Below is the Afterword writted by the late Ilyene Barsky, pioneer in the field of maternal mental health. We will not forget her professional influence and her personal grace and fortitude.
As Amy and I proceed to work on the second edition of “Dropping the Baby and Other Scary Thoughts”, I feel compelled to bring Ilyene to the forefront of this process. She always did, and will continue to, provide inspiration for all of us in this specialized field.
This book is dedicated to
Whose words, wisdom, and infinite presence continue to inspire and heal postpartum women.
For the last twenty years, I have planned, promised myself, and intended to write a book about perinatal mood disorders. Karen Kleiman does not plan, promise, nor intend. Karen Kleiman writes books. She is, perhaps, the most prolific and most recognized writer on the subject. Karen and I have “known” each other for about fifteen years yet, we actually met just a few years ago. The bond was instantaneous. We’ve traveled many of the same paths. We can say, unabashedly, that we are pioneers within this “movement” of awareness, consciousness raising, training and educating the public of, what was once, an unrecognized, overlooked, and misdiagnosed illness. We figured out how to treat depressed and frightened moms at all levels of distress. We were there when the rumblings began. Barely perceptible. No Internet. No email. Slowly the connections and the weaving began. The rumblings grew louder and became stronger. Organizations began to emerge. We found Depression After Delivery (DAD) and Postpartum Support International (PSI). Newsletters and articles began to appear. We received them via snail mail.
Like most of us involved in the postpartum “movement”, I am a survivor. It was 1980. I was truly enjoying my pregnancy. Absolutely loved the attention and the movement in my belly. Strangers let you ahead of them on lines. They help with heavy packages. They give themselves permission to touch your belly. While some women object, I never minded that boundary being crossed. Somewhere around the eighth month of my pregnancy, reality hit. This baby has to come out of me. It truly was a different time. Painkillers were shunned upon as they would be harmful to the baby. The only way to go was “natural”. Some twenty-two years later, I read Naomi Wolf’s book “Misconceptions” and came across this African proverb:
Being pregnant and giving birth are like crossing a narrow
bridge. People can accompany you to the bridge. They can
greet you on the other side. But you walk that bridge alone.
This proverb, this metaphor, has stayed with me all these years. We all encounter bridges of various types, lengths, and strengths as we travel through our lives: Adolescence, leaving home for the first time, and marriage, to name a few.
I’d like to share with you three bridges I have crossed, and continue to cross. These three bridges are structurally quite similar. I imagine them to be primitive suspension bridges made of wood planks and rope. A pair of supports at either end (trees, stakes, or poles) secure the bridge. Wood poles are intermittently bored through the wood planks along the bridge to secure the length of rope which the traveler holds on to as he/she makes their way to the other side. Beneath the bridge lie sharp rocks and turbulent waters.
Back to my own personal experiences: Bridge number one, pregnancy, was rather fun. The bridge was sturdy. I walked across with great confidence. But as I got closer to the other side, thoughts of labor and delivery began to permeate my brain. I froze. I had nightmares of being sliced open. I had nightmares of a “natural” delivery. I had nightmares of dying on the table. There was no escape and the bridge began to wobble.
“The hell with Lamaze classes. This is going to hurt. A lot”. Of course I had the option of the much frowned upon painkillers, but that would make me a childbirth failure and a bad mother before even leaving the delivery room. Surely medication would harm my baby in some way. Could I ever forgive myself? What would others think? But I saw all those women on the other side of the bridge, supporting and encouraging me. Women since the beginning of time.
“If they could do it, I could do it”. And so, with the help of a shot of Demerol (took years to forgive myself for that one), and nearly 15 hours of labor (I think the number of hours get longer every year), I crossed that bridge with my son in my arms. I was greeted with excitement and joy. I was carried on their shoulders like the MVP after a football game. Then, I was back on the ground and they slowly drifted away. The fanfare was over. I quickly learned that labor doesn’t end in the delivery room.
My son was a preemie, born one month prior to his due date. His skin seemed nearly translucent and hung from his body like a raw chicken. Colic began within a few days. No respecter of day or night. It didn’t take long for it to reset my inner clock and for the insomnia to set in. I’m anxious. I’m depressed. I’m immobilized. I’m exhausted. I can’t seem to do anything right. My baby hates me.
No support whatsoever. My own undoing. I’m a master of disguise. Besides, I had a reputation of being strong and competent. I had an image to maintain. I told no one. You know the drill: shame, embarrassment, guilt, and fear. Obviously, my (ex) husband was aware of the insomnia and my uncontrollable crying. Each day he’d come home from work and see me in the same shapeless housedress. I engaged in little to no self-care and was totally isolated. My husband’s initial show of concern soon turned to annoyance. I’ll never forget the day he came home from work and pulled the dress off my shoulders and threw it in the garbage. He just didn’t get it. Neither did I. He became more and more distant and unavailable. Today, we recognize that men can have postpartum depression, too.
I approach bridge number two. I am surrounded by “seasoned moms” who have frequently offered me well meaning, but unsolicited advice. They contradict one another. They confuse me and add to my mounting sense of inadequacy. But now, everything is OK… I can see the sign as I stand before the bridge: “Motherhood Straight Ahead”. It is framed with cherubs and fluffy white clouds. It’s going to be a long walk, but when I squint, I can see all the beautiful, blissful mothers nursing, nurturing, and nuzzling their newborn babies on the other side. The babies are content and cooing sweetly. I want that.
I take my first tentative step. Baby in one arm; hand of the other grasping the rope. Clearly this is going to be a challenge. This bridge is not the same as the first. The slats are faded and worn. The links connecting the slats are rusted. The ropes are frayed. This bridge wobbles and sways as the wind whips up. The water below is turbulent. Besides my baby, I am carrying all the symptoms I had before I embarked upon this new journey.
However, there is now a new dimension: “What if my baby falls from my arm?” “What if he is swept away by the waters below?” “What if he is crushed by the rocks?” “What if we both topple over?” I can see it all in my mind’s eye. Other thoughts, intrusive thoughts, each one more horrific than the last, leave me shaken and gasping for air. I would never harm my child. The depression deepens, the anxiety turns to terror. I am thoroughly exhausted. I am holding on to that rope for dear life. I take that final step off that bridge and am now surrounded by the serene and peaceful images I saw when I squinted at the beginning of this journey.
“I made it!” But not really. I am not like them. I’m different. There is something wrong with me. I am as unsteady and as unstable as the bridge I just crossed. I need to sit and rest. I find a shady tree. Propped up, baby in arm, I close my eyes. At last, some respite. I drift off. But not for long. Here come those images again. They are vivid, tragic and revolting. I am startled into awareness; sit up abruptly, and once again, I am gasping for air.
The jig is up, the mask is off and I am desperate for help. I find an older, kindly, female psychiatrist and tell her about my depression, anxiety, and worst of all, insomnia. No mention of intrusive thoughts and how they exacerbated my sleep disturbance. I am diagnosed with “Major Depression”, given a prescription for an antidepressant and am on my way. The medicine did work. Sleep did come, and with time, the thoughts began to drift away.
Some four years later, and by a sheer luck, I come across an article in a magazine about “postpartum depression” (PPD). I call the author (founder of Depression After Delivery) and find enormous relief. I was never really alone. I “suffered in silence” like hundreds of thousands of women in the U.S. every year. They, too, did not come forward due to shame and embarrassment. Note: By now, my son is four and my daughter is a newborn (by the grace of God, the PPD following her birth was mild in comparison). The networking began. “The New Mother Syndrome”, by Carol Dix, was published in 1988, eight years after my trauma. The book was informative and validating. As a social worker, and in the helping profession, I knew I had to enlighten others. My “lectures” began in the living rooms of childbirth instructors, then hospitals, and then large organizations. By now, I have established The Center for Postpartum Adjustment and the moms begin to trickle in for counseling and psychotherapy. I am flying by the seat of my pants as there is no script, no manual for treating this population. I am my own frame of reference. The common threads begin to emerge. The symptoms, the myths, the unrealistic expectations. We discuss grief and loss associated with becoming a parent. Their “normal negative feelings” are validated. I learn to ask the hard questions: “Do you think you will harm yourself or your baby?” “Are you having scary thoughts?” They know they are safe and accepted.
It’s been thirty years. I am fifty-six years old. I have treated thousands of women, and have been blessed with a wonderful reputation in a very large community. I’ve got my treatment techniques down pat: Cognitive Therapy, Interpersonal Therapy, and Ilyene Barsky Therapy (AKA…gut feeling). Thanks to Karen Kleiman’s recent book, Therapy and the Postpartum Woman, clinicians now have a “how to” manual. I am also the longest standing member of Postpartum Support International, a worldwide organization working toward the eradication of ignorance surrounding perinatal mood disorders. I have been their Florida coordinator and volunteered in numerous capacities for many years. I have lived to see this illness printed in scholarly journals and books, woven into TV plots, and been the subject of Public Service Announcements. I have lived to see women routinely screened by their medical providers and the passage of The Mothers Act. I am enormously proud of the role I have played. I will be leaving my footprint.
I just learned six months ago, that I am standing in front of my final bridge. Many other bridges have come and gone, but it is this third bridge I’d like to share with you. It is strong and sturdy.
My husband, Mark, has seen to it that this bridge is safe. He has replaced the old slats with new ones. No more rusty links. The rope is taut and secure. I am sad, but not afraid. I look behind me and see my greatest legacy of all…my children. I have lived to watch them cross their own bridges with style and grace and their own personal flair. Gavin, now thirty and Monica, now twenty-six allow me to go this final journey with peace. They are college grads, working on their careers, and will be self-sufficient. They are genuinely good, warm, caring people. The best part of my life? Being their mother. In fact, despite turbulent beginnings, I have been an awesome mother!
I do believe that my own mother and father will be there to greet me on the other side. I know they have been watching over me and are proud of me, too. I hope my beloved childhood dog is with them. I believe we will all appear to each other as we were when we were last together, but before we became ill. I suspect I will be tired by the time I reach them and will want to rest. I remember, as a child, falling asleep in one room and waking up in another. They carried me. I am still their child and they will carry me again.
I do not know how long it will take me to cross this bridge. Who does? But I will be ok. Remember what I said at the beginning? Despite the oxymoron, I am a survivor.
♥ I will listen to my body and my good instincts to determine whether I need help or not.
♥ I will be prudent when listening to the well-intended but sometimes misled suggestions from others.
♥ I will spend less time on the Internet, on my phone, on social media media, and any other place or temptation that increases my anxiety when I compare myself to others or expose myself to misguided information.
♥ I will surround myself with people and things that make me feel cared for.
♥ If I tell my healthcare provider that I do not like the way I am feeling, and I feel dismissed or unheard, I will find another way to express myself and if that does not work, I will find another healthcare provider who will take my concerns seriously.
♥ I understand having symptoms does not interfere with my ability to be a good mother.
♥ I can accept that good mothers get sick.
♥ I will not surrender to the pressure from others or from myself to pretend I am okay if I am worried about the way I am feeling or thinking.
♥ I will not let feelings of shame, embarrassment, awkwardness, humiliation, or nervousness stop me from getting the help I think I need.
♥ I understand that asking for help is something that comes from strength, not weakness.
♥ I will not blame, berate, or punish myself for being sick during a time I hoped I would feel wonderful.
♥ I will do my best to take care of myself with self-compassion and kindness.
♥ I will remember that I will not always feel this way. I will feel like myself again.
♥ I will be patient. I will be hopeful. I will believe in my ability to heal.
pic credit: Stephanie Pruitt Johnson. Follow her work https://shellypruittjohnson.wordpress.com/
We do not completely understand the etiology of postpartum depression.
Those of us in the trenches with moms who suffer deeply know only too well that our best efforts to understand and prevent postpartum depression do not always prevent it. We simply cannot isolate the serious and complex origins of this mental health crisis.
So, yes, what we have here is an outrageously expensive result of a small study with rapid and impressive results. We hope that this new drug, Zulresso, leads to better, more affordable and more accessible treatments in the future. The understandable outrage from women who suffer should be balanced by our relentless quest for understanding and improved treatments.
But in addition to the promise of this new biological pathway to treat severe postpartum depression, we must not disappoint families by dismissing the myriad social, cultural, medical, psychological and financial influences that bombard postpartum women.
We can be grateful for this progress as well as attentive and responsive to the enormous challenges that families face after childbirth. Both positions can coexist.
Rosemont, Pa. The writer, a social worker, is the founder and director of the Postpartum Stress Center.
Written by Hilary Waller, MS, Director of Education and Programming at The Postpartum Stress Center
Reposted with permission from Rise Gatherings
When my first child was just a few hours old, my then 7 year old niece was among the first visitors to arrive. When she entered my hospital room her dad leaned down and said “she’s been coughing today, I think she’s pretending to have a cold, but I warned her that whether she can hold the baby is completely up to you.” Looking at him through my exhausted and weepy eyes I remember replying “I’ve been a mom for like an hour, you’ve been a dad for fifteen years- is it ok for her to hold the baby?” Whether my brother-in-law remembers this moment I have no idea, but, for me, this moment has defined my mothering experience and I think of this exchange almost daily.
Why? In that moment it became clear that when my daughter was born, so was I. I was as new as she and neither one of us had any idea how to exist in this brand new world- she on the outside, and I as her mother. I consider this one of my wisest moments as a parent- somehow, instinctively knowing that I needed to ask for help from those experienced parents whom I admired without guilt or shame.
My first child is now just shy of 8 years old and although it feels like I’ve been mom-ing for a while, somehow, I always feel a little bit new. With each stage her needs become more complex. Her questions, her concerns, her physical being, her emotions, her body become different. Not necessarily harder or easier to manage, just- different. With each stage I find myself wondering in which ways I will need to adapt to her while understanding that she will continue to surprise and confuse me.
Mothers tend to feel that “keeping it together” is a priority. Sometimes to impress our peers, to create a sense of stability for our children, or to simply act the part- a strategy that can lead to success, but that can feel isolating and frightening. A most cherished and fulfilling aspect of my work at The Postpartum Stress Center is creating spaces that invite sharing of the raw newness that we all experience throughout our mothering experiences. Without this opportunity, it is easy to become caught in the masquerade and to miss the opportunity to grow as mothers, as women, and as human beings. I encourage every mother I meet to seek out opportunities to truly confront the part of herself that is brand new. I believe that when we do this, and when we do this within a community of other parents, we are able to see that along with the new comes a profound beauty, strength, and wisdom.
Written by Hilary Waller, MS, Director of Education and Programming at The Postpartum Stress Center
Reposted with permission from Rise Gatherings
Rise Gatherings is teaming up wiht the Postpartum Stress Center to offer
Saturday, March 16 - New Hope, PA
A retreat day for mothers with little ones to feel supported by community and enjoy a da of self care and renewal
ONLY 3 SPOTS REMAIN
CLICK HERE TO REGISTER
“In an often unrecognized reality where 1 in 7 new moms are affected by mental health issues, Karen Kleiman’s new book, Good Moms Have Scary Thoughts, with powerful, pervasive cartoons illustrated by Molly McIntyre, should be required reading for moms and every single person who associated with them–friends of moms, family members of moms especially her own mom and mother-in-law, pediatricians, OBs, nurses, psychologists, psychiatrists, etc. should be well-versed in the types of scary thoughts a new mom can have as well as how common they are, ensuring that women always have a safe, non-judgmental place to admit how they really feel about a role they were taught to believe comes naturally to all women and should be the most satisfying, joy-filled role of all time.
In her book, Karen covers isolation, comparing, hating your baby, wanting to prolong your 6-month OB check up so you don’t have to get the okay to resume having sex, thoughts of ending your life, rage, partner resentment, thinking that your baby and family would be better off without you, pretending everything is fine to cover up the pain, and so much more to help women realize these thoughts are often a common part of new motherhood and don’t make them bad mothers or failures. Maternal mental health taboos have been doing an amazing job hiding out in dark places and Karen Kleiman is fighting to turn and keep the lights on. Her professional, but warm commentary and advice after each picture is like a friend holding your hand reassuring you that what you are feeling is okay and you are not alone.
I remember when I had postpartum depression and anxiety with my son and while I desperately searched for other moms’ stories and experiences, and would have read pretty much anything, I was way to exhausted and overwhelmed to read a long, wordy book. Karen has solved this with Good Moms Have Scary Thoughts by using the comic book format. And moms reading this book don’t just get to absorb the words and pictures, but each page has a space to write, color, and document their thoughts to help ground and calm them.
I wish this book came out six years ago when I gave birth to my son but, I’m beyond grateful this book has come out now. It’s unacceptable that only 15% of the 1 in 7 women affected by maternal mental health issues receive treatment. It’s outrageous that suicide is the second largest cause of maternal death. We need to do better. We need to fight harder. We need to do more. We need to reframe self-care. Self-care is not a luxury. Self-care is not indulgent. Self-care is not selfish. It’s essential and necessary. We need to reframe professional-care. We need to reframe how we talk to knew moms.
Please indulge me with this personal post, so I can tell you why this book is so important to me.
Those of you familiar with my work, know that my support of women with perinatal depression & anxiety began a long time ago. The Postpartum Stress Center started in 1988. This is when I knocked on doors of uninformed doctors with the hope of enlightening them – long before anyone really talked much about PMADs and the strong emotions/thoughts new moms experience. In the meantime, I was learning about maternal mental health from my clients, and I drew upon their experiences to write and teach others. While some are helpful to partners and support people, my books are primarily geared to women in distress and the therapists who work to help them navigate this distress.
This NEW BOOK is the first book I have worked on that is suitable and necessary for EVERY MOM – diagnosed or not, in therapy or not. I have witnessed the shift of social and medical attention to women’s moods. I am thrilled that women are expressing themselves and medical providers are beginning to listen. We have come very far. But as they say, the more things change, the more they stay the same. WOMEN ARE STILL RELUCTANT TO TALK ABOUT HOW THEY ARE FEELING. We all know why. There is a great deal at stake.
This is why this book is so important. It is a small sweet book that expresses the inexpressible. It calms a mom’s greatest fears and embraces her anxiety. It reduces her shame. It offers expert guidance. It provides tools for self-help relief. It will help her feel less isolated and better understood. It will curb her spiral into the darkness of her own fears. It will inspire her to ask for help, if she needs it. It will help her feel grounded and reduce her distress. That is why this book is for every.single.mom. That is why our Instagram account will spend the next couple of weeks highlighting the book so we can make sure EVERY MOM feels understood.
Bravo. Your articles about postpartum depression are a comprehensive, accurate account of the various ways that perinatal illnesses can present. Postpartum depression often manifests with acute and high levels of anxiety. Anxiety can take many forms, and for the majority of postpartum women, it appears as negative, intrusive, scary thoughts. The article cites Jeanne Marie Johnson, who “imagined suffocating her [baby] while breast-feeding, throwing her in front of a bus, or ‘slamming her against a wall.’ ” You report that most women who have such thoughts do not hurt their babies. This is true.
This phenomenon is extremely common. One researcher found that a whopping 91 percent of all new mothers (not restricted to women with depression) experience these unwanted thoughts. Furthermore, 88 percent of new fathers experience similarly negative thoughts. And when we talk about scary thoughts, we are sometimes talking about horrific, gruesome, shocking thoughts.
These are not easy to shake off, and women fear that the worse the thoughts are, the sicker they must be. This part is not true. When women feel safe enough to disclose these thoughts and don’t feel judged, they often experience immediate relief, even if the thoughts persist.
Rosemont, Pa., June 17, 2014
The writer is director of The Postpartum Stress Center and the author of “Dropping the Baby and Other Scary Thoughts.”
“Nobody would believe what an effort it is to do what little I am able.” -Charlotte Perkins Gilman 1892
NOBODY WOULD BELIEVE…
Maybe it’s because nobody’s listening
Or maybe it’s because women are not telling us how bad they feel
Or maybe it’s because nobody’s asking the right questions
Or maybe it’s because women are so good at pretending that everything’s okay
Or maybe it’s because we are bound by social constraints that make it hard to admit that being a mother doesn’t always feel so good.
Maybe it’s because women afraid to tell someone how they really feel for fear that they’ll be misunderstood
WHAT AN EFFORT IT IS…
It’s hard to pretend that everything’s okay when you feel so bad.
It’s hard to get through the day when you believe that your children would be better off without you.
It’s hard to go through the motions when you’d rather be sleeping or crying or withdrawing, or running away.
It’s hard to cope with the daily task of living when every breath hurts, when the day feels impossibly long, and when being alone with your baby feels paralyzing and life threatening
It’s hard to make sense out of feeling so bad, so scared, so alone, so misunderstood, so guilty, so angry, and so confused.
WHAT LITTLE I AM ABLE…
Symptoms get in the way. Suddenly, little things become big things and big things become insurmountable. When you factor in the depression, the deep sadness, the weakening of spirit, the exhaustion – there’s nothing left to access in order to simply get through the day…
“Nobody would believe the effort it is to do what little I am able.”
I was one of the lucky ones who determined very early on, without much guilt, that I would be a much better mother to my children if I returned to work, part-time at first.
The part-time option sounded good. I could be home early to spend more time with my baby, and it felt right, because i was to tired to work a full day, anyway. It was relatively easy for me – I’m not particularly proud to say – to be selfish during those early postpartum months and put my needs right up there next to those of my baby. I have a slight rebellious streak that dates as far back as i can remember. I remember the exultation I felt walking into the high school gymnasium with my boyfriend, clad in jeans, to the formal prom. I remember the work boots I wore with colored socks accompanied by a way-too-short mini skirt, long before it was a fashion statment, simply because I hoped I could get away with it.
Similarly, as I entered the world of motherhood, I recoiled from what was expected of me, whether that pressure came from my family or society as a whole, and soon discovered the comfort in doing things that felt right for me, even if it meant ruffling some feathers. That didn’t mean I wasn’t tempted to surrender when I found myself sucked into the pressure cooker of “opportunities” for young mothers and their babies…
Longing for daytime companionship, I took my 4-month-old baby to a local baby gym class. Hopefully, I won’t offend any readers by saying I am almost positive he did not care whether he was in this brightly decorated room filled with expensive baby-friendly equipment or snug in our living room surrounded by unvacuumed dog hair and a Sesame Street video that had looped in repetition for the fifth time. I sat for a while in the circle of neurotic competitiveness, listening to mothers chatter on about whose baby was doing what and how many activities they had squeezed into their sleep-deprived schedules. Why was I there, I ask myself. Who, exactly expected this of me? That was the first and last class to which I would drag myself.
It was then that I decided that if I were to maintain my sanity, I would pledge to:
Not go to baby classes programmed to make my baby smarter, faster, more agile, or speak foreign languages.
Not compare myself to others.
Not compare my baby to other babies.
Do what I needed to do for ME and bring my baby along in the process.
Do the best I could.
Not be hard on myself if I failed to live up to unrealistic expectations.
Ask for help when I needed it.
Trust my instincts.
This is what I try to help other mothers do, today. ♥
Before I became a specialist treating perinatal mood and anxiety disorders (PMADs), I was a postpartum therapy client. 6 weeks after our oldest child was born, my husband and I decided to check in with a wonderful and experienced therapist whom we knew both liked. At the start of the session my husband looked lovingly at our daughter and talked about overwhelming adoration and paternal bliss. I sat with my shoulders hunched as our daughter nursed, bracing myself against the intense pain I felt in my breasts. I described constant nursing without a break, constant severe pain throughout each nursing session, and insisted that I would be nursing for a year no matter how much it hurt. I said I was stressed, sad, and hopeless. With a caring and warm expression our therapist quietly and gently offered “sounds like it’s time for some formula” and shared stories about formula feeding her own children. When we left, my husband suggested we talk with our pediatrician about trying some formula, energized, encouraged, and empowered by our therapist’s suggestion. He was comforted by the experience of another mother and was relieved to have a solution for my apparent problem. I, on the other hand, was gutted. We never visited that therapist again.
I was gutted because deep inside I knew that nipple pain wasn’t my problem. That I was postpartum was my problem. I felt isolated, profoundly exhausted, confused about why having a baby seemed so easy for everyone else. I felt like there were right and wrong ways to do things, and I really didn’t know if I was getting more things right than wrong. I focused so much on breastfeeding, that I decided my nursing relationship must be the barometer for my success as a mother, a woman, a human being. Imperfection did not seem like an option. I was failing. I couldn’t believe I could be feeling such emotional pain at this time in my life. I couldn’t believe the therapist said what she said.
Almost 8 years later I am a therapist specializing in PMADs. Here are a few things I’ve learned from sitting on both sides of the couch:
A lesson for you and a lesson for me: good therapists say the wrong thing and can still be good therapists. Speak up if you are triggered or if your feelings are hurt. Your therapist will learn from you and that will benefit you and others. Be braver than I was and use your voice.
If you are a few days or a couple weeks postpartum and you feel a little sad, weepy, or teary, you might have the baby blues. Baby blues lasts for a few hours or maybe a few days and feels better with self care- rest, eat well, enjoy Netflix, and surround yourself with good company. If you are more than a few weeks postpartum and you are still feeling “blue” you may need a little more help overcoming your symptoms. At this point, see suggestion number 3.
Remain hopeful and do not give up. There are an incredible number of resources for pregnant and postpartum women around the world. Specialists, groups, and online communities are eager to help you. Don’t stop asking for help until you find it. Your person is out there.
MOST important, there is no such thing as not sick enough for support. All mothers, happy, sad, anxious, blissful, depressed, all mothers, are entitled to support. Becoming a mother is a monumental change and no matter how you spin it, it’s hard. No matter how well or how bad you feel, reach out if you want to talk or grow your support network.
Bonus tip: I learned that if you show everyone who will look your bleeding and cracked nipples eventually a pediatric nurse might recommend antifungal medication and all purpose nipple ointment…. Which just might miraculously clear up that nasty 6 week old case of unusually presenting thrush that was causing So. Much. Pain.
For couples who believe in their relationship, aspire to keep it strong, and wonder how awesome it will be to read this together in 20 years… Each of you should fill it out separately and share as a gift for a special occassion that is meaningful to you. Then, put somewhere for safe keeping.
The first time I knew I loved you was__________________________________________________
One of my favorite things to do with you is _____________________________________________
One thing I don’t tell you enough is ___________________________________________________
Sometimes, when I find myself needing you the most, I ___________________________________
One of the things I need most from you is ______________________________________________
After twenty years together, I’ve learned that you ________________________________________
When I’m sad or scared, I ___________________________________________________________
I love it most when you _____________________________________________________________
What makes me laugh the hardest when we’re together is __________________________________
If I were to be completely honest, sometimes I wish _______________________________________
Loving you has always felt easy, but one of the hard parts is _________________________________
One of the things I like best about you is ________________________________________________
One of the things I think we should do more often is _______________________________________
When we’re together, I wonder if you know ______________________________________________
My life with you is __________________________________________________________________
I love to hear other people tell me that you ______________________________________________
Since we’ve been together, I’ve gotten better at __________________________________________
I love the way you _________________________________________________________________
I need you most when I _____________________________________________________________
One of my favorite memories of us is___________________________________________________
One of the dreams I dreamt that has come true is_________________________________________
One of the dreams I dream that I hope will still come true is_________________________________
I wonder if you really know how much __________________________________________________
Twenty years from now, I hope ________________________________________________________
I am so proud of how we_____________________________________________________________
“I know what I’m ‘supposed to do’ to feel better. Everyone keeps telling me the same thing. I should exercise. I should sleep more. I should eat well. I should take the medicine. I know, I know, I KNOW. But something inside my head keeps telling me to push through this. I can get better. I don’t want to take the medicine while I’m breastfeeding. I can’t possibly keep feeling this bad, so I’ll just wait. But then I start feeling desperate, like I’ll never feel better again….This isn’t working. Nothing I’m doing is helping. It doesn’t matter if I exercise or not, everything is dark and heavy around me. Inside and out. Nothing looks the same. I wish someone would just tell me what to do. Or do it for me. My head keeps spinning with all the reasons I shouldn’t take the medicine. I know I’m getting in my own way, like my therapist keeps telling me. I know that. But I can’t help it.”
Women with postpartum depression know only too well how the symptoms of depression interfere with help-seeking and solution-oriented behaviors. Therapists, doctors, partners, friends and family members can tell them over and over and over again, how they should be taking care of themselves, but many women find themselves swirling around the vortex of distorted thoughts and misperceptions. Anxiety driven ambivalence becomes a fierce enemy, what if…? Why can’t I just…? How do I…? Maybe I could just…
Postpartum depression and anxiety do not discriminate. Symptoms impede the functioning of devoted stay-at-home moms and Harvard-educated attorneys. Intrusive thoughts can puncture the most perfect plan. When this occurs, rational thought seems to evaporate. Any previous accomplishment or personal triumph takes a back seat to the all-consuming and interminable anxiety. Soon, that is all that is felt. Women describe this by proclaiming “this isn’t me” or “I just don’t feel like myself” or “I’m usually so easy-going, I don’t know who I am now.”
As thoughts and feelings alternate between despair and rapid-fire obsessiveness, women with PPD begin to lose focus, along with the ability to successfully advocate for themselves.
If your baby were sick right now, would you know what to do to get him help? The answer is usually yes.
If your husband needed to get to the emergency room right now, while you’re feeling this bad, would you know what to do? The answer is usually yes.
But women have difficulty fighting for themselves when they are entrenched in this battle of their lives. Their energy, motivation, inspiration and zest for life has been eclipsed by the cruel paralysis imposed upon them. They also have difficulty responding appropriately to the loving guidance from those around them. They simply cannot see through the shame, the guilt, the incredible disbelief that they feel so ineffective in their own life. And so they sit, rocking back and forth between their opposing thoughts.
If symptoms are bad enough, if hopelessness sets in, functioning is severely impaired, and clarity has vanished – others must make some decisions for her. When it reaches the point when her wellbeing is at stake, we become less concerned about hurting her feelings or saying things to protect her. At this point of personal crisis, we no longer defer to her sadness or her longing to do this “her way.” If doing it her way means postponing treatment or prolonging suffering, it is not okay. This is when it becomes necessary to intervene on her behalf, tell her exactly what she needs to do next and how we will help her do that.
This commanding posture is not always a comfortable one for therapists who are working hard to empower their clients. But remember: Our objective is to lead her to symptom relief, before any other work can be done. One of the ways we do this is by demonstrating a sense of expertise, confidence and composure. After all, it is our composure, our self-control, our trust in the process, that will convey our expectations of a positive outcome. And that, indeed, is empowering for her.
And so, we say:
1. You will not always feel this way.
2. You must take care of yourself and you need to follow through, whether you feel like it or not.
3. If medication is part of your treatment plan, you need to take the medication – whether you are breastfeeding or not. Discuss any concerns you have with your doctor and then decide whether you will continue breastfeeding or whether you will wean. Either way, take your medicine if it has been prescribed for you.
4. Do not let the noise in your head sway you from doing what you need to do. It may feel like you have no energy but you do. It may feel as if you have no power left, but you do. It may feel like no one knows how bad you feel, but some do.
5. Pick a person you trust and listen to them. Do not question the veracity of their words. Let yourself believe that this person can help guide you through the darkness and then, stop fighting against them.
6. You need to keep moving forward through this, even if you don’t feel like it. Get up when you don’t feel like getting out of bed. Go outside even if the sunshine is too bright for your weary eyes. Eat even though you may not be hungry. Rest even when you are not tired. Try to turn off the chatter in your brain. Distract yourself. Count backwards from 300. Take a walk. Call a friend. Avoid caffeine. Avoid alcohol. Avoid people and things that make you feel bad. Come to therapy. Talk to your partner.
7. Your depression is not your friend. It is an illness that confuses you and distorts your thinking. Do not forget this. Challenge the illness, not those who are there to help you. Take your pills, no matter how you feel about having to take them. Remember that your fight is against the illness, not against yourself or those who support you.
It has been reported that maternal suicide is the leading cause of death during pregnancy and the first year after birth. This is why the current shift in attention toward greater awareness to maternal mental health is urgently necessary and long overdue. We are just scratching the surface, and have far to go, but this momentum toward improved care and education can only be seen as positive energy in the right direction.
It has taken a long time and too many women have died.
Many of us in the field would agree that awareness is increasing and medical organizations are responding with attention to improved screening protocols, services, and resources. The advocacy movement has been wildly successful at shedding light in the dark corners of widespread misunderstanding across multiple disciplines. More research and powerful legislative initiatives are emerging. Universities and medical settings are beginning to identify and actualize the relevance of perinatal research and recommendations. Clinical trainings are expanding. Families are becoming informed and collectively speaking out of their own behalf with robust determination and strong social media support.
This is all good.
One of the problems with identifying and treating perinatal women in distress is that symptoms are hard to discern. This is true for the women, men, and families who suffer. And this is true for the healthcare providers who treat them. Symptoms overlap with normal, expected perinatal changes and do not always fit into discreet or identifiable categories. Unlike other medical conditions that might present themselves in a measurable fashion, perinatal distress is often subjective.
There are an infinite number of barriers that prevent her from asking for help in the first place and even if she DOES find the courage to ask for help, the outcome of that effort depends on many hard-to-define variables. Clearly, the outcome that follows a mother’s cry for help doesn’t always simply depend on the circumstances or obstacles. An accurate assessment can, indeed, be achieved despite the challenges listed here. Still, these examples, to name just a few, show what is likely to contribute to the overwhelming lack of clarity:
It “depends” on her willingness and readiness to express how she is feeling.
It “depends” on how bad she feels. Or how sick she is.
It “depends” on how much her symptoms are interfering. Or how worried she is.
It “depends” on how much, or what, she actually chooses to reveal to her family or healthcare provider.
It “depends” on her current belief whether she is in a safe place where she can be transparent about how she feels.
It “depends” on the culture of the society in which she lives and how her disclosure might be perceived or misunderstood.
It “depends” on whether or not the provider asks the “right” questions.
It “depends” on how well trained the healthcare provider is to recognize and respond appropriately to the nuances of the perinatal period, which can masquerade as a million things and never quite reach the surface of precise diagnostic distinction.
And just to complicate things further, it “depends” on her personal history, her family history, her mood/symptoms at the moment, her relationship and support system, her biological and genetic influences, her personality and belief system, her history of trauma, current environmental stressors, her relationship with the provider, her level of distress, her symptoms, and so forth.
And it “depends” on the ability of the treating professional to tease out what this woman is saying, from what she might be feeling, from what she may be hiding.
Even the very best, well-training, attentive healthcare provider who is leaning into the needs of his or her patient can be stymied by the very nature of perinatal symptoms which can easily be mistaken for “normal” perinatal mood and anxiety experiences.
This is just the tip of the iceberg. If symptoms of a serious depression or anxiety disorder are missed by a healthcare provider, even with screening, even with a good assessment, even with a mother who wants and asks for help, there is reason to believe that her suffering will persist and the risk is increased that she will feel worse, before she feels better. The risks of untreated perinatal mental health issues—to the family, to her children, and to her own well-being—are well-known, and beyond the scope of this article.
Suffice it to say, that the amazing advances in legislation, public awareness, expert training and improved interventions will make little difference if we continue to miss what she is saying when she reaches out for help. Or if we continue to overreact, or underreact, or don’t know how to react to the acute, sometimes, terrifying, presentation of severe perinatal distress.
Should primary care providers, obstetricians, or pediatricians be asked to make a psychiatric diagnostic determination during their 10-to-15 minute visit? Of course not.
But every single physician and provider who comes face to face with a pregnant or postpartum woman can and should provide every single pregnant and postpartum woman resources. They should talk about postpartum depression and anxiety. They should say those words. They should talk to their patient, the way they talk about high blood pressure, or good nutrition, or what to do and what not to do during pregnancy and the postpartum period—they should encourage her to take care of herself with an action plan, if she does not like the way she is feeling. They should tell her that symptoms of postpartum depression and anxiety are common. They should tell her that while we expect some level of adjustment distress, she should not have to suffer or wonder what is wrong. Because symptoms of depression and anxiety quickly morph into a distorted core belief that “something is terribly wrong with ME” and then, it is no longer just about symptoms, it’s about who she is. This irrational belief that she is impaired, or flawed, or somehow unfit to be her baby’s mother, is part of what drives the shame and potential for suicidal thoughts.
To repeat: Every healthcare provider who treats or comes in contact with a perinatal woman should hand her a list of reputable, reliable, and accessible local maternal mental health professionals. (If that list is not available, make one. If there are no available resources in your area, try here or here or here.)The provider should inform her that she should contact someone if she does not like the way she is feeling and share this list with her partner. Every single woman should receive this. Period.
Perinatal women continue to die. The need for medical vigilance and careful monitoring is mandatory. Not just during the early postpartum weeks. Perinatal women are at an increased risk for suicide for months into the first postpartum year. Some of them are more likely to visit their primary care provider for mental health reasons. If you are a healthcare provider and you have not asked your perinatal patient if she is having thoughts of harming herself, you have absolutely no idea if she is having suicial thoughts or not. Even if you do ask, she might not tell you.
Give her printed resources that she can take home with her.
So she can hold tight to that information.
So she can know you care.
So she knows she has options.
So she can increase the likelihood that she will get the help she needs.
copyright 2018 Karen Kleiman, MSW
The Postpartum Stress Center postpartumstress.com