Are There Still Gaps in Screening?

follow-me-on-psychology-todayPublished on October 29, 2013 by Karen Kleiman, MSW, LCSW in PSYCHOLOGY TODAY This Isn’t What I Expected

In healthcare or clinical settings where women are presumably in the care of providers who are well-equipped to provide relief, women who harbor scary thoughts remain reluctant to reveal what they are thinking.  When women are asked specifically if they are having scary thoughts, they might respond in a number of different ways, depending on who is asking, how they ask it, why they are asking, and what the mother has to gain or lose by answering. Because of these variables, we should first consider a mother’s personal experience in the context of being directly asked about the scary thoughts she may not have come to terms with having in the first place. After all, we’ve seen that what is scary for one person may not feel scary to another. This is illustrated by the array of responses that provide insight into the vast range of interpretations of questions about scary thoughts.

At The Postpartum Stress Center, during an initial phone intake, clinicians ask: Are you having any thoughts that are scaring you? When this question regarding scary thoughts is asked, it is deliberately left open-ended to encourage an individual interpretation. Below are commonly heard responses to this question: Are you having any thoughts that are scaring you?

1) Silence

This response can mean a number of things, ranging from taking time to think, to a pause for clarification, to a quiet panic, or hesitation to disclose. It is reasonable that the caller would be wary of the question or the person on the other end of the phone asking the question. Clearly, the phone is not the best medium for self-disclosure of this nature , but given the potential crisis inherent in working with postpartum women, it is often the first line of intervention.

2) Oh, no.  I don’t want to hurt my baby or anything like that. I love my baby.

Many women immediately flash to the sensationalism put forth by misleading media attention and think the question is trying to scope out whether there is intent to harm the baby. The truth is, whether there is intent to harm the baby or not, most women will not reveal this on the phone. Whether or not the answer is truthful at this early stage is less relevant than the fact that she knows she is speaking with someone who understands that scary thoughts can be a part of her current experience.

3) Yes. I’m scared I’m not going to feel better.

Although some women presume that scary thoughts pertain only to thoughts of harm coming to the baby, as we’ve seen, any thought can be scary if it is experienced as such. It can certainly feel scary to think that one will always feel this bad. This response demonstrates the ruminative quality of some postpartum thought processes, which may or may not indicate that there are additional scary thoughts lurking.

4) Well, sometimes it scares me that something bad could happen, like I could snap and do something terrible.

This response reveals the woman’s initial trust in the dialogue and her willingness to reach out for help. This is an instance in which further probing, done in a sensitive manner, would be appropriate to determine if emergency intervention is necessary or if reassurance and an appointment would be appropriate.

5) What do you mean, like what? You mean, do I want to hurt my baby? Never!

Some women will immediately ask for clarification. Such a response may be indicative of a defensive posture, shielding them from an authentic exploration of their thoughts. If a woman is frightened by her own thoughts so much so that she is defensive about the question, she may not be able to answer, even with a sensitive clinician. In addition, lack of understanding as to why the question is being asked will likely lead to suspicious or self-protective reactions.

After posing the initial assessment question, a provider might find it helpful to expand the questioning with more specific prompts: Are you having any thoughts that are scaring you about hurting yourself or your baby? Are you having any troubling thoughts that seem to come out of nowhere over and over again? This line of questioning is not intended to judge one’s mothering, even though it can feel that way. It’s a critical part of early assessment and lets women know that scary thoughts are common during the postpartum period. By and large, women are relieved to discover that their thoughts are shared by others and are not necessarily a worrisome phenomenon. This early intervention is one of the first ways to peel back the layers of defense that could otherwise obscure the clinical picture. By acknowledging the anxiety associated with uncontrollable scary thoughts, the clinician offers reassurance and immediate relief, thereby reducing the feelings of shame and establishing trust.

When considering aspects of the clinical environment, it is reasonable to presume that the setting is directly related to a woman’s readiness, or lack thereof, to disclose. For this reason, efforts to increase awareness of maternal mental health issues have focused not only on educating providers regarding assessment and treatment protocols, but also on empowering the mother to become her own best health advocate.

The bottom line is this—the experience of having scary thoughts means different things to everyone. This includes healthcare providers and the women who are struggling with these thoughts. New mothers will be more inclined to seek help when they can trust that they are being cared for by healthcare providers who understand the implications of the stressors of new motherhood and their impact on the way a woman thinks and feels. It is reasonable that, until women feel safe in this way, they will continue to be wary when these questions are asked.  Shame, embarrassment, and fear continue to take center stage for the woman who harbors thoughts that are scaring her.

Finding the right place to express this and feel safe is paramount.


Adapted from Dropping the Baby and Other Scary Thoughts (Routledge, 2011) Kleiman & Wenzel

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