Blog: Postpartum Matters

The Magic of Connection in Meaningful Relationships

I was stunned and embarrassingly heartbroken when I posed the ridiculous question to my well-informed virtual group of over-worked psychotherapists:

“As long as we are discussing self-care strategies during these unprecedented times, just curious… how many of you are watching Outlander?”


I was shocked. (Perhaps their computer audio was not working. Was I muted?)

I double-checked, then repeated my question:

“Anyone watching Outlander?”


I’m pretty sure my eyes popped open as I froze on the spot, equally dumbfounded and mortified. In an instant I had shifted from my role as a well-respected and accomplished mentor to a shallow-minded, Netflix groupie hooked on a romantic drama and soft-porn.

The echoes of joy and giggles I predicted were replaced by blank stares. Why would I ask such a ludicrous question in an academic setting? I promptly did what I always remind the group to do when caught off-guard in session — I breathed through my nose. Slowly. In and out. And I smiled. I realized I wouldn’t convince any of them to watch it, and why should I? Surely they have each discovered self-care routines that can help ease the distress imposed upon them by the pandemic, universal unrest and the growing list of external stressors.

Together, this awesome group of clinicians and I spend one hour a week, sitting in the muck of this challenging territory, fueled by our collective quest for meaning. The recent months have inflicted extraordinary pressure on this group, as psychotherapists, as women and as mothers.

But back to Outlander.

Jamie Fraser is not my type. This feels awkward to write at the ripe age of 66, but honestly, he’s not. By objective standards, he is extremely attractive with God-like proportions. Still, as an old hippie with an affinity for the more earthy, unpretentious type, I frankly didn’t expect to get sucked into this world of time travel, rousing rebellions and 18th century melodrama.

Until Jamie looked me in the eyes.

OK, so it wasn’t me. But it felt like me. I wanted it to be me. I remember one scene, when Claire was telling him the truth of who she was — a story so far-fetched that even the most trusting soul surely would respond with a healthy dose of skepticism — after which she returned his attentive gaze by asking something like, “do you believe me?”

“Aye.” He softly replied with conviction and gorgeous Scottish simplicity. His piercing gaze was loving and steadfast.

I turned to my precious husband of almost 40 years and asked with a smirk, “Is that so hard?”

One of the tenets we emphasize in the world of psychotherapy, particularly in the new world of virtual psychotherapy, is the importance of eye contact. Of staying connected. Of conveying the message that we are staying present and listening. Really listening. Notably, there are many levels of eye-contact, ranging from “I-am-pretending-to-listen-and-I’m-really-thinking-about-something-else” eye contact, to “There-is-no-place-I’d-rather-be-right-now-than-listening-to-you” kind of eye contact. The closer two people get to that second end of the spectrum, the closer they get to magic.

In our current state of rampant uncertainty, pervasive anxiety and widespread grief, many of us crave constancy and the affirmation of our self. As psychotherapists, who by definition must restrain from expressing our personal needs when we work to stay focused and available during any current crisis, it’s easy to feel unheard in our own relationships. Even the best of partnerships cannot tolerate constant, unremitting demands for unwavering attention and concentration. (Believe me, I have tried.) And eye contact? Well, life gets in the way and we are all way too busy. Dogs, cell phones, work, priorities, pandemics and so forth. It’s absurd to even ask for it given the state of worldwide suffering. And yes, I get it. On balance, we are talking about real-life here, not historical fantasies streaming in the background.

Even so, the desire to feel heard and acknowledged is a universal human need and perhaps one of our deepest longings. When we manage to lock in that sacred moment of connection, as fleeting as it may be, it feels gloriously indulgent. I matter. What I am feeling matters. Not to be confused with seeking confirmation from others to secure one’s own self-esteem, the hope that one will be heard is a legitimate expectation of healthy, intimate relationships. The end result is less important than the process itself. In other words, when efforts are made, when phones are put down, when eye contact takes place, when interest and attention is offered, partners move from listening, toward empathy. Within the context of meaningful relationships, that is magic.

We are all trying to do our best. Those of us who feel fortunate in the midst of so much global chaos, most certainly can, and must, settle for unexpected relational disconnects. Still, we must remember not to take our relationships for granted while we are busy worrying about everything else. We must learn how to ask for what we need and do our best to listen. Let’s remember to take care of each other while we take care of the world around us. Let’s remember how good it feels to stay present if we are lucky enough to be in a relationship that feels safe and cozy to us. And during those off times when we might want or need a little bit more, because we are exhausted, or scared, or weary …

There is Jamie.





Tokens of Affection: The Book You Might Need For Your Relationship

I love being married.

I am the selfproclaimed master of all things relationshiporiented, while my husband, well, he does everything else. We each surrender to the other’s area of expertise. Like everything else in life, our marriage has its good days and cranky days, and days when the relationship simply must take a back seat to everything else. Now that our children have grown and moved out of the house, we have the luxury of looking back at the early days through the filter of longgone precious moments and hindsight.

While I acknowledge my comfort with my role as our relationship healer, and agree that it is something I do fairly well for the most part, I am also aware of all the things I do wrong, or notsowell, or not at all like other people might do them. So much so, in fact, that those closest to me are often taken aback by my intrinsic willingness to expose my vulnerabilities to the outside world. Friends and family, often stunned by my frankness, weigh in that I should, perhaps, be more discreet and less impulsive when it comes to disclosing my vulnerabilities. They may be right, to an extent, but it is a reflex of mine. I know no other way to be. When circumstances dictate, I restrain myself but it’s not a natural state for me and I believe with great confidence that this inclination to be forthright, is one of my greatest assets – one that accompanies me into every session with every client.  I’m quite certain it’s part of what disarms a new client who is often paralyzed by unspeakable anxiety and hopelessness.

Though I suspect my affinity for directness has been a lifelong proclivity, the longer I do this work the more value I see in balancing my professional expertise with my perceived “weaknesses”.  As a therapist, bringing one’s entire self into a session is risky, to say the least, and an act that should only be carried out with the wisdom of what it will mean to the client. I believe it’s critical to my work, that my clients see me as real. While initially it may seem counterintuitive, ultimately, it’s more human. Our genuineness as a therapist is our supreme tool.  It holds infinite healing power.

Even so, what do my personal vulnerabilities have to do with the message of this book? I believe we all must work hard to put our best selves out there, in our work, in our marriage, in our lives. At any given moment, we can all be challenged by contradictions between what we expect and what we experience. There are powerful paradoxes within each of us. A person can be competent and emotionally accessible at the same time. Someone can be proficient in one area and less skilled in another. Someone can not feel good and still do a good job. A person can be successful and symptomatic, simultaneously. This last example is hard for postpartum couples to come to grips with. All too often they will misinterpret symptoms as a reflection of who they or their partners are. If someone feels bad, everything is bad. If someone is scared, everything feels scary. That’s because things appear very black and white for postpartum couples who are struggling to resume control over their lives and reconciling these apparent contradictions feels impossible.

Other examples of these paradoxes affect thinking during the postpartum period:

If I’m anxious all the time, I can’t be a good parent.

If I want to go back to work so badly, I must not love my baby.

If my partner isn’t acting lovingly toward me, I must be unworthy.

How can I attach to my baby if I feel so unlovable?

What if pain from my troubled past means I cannot be a good parent?         

How can I possibly take care of my marriage if I can barely take care of myself?

These dichotomies are difficult to resolve, especially for new parents who are trying so diligently to do everything right. People forget that life consists of opposing forces much of the time. And after a baby comes into the picture? These contrasting desires and urges can squeeze the joy right out of the high expectations of this time in a couple’s life. It is precisely these paradoxes, fueled by depressive thinking, which can drive a wedge into the connection between the two of you.

That is why it is essential that you begin to understand that paradoxes do exist right now. Yes, I can be an effective therapist and not be good at speaking extemporaneously about a topic with which I am unfamiliar. Yes, you can be a good mother while you are experiencing excruciatingly scary thoughts. Yes, you can be a good father even if you are ashamed that you feel so bad. And yes, your marriage can sustain high levels of painful resentment and misunderstanding and still be a safe place for both of you to rest comfortably.

Depression sets the stage for many such paradoxes for any postpartum couple. Selfdoubt permeates the martial system after depression takes hold. Unexpectedly, the relationship can be seriously jeopardized by ties that have shattered and replaced by an unfamiliar landscape of misunderstandings and ineffective communication.

Things that used to make sense, now feel unsteady and vulnerable.

Vulnerability can be an uncomfortable state, but it can also serve as a catalyst toward a better sense of self and a deeper relationship. In order for that to happen, you need to be willing to take the risk of letting yourself sound stupid, be wrong, be seen, be heard, be messy, make a mistake, or feel pain, in order to achieve authenticity and ultimately, greater intimacy between you and your partner. Brené Brown, a research professor, refers to this as “the courage to be imperfect” (Brown, 2012, p.218,) and believes this is the root of earnest parenting and partnering. Being comfortable with your own vulnerability is not easy but it is something you can learn. It begins with trusting yourself and believing that you have your own best interest at heart.

This is the only prerequisite for your work in this book. Open your mind. Believe in yourself enough for you to expect the best from your relationship. Find the courage and give yourself permission to lean into your marriage and see where that takes you.

The driving force behind this book

I am grateful to the postpartum couples who have been brave enough to share their stories, expressing what they needed most from me and from each other. Some express this with their words. Some convey it with the silence of what they cannot say. At present, almost thirty years into my clinical practice and thirty years of marriage, I am in position to merge these parallel life experiences into this book, on behalf of postpartum couples who have struggled with depression.

Sometimes it seems that couples put too much effort in the wrong direction and are unable to see what is often right there in front of them. Couples with new babies are tremendously preoccupied and busy worrying. They are too tired to understand what their partner is saying. They are overwhelmed by the demands of their schedule and too depleted to give anything back. So they often bark back and forth or decide to take care of things themselves, because it’s just easier that way.

When depression has been part of this picture, one or both partners may continue to feel angry, resentful or unworthy. These negative emotions can remain hidden by daily distractions, or they may blast into every single interaction. Either way, they are apt to fester. Even when the welcomed relief of recovery from depression brings renewed hope and anticipation of good things to follow, the fallout from the illness can confuse intentions and lead the marriage both astray.

Postpartum couples crave and deserve relief. The birth of a baby can inflame various forms of life’s ultimate contradictions: joy and despair, pleasure and grief, elation and exhaustion, euphoria and anxiety. The impact of these incongruent states of emotions can wear heavily on the spirit of a marriage. This book was a response to working with couples who have shut down from the weight of this pressure, to help them revitalize their connection.

TOKENS OF AFFECTION by Karen Kleiman with Amy Wenzel
Available here on Amazon

Finding Joy

There’s a sweet saying that has been plucked from the chamber of anonymous authors and found its way into popular culture and right into my heart: Just when the caterpillar thought the world was over… it became a butterfly.  I just adore it.  The large blue square-shaped magnet that displays these words is posted at home and at work, as an ever-present reminder to myself and to those around me, that good things are going to happen.

I love the image it conjures up and the message is particularly important to someone who is besieged by despair.  The implication that change does not come to pass overnight is unthinkable to someone who is anxious for an immediate reprieve.  Transformation in nature or recovery of one’s body and soul takes place after untold periods of time, hard work, pain, and discomfort.  When healing does take place, it is, indeed, a metamorphosis.

Butterflies are amazing creatures that can take our breath away.  How many of us have found ourselves sitting outside in a warm sunlit spot catching a glimpse of a butterfly who was diligently trying to avoid us?  Or what about being blessed by a rare occasion of contact with such a creature who for reasons unknown decides to settle somewhere on our body, tickling our knee or perching on our arm?  When that happens, we stop breathing for a second.  Don’t move, we think, lest we lose this precious moment of connection too divine to really understand, while we gaze at the loveliness of it all.

In my work with postpartum women, I rely on butterflies as an icon of good things to come and joy that is possible and within reach.  This belief that good things can still happen, perhaps unfathomable in early therapy sessions, will eventually be endorsed by women who long for it.

When discussing butterflies with clients, I tell them there are some people in this world who seem to be surrounded by butterflies.  Good things just seem to happen to them.  People are attracted to them.  Positive energy emanates from them.  This is not something you can see, of course, but most who are tuned in, can feel it.

Some women respond to this notion with objection, reminding me that they just are not wired that way.  I agree that it’s hard to find the butterflies in your life if it’s not something that comes naturally to you.  Try convincing any pessimistic thinker that all they have to do is think optimistically!  We know it doesn’t work that way.  But if I didn’t believe on some fundamental level that people could change the way they think and the way they behave, I certainly couldn’t do the work I do.

So we look for butterflies.  One could make the argument that’s it’s a cognitive intervention and that we are helping our client engage in a process of reframing their negative thinking.  This would be true.  I prefer to think of it as increasing their awareness and tapping into their own unsung potential for healing and self-renewal.  There are butterflies all around us, I continue, we just have to look for them.  Hard to do when everything appears dark and menacing, but important for us to say, nonetheless.  Looking for butterflies when your client feels like her world is crashing around her is an instruction that might, quite frankly, infuriate her.  Yet, what we are doing is instilling the early stages of hope and providing a hint of reassurance that it will not always feel this way.  As treatment progresses, looking for butterflies gets easier.

If a woman isn’t sure what this means, I will help her, but most of the time, women bring their butterflies right to the session:

“Sitting in the grass with my three year old looking for four-leaf clovers.”

“The look on my toddler’s face yesterday when she saw her first balloon.”

“A cloudless crystal blue sky.”

“My husband taking my hand and squeezing it tight when I least expected it.”

“The smell of home-baked cookies when I passed the corner bakery.”

What is a butterfly?  It’s a moment of pure joy.  It’s an instant in time when everything feels right.  It’s a thing or a look or a feeling, a sense or an energy that grabs us from behind, often when we are not looking.  Most of the time, it is fleeting.  Sometimes, it rests right in front of us.  We cannot see it if we do not look for it.   If we aren’t mindful, we will miss it; it will be gone.   If we find it, it’s exquisite.

Excerpt from “Therapy and the Postpartum Woman” by Karen Kleiman

When Being a Maternal Mental Health Expert Doesn’t Help Much

I thought I knew what postpartum anxiety was. Until my daughter with a history of OCD gave birth to a premature baby the day the pandemic was broadcast.

I have been studying, researching, practicing, writing, and interviewing about maternal mental health for over 30 years. For some time now, my work has been acknowledged as “groundbreaking” as it has been instrumental in getting the conversation about prenatal and postpartum depression/anxiety started. I have been honored to be recognized as a trailblazer in this amazing field of study and clinical practice.

Suddenly, none of that mattered. Not one little bit.

Without hesitation, my expertise took a backseat when my daughter called the night before my 2-day professional training and said, “Mom, my water just broke.”

“What?! Are you kidding?” (Not the best mom-response, nor the best maternal expert response but it was the best I could come up with since she was 4 weeks early and labor was not yet on our list of things to worry about or plan for.) My hope of getting a good night’s sleep before the long weekend of teaching rapidly vanished.

Drop everything. Recalibrate. Make sure she is safe and prepared for the next step.

My head was unexpectedly flooded by the convergence of professional and maternal responsibilities splitting my brain into conflicting obligations. Somehow, I managed to do both, doing neither as well as I would have liked.

Fast forward to the NICU. Everyone was well. Baby needed some extra time catching up. My daughter went home a few days before her son was ready to join her. In the meantime, we did our best to protect her from being inundated by the developing news of the Coronavirus outbreak. Although there were some changes already in place at the hospital, such as visitor restriction and intense hand-washing guidelines, all of these expectations seemed in line with having a preemie, and in fact, helped us all feel well-protected.

PANDEMIC announced. Immediately, nothing was the same. For everyone. In the world.

For us, in our small circle of elated grandparents, and brand new parents of a preemie, the uncertainty hung over our heads like someone had their finger on the nuclear bomb and was waiting to push it. Stay safe. In our baby bubble. Take precautions. Stay home. Wash your hands. Wipe down the house. Wash hands again. And then, again.

My daughter was good at that. Over the years, she had established routines and daily practices that worked well to protect her from her irrational beliefs that certain foods would make her sick or germs would invade her space. She was good at taking care of herself and able to laugh at some of her compulsive habits that were engrained in her moment-to-moment thought process. She had always functioned perfectly well despite extraordinary internal distress and interminable self-monitoring.

So when she brought her baby home, the timing was staggering. The air permeated with endless breaking news messages while all irrational fears quickly became rational. Soon, the world was feeling what my daughter had always felt. Nothing was safe.

My anxiety did not help. But it did contribute to some pretty absurd exchanges that I swore I would never reveal to those who look to me for personal or professional guidance.
Such as, “Mom, why is he sleeping so much? I can’t wake him up,” She asked, while I stood there beside the two of them watching him sleep peacefully.

“He’s fine. He’s a preemie. He’s okay, honey.” WHAT? why can’t you wake him up? What does that mean? WHY IS HE SLEEPING SO MUCH? I have no idea if he’s okay or not.

“Mom, what is this? Is this okay? (Referring to a mark or a look or a sound) Why is he squeaking like this? Why is he breathing like this?”


“He’s okay.” I would try to reassure with little conviction behind my words. “He’s still catching up. But you can call the doctor if you are worried. That’s what they are there for.”

“My breasts are so engorged. Should I start with this one, instead? Should I feed him again since he keeps falling asleep? Is he getting enough? How do I know? I found a lump in this breast, do you think I have cancer?”

HOW DO I KNOW? I have no idea. About breastfeeding? About cancer? Omg.

“Let’s call someone from my team. It’s been 34 years since I’ve breastfed! They can help, I’m sure!” I hope she doesn’t get mastitis. What is that lump in her breast? Am I exposing her to the virus?

Anxiety is a funny thing, the way it convinces us to believe the crazy thoughts that come and go. Our best defense is to try not to pay attention to those thoughts. To not empower them. To distract our mind and stay focused on things that feel good as best we can.

My daughter is a wonderful mother. I am so impressed with her ability to transcend her pervasive anxiety and begin make sense out of the shock of being unprepared for the birth, the dreadfully long and scary delivery and ultimately, her early connection with her precious little one. While I knew how important it was, and continues to be, for us to feel especially grateful during such dark and uncertain times, that juxtaposition between gratitude and the unknown was a source of incredible anxiety. For both of us.

Postpartum anxiety has never exposed itself with such magnitude and personal investment. The world has been shaken by a force outside of ourselves. Distress is at an all-time high. Panic is lurking at every corner. My daughter’s anxiety was expected and understandably largescale at this point. Mine, well, that’s just a bonus for her. She gets to see her mom’s anxiety in full bloom. Not because I’m showing it all that much. But because we know each other so well and cannot hide anything, as hard as we both may try.

What has surprised me the most is how regulated she feels and how little her OCD is interfering with her day to day routine. Alone with her baby. Normal outlets for support are not always comforting to new moms with anxiety, she reminds me. Sometimes, group support, now online, or social media, can be enormously triggering. Still, I am only too aware that if we ask moms to shelter-in without outside support, and align themselves with the mandate to practice social distancing, they put themselves at risk for significant isolation, which we have known for some time, can increase perinatal distress. So we do the best we can and enourage connectedness.

I remind my daughter what I have always told my clients and my students, that new moms can be symptomatic and competent at the same time.

You can be scared and still take care of your baby.
You can be uncertain and still do things that help you feel more in control.
You can have scary thoughts and be a wonderful mother.
You can be anxious beyond belief and still experience joy.

My daughter has been outstanding. My grandson is outstanding. Our combined anxiety is outstanding. But for the first time, in a long time, the anxiety feels justified from a global perspective. In a strange way, that feels validating. It also feels terrifying. One thing I am certain of is that my daughter will have good days or moments, when she feels distracted and enjoying her baby, and she will have bad days or moments, when she feels overwhelmed and utterly distressed. I am oddly comforted, however, by her lifelong practice of OCD rituals which appear to help her feel more in control, during a time when few people are feeling that way.


Karen Kleiman, MSW
Founder, Director, The Postpartum Stress Center, LLC
Maternal Mental Health Expert
Author of Good Moms Have Scary Thoughts (Familius) and several additional books on postpartum depression and anxiety

photo credit: hermione13

Why Postpartum Moms Need to Talk About How They Are Feeling: Shamed into silence

New moms shouldn’t have to explain, justify, defend or substantiate the reasons they do things or the way they are feeling.

But we live in a culture that demands that they do so, usually indirectly, but sometimes, blatantly. Do this. Don’t do that. Feed this way, not that way. Go here, not there. Wear this, not that. It’s mind-boggling, even for the most stable and well adjusted mommy-brain. Mothers are constantly put in an untenable position where they must stand their ground and assert with clarity and conviction, what they are doing and why.

And then we wonder why they hesitate to tell us how they are feeling when they are besieged by symptoms of depression and anxiety. We wonder why they retreat deeper into isolation, fearing the public flogging if they dare disclose the truth of what they are thinking and experiencing. Regrettably, the reality is, they ARE judged. They are indeed judged by their family, their doctors and their peers. They are told how they should feed their baby, how they should feel, what they should to do feel better and what will happen if they don’t. The judgment doesn’t always come in the form of condemnation. Sometimes it is shrouded in words of love or support so it’s hard to know what is what. That can make a postpartum brain spin relentlessly.

Therefore, postpartum women shut down. They suffer in silence and try desperately to simply get through the day with no one noticing how bad they feel or how much difficulty they are having.

Still, the message from the PPD community is to challenge this inertia and push forward despite the very real obstacles. Your suffering matters. You need to talk about your postpartum depression. It is real. It is treatable.

For women with prenatal or postpartum depression and anxiety, the list of help-seeking barriers is extensive:

  • Fear that someone will judge you. Stigma and shame are pervasive.
  • Fear that someone will label you a bad mother or worse, take your baby away.
  • Inability to distinguish symptoms of depression and anxiety from normal changes during pregnancy or motherhood.
  • Worry that your partner or family will deem you incapable of caring for your baby.
  • You may be denying that you are experiencing symptoms of depression.
  • You don’t think a healthcare provider wants to know or can help, or may not trust them to understand and respond appropriately.
  • You don’t see mental health issues as part of your provider’s job description.
  • You may not understand postpartum depression and anxiety so you might assume that what you are feeling is a normal part of motherhood.
  • You may feel pressure to pick yourself up and just cope.
  • Deep depressive symptoms, such as feelings of despair, fatigue and apathy may have set in making self-advocacy difficult.
  • You may simply feel too tired to make the phone call or drive to the appointment.
  • You may hope it will all go away on its own.
  • You may feel that disclosing how you really feel would be a burden to others.
  • You may find it difficult to focus or concentrate on the things you need to do.

But this is why you should tell someone how you are feeling:

  • You will feel better, sooner.
  • You will be modeling good self-care behavior for your children.
  • You will be advocating for yourself and your health.
  • Untreated depression can lead to a longer course of illness and increase the possibility of recurrent episodes.
  • Earlier initiation of treatment is associated with a better prognosis.
  • Untreated depression during pregnancy has been linked to other adverse outcomes.
  • Women with untreated prenatal depression are also at increased risk for postpartum depression.
  • Untreated depression can be harmful to both you and your baby. Perinatal women with depression ten to eat poorly and have trouble sleeping.
  • Your moods and your symptoms will have a direct impact on your ability to take care of yourself and your baby.
  • If you are having thoughts that are scaring you about harm coming to your baby, you will likely feel better if you find a safe person to tell this to.
  • If your symptoms’ persist, they have a tendency to reinforce themselves and can lead to an increase in worsening symptoms.
  • Untreated depression as been associated with dissatisfaction in relationships.
  • Your symptoms may directly affect your physical health and make you more susceptible to illness.
  • It is not unusual for women to knowingly or unknowingly self-medicate their distress with alcohol and/or drugs.
  • Untreated, severe postpartum depression can interfere with the mother-child relationship.

Talk about your postpartum depression and anxiety. Remember that YOU are your best advocate. Take care of yourself. Do what you need to do to get the help you deserve. You will feel better again.


Image credit: 123rf.Viktoria Lukonina

Finding a Therapist to Help

Are you trying to find a perinatal therapist?

• A personal recommendation from someone you trust is one of the best places to start.

• The following organizations have searchable lists of therapists in the U.S. and outside the U.S. who are trained as postpartum specialists.

  1. The Postpartum Stress Center
  2. Postpartum Support International
  3. Postpartum Progress
  4. Postpartum Resource Center of NY

• If you’re searching on your own, Below is a partial list of questions and considerations:

  1. Are they licensed to practice in the state you live?
  2. Do they have specialized training in perinatal mood and anxiety disorders by reputable organizations? (e.g. Postpartum Support International, Seleni, 2020mom, The Postpartum Stress Center, The Motherhood Center)
  3. How long have they been practicing? (Longer is not necessarily better, but it increases the likelihood that they have experience with a greater range of illnesses and symptoms.
  4. Do they endorse a variety of therapeutic modalities that appeal to you? (e.g. individual counseling, couples counseling, group support, medication options, psychiatric support)
  5. Do they offer a therapy regime or adjunctive interventions that interest you? (Supportive psychotherapy, CBT (cognitive behavioral therapy) IPT (interpersonal psychotherapy), EMDR (eye-movement desensitization & reprocessing)
  6. Do they support the use of medication (if necessary) together with therapy?
  7. Will they see you as soon as possible if your symptoms are acute/severe?
  8. If you want to use your insurance, make sure you have coverage for outpatient mental health services. If you are referred to a specialist who does not accept your insurance, ask if they have a sliding scale for fee-for-service (cash) clients.
  9. If you make a first appointment and do not feel safe to express how you really feel, decide whether you want to explore that further or whether you would feel better finding another therapist. Do not underestimate your gut feelings, even though it’s difficult to trust yourself when you don’t feel good. Consider how this person makes you feel when you talk to them on the phone, or in person. Do they sound professional and skilled without being overconfident? Do they believe they can help you? Do they come across caring and compassionate? Do you feel any relief while, or after, talking with them?
  10. IF YOU ARE WORRIED ABOUT THE WAY YOU ARE FEELING, or having thoughts that are scaring you, do your best to let the therapist know. If you do not feel safe enough to express this, ask yourself if it is you, or if it’s them, getting in the way. If you are not sure what’s getting in the way, ask someone you trust to accompany you.
  11. If you do not feel comfortable with the answers or feelings you have, keep looking until you do.

Afterword Lives On…

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

Ilyene Barsky

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.


“Kol haolam kulo gesher tsar meod v’haikkar lo lefached klol”  (Hebrew)

Translation:  The entire world is a narrow bridge. The main thing is not to fear.


Ilyene Barsky, MSW

The Center for Postpartum Adjustment

April 25, 2010


A Pledge to My Postpartum Self

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.


Image used with permission by artist: Shelly Johnson. Follow her blog: Love is Stronger

A Drug to Treat Postpartum Depression: A social worker says outrage at the cost of Zulresso should be balanced by hope for more affordable treatments.



Image Credit:Chloe Cushman

To the Editor:

Re: “Can a Drug Stop Postpartum Depression?,” by Elisa Albert and Jennifer Block (Op-Ed, March 25):

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.

Karen Kleiman
Rosemont, Pa.
The writer, a social worker, is the founder and director of the Postpartum Stress Center.

From One Mama To Another

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



GoodReads Review by Jen Schwartz

Jen Schwartz is founder of the fabulous MOTHERHOOD | UNDERSTOOD Follow her on Instagram.

“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.

And Karen is helping to do it all.”

-Jen Schwartz, Founder,


Good Moms Have Scary Thoughts: A Passion Project

Yep. That’s me. Working on my first book, This Isn’t What I Expected circa 1992. ⁣

In one month from today, Good Moms Have Scary Thoughts: A healing guide to the secret fears of new mothers is coming out. (March 1, 2019, Familius)

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 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.⁣

Thanks for your enduring support. ♥

⁣#speakthesecre#GoodMomsHaveScaryThoughts @brooklyn_rabbit @familiustalk

LETTERS [To the Editor]: Postpartum Depression

Image Credit Jillian Tamaki

New York Times Readers react to articles on the various ways that mental disorders can afflict new moms.


June 21, 2014

To the Editor:

Re “ ‘Thinking of Ways to Harm Her’ ” and “After Baby, an Unraveling” (“Mother’s Mind” series, front page, June 16, and Science Times, June 17):

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…

“Nobody would believe what an effort it is to do what little I am able.”
-Charlotte Perkins Gilman 1892



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


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.


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.”

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