The need for attachment

Science is showing that the need for attachment begins even before birth. The in utero environment can impact a fetus's developing brain. After they enter the world, you attach to your baby by making eye contact, holding, cuddling, cooing, feeding and other ways of otherwise nurturing and letting your baby know you are there for them.

Once the "baby stage" ends, they enter toddlerhood. The often tumultuous, emotional time where children want to be both "big kids" and babies all at the same time. This can be frustrating for both parents and children, who do not understand the process that kids are going through developmentally. Watch the video below, which does a much better job than I can of demonstrating the attachment needs of toddlers:

As anyone who has survived the twos, threes and fours of early childhood, it is a no-brainer how challenging and tiring it can be at times for your child to need so much of your energy. It can be overwhelming some days, and not make sense on others. It can feel like a breath of fresh air for kids to become school-aged, and not need those frequent attention and check-ins. Or so it seems...

I have a nine year old daughter who plays hockey. Last weekend, at her hockey game, I had a light bulb moment where I was reminded that this need for safety and security does not end after toddlerhood. My daughter plays goalie- which is a really tough position to watch your child play, BTW- and I noticed that after someone scored on her, she would look up to the stands where we were sitting, needing to check in and make eye contact. I would give her some kind of sign to let her know "It's OK! Keep going!" and she would turn back to the game. I then observed her block a puck, and I was hoping she would look up to me with the excitement I knew she was feeling. But she didn't. I noticed this pattern throughout the game- check in if a goal went in, but stay focused on the game if it didn't. And it occurred to me that she was checking in, just like in the video, seeking reassurance ONLY when she was disappointed, worried, in need of reassurance. A sign of her secure attachment was not seeking out our connection when she was successful- likely because she knows we are proud of her.

As kids get older and become adults, they will continue to search for safety and security. The need to attach to loved ones, to find that secure base, never ends. It just changes.

Can I take it or not?

There've been a lot of articles in the media recently about whether it is safer not to take medication during pregnancy or while breast-feeding. It can be very confusing and scary to those reading to know what the "right" thing is to do. You may hear different information from your OB/GYN, your psychiatrist and the pharmacist. And then, when you finally do get the nerve to decide to take the medication, you read something different. I have had some clients who finally make a decision to try a medication, only to have it filled and be told by their pharmacist that they "can't" take that medication while nursing.

Taking medication is a very serious step. In some cases, medication may not be warranted. However, especially when there is severe depression, anxiety, bipolar, or psychosis, medication may not be a choice, but rather a necessary decision in order to be out of, or prevent, a crisis.

The good news is that there are credible resources that you can look to for information, so that you can make the most informed decision. The other good news is that it does not mean that you cannot breast-feed or that you will (for sure) cause damage to your baby by taking certain medications. The harder news is that information is not always black and white. There may be risk involved. There may be a time where you are not 100% sure, but it is clear that the benefits will outweigh the risks. Here are some resources where you can find research-based information:

http://www.mothertobaby.org: a service of the non-profit Organization of Teratology Information Specialists, is dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding. (Copied from their website). This website has a ton of information, as well as toll-free numbers to call for more support.

http://www.infantrisk.com: By educating healthcare professionals and the general public alike, we aim to reduce the number of birth defects as well as create healthy breastfeeding relationships. This website provides great information, and also has forums online for questions.

http://www.motherisk.org/women/index.jsp: this website has a page for both parents and providers. It also has several various toll-free helplines not only about medications but also about things like morning sickness and substance abuse.  

http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm: I really really really like LactMed. However, the information (A medication database) can tend to be more scientific, so if that makes your brain feels like mush, then don't use this website. It does have an app that you can also download onto your smart phone or tablet, so that may come in handy.

The decision to take medication during pregnancy or while breast-feeding can be very daunting. Knowledge is power. If you must read other information aside from what your doctors provide to you, make sure that it is coming from a reputable source. All of the above, in my opinion, fit that bill.

What to expect when you start therapy

Making the decision to go to therapy can be intimidating for some, and downright scary for others. If you have never been to therapy, you may have no idea what to expect. And even if you have been to therapy, starting over with someone new... they may have a completely different style from other therapists.

You may be surprised to find that I, and many other therapists I know, take the first couple of sessions not just to get to know you, but to "get back to basics". Many people who struggle with anxiety, depression or any other mental health difficulties have let go of the things that we KNOW we should be doing, but lack the energy or motivation to do. Part of my job is to help get that back on track before diving into deeper emotional concerns, like trauma or emotions.

The top four:

Sleep:  Anxiety and depression can really impact your sleep. You may find that you can't sleep, or are waking up at 2-3 am and toss and turn until the sun comes up. You may find that all you want to DO is sleep, and struggle to get out of bed, or nap several times a day. Or you may find that staying up late is the answer to getting things done around the house, catching up on Breaking Bad episodes, or playing Words With Friends on the iPad.
Why this matters: Sleep deficiency can cause many issues- poor driving, poor decision making, difficulty losing weight, mental deficiencies... and just feeling tired and crabby. This makes you not only uncomfortable in your own skin, but usually not very fun to be around. It also means that you likely don't have energy for exercise, relationships, or hobbies (the other important self-care items).
What to do: Create a sleep schedule, committing to be in bed by a certain time, and that time should be relatively consistent. Cut out the use of screens before bed, and stop using caffeine after 2 pm in the afternoon. Consider meditation or deep breathing/relaxation to help ease you into sleep. If your pets or kids sleep with you, and this is interfering with sleep, consider a new plan.

Can't... stay... awake....

Exercise: Before you think I am sadistic, I refer you to a previous blog post where I talk about how much I HATE exercise. There. Now we are on the same team.
The reality is that many of us are not getting enough activity, whether that is because we are overtired, we work full time, the kids take too much of our time, etc. etc. etc. Or we just hate to exercise, and nothing sounds fun. Again, small amounts can make a big difference. Start with a ten minute walk around the block. Park your car farther away when you work or shop. Take the stairs. Play in the yard with your kids. You don't need to be able to afford exercise equipment or a gym membership in order to get exercise.
Depression, especially, takes away any motivation or interest in exercising. So you will have to make yourself do it. There is no simple answer, unfortunately... I'm sorry. However, you will likely feel better after you do something, and that I know is true.

Exercising with a friend is always more fun

Diet: Please don't hate me. When  I use the word "diet", I do not necessarily mean "going on a diet". Although sometimes that is the case, the healthier approach is making small changes in the daily ways that you eat, or don't eat. Drinking more water. Not skipping breakfast. Eating less carbs.
Depression and anxiety can make people crave carbs and junky foods. Then they have an energy crash which does not help anything. Or it can completely rob you of your appetite, leading you to skip meals and either lose weight or binge/make poor choices later in the day.
So again, start small. If you are skipping breakfast, have a hard boiled egg, a piece of fruit or a smoothie for breakfast. If you go several hours without eating, have healthy snacks available that you can reach for rather than something processed from the vending machine. Or keep a full water bottle nearby so that you remember to drink more water. Cut out one serving of caffeine, particularly if it is the afternoon. Focus more on how you feel rather than the number on the scale.

Nom nom nom....

Socializing/Hobbies: Finally, a big one. When you work full time, or are a new parent, or have young kids... friends and hobbies seem to be the first thing to go. Then, add a mental illness that can either sap you of any motivation to socialize, or cause you a lot of anxiety or panic attack to think of engaging in. Often, this are seems to take more time for me to get clients to buy into. They say, "Nobody wants to be around me right now" or "Everyone will think I'm stupid/fat/weird". "I don't have time/money/space to engage in my hobbies".
There are many approaches we can take in counseling to address these thoughts or low motivation, and also find some ways around any concerns to help you get reinvolved in your life. I promise, you will feel better when you do.
Again, start small. Think of something that used to bring you pleasure, and do it for 10 minutes. Go to the library and get a book. Go to an art museum. Grab your camera and go outside and take pictures. Call up a friend and commit to talking for a short period of time, or send an email to someone you haven't connected with recently but would really like to. Ask a co-worker to join you for lunch. As daunting as some of these things feel, you are in control of what you do and for how long.

This looks fun, right?

I share this information in the hopes that it will encourage you to reach out for help if you are struggling. Don't try to figure things out alone. Have a professional who is non-judgmental and is there to offer support and encouragement as you get back on your feet. Ultimately, when you are struggling with anxiety or depression (or any other of it's close friends), you feel very out of control. Self care is something that you do have control over, and small changes can add up. Pick one small thing to try, and start doing it.

Words matter

With the recent suicide of Robin Williams, discussion about suicide, depression and mental health are at the forefront of everyone's mind. And if there is anything positive that can come out of this terribly sad loss, it is bringing more awareness to the need to feel like we can talk openly about mental health. To feel like we can say, "I am not OK" without fearing shame and stigma from the people around us.

What I have noticed when reading numerous articles that have come from this loss is the way that people stick a diagnosis on people like a label. That it is as if their mental health diagnosis is who they are, rather than a part of them that they struggle with. Fill in the blank: "I am..... " Bipolar. Schizophrenic. Mentally Ill.

The reality is that while we need to be able to talk about these disorders without shame, our label is still not who we are. We are so much more than that as people. How ridiculous would this sound:

"I'm green eyes"

"I'm polycystic ovarian syndrome"

"I'm cancer"

We don't say those things. We say, "I HAVE cancer". "I HAVE green eyes/brown hair/my dad's nose".

Why does this matter? Because it is so easy to become our label. To wear it like a Scarlet Letter of shame, and say that certain parts of us are not acceptable. We are so much more than our labels, in the same way that our physical appearance are not all of who we are.

People first language matters. Be mindful today of how you label people in any way.

"That autistic kid" becomes "That child with autism"
"That depressed/crazy/anxious person" becomes "He has depression" "She struggles/lives with mental illness"

It only takes seconds.

The Climb...

Feelings about the twerky Miley Cyrus aside, her song, "The Climb" (which she wrote back when she was sweet and innocent) has played through my head a lot lately. It even randomly popped up on my iPod while I was driving one day, ruminating about my stress level with this whole private practice business. This journey has definitely been a climb, one worth making, and I am hoping that I am heading back down the mountain, but I am sure there is another one somewhere in the distance.

The struggles I'm facing
The chances I'm taking
Sometimes might knock me down, but
No I'm not breaking
I may not know it, but
These are the moments that
I'm gonna remember most, yeah
Just gotta keep goin',
And I, I gotta be strong
Just keep pushing on, 'cause

There's always gonna be another mountain
I'm always gonna wanna make it move
Always gonna be an uphill battle
Sometimes I'm gonna have to lose
Ain't about how fast I get there
Ain't about what's waitin' on the other side
It's the climb

The biggest mountain I have faced so far is transferring all of my credentialing with insurance companies over to my new location. I am very lucky to be part of a large clinic that already had me credentialed with just about every possible carrier. What I wasn't sure of was how that would translate to my new solo practice at Stages. Two carriers denied me initially. I appealed and only one of them overturned. Which means that one (rather large) carrier continues to deny me coverage, and it means saying goodbye to those clients, unless they can afford to use their out-of-network benefits and pay for it... many people cannot do this.

The carrier that continues to deny me is Health Partners. They denied me originally saying they have enough providers in this demographic area (keep in mind, I was already in their network at my current practice). I appealed with a letter very specifically outlining the need for more providers in the south metro that specialize in perinatal mental health. They responded, "we have enough... " When pressed further (through many many back and forth emails with a rep there) I was also told that they rarely credential solo practices, and that there isn't anything I can do.
Pregnancy and Postpartum Support MN (PPSM), of which I am the proud Co-Director, has spent a lot of time (a LOT) interviewing and vetting providers in the Twin Cities metro area that declare a specialty in perinatal mental health, and who have paid an additional membership fee to be part of our resource list. This means something to us within PPSM. It means that they care so much about the area of perinatal mental health, and have had so much training, that they want to be known as having a competency in this very specialized area so that new and expectant parents can find them and be confident they are seeing someone that knows about this specialized area of mental health. We have ALL heard horror stories from clients who have seen providers who do not have a specialty in this area, and how many of them have left feeling ashamed, frightened and misunderstood not because the therapists hearts aren't in the right place, but because they are not adequately educated about working with Perinatal Mood and Anxiety Disorders (or PMADs).
Interestingly enough, my fellow co-director Lisa Cross and I did some research on the providers Health Partners has on their list with a declared specialty in PMADs. And guess what? Not one single one of them is on the PPSM Resource List. Lisa could also not find any that mention on their personal websites that they specifically work with PMADs. Why is that? Likely, it is because when Health Partners does credential someone, they are sent a generic checklist asking what things the provider will work with. A provider can check the box for postpartum depression or maternal mental health (depending on how it's worded on their form) but they do not need to prove their training in these areas. This explains why their list makes it appear that they have an adequate supply of providers who work with this specialty.

I'm still climbing this mountain, and while I have not crested the peak, I have had to stop and get some air. The truth is that we need some reform and education within insurance companies to let them know how specific PMADs are. Lisa and I attended a wonderful breakout at the PSI Conference in June about how Cigna is tackling this issue. We know it is happening (just not at Health Partners), it just needs to spread.

My New Adventure

Funny...I looked back right before I started writing this post and noticed that the last blog post was titled "Things will never be the same". I am on a new adventure to starting a private practice, and that is about how I am feeling right now. There is no turning back. It has been such a whirlwind of emotion (see Spongebob below) that I think I have probably gone through all five stages of grief at some point. But here I am. Breathing and everything. 

My friend and colleague, Veronica Jacobsen, owner of Baby Love in Eagan, MN, approached me several months ago about renting office space at her business and providing mental health services there. At first, I said no. I am very comfortable where I am now- Clinic Director of a large, thriving practice- and I just do not like change. I like comfortable. Very much, thank you. *cuddles in virtual blanket*

Veronica and I met again a couple of months later, and Veronica told me, "You know I'm holding that space for you, right?" I gave a very hesitant, "I will think about it" and said I had to get through the Daisy Dash 5K first. She was very patient with me, thankfully. But driving home, I started considering possibilities. There are SO many things in the field of perinatal mental health that I would like to do that because of my current position, I just realistically could not do them. Plus, I would definitely be more accessible to new and expectant parents if I were INSIDE of Baby Love (kind of like Starbucks in Target). I found myself getting more and more excited about the prospect of making the change. I talked it over with my husband, who has been wonderfully supportive in almost every idea that I come up with, and there it was... a decision was made to take this chance and join forces with Veronica to see what we can do together. 

I have now given my notice with my current employer, and I am in the process of transitioning my patients. I still go up and down on this wacky rollercoaster ride- excited, scared, sad, nervous... but mostly excited. I love a new challenge, and have been reminded what a great village I have. 

In the meantime, my new website is up, Stages Counseling and people can schedule appointments ONLINE! Which I am very, very excited about. I have a lot more to process and write about, but all in good time. 

More to come...

 

Things Will Never be the Same

Many of the new moms that I work with come in with the goal of "being like my old self". When I was newer to this field, I felt that was a realistic goal. We would discuss what that would look like, and how they would know when they are making progress, as any good therapist should in the process of treatment planning.

However, the longer that I work with this very special population of clients, and the further I get away from my own experience with postpartum depression (PPD), I realize that it is NOT a realistic goal. I also realize that often, people make their new experience to a new phase of their journey and realize that not only is that not a realistic goal, but that going through a perinatal mood/anxiety disorder (or PMAD for short) has strengthened them.

You don't believe me, do you?

You see, going through a PMAD is a life changing event. And in many cases, it is a traumatic one. Having a baby is supposed to be the happiest event in your life. You are supposed to be glowing, and thrilled, and becoming a mother or father should be "natural" and a state of bliss. Right? WRONG. Even for a parent who has not experienced a PMAD, becoming a parent is not always an easy transition. You are sleep deprived, generally feeling awful about your body, feeling incompetent at moments, and have a lack of time for your relationships. Now throw in some depression, anxiety, OCD, birth trauma, a preemie, multiples, etc. etc. etc, and one might be able to see how this could be a life-altering experience.

Living with a PMAD is like creating a line in the middle of your life- "before PMAD" and "after PMAD". Just like any other line with a before and after, there are changes that happen. A PMAD can change how you view the world, and everyone in it. You may become more cynical. You will likely learn who you can (and cannot) count on. You will be reminded that life is not fair. A PMAD can also change your body chemistry so that your brain may not be capable of going back to how it was "before". Generally, with a combination of therapy and self-care, and often, medication, you can return to a very good level of functioning. But you as a person are still different.

There are positives that come out of this experience as well. In hindsight, people are able to look back and see that they didn't realize how strong they were. How resilient they were. How wonderful their partner is, or how their relationship was strengthened as a result of weathering such a storm. But just like going through any major life altering event, like cancer, or a death, you are still not the same person that you were before.

Being the "same" does not mean that you failed. It means accepting that because of this event, you will not be the same. Ever. And that isn't a bad thing. You will be stronger, braver, and healthier. You may have scars, but you have a story of perseverance to go with the scars.

Toxic Workplaces

The theme this past week has been people who are miserable in their jobs. It could be the winter talking, but it could be so much more.
People tend to minimize how much damage working in a toxic work environment can cause. I have met with clients with anxiety and/or depression severe enough to need to apply for a leave of absence (which can be traumatic, in and of itself). I have heard stories of narcissistic bosses that have torn people down and led to a loss of confidence. Ultimately, people end up feeling helpless and stuck.

Here are some ways to identify that you may work in a "toxic" workplace:

• NO appreciation... your boss, makes no effort to give positive feedback to employees. There are no incentives to do a good job. You feel like another faceless pawn, and you either receive no feedback at all, or you only hear the negative. You may ask your boss how you're doing, and get very little back. You may assume "no news is good news" until your annual review (if you get one), where you are unpleasantly surprised to see that your boss thinks are you underperforming. This may be the first you have heard of this. No encouragement, no coaching, no validation. 
• NO boundaries... your boss or co-workers have no qualms about asking inappropriate questions about your personal life. They overshare their own personal information. You may decide to share something personal, only to hear that everyone else has heard about it. You have no personal space, and your possessions are not respected. They may be overly touchy-feely. And despite your requests for space, privacy, and ownership, these requests are not respected, or, worse yet, you are made to feel like you are being "sensitive". 
• NO support... You may be struggling with work or something personal, and the boss doesn't have time to help you. You may go to your Human Resources department to seek out help or file a complaint that falls on deaf ears. You may be turned down for short-term disability. This is the biggest difficulty I have heard from clients-- when they finally get the courage to go to HR, only to be told there is nothing that can be done, or the complaint is never addressed. This is often the last straw for employees who have felt discouraged for a long time. 

So what can you do?
As mentioned above, it is an option to contact HR, if you have a decent HR department, and inquire about short-term disability or FMLA benefits. While this may not work for everyone, it can help you feel like you have options. You can also ask your doctor or therapist, if warranted, to write a letter to your employer that you change your schedule temporarily, be allowed time for appointments, or be allowed to work from home.
If that doesn't work, or it isn't an option, start getting your ducks in a row. Finding a new job is NOT easy, but you can take steps towards doing that. Go to the library and check out some books that will help you update your resume and cover letter. Take some career assessments. Look for classes (many libraries have free ones!) about job searching and updating your resume. Many also have classes that can help you brush up on your computer skills.
Meetup.com is a free networking site to look for local groups, including networking groups. This could lead to potential job leads. I have also seen churches and work centers in our area with networking groups. Many of these are free.
Check out LinkedIn, which is a social media outlet for people looking for jobs (also free). Putting your resume on this website and joining some networking groups may lead to companies contacting you.
A (usually) non-free option is to meet with a career counselor. Community colleges often have some, but there are also independent ones that you can hire to help you determine what your next steps are.

Have you ever worked in a toxic work environment? How did you get through it?

The Best Self-help Books of 2013

I admit it: I'm a bit of a nerd.  If I have some free time, you can usually find me with my nose in a book. And because people who know me know that I'm a bookworm, I often get requests for recommended books.

This post is dedicated to the best self help books read in the last year. (Note: this is just my own opinion!)

"The Gifts of Imperfection" by Brene Brown... This writer has done a ton of research, writing and talks about shame, writes about accepting ourselves and our imperfections without feeling like you are being told to "just stop thinking about it and love yourself". This book was very real, and the tools very doable. If you want a taste, look Brown up on YouTube.

"Dropping the Baby and Other Scary Thoughts" by Karen Kleiman... Dives into postpartum OCD, and gives readers wonderful insight into this disorder, and ways to navigate it. I have found myself recommending this book often, and hear great feedback about how validating it is for the mom, and a great way to help her partner understand what is going on without fear. Intrusive thoughts are very real. Anyone who works with moms regularly could benefit from reading this book.

"Women, Food and God" by Geneen Roth... Recommended reading for anyone with a negative relationship with food/eating and self worth. It was really great to get some useful advice for how to let go of all that without just being told "let go of all that!" It was also about faith and spirituality, without being overly preachy. Which I like.

"I Love You But I Don't Trust You" by Mira Kirshenbaum... One of my favorite books of all time was "After the Affair" by Janis Abrams Spring. This book was equally good, and it covered working through trust issues in a more general sense. This would be a good read for anyone who struggles to trust their partner, but really really wants to.

And saving my fave for last.... "The Worry Trap" by Chad Lejeune. Why do I love this book? For two reasons... There seem to be a bajillion books on the shelf about depression, but had yet to find one that I loved and felt confident recommending to patients. This is it. The second reason was that it introduced me to Acceptance and Commitment Therapy (ACT), which has been showing promise in my practice.

What's the best self-help book that you read in 2013?

Acceptance and Commitment Therapy... Say what???

"When we are in the midst of chaos, let go of the need to control it. Be awash in it, experience it in that moment, try not to control the outcome but deal with the flow as it comes" ~ Leo Babauta

Acceptance and Commitment Therapy (or "ACT", spoken as the word, not A-C-T) has been around for a while. However, it has been getting more press recently as a therapeutic modality, and I have fallen in love with it! I have found that it can work really well for anxiety and depression, because it helps with emotion regulation. The main tenet of ACT is "acceptance". Acceptance of your emotions and thoughts- rather than avoiding them- which is our naturally tendency when we are feeling anxious or scared. Fight or flight, right?

Watch this YouTube Video called "Demons on the Boat"... (yes, I am aware of how incredibly cheesy this is- I just love how well it gets the point across, and causes a little giggle at the same time!):

Acceptance is MUCH easier said than done. But here are some ACT tools that you can read about to get a flavor...

B.O.L.D. skills- 
B- breathe deeply/slowing down   When you notice the anxiety, pause and do some belly breathing (see below). Physically focusing on your breathing, while seeming like it can't do much, can physically slow down panic attacks. It takes you out of your head for a moment, and puts you back in touch with your body.
O- observe Once you have slowed down and lessened the emotion, you can take a look at what is going on. Observe the sounds you hear, the things you see, the smells you smell. Or create some of those things- if there is a smell you like, put on some lotion that smells good or light a candle. Put on some soft music.
L- listen to your values  What matters to you? What do you stand for? When we are in our emotional mind, we lose sight of our values and let our emotions rule our brain. But ask yourself these questions. Maybe you value being a good mother, or kindness, or your faith. Hold on to these values.
D- decide on your actions, then do them Use your values to help you decide what you would like to be doing. How you can use your values to help you accept how you are feeling right now.

Belly breathing:
When people feel anxious, they tend to take short, shallow breathes through their chest. Slowing it down means making a conscious effort to push the air into your stomach (not really, but you know what I mean) like you are blowing up a balloon in your stomach. This is something that can even be taught to kids who struggle with anxiety or tantrums. Have them lie down on their backs, and put a stuffed animal on their tummy. They are belly breathing correctly if the animal is going up and down.

Acceptance does not mean that "like" how you are feeling, or that you are OK with it. It means that you are willing to let yourself feel the feelings rather than frantically avoiding or trying to change them. Willingness is saying to yourself, "I am willing to feel __________________ in order to have/get/gain ________________". (Ex: "I am willing to feel anxious in this moment in order to gain this time with my baby." "I am willing to feel/tolerate this anxiety in order to have better sleep/be healthier".)

It is hard to do, but it is possible. And the more you practice acceptance, the easier it gets.

If you would like to learn more about ACT, I recommend the following books:

"Notice that the stiffest tree is most easily cracked, while the bamboo or willow survives by bending with the wind". Bruce Lee