-like shelter to promote healing while simultaneously separating a fragile newborn from the nurturing limbs of life. I imagine this is one of life’s earliest, if not most acute, experiences of ambivalence. Has this newborn been prematurely seized from her mother’s secure haven only to be shuffled to a temporary incandescent chamber? Or, has this infant been rescued from an insufficient breeding ground to be nurtured and shielded from harm’s way until she can move forward as expected? Was it merely an interim therapeutic residence or was it, in fact, a sanctuary?
I try now, with the wisdom of adult retrospection, to see if from both sides. How scary, it must be, to be whisked out-of-womb with seven vital weeks of development remaining. Wait! I’m not ready. (Though my mother insists it were she who was not ready and I who was so hasty and impatient– so true to my nature – with my arrival). I’m tiny, I’m crying, I’m red with the tension of copious blood vessels bursting with disappointment. I’m cold and alone, even confused, perhaps. I suspect when babies of any species are separated from their mothers, there is a flood of panic. Where are you taking me? Why? In those days, mothers were knocked out, as they euphemistically referred to it, anesthetized to oblivion, so even if my mother were able to hold me, she wasn’t aware of it, which takes all the pleasure away from me.
Scooped out of this unfriendly transition, I’m then ever-so-gently wrapped in a very pink and very tiny blanket that was, I am certain, not a fair substitute for my mother’s loving arms and hungry heart. She missed me, I know for a fact now.
I’m sure I knew that then, too.
But let’s face it. This was over 60 years ago. What if, the medical community of that time was right? What if, that instrument that embraced my feeble self was, indeed, the optimal environment within which I could thrive? What if, without that intervention, however detached it may seem or be, preemies would die? Without which, I would have died? What if, as frightened as I might have been, I knew I was safe and free from the assault of unkind forces that were way beyond my control? What if, nothing could hurt me as long as I was secure within the confines of this clear plastic home?
Or, what if, I spent the rest of my life trying to free myself from this box so I could step into the world while trying my best to stay within its protective walls at the same time? What if this primal ambivalence persisted and shadowed every step I took? What if, I were to spend much of my adult life trying desperately to grow up despite a profound desire to stay put or go back, perhaps, to put closure on that which was left undone. A raw, unfinished innocence. Organic anxiety.
Premature intrauterine development. Eager, I dare say anxious, and at such an unripe age, to embark upon the challenges that lay ahead. I suspect I had little choice in the matter and consequence of prematurity, though primal therapists (who may believe that any early trauma could cause repressed pain and subsequent neurosis) would claim I knew exactly what was happening, on some level.
So many risks. Low birthweight. Thermal shock. Cyanosis. My mother recalls the day her nurse reported that overnight I had experienced a cyanotic attack. Apparently I turned an alarming shade of blue, and then, everything was fine.
“Wow. That’s scary. Were you worried?” I asked, as I gasped for a deeper breath, doing my best to resemble that same shade of blue.
“No. I wasn’t worried at all.” My mother claimed, with a smile I could actually feel through our long-distance phone connection. “By the time she told me about it, it was over, and I knew you were fine.”
“But I stopped breathing. Weren’t you afraid that could happen again?”
“Truly, no, I wasn’t. I knew everything was fine. Really.”
And it was. To be sure. So why did my chest feel so tight and my breath feel so shallow while we recreated this 60 year old story?
Respiratory distress syndrome.
I think I had that then.
Or is it now?
Sometimes, I wonder what the difference is.
The Secrets Women Keep
This thread is amazing. Needs to be turned into a list and handed out to expecting moms by every ob/gyn. They tell women everything under the sun about what to expect for 9 months; why not this?!
I think it’s wonderful you’re making this list for new moms. It would have been reassuring for me to know I was “normal”
“Scary Thoughts” is an expression used to encompass any and all categories of upsetting thinking that can interfere with the well-being of a new mother. Scary thoughts refer to negative, repetitive, unwanted and/or intrusive thoughts or images that can bombard you at any time (Kleiman & Wenzel, 2010). Scary thoughts are anxiety-driven, they are extremely COMMON, and most new mothers admit that have, at some time, imagined or worried about harm coming to their babies. The shame of having these thoughts can prevent women from speaking about them. In response to women telling us they feel isolated and ashamed of their thoughts, we asked women to share their scary thoughts in an attempt to help them express these distressing ruminations, so they can get relief and also help other mothers understand how universal this phenomenon is.
The objective of our PPSC project #speakthesecret is to obliterate the stigma attached to scary thoughts which are so common in new motherhood.
Our page is an ongoing list of the thoughts that brave women have chosen to share in the hopes of helping women know they are not alone and that having scary thoughts is common during pregnancy and the postpartum period. We will add thoughts as they are submitted.
DISCLAIMER: This list is anonymous. You can contact us at any time if you want to modify or delete your submission. If you are worried about the way you feel, let a healthcare provider you trust know if you are worried about the way you feel.
♥ THANK YOU ♥
to all the brave women who continue to disclose their scary thoughts.
Together, we will educate many and help reduce the anxiety and stigma. #speakthesecret
Click here to SUBMIT Your Scary Thought and help reduce the stigma
Experts and postpartum women themselves have long been aware of the interrelationship between postpartum distress and some individual predispositions. We cannot make any claims of direct causality, nor do we have research to back it up. What we have is tons of anecdotal evidence that postpartum women are doing too much.
Women who describe themselves as “Type A” or “perfectionistic” seem to be particularly at risk for postpartum depression and anxiety. Responding to the overwhelming responsibility of caring for a newborn can catapult vulnerable women into hyperdrive, kicking off a compulsive response to conceal how they really feel or think. Efforts begin to focus on making sure they look good and appear to have everything in order.
The effort it takes to present this pretense that all is good, if they are severely stressed or in need of immediate support, can be grueling and unsustainable. And yet, the fear of making a mistake or doing something wrong, keeps women locked into a no-win scenario while constantly bombarded by the uncertainties and unpredictability of new motherhood.
But here’s the real problem. Most of these women are, by nature, doers, high-achievers, accomplished women who have limited insight into how their successful attributes also put them at risk. This proclivity toward busyness and goal-oriented behavior keeps them focused and distracted. They simply do not always see it or feel it, when they are overdoing it. In addition, they often go unnoticed by friends and family as being in trouble or needing support.
Therefore, women who are pregnant or postpartum and have self-identified as perfectionistic by nature need to place close attention to how they are feeling and how they are doing. Literally. Sometimes, I will listen to a client describe her day and be slightly surprised by her lack of awareness that she is wildly overbooked and obviously exhausted. Often, the mention of this is met with disbelief or denial. We understand that these situations are complicated by imposing variables and intricate dynamics, but the bottom line is this:
Postpartum women are doing too much. And it is making them sick.
While we could launch into a discourse on the impact of our oppressive postpartum culture, let’s just focus on what moms can do today to help themselves.
- If you think you might be overdoing it, you probably are.
- Pay attention to your tendency to overdo, overthink, overworry, overreact, overwork. Then, do less. Give yourself permission to let go, to stop working so hard, to accept help from others.
- Making mistakes are a normal part of motherhood. Accepting this early on will protect you and create resilience.
- Think of overdoing like dehydration. You’ve heard that by the time you are thirsty, you are already slightly dehydrated and the key is to drink enough water throughout the day before your body responds with feelings of thirst. Likewise, if you are overdoing it, by the time you feel exhausted or depleted, it will be much more challenging to feel better. Intervene before you are overtired. Stop doing so much. Stop believing that your worth as a mother is defined by how hard you work and how good things look.
Take care of yourself while you take care of your baby.
photo: Dmitriy Melnikov
When you are in an anxiety-producing moment, it can be tempting to continue to focus on scary thoughts and exaggerated worries.
Accepting that anxiety is a part of your life right now and that there are things you can do to help yourself through the challenges will help you gain a sense of mastery over the anxiety.
The Six Points is a tool that was developed to help manage symptoms of anxiety by Manuel Zane in 1984.
Copy these points down or print it out so you can keep them handy as reminders. The more you practice them when you anticipate anxiety or actually feel anxious, the more you will see how they work to ease your discomfort.
I swear I was possessed. It was like one part of my brain was off on its own with stabbing thoughts that didn’t make sense to the other side of my brain. I felt like a stranger in my own body, almost like I was there and not there at the same time. It was weird. I told no one how I was feeling. Absolutely no one. I believed if I told anyone how I was feeling they would surely think I had lost my mind. Everything looked good on the outside so I just pretended everything was fine. I mean, no one could tell there was so much chaos in my head. But the thoughts would pierce through my brain when I least expected it, usually when I was bathing the baby. Bath time took only as long as I could hold my breath and get it over with. I didn’t know what else to do.
– Jen, 5 months postpartum
Dealing with scary thoughts is not just a matter of willpower, as some claim. Although willpower may indeed be part of the solution, it is more complicated than simply wishing thoughts away. We’ve all heard the truism that we should think positively, and we’ll feel better. Sounds good, doesn’t it? One of the most significant attributions for recovery from anxiety or depression seems to be the person’s belief in her ability to take control and be successful. In other words, if you believe you will be successful, you are more likely to succeed.
Surely it is easier said than done, but great personal power can come from shifting the focus of your energy from fear (negative) to acceptance (positive). For mild to moderate degrees of distress, women report that they feel more in control of their lives when they take responsibility for how they are feeling and identify the specific actions they can take to feel better.
Here are some specific self-help strategies you can rely on to ease the impact of your anxiety, depression, and scary thoughts.
Keep these points in mind:
- Denying the feelings and thoughts will not make them go away.
- Panicking will make them worse.
- Resistance creates persistence.
- Distraction will help for a while.
- Enhancing awareness might feel counterintuitive, but it is meaningful.
- Acceptance is hard but essential.
SO WHAT HELPS? Here are a couple of ideas for short-term relief:
1. First, acknowledge your current state
This is hard, but there is power in acknowledging one’s powerlessness. Great resiliency can be achieved when one is able to surrender, to some extent, and let go of secondary panic. It is natural to react with alarm when thoughts and feelings are scary and unsettling, but it is well-established that when one fears the fear, distress escalates. Straightforward affirmations reflecting the current state can be a self-compassionate way to regain some control.
- I am having scary thoughts. I might not understand why this is happening, but I know it is common and it happens to many mothers.
- My scary thoughts are not me. They are either a symptom of OCD or PPD or they are just a function of my anxiety right now. They will not always be here.
- I don’t like the way it feels, but I am doing what I need to do to feel better.
- I understand that my anxiety is a natural part of becoming a mother and even though it makes me feel terrible at times, I can endure it because I know I will not always feel this way
2. Distraction works!
Distraction has actually been shown to temporarily interrupt the loop of negative thinking. This is not the same thing as avoidance or denial. Rather, it is a way for you to remain in the stressful situation by coping with it.
If you are terrified of your own scary thoughts, can you really distract yourself from this uncomfortable mental state?
When you feel fear taking hold, do something that feels manageable. When you engage in work or activity that feels manageable in the present, you minimize your involvement with anxiety-generating thoughts and images and keep the mind actively focused. Your body, in response, is able to settle down a bit allowing you to feel more in control. Once you acknowlege that you are currently suffering from the scary thoughts and want to feel better, your brain will be going: I’m feeling bad right now, (acceptance) but maybe I’ll go for a walk, or call my sister (self-care) so I can feel better (self-compassion).
Here are just a few examples of distracting activities:
It can be pleasing:
- Listening to music.
- Watching TV
- Sitting outside in a relaxing environment with nature sounds/ocean waves/birds singing/warm sunshine
- Making a phone call to a friend.
It can be absorbing:
- Engaging in work-related projects.
- Planting in the garden.
- Helping a neighbor.
- Making a scrapbook with baby pictures.
- Playing computer/phone games.
- Reading a novel by your favorite author.
It can be detailed-oriented:
- Doing puzzles or playing games.
- Counting the tiles in the ceiling.
- Counting backward by 3’s from 100.
It can be physical/bodily: (It is helpful to simultaneously insert a cognitive association, like “It’s okay” or a gentle “stoooop” or “everything is good” as you use these)
- Snapping a rubber band on wrist.
- Visualizing and repeating the word STOP.
- Splashing ice cold water on face.
- Gently slapping cheek.
- Talking or reading aloud.
- Use and say your name as you comfort yourself in the third person (“you’ll be okay, Karen. Let’s go outside for a walk.”)
It can be energizing:
- Taking a brisk walk in the sunshine.
At first, this may appear ridiculously insufficient, or fleeting, at best. Sometimes, it’s even tempting to resist the distraction, almost as if it feels important to STAY WITH THE ANXIOUS THOUGHT; A sort of inertia sets in and it feels almost easier to remain anxious. But while your body may fight this, you might be surprised to discover that it really works if you stick with something and keep your mind focused on whatever you are doing.
These distraction techniques work to temporarily take the mind away from the worrisome thought and redirect it to something that feels different. This is based on the principle that there is a limited amount of functions that one’s brain can perform at one time. By keeping your brain busy as much as you can, you are less able to accommodate the anxiety. This is not as easy as it might sound. Keeping your brain busy requires a dedicated effort; it will not be enough to turn on the television and let your brain wander. Before you know it, it will meander right back to the object of your obsession. It requires a deliberate desire to absorb yourself in an activity. Count, read, paint, design, clean. Teach your brain how good it can feel to focus on something other than your scary thought. Your thinking is getting in your way right now. Give yourself permission to play and not to think.
Dont forget to:
- Eat frequent small meals to help stabilize blood sugar. Swings in blood sugar can cause symptoms that mimic anxiety, such as lightheadedness.
- Drink lots of water.
- Eat complex carbohydrates (whole grains) can increase serotonin, which is associated with feelings of calmness.
- Restrict simple carbohydrates (sugar).
- Avoid alcohol.
- Avoid caffeine.
Adapted from “Dropping the Baby and Other Scary Thoughts” by Kleiman and Wenzel (Routledge, 2010)
A CAUTIONARY NOTE TO THERAPISTS WHO THINK THEY CAN/SHOULD TREAT PREGNANT AND POSTPARTUM WOMEN IN DISTRESS WITHOUT SPECIALIZED TRAINING
This past weekend, I was fortunate to speak at Postpartum Support International’s (PSI) annual conference, whose clear and inspirational mission is posted on their website:
“The mission of Postpartum Support International is to promote awareness, prevention and treatment of mental health issues related to childbearing in every country worldwide. It is the vision of PSI that every woman and family worldwide will have access to information, social support, and informed professional care to deal with mental health issues related to childbearing. PSI promotes this vision through advocacy and collaboration, and by educating and training the professional community and the public.”
This is exactly what they do. Like no other organization. And by all accounts and my personal observation, they do it extraordinarily well.
But they do more than this, which was brought to my attention, this past week during the conference.
It was my pleasure and honor to present one of the keynotes speeches with Amy Wenzel, PhD, my esteemed colleague and co-author. Myself, along with other perinatal (pregnant and postpartum) advocates connected with hundreds of like-minded clinicians, researchers, lay people, and various medical and support professionals who convene once a year to share, educate and inspire. Those of us who have dedicated our professional lives to this work are unquestionably impressed and inspired by their mission and the execution of their vision. We work hard to support this cause and many of us write and speak and educate on various aspects of perinatal mood and anxiety disorders (PMADs, or PPD for short). We do so to increase PPD awareness, provide access to state-of-the-art information and disseminate details of current research and treatment options.
Yet, the unique needs and nuances that are intrinsic to the perinatal population can actually put women at risk for being misunderstood or misguided by otherwise well-informed and well-intended providers. Those of us in the PPD community worry about this.
After my talk, I was greeted by a friend in the field who came up to me to tell me how much the presentation had moved her. (That is always a welcomed bonus of speaking in front of a large audience, when one person is personally or professional touched in some meaningful way and shares that with me.)
Sonia Murdock is a past president of PSI and founder of the Postpartum Resource Center of New York, Inc., where she tirelessly trains and consults professionals and non-professionals who are equally dedicated to this specialized field of practice. Sonia proceeded to share her thoughts:
“This is the missing link,” she claimed. “The missing link.”
“Thank you, Sonia. But, what? What do you mean?”
“Your talk. Your focus on her authentic suffering. This is it. This is what will save lives.”
“Wow. Sonia. Thank you for that,” somewhat stunned by her generous praise of my work and my own mission.
I thought about what she said.
And what she meant.
Some of my words in the speech made reference to the more global efforts that are being made on behalf of perinatal women in distress, such as the research, the advocacy, the legislation. Which is, decidedly, movement in the right direction, away from the shame and isolation of distant days and current stigmas, but still…
Women continue to die.
The reference in my presentation to authentic suffering was this: Authentic suffering, is defined as:
Authentic suffering is that which is obscured by what she wants us to know and what she will let us see.
It’s the pain she conceals.
It’s the terror that immobilizes her and keeps her up at night.
It’s what drives her anxiety and her fear that she will continue to fall, forever.
It’s what’s in her suicide note when loved ones cry out that, “there were no warning signs.”
As therapists, we don’t always see authentic suffering at first, especially when she doesn’t want us to.
But our job is to find it and connect with it.
Ah ha! This is what Sonia was referring to when she articulated precisely what I was trying to say. “After all,” she said emphatically, “it’s ‘what’s in her suicide note.’ THIS is what will save lives.” she said.
Yes, indeed. If women are not always revealing how bad they feel, if women continue to be silenced by stigma, by shame, by fear of judgement from others or from themselves – it doesn’t matter what legislation is passed, it doesn’t matter which screening protocol we use, it doesn’t matter how good we think our interventions are – if she doesn’t feel safe enough to disclose the nature and severity of her symptoms, she will save them for her suicide note.
And that is not okay.
Therapists with specialized training in perinatal mental health are obliged to consider the best and immediate way to access her authentic suffering. While I shameless promote the Holding approach (Kleiman, 2017), I will be the first to proclaim that I do not care how or where clinicians obtain the necessary information; I only ask that therapists who find themselves sitting face-to-face with a pregnant or postpartum woman in severe and acute distress make sure they do what they need to do to become informed and capable of responding appropriately and urgently.
The stakes are very high.
Passion and devotion to this work is a bonus, but expert training is essential. On-going supervision/consultation/mentoring is a clincial imperative. The board of directors and staff at PSI know this only too well and continue to train scores of professionals who can positon themselves to catch vulnerable women when they fall.
So, in addition to the love and giggles that permeate the otherwise informational and educational nature of the very serious subject at hand, PSI is saving lives. All too often we are thrust into a rapid and excruciating response to a perinatal tragedy. Those of us who work in this field know that at any moment, we are just a heartbeat away from a woman in despair losing her battle with depression.
This is why we do this work. This is why it feels so important. This is why it is not okay for perinatal women who are bone-tired and weary from hopelessness, to traipse from one misinformed provider to another.
If this is an area of interest for you, study the literature. Read the books. Go to trainings. Be informed before you sit with her. Get in touch with your best professional self and work hard to access her authentic suffering. She is not going to offer that up to you. She will withhold it. She will disguise it. If her pain is unendurable, she will pray you never find it.
Make no mistake about it, she may not know it yet, but she is counting on you to help save her life.
image credit: 123rf.com/orkidia
While sitting with palpable pain in therapy, I am often moved to find some tool, some intervention, some words of comfort, to ease the suffering. When I’m lucky, I find a way to express hope, in some form or another.
But today, I could not find the hope. So I sat with the pain. I thought about his history of trauma and loss. I recalled the trauma-informed literature which teaches us that resilience is an antidote to trauma. One way to cultivate resilience is to find meaning in the loss or purpose in recovery. It turns out that finding purpose is a key factor in one’s ability to cope.
Together my client and I explored caretaker anguish; The guilt of having fierce, negative emotions when you are not the one dying; the heavy load of day-to-day management of grueling, thankless, tasks that take you nowhere but back to where you started. We both spoke with somewhat of a scholarly tone, about the darkness, the heartache, the meaninglessness and the existential agony. We had nowhere to go.
This is when we sit with suffering.
So I brought my mother into the conversation, as I tend to do when I am thrust into unfamiliar yet familiar despair. I told my client about my mother’s history of profound loss and how the Holocaust had become a measure, for me, of what excruciating suffering looks like, feels like is like. I told him how hard and how well my mother works to devote her life to finding joy, for her own sense of sanity, and on behalf of the love she sprinkles wherever she goes, making this world a better place, to be sure.
I told my client that now, my mother finds herself confined by her love and devotion to my father who suffers from Parkinson’s along with its cruel pain and suffering. His days begin with tedious attention to detail colored by pervasive distress and debilitating physical symptoms. My siblings and I observe from afar, as my mother dances, sings, and whispers sweet nothings in his ear, hoping against hope for a flash of a smile or, a thank you.
She will wait.
She dances and sings in the meantime.
My client and I share a smile at her persistence. Her impressive devotion. Her hope. This is when I told him what she said to me one time, when I asked her, “how do you do this? Every day. With no complains. Asking nothing from anyone. How do you do it?” I asked with full knowledge that I am not made of such self-sacrificing DNA. And while I may share her kind heart, I DO ask for help and I DO ask for attention when moved by a generous moment of my own.
She told me it makes her feel valued. It makes her feel necessary. It makes her feel useful. She found purpose in her day-to-day struggle. She found meaning. A key to resiliency.
And she smiles.
She had, unknowingly, used her unwavering determination to master her environment. In doing so, she embodied the brilliant words of Viktor Frankl, a concentration camp survivor:
“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”
My client listened intently to my words with a tear in his eye. “There is nothing I would rather do, on any and every single day, than take care of my Laura. Absolutely nothing.” he said warmly.
“I know.” I smiled, with a hidden tear of my own.
Mastering our environment is something that can feel impossible when the odds of anything getting better are slim. The chronic wear and tear of grief and loss paralyzes any prospect of hope. Still, if we can summon the strength to confront the anguish and do our best to find bits of joy in the face of unrelenting grief, it might pay off.
This is one way to find purpose. And finding purpose provides meaning to the suffering, it creates resiliency, and it inspires hope.
Guarire dalla depressione postpartum. Indicazioni cliniche e psicoterapia
INTRODUCTION TO THE ITALIAN EDITION
With my deepest gratitude, I post the translation of the introduction to the Italian edition of: Therapy and the Postpartum Woman by Pietro Grussu and eRosa Maria Quatraro:
Fourteen years have passed since the Editorial Collection “Psicologia della Maternità” (Psychology of Motherhood) debuted with the publication of its first text entitled “Treating Postnatal Depression” written by Jeannette Milgrom with several of her colleagues. In Italy, this manual became, and remains, among the principal clinical-practical references for those who treat postpartum depression. When we discovered that work at the book exhibit of the First World Congress on Women’s Mental Health held in Berlin – Germany – in 2001, it seemed important to us to make it known and to promote it to the public in our country for its clinical value, but also because at that point in time, there were few publications in Italy that proposed such an exhaustive and systematic approach specifically for the treatment of postpartum depression.
Today the situation is decidedly different: for example there are numerous conferences and cultural initiatives offered in the Italian context. Additionally, the dedicated health services are in full expansion mode, despite limited economic resources available to regional health and hospital services. Furthermore, many professionals who specialize in perinatal psychological health document read up on the topic and are constantly updating their knowledge. Additionally, women who suffer from emotional disorders are more willing to ask for help and to admit to being in difficulty at a time of life which most people think should be a time of joy and happiness. There are still many cultural barriers and prejudices surrounding motherhood which is often viewed in a manner that either idealizes or belittles (the mother who harms), both by the women themselves as well as by the surrounding social context.
Usually, when something doesn’t work the way we would like, we have difficulty coping with it and admitting that we have limits, and we process the sorrow of our own vulnerability. Everything must work well; there is little room for error, or for the feeling of incompetence and solitude, especially when one becomes a mother. There are dangers and pitfalls hidden behind the ideal of perfection, the organization and efficiency that our own society requires and to which women are often convinced to adhere if they want to move forward in their careers and in their family life. Becoming a mother inevitably compels a woman to come to terms with her own limits and weaknesses.
It is from this key point that Karen Kleiman starts, taking us on a journey of 38 chapters, packed with clinical psychology, kindness and a deep understanding of the lives of women with postpartum depression. The text, written by an American psychotherapist for professionals and for American mothers, has a down-to-earth style without, however, ignoring the quest for a direction of treatment and the theoretical roots that support the therapeutic model that the author follows at the Centre which she founded and directs in the United States. The important references to the teachings of Donald W. Winnicott, together with the attention given to several concepts of cognitive-behavioural and interpersonal theories make the book a tool of the trade rich with original tidbits that make up a solid theoretical-clinical framework for the working model described by Karen Kleiman.
What stands out is the importance of offering women suffering from depression an all-embracing context where the concept of holding is in the foreground, as is the capacity to hold-contain, and to make the mother feel supported and included. All of these elements thus become the therapeutic-experiential premise from which the author begins the assistance offered to patients. To mother a mother, in that scenario which the French call “maternage” and which depicts a way of being cared for in order to be able to care for others, is the principle which, according to the author, must guide the clinician who practises perinatal psychotherapy.
The author, who in her writing style shows a distinct ability to render plain and apparently simple that which in reality is not, succeeds in freeing herself from theoretical dogmatism, applying theory by putting it at the core of the treatment. In developing the text, the author seems to be guided by the need to find all that the different theories and techniques have to offer, in order to achieve the greatest possible well-being of each patient. Karen Kleiman graciously reveals herself, describing in detail what happens between her and her patients. Each chapter and each passage are explained with clear clinical examples which demonstrate a remarkable relational ability and a deep intellectual honesty. Additionally the author shows unceasing attention to clinical reflection, insisting continuously on the importance of providing ongoing supervision (supervision to which she herself claims to be subject at all times, despite her considerable experience) as an instrument of growth, reflection and awareness of one’s own clinical performance.
Even the parameters introduced in the therapeutic technique are described bearing in mind that not all professionals will be in agreement, but also, in this case, explaining in detail the clinical thinking behind the potential deviations in technique. The result is a text that is eagerly read, and that engages even those who are not psychotherapists. We believe that with this work, diverse professionals who concern themselves with the perinatal period, as well as the women who experience it, can feel that they have a guide in the exploration of all those aspects that characterize the life and classic adversities of the depression that follows the birth of a child.
Postpartum depression, which in chapter six the author herself considers to be like a syndrome made up of a set of symptoms and clinical manifestations which can vary in intensity, duration, time of onset, and severity, but which always must be taken into consideration with the utmost attention, even with the involvement of a long-time professional in the perinatal field.
The concept of postpartum depression is more fully explored in its clinical aspects and its numerous symptomatological manifestations, recognizing the relevant importance of a potential psychiatric diagnosis, sometimes necessary for a good therapeutic intervention. Beyond that, Karen Kleiman emphasizes the importance of making differential diagnoses so as not to err by underestimating or overestimating some clinical manifestations present in the affected women. These skills can be honed only by daily clinical experience with this typology of patient.
With a simple, fluid and understandable explanatory style, Karen Kleiman describes the diverse transitions and labyrinths that the therapist and patient must deal with on the path to healing. In the first part of the book (chapters seven and eight), the author illustrates with clarity the model of “the voice of depression” which she has structured during the course of many years of work at her Centre. The book is intriguing because it proposes an eclectic work model which integrates several techniques of cognitive behavioural therapy, interpersonal therapy and support therapy with the ability to move to a deeper level tied to the world of interpersonal relationships past and present.
The urgency of making the mother feel better in the shortest time possible, relieving her, first and foremost, of the most debilitating symptoms, is the departure point for Karen Kleiman, given the important repercussions that postnatal emotional suffering, even of brief duration, can have on the mother-child relationship, the marital relationship, and the well-being of the entire family.
“The Tools: Doing What Works” is the title that opens the second part of this book. How can one not concur with the author who, step by step, leads us through the pitfalls and difficulties that accompany the clinical evaluation, the diagnosis and the management of treatment of this particular form of perinatal emotional suffering?
It is not easy to help women who are in profound difficulty and are suffering psychologically during the phase of transition to parenthood, nor to motivate them to seek and accept qualified help. It is precisely for this reason that Karen Kleiman dedicates great attention to the initial phase of taking charge of a patient’s care, looking at it from the point of view of the healthcare professional, but also taking into consideration the woman’s past experiences. Together they affront the “thorny knots” such as the rationale to undertake psychotherapy or the potential use of psychopharmacological drugs.
In the third part of the book it comes to light that psychoanalytic therapy with these patients is a significant challenge, given the multitude of clinical aspects associated with the anxious-depressive past experiences typical in this transitional phase of a woman’s life. Alarming thoughts, hostility, the idealization of oneself as a mother, suicidal thoughts, breast feeding, insomnia, problems with one’s partner and with the mother-child relationship, and the therapist’s countertransference are all aspects which are dealt with chapter after chapter, investigated in great detail in their diverse clinical aspects and debated in a descriptive style which makes reading enjoyable.
Following occurrences such as pre and postpartum depression, the women no longer recognize themselves, and they struggle to find themselves. This is why they are often unable to find the words to express how they feel so that they might be helped to find clarity within a tangle of sensations, emotions and thoughts that make them feel like outsiders.
Another aspect of great clinical honesty lies in the author’s ability to leave the woman free to decide the point she herself wishes to reach on her own therapeutic pathway—to choose how far to deepen her understanding of herself and of her own cognitive, affective and relational conduct.
There are, in fact, women for whom it is enough to be relieved of the most debilitating symptoms, while others want to understand why they became ill and seek to make deeper sense of their own experience of the illness. But this, when it does happen, cannot help but occur gradually, in the course of the work that Karen Kleiman describes and proposes to move forward. Of course, therapy has a financial cost and demands the additional non-monetary outlay of revealing personal matters, which is why it may not be possible or important or urgent to explore how ties with their own caregivers can possibly be connected to the malaise that the woman is experiencing when, at the same time, she must care for a being who is totally dependent on her.
In the last part of the book, it becomes clear how helping women come out of their postpartum depression is possible not only thanks to the theoretical-technical competence of the psychotherapist, but especially thanks to the transformative power that an empathetic and supportive therapeutic relationship can have on the patient. This premise is the point of departure for the author, but also for the writers: that all clinicians, if they want to work with women suffering from postpartum depression, must closely monitor their own work in order to continually grow and improve.
All that remains is for us to wish you a good read, with the hope that the offerings of Karen Kleiman in this work may be beneficial and fruitful, especially for the professionals who are involved in the perinatal field every day, but also for the women who have experienced or are experiencing emotional difficulties at a time of their lives that is rich with excitement and change which, although sometimes frightening, has great potential for development and for personal growth.
Rosa Maria Quatraro e Pietro Grussu
Padua, ITALY, March 2017
When you are asked to appear in court, you will be testifying at a trial or hearing presided over by a judge. There may or may not be a jury. A court stenographer will record the entire proceeding (anything said). The judge is there to assist you if you do not understand a question and to see that you are treated respectfully.
When you are asked to appear at a lawyer’s office or to testify at your own office, you will be testifying at a deposition. There is no judge present at a deposition. A deposition is like a mini-trial, except that it is informal. Usually, at a deposition, you, the lawyers from both sides, and a court reporter sit around a table; the parties to the lawsuit may or may not be present. As in court, your testimony is taken under oath. The court stenographer will record all questions and answers.
At the end of the deposition, you may be asked if you will waive signature. You have a right to review the transcript produced by the court reporter and to correct any errors. Please note that you can only correct errors in transcription, e.g., if you said “the client had a CD problem” and the court reporter recorded it as “seedy problem”. You cannot change your testimony no matter how uncomfortable you are with what you said. Because court reporters are professional and usually do not make a lot of errors, you can waive reviewing and signing the transcript. It is up to you whether you want to spend the time reviewing the transcript or are willing to rely on the court reporter’s expertise.
Tips on Testifying
- Listen very carefully to each question asked. Make sure you understand each question and give an accurate answer to the best of your ability. If you do not know the answer, be sure to say so.
- Answer only what is asked. Do not volunteer information; if you think the lawyer asked the wrong question, that is the lawyer’s problem. However, it is not necessary to answer in monosyllables. You do not want to give the impression that you are withholding information.
- Be yourself and answer in your own words. Do not pause to try and figure out if your answer will hurt or help the case.
- If you do not understand a question, ask for clarification. You do not want to answer the wrong question. You may also ask that the question be repeated.
- If you do not know the answer to a question, please say so. You are not expected to know everything. Even if you say, “I don’t know” repeatedly, you do not need to feel stupid or that being repetitive is wrong.
- If you do not remember, say so. With all the cases you work with, you cannot possibly remember every detail on all of the cases.
- If a lawyer makes an objection, stop speaking immediately, wait until both lawyers have had their opportunity to state their objections, if unsure when to continue speaking, ask.
In a trial: the judge will make a ruling on the objection. If the objection is sustained, you do not need to answer the question. If the objection is denied, you need to proceed with responding to the question. If you do not understand, ask for clarification, turn and ask the judge, “does that mean that I should go ahead and answer the question?”
In a deposition: the lawyers will state their positions for the record. Because a judge is not present at a deposition, the objection will not be resolved at this time. The objection will simply be noted in the court reporter’s transcript. This will preserve the lawyers objection for resolution at the trial should the question be asked at the trial or your deposition is used at the trial in lieu of live testimony. Usually, after both lawyers have stated their positions for the record, you will be instructed to answer the question. If you are unsure, ask if you should proceed.
- If you do not remember a question, ask for it to be repeated. In most cases, the court reporter will read it back to you. It is the attorney’s duty to make a question answerable. If you did not hear it or understand it, ask for it to be repeated.
- If you think that a question has been asked before, you can say, “I think I have already answered that.” The lawyer may respond that it is not exactly the same question and insist that you answer again. However, your indication that you answered previously may alert the other lawyer to intercede on your behalf if there are additional questions along the same line. The questioning lawyer may be trying to trip you up by getting you to answer differently when the question is asked in a different way.
- If you are requested to bring records with you, you are not required to study the file before appearing. You do not need to look at it at all. It will be available during the testimony for your reference. It is up to you whether you review the file before your appearance.
- Try to avoid giving a professional opinion, particularly if the case is against a client organization or another individual client. If you get pushed into giving an opinion, use as many qualifiers as possible. For example, “As I said before, I am not an expert and did not evaluate Ms. X in this connection, however, given the facts that you stated, it is possible that…”.
- Do not be hard on yourself if you say something you did not intend to say or something that, in retrospect, does not make sense. Witnesses frequently have regrets about what they said. Even if you prepare for the experience, it is likely that you will be caught off-guard on some issues; you cannot predict how the questions will be asked or all the paths of inquiry.
- Do not personalize criticisms or implied criticisms of your testimony or your handling of the case. You have to realize that a trial or a deposition, to some extent—is a drama in which you are playing The Witness and the lawyers get to play their part. If your testimony is adverse to their case, their role is to discredit The Witness. But that does not mean that you are stupid or foolish or incompetent. Remember, if the other attorney makes you feel uneasy, he is just doing his job. You are NOT the one on trial. You are in control.
- Being polite makes a good impression. Do not argue with attorneys or allow yourself to become upset during questioning. Remain calm and do not lose your temper.
- Above all, tell the truth. You are there as a reporter only, not as an advocate.
Magellan charges for its employees to testify in a court proceeding or at a deposition.
Suicide is a scary word and if you work in the mental health field it is a word that conjures up panic in the hearts of dedicated professionals who are trying hard to support, enlighten, inform and protect individuals who might be tormented or tempted by the distorted lure of an end to their suffering.
An end to suffering. It was what we work for, what our clients wish for and if we are not careful, it is what they die for.
I think I can say with confidence that pregnant and postpartum women in despair do not want to die.
They might, however, believe that their baby would be better off without them. They might misinterpret their hopelessness as a permanent state, rather than a symptom that can be treated. They might pay too much attention to the intrusive thoughts screaming in their head and think they cannot possibly be a good mother. They might, through the lens of depressive thinking, believe that they have no other option.
In a recent piece written by Rich Larson, “It’s Not What You Think”, he poignantly and skillfully describes the misunderstood and unpredictable nature of depression and suicide after the death of an adored musical artist, Chris Cornell. In this piece, Larson writes:
…it’s really about depression and cynicism. Those two go hand-in-hand, along with their nasty little sister, anxiety. When the three of them get going, they just eat hope as quickly as it can be summoned. That leaves despair and despair is exhausting, not just for those who experience it, but for the people around it as well. So we keep it to ourselves because we don’t want to be a burden. And then it gets to be too much. Doesn’t matter if you’re a student, a mom, an accountant or a rock star. It doesn’t matter if you’ve written about it your entire life as a means of keeping it at bay. It doesn’t matter if the music you made about it brought in fame, respect and millions of dollars. It doesn’t matter if your entire generation has suffered from it. Depression makes you feel totally alone. You hit the breaking point, and then, like Chris Cornell, you die alone in the bathroom.
This was a well-respected member of his community; a beloved musical hero who seemed to have it all together. This could have been any of us. And brothers and sisters, if it’s you, don’t mess around with it. Please find some help.
This scares us. As well it should.
Which is why we teach novice therapists to take any mention of suicide very seriously. While that may seem too obvious to mention, we forget, sometimes, because postpartum women are so good at looking good, because we believe they don’t really want to die, because we believe that passive thoughts are transitory and less dangerous than active thoughts or plans.
Still, some therapists wonder: When should we intervene? How bad does it have to get? What if we insult her by presuming the worst? What if we are wrong? What if we are overreacting?
I say, overreact. Protect her. Prepare for the worst scenario because, well, severe symptoms of depression are unpredictable, they are volatile and they are seductive. They can convince the most loving and precious mother that the opportunity to disappear forever is the only and the best option.
Passive thoughts of suicide should alert every therapist to the possibility that darkness is looming. She should not be expected to stay there too long without a lifeline. Get in there with her and sit with her suffering. No matter how good or healthy she looks, do not be tempted to let her sit there alone with these thoughts.
- Sharp objects, weapons removed.
- Medications should be out of reach.
- Reduce access to potential means of harm.
- Make phone calls; instruct loved ones to stay close. She should not be alone.
- Implement a safety plan.
- Be clear about your intention and ability to safeguard her.
- Let her know she is safe with you and that the option to hurt herself is NOT the only option; It just feels like it is.
- Let her know that a decision to kill herself will have permanent and tragic consequences on her children and her entire family.
- Let her know that you will do whatever you can to help her pass by this open window and not jump, today. Delay the impulse.
- Remind her that these are distorted thoughts. When the symptoms are treated, she will no longer feel this way. Tomorrow is an option.
Do not underestimate the power of depressive thinking. Do not presume she will be okay because she has convinced you that she is fine. Do not presume she does not have a weapon in the house because she doesn’t look like someone who would.
Ask the hard questions. Then, ask again. Do not let her suicide note be her first opportunity to express her suffering.
Karen Kleiman, MSW
Does your relationship need a booster shot?
Are you taking good care of your self?
Are you taking good care of your partner?
Here’s a brief primer that can help kickstart your connection.
Selfless support refers to the energy and attention we place on our partner. It’s about him. Or her. Not me.
Selfless support is easy to ignore. When our relationships feel strained, we can begin to feel self-absorbed and anxious for something in return. Paradoxically, one of the best ways to feel more connected is by paying attention to the needs of your partner. Selfless support refers to each partner’s attention to the emotional well-being of the other partner. Investing in the relationship is one of the best ways for you to reap the dividends!
Generosity, unconditional acceptance, determination, restraint and self-worth; these are the components of selfless support that make enhance connection.
Take this pledge. Remember these rules of selfless support and the underlying principle upon which they are based:
- I will act in your best interest at all times. (generosity)
- What is important to you is important to me. (unconditional acceptance)
- I will do what I say I will do. (determination )
- I will refrain from asking or wondering what I will get out of this. (restraint)
- I will let myself be loved (self-worth)
I will act in your best interest at all times. This statement is one of spirit. A generous nature is one that balances a belief in the partner with a belief in oneself. It does not imply a forgoing of self-interest. Rather, it’s a sense that if you are okay, then I am okay. And vice versa, of course.
What is important to you is important to me. This statement implies an unqualified, nonjudgmental position. These are no absolutes, as there will surely be times or circumstances when life gets in the way and positions must shift to accommodate the moment. The components of this pledge entail the heart, not the head. Sometimes the heart can override the details of the moment, and sometimes, for sure, it must not.
I will do what I say I will do. Follow up is crucial. Words don’t always hold value if they are not followed up with action to support it.
I will refrain from asking or wondering what I will get out of this. Restraint is a form of bigheartedness, especially if you are restraining from anger or contempt. Having control over negative responses is a gracious and selfless stance.
I will let myself be loved. When you allow others to support and give to you, you are at the same time, giving them the pleasure of doing something good for you and allowing yourself the pleasure of receiving it. This is not easy for everyone to do but it is a win-win situation. Our brain’s pleasure centers respond positively which turns the act of giving and receiving into a mutually gratifying experience.
Keeping the principles of selfless support in mind at all times will help you focus on the core of your relationship, rather than the emotional residue that may be contaminating the work you are doing. It will help you consolidate your individual and mutual efforts while you continue to secure your connection.
Adapted from “Tokens of Affection” by Kleiman and Wenzel (Routledge)
Photo credit: Antonio Guillem
Say them. Say them aloud. Write them on a post-it. Post reminders in places you are most likely to see them. Say these statements several times throughout the day. You don’t have to believe them. You just have to say the words. As you continue to recovery, you will start to believe what you are saying.
1. I’m doing the best I can.
2. This is going to take a long time, whether or not I try to speed it up. I must take one day at a time.
3. I cannot expect too much from myself right now.
4. It is okay to make mistakes.
5. There will be good days and bad days.
6. It is okay for me to have negative feelings. If I fight having these feelings, it might take longer to feel better.
7. Even though I feel so bad, just getting through the day is proof of my strength. I can be proud of how much I have accomplished when I get through the day feeling this bad.
8. I know that some of the pain I am feeling right now is part of the recovery process.
9. Today, when I am feeling bad, I know that I will not feel bad all of the time. This is just a bad day. I will get through this day the best I can. I will try to rest. I will pamper myself a bit. I will treat myself well because I deserve it. And I will wait this out.
10. Some of what I am feeling is just like what other mothers feel. Not all of my bad feelings are symptoms of PPD. All mothers of new babies feel tired, irritable, or stressed at times.
11. It’s okay that not everyone understands what I am going through. I still have a real illness that is treatable, even if other people don’t know anything about PPD.
12. I will feel like myself again.
Adapted from “This Isn’t What I Expected: Overcoming Postpartum Depression” (De Capo Press) by Kleiman & Raskin
You do not feel like yourself. You wonder if this is what being a new mother feels like. You are worried all the time and find it’s hard to take a deep breath. You believe that if you tell anyone how you are feeling they will either dismiss it as normal or tell you that you should be happy because your baby is healthy and everything is fine. You are concerned that if they knew some of the thoughts you were having they would deem you an unfit mother.
So you don’t do anything.
Your symptoms are making you doubt yourself right now. Symptoms of depression and anxiety have a way of making you believe this is about who you are. It is not about who you are. It’s about having symptoms that are treatable. Find a safe place where you can talk about how you are feeling so you can find relief. Research has shown that the earlier you seek help for any postpartum-related anxiety or mood disorder, the sooner you will feel better and the smoother your recovery will be.
Therefore, if you have recently had a baby and do not like the way you are feeling, you should:
1) Believe yourself. No one is in a better position to assess how you are doing than you are. Trust your instincts. You do not need validation from anyone else. What you need is clarity, support, and possible treatment, depending on the symptoms you have.
2) Stop comparing yourself to others or to your own expectations of perfection. Right now. It does not matter how others are doing or what things look like from the outside. Everyone has her own struggle. Listen to your heart.
3) Talk to your partner. Even if you are worried that you will be misunderstood. Sit your partner down and find your bravest voice to express why you are worried about the way you feel right now. Your symptoms are real.
4) Quiet your inner critical voice. Rush to find some self-compassion exercises and listen carefully to the words. You are suffering right now. Be kind to yourself. Believe that help is available. Believe you are worthy of getting that help. Believe you will feel better.
5) Do not accept indifference. Do not stop until you are comfortable with the responses and the support you receive. There are many well-intentioned but misinformed friends, family members and healthcare providers. Be your own best advocate.