Three reasons why pediatricians should be screening new parents for postpartum mental health disorders

I know, that title is a mouthful... but I had to get your attention, because the way we are helping new parents now is not working. And pediatricians are just ONE spoke in the wheel, but a very important one. Yet, the majority of pediatricians are resistant to screening new parents for mental health concerns. Why? The most often cited reason is that "Mom is not my patient- baby is". If you believe that, or if your pediatrician has not screened you at a well-baby check, please consider the following reasons why this belief can lead to serious consequences:

1. Because time is of the essence. Statistically, postpartum psychosis (PPP) onsets within the first month postpartum. Most babies are brought to their well-baby check within 1-2 two weeks postpartum. When does mom go for her checkup, IF she goes? Six weeks- and often later. Even without the severity of PPP, depression and anxiety can begin immediately after the baby is born, and sometimes is occurring during pregnancy. Early intervention is key.


2. Because it is risky to NOT screen. Numerous studies point to the long-term effects on children raised by parents with untreated mental health issues. Developmental, emotional, behavioral. Having a parent who is depressed, and not taking good care of herself, is also at risk of not taking good care of her baby. She may have breastfeeding issues, may not address health problems in a timely fashion, and in tragic situations, is at risk of neglect, abuse or infanticide.
Hypothetically, if a parent arrived at your office who had clearly been using drugs or alcohol, it seems a no-brainer (especially as a mandated reporter) that you would not send a newborn baby home with that parent. That parent is impaired, and at risk of harming herself or others. Would you still believe that mom is not your patient? Depression, anxiety, and psychosis can also cause significant impairment that puts everyone at risk.

3. Because the American Academy of Pediatrics (AAP) has been recommending screening for several years.  Yes- several years. Here is an abstract from a research article back in 2010 (!) that recommends screening new parents for mental health disorders because, "This system would have a positive effect on the health and well-being of the infant and family." Another, from 2009, cites that not only should screening occur during the first well-child visit, but found screening beneficial at the 2 month and 6 month postpartum visit as well.

What is the solution? If you are not screening in your office, or if you are a new parent reading this and your pediatric office is not screening,  please consider the following:

-If you do not have a copy of the Edinburgh Postnatal Depression Scale in your office, please consider doing so. It is free to download and print. (There is one here- and it's on the AAP website... I'm just gonna leave that here).

-Determine your community resources. Many peds and OBs state that they are reluctant to screen due to the ethical dilemma of not having resources to offer to potentially depressed patients. But help is available. Postpartum Support International has a network in nearly every state with resources and a free HelpLine to get information.  They also have great info on their website that can be printed and given to patients.

-Don't forget about DAD! Men get PPD too- and more often than not, if there is a partner involved, he comes to the first well-baby visit. This is a great way to not only get his perspective on how he thinks mom is doing, but also to see how he is doing. Having two parents struggling with mental health issues can be a poor environment to send a newborn home to.

In order to more effectively help families, we need to work as a team. Again, pediatricians are only one cog in the wheel, but, again, a very important one, and often the first one to get a look at how the family is doing. We all agree that we have a precious package to protect!

The mixed feelings of fundraising

Having been part of the non-profit Pregnancy and Postpartum Support MN (ppsupportmn.org- check it out), for the past eight years, and co-running it for the past two, I have had plenty of experience with fundraising. I am here to tell you that fundraising really sucks. You get more nos than yesses, and making phone calls is just not fun for me to begin with. 

Except when it doesn't. 

Last night, we had a winter fundraiser at a restaurant. A gathering to mingle, drink, eat and hopefully raise a little money. I spent much time securing donations, and creating gift baskets to raffle off. I am not terribly creative. I was already exhausted before it began. I was stressed all day worrying about the baskets freezing in the back of the van, but not having enough hours in the day to come up with a different solution other than to leave them in the back of the van ALL DAY. In Minnesota. Where it is cold. 

And yet... 

I pulled into the restaurant parking lot, excited at the prospect of spending a fun evening with a group of women that I adore, who have come to be family. The Steering Committee of PPSM. I get a text from the other co-director telling me she's on her way. I see the beautiful room we are going to be spending the next few hours in, complete with a fireplace, and a white board where we can write inspirational messages. We bring in the baskets and arrange them, and exclaim over the wonderful donations that we received. 

People start to arrive, and we have a wonderful night. Meeting new people, seeing familiar faces. And hearing stories... 
The mom who needed to be admitted inpatient postpartum, because she really thought it would be better to die than to deal with a new baby. 
The woman who I networked with two years ago, when she was making a decision about going to grad school. Guess what?  She has now completed grad school, and is lining up her internship in maternal mental health. 
The man who is a dad of six children, that tells us how wonderful it is that we are helping moms, but also recognizing that dads are important too. 
The people who want to know how they can get involved, and help give back and help further our mission. 

I left exhausted but exhilarated. Emotional. Excited. Glad to be done, but looking forward to the next event. Ugh. 

And then I went home and looked at how much we raised.... after expenses, $1000. I felt like Oskar Schindler. The exhange towards the end of the movie where he is lamenting, "I could have got more out. I could have got more. I don't know. If I'd just... I could have got more." I felt like I should have been able to accomplish more, raise more money, get more people. What did I do wrong? 
And then I had to step back and realize that to many people, $1000 is a LOT of money. And the people we had there... it wasn't the number that mattered, but the hearts in the room. 

So, dear reader... I have decided to follow my own advice, to treat myself today with "loving kindness" and instead take a different quote from the movie: "It's Hebrew, it's from the Talmud. It says, "Whoever saves one life, saves the world entire.""
The purpose of my writing this is NOT to get attention, and have people pat me on the back. It is to give yourself credit for the difference that you can make by small changes. Don't focus on the dollar amount, or the amount of time, but rather the impact. You can make a difference. 

If you would like to know more about PPSM, or make a tax-deductible donation, visit our website, http://www.ppsupportmn.org/. Thank you!

Best Books of 2015....

Happy New Year from The Shrink Rap and Stages Counseling (www.stagescounselingmn.com). Here is my annual post about self-help and memoirs that I have read, and found helpful, this past year. Please note that this is only MY opinion.

 For those in a relationship that needs a little tweaking... 
 
Snap Strategies for Couples: 40 Fast Fixes for Everyday Relationship Pitfalls Staheli, Lana
This book is easy to read, not boring or too research-laden and has great tips to try for all couples. I loved how it was not too long, and if a particular "fast fix" was not a problem area for you, you can just skip over that section, and move on to the next one.



For biography lovers... (Or for those who loved SNL in the 90s)

The Chris Farley Show: A Biography in Three Acts   Tom Farley, Jr.
Not a self-help book, per se, but a biography written by Chris Farley's brother about his rise and fall, due to anxiety, low self-esteem and addiction. He interviewed those close to Chris, so it is his own info, then commentary mixed in from others who knew Chris. A great biography.

For those who have had a connection with birth trauma...

Heal Your Birth Story: Releasing the Unexpected   Maureen Campion
This is combination memoir, combination self-help for those who have lived through a traumatic birth, and their partners. It would also be helpful for those, like myself, who are helpers of those who have experienced a traumatic birth. It has great tips and exercises at the end of each chapter. Not a book to sit and read, but rather to digest and use to heal.


For those with a narcissist in their life... 

Disarming the Narcissist: Surviving and Thriving with the Self-Absorbed    Wendy T. Behari
Whether you live with one, work with one, or were raised by one, narcissism is everywhere in many forms. This personality type can leave people feeling quite helpless and hurting. This book is one of the better ones I have read on this subject, and felt very helpful.

For those who wonder if there is any good left in the world... 

Ask Me Why I Hurt: The Kids Nobody Wants and the Doctor Who Heals Them  Randy Christensen
Dr. Christensen in a doctor in Arizona who creates a mobile medical unit to help the homeless youth living on the streets. A great story of hope and a reminder that there are people in the world that really want to make the world a better place.

For those who want something different in their parenting style...

The Conscious Parent: Transforming Ourselves, Empowering Our Children  Shefali Tsabary
Mindfulness is a big buzz word. But do you use it in your parenting? When you feel like you have exhausted your last nerve, this book has some wonderful ways to help you feel empowered as a parent while also empowering your children.

For those who question their value...

Look up for Yes Julia Tavalaro
Another memoir written by a woman in her early 30's who ended up paralyzed and unable to speak. Those around her figured she was a "vegetable", but boy, she proved them wrong. A look at how we all have value and worth!

For parents of tween or teen girls...

The New Puberty: How to Navigate Early Development in Today's Girls  Louise Greenspan
I mostly read this because I have a 10 year old daughter!! But there was great information in it that contradicted a lot of what is out there. Girls are developing earlier, but it's not just about the hormones we are putting in our food. Evidence-based information and great tips for parents while navigating this stage of life.

For those who need to SLOOOOOOW DOOOOOWN...

Margin: Restoring Emotional, Physical, Financial, and Time Reserves to Overloaded Lives  Richard A. Swenson
We are all SO busy, busy, busy these days. How do we even try to have balance? Read this book- you will be glad you made the time. 

For postpartum parents who need to know they are not alone...

Inconsolable: How I Threw My Mental Health Out With the Diapers  Marritt Ingman
A memoir about Ingman's experience with motherhood and a postpartum mood disorder. With perinatal mental health being the bread and butter of my therapy practice, it is so important to have real, raw information to recommend. This was a good one. 

If you have read any books that you found helpful this past year, please send me an email at stagescounseling@gmail.com. I will do my best to read it! Thank you, and happy reading!

Making meaning of your wounds

This blog post was inspired by this Video. Worth the watch...


This speaker was talking about cancer and about how we process and making meaning of the challenges in our lives. This speaker is a chaplain by training, but also went through her own experience with cancer, and spoke about how we can either learn from our challenges, or become defined by them.

In my counseling practice, I see this happen frequently. People get stuck in the process of wading through the mud of the horrible things that have happened in their lives, and trying to move forward, but feel powerless to do so. And some have an unwillingness to do so.

In the video, the speaker talks about her training as a chaplain, and learning "The Three C's: comfort, clarify and challenge (or confront)". She uses examples for how this applies to her work, and it occurred to me that this is exactly what is done, or should be done, in the therapy process.

Comfort
Our clients are in pain, both physically and emotionally at times, and need us as a source of comfort. Often that comfort comes in the form of giving them a space to talk, vent, cry, yell and purge their pain to someone who is non-judgmental, and a neutral person. As therapists, we have an obligation to provide this. Many are stuck because they feel they have nobody else in their life who can comfort them, or people just don't know how. Or perhaps they have exhausted the people in their lives. This is a great first step to connecting and building trust in therapy, and in healing for the client.

Clarify
Things get harder here. We have to work through the client's experience, and either clarify for ourselves, or help them better see how things really are. Sometimes they are stuck in the perception of their story, or how others see them. Helping them learn how to fact check can be very powerful and healing. It can help them feel understood, and help them take the first step in finding meaning of their experience.

Challenge/Confront
The speaker admits that this is the hard part. And it is also a part where many therapists either don't get to- because clients discontinue therapy- or they don't feel comfortable with this part, so never do it full with the client. And this is a disservice to clients. How many of us therapists have heard stories from clients about previous therapy, where all they got was "smile, nod, and 'tell me how that feels'"? This is not thoroughly helping our clients heal.
But confrontation is hard. It means taking a risk- that your client might get angry with you. That your client may not come back. And perhaps your client isn't ready for this phase yet, but if you don't get to this point, your client will likely never learn how to define him or herself as anything other than a victim.

One of my favorite books ever is "Man's Search for Meaning" by Viktor Frankl, who was a Holocaust survivor. He talks about this same process- how in order to heal, and be resilient, we must make meaning of our traumas. Therapists- you can be such a powerful part of this journey. And clients- you can achieve true healing and find a way to define yourself in other ways than your trauma. Because you are so much more, and you deserve it!

Old Wounds

As a marriage therapist, one of the biggest reasons couples present for counseling is because they say they want to fight less, and learn how to fight fairly. Many times, they think the solution is just about communication- reducing black/white/all/nothing statements, namecalling, stonewalling... all that good stuff. And while that is important, a bigger part of therapy that will result in deeper connections and healing is uncovering what is beneath the scars, and being vulnerable with each other about those old wounds.

Think back to your common conflicts in your relationships. Really observe what happens- like creating a flowchart in your mind. Where is the breakdown? What is the moment when all hell breaks loose? That is generally where an old wound has been triggered. That is where people will engage in negative behaviors, or shut down. When something from the past, whether childhood or previous relationships, or both, has been reopened. All of your insecurities, worries,

and fears come bleeding out, and you don't know how to stop it.

How to break this painful cycle? Here are some techniques that I have found helpful in my practice:

• When you are both hurting, picture your partner as a child. When old wounds are sliced back open, we emotionally become a much younger age. In fact, many survivors of trauma find themselves stuck at the age they were originally wounded. Instead of holding on to that anger, attempt to connect with the vulnerability that your partner is showing, even in what is sometimes very ugly behavior. This visualization can often result in a much-needed emotional break for you both to regroup and reconnect in a better way. (Note: This does not apply to abusive behavior. If your partner, male or female, is harming you physically, emotionally, or sexually, that is a different topic, and one that requires seeking professional help). 
• Sit down with your partner and make a timeline of the events in your lives that have wounded each of you. This will help you both see where you are vulnerable, and will help you be more aware of what to keep in mind when needing to have emotional conversations or conflict. Share each others events, and help your partner understand why this hurts you- even if it doesn't make sense, or seem logical. When we are in conflict, we are rarely logical. 
• In conjunction with the timeline exercise, have a discussion about each of your families of origin. Talk about events, how conflict was handled (or not handled), how emotions were expressed, if there were emotions that were not allowed to be expressed, abusive behaviors, and other topics that you feel have shaped you. 
• Read the book "Hold Me Tight" by Sue Johnson. It is just SO good, and all about attachment in relationships. It helps couples stick together when they want to push each other away. Enough said.

The key is awareness. Learn what your old wounds are, and be honest- not just with yourself, but with your partner. Take a chance to let him know what has happened that has contributed to that response. This is when true healing can begin. 

Not what I envisioned... Part 1

When I was inspired by this topic, I realized that I could take this post in two different directions. And since I am not a professional writer, I decided it would make more sense to my readers for me to break this subject up into two different blog posts.

With my specialty in perinatal mental health, I work with many people who feel shame about their emotions as they navigate new parenthood. Women especially grow up with an image in their heads about what being a mom was going to look like. They envisioned being blissfully pregnant, then having an unmedicated, vaginal birth, followed by a beautiful mother/baby bond that nobody could break. They would hold their baby and attend to every need, knowing exactly what to do.

I have never met anyone who actually had this experience. Have you?

Processing this involves grieving, which means stepping outside of your shame and embarrassment, and learning to accept that you will not get your dreamed of parenthood experience. And that this is OK. Normal, for lack of a better word. There are three main tasks involved in this process, although not everyone will go through these at the same rate, time, and even order. It is also helpful to note that if your partner has his/her emotions about becoming a new parent, s/he may not feel the same way that you do. And this is OK. Talk about it anyways.

Task 1: Getting angry. Many people are raised to feel that anger is not acceptable. You "shouldn't" feel this way, or anger is bad. Anger is not the problem. And anger is fueled by fear and anxiety. So take some time- a day, a week, a month- to understand your anger rather than judge it. Are you angry that you were robbed of your envisioned experience? Are you angry at someone in your life who contributed to this? Let yourself feel that. Journal about it. Write therapeutic letters to the people who you feel have wronged you, or to yourself (note: do NOT send these letters, at least not right now!). Talk about it with a trusted person or therapist. Just don't keep it locked inside, stuffed down by shame.

Task 2: Allowing sadness in. This is another toughie for people. Sadness is often associated with depression, when really- sadness is a normal human emotion. Many men, especially, don't know how to express sadness, as they are raised to believe that it is not OK for boys to cry. Women tend to be more comfortable with sadness, but may feel guilty that they feel sad about their experience- they "should" just be happy that they have a healthy baby now. But reality is, that this is a process, and the more you fight sadness, the longer it will take. So feel it- again, journaling and letter writing can be helpful. Crying to a trusted friend or family member or therapist can also be helpful. Don't resist.

Task 3: Acceptance. First, we must define acceptance. Acceptance does not mean that you are happy with the way things went or turned out. It just means that you accept it. It is what it is. And you may have moments of feeling sad or angry at times, but you find that these are fewer and far between. You don't feel guilty for your feelings any longer. You have a new meaning for your experience, and some people use this meaning to help others.

There is no timeline for these tasks, and they will go more smoothly if you don't fight them. We are all a work in progress!

If you have recently had a baby, and you are finding it overwhelming to parent, help is available! My, and several other MN resources, information are all part of Pregnancy and Postpartum Support MN. See the resource list at www.ppsupportmn.org, or call the PPSM Helpline at 612/787-7776. You are not alone!

What about dad's village?

I have spent a lot of time this past month focused on maternal mental health. We had the Daisy Dash 5K (our annual fundraiser for PPSM) mid-May, a screening of a documentary on maternal mental health, Dark Side of the Full Moon, and today, spent the day at the Beyond the Baby Blues conference.
When people discuss perinatal mental health, much of the focus is on moms. This is definitely important, as statistics show that 1 in 5 moms will struggle with some form of perinatal mood or anxiety disorder. The numbers may be even higher.

But did you know... dads can also get postpartum depression (PPD)? Depending on which site you are looking at, stats are roughly 1 in 10 dads. That is way more than many people realize, and WAY more than we are talking about.

Why is this?

Men with depression look very different from women with depression. Men are not weepy, sad, or talking about their feelings (in general). They tend to become withdrawn and easy to anger, and pour themselves into their jobs, hobbies, and, sometimes, substances (alcohol or drugs). The odds of depression increase further if the dad has ever experienced depression in the past, and if his partner is depressed.

We need to talk about this. Dads need a "village" too. But their village may look very different, so it's important to recognize this.

Here are some ideas for dads who are struggling postpartum, and really need an outlet for that:

• Self care is important. Aside from sleeping as well as possible, and eating, other things like exercise and time for yourself are key. Is it harder with an infant? Yes. But not impossible. If your partner is struggling too, have a discussion about how you are both going to take care of yourselves. It would benefit you to work out a plan or schedule for this. It may also be necessary to enlist help of others- such as friends or family members who can come be with your partner, so that you do not feel guilty taking time to go to the gym or going out with friends. It may mean asking someone to take the baby for an hour or two so you can go have a date with your significant other. 
• Support... while there is definitely a shortage of men's mental health resources, especially postpartum, it is not impossible to find. Below, I will list some specific resources geared towards men, some specifically for depression, but others just more about the challenges of being a dad. Feeling at times like you don't know what you're doing. Feeling like you aren't sure what to do with a newborn who eats, sleeps, cries and poops. Wondering what happened to your partner.... while men tend to not talk about feelings, it is OK to share your story and speak your truth. 
• Professional help may be a good idea. In my practice, it seems that men have an easier time accepting the idea of taking medication for depression versus going to therapy. AND THIS IS PERFECTLY FINE. If you have felt depressed, down, hopeless, angry, or having thoughts of running away or harming yourself, medication may be an option to explore. If you do decide you would like to talk with someone, whether that is therapy or a support group, it is really important to find someone who is trained in perinatal mental health or understands male depression. Resources like Postpartum Support International, and in Minnesota, Pregnancy and Postpartum Support MN, are great places to look to find people who will get it. It is hard to open up to a stranger about what is supposed to be the greatest event of your life, so make sure you have someone who understands. It is also an option to attend some sessions with your partner. If she is going to therapy, ask if you can come along sometime. She will probably LOVE that, and it is very helpful as a therapist to get both perspectives, and for me to assess depression or anxiety in both members of the couple. 

Dads are SO important. Your relationship with your baby matters too!

Resources:

http://www.postpartummen.com/

PSI: http://www.postpartum.net/family/tips-for-postpartum-dads-and-partners/

Locally (in Minnesota):

PPSM: http://www.ppsupportmn.org/

FaceIt Foundation: http://www.faceitfoundation.org/

Dads groups can be hit or miss. But some places to check are http://www.meetup.com/ and Facebook. PSI also has phone chats for men, and PPSM has a free HelpLine for all new parents and their providers who are in need of resources and support. 

Books:

The Postpartum Husband by Karen Kleiman

I Don't Want to Talk About it by Terry Real

P.S-- there are NO books specifically for dads with PPD!!!

Mothers Day is great... except when it's not

Don't get me wrong. I LOVE Mothers Day. One of two days of the whole year that is just for me. However, there was a time when Mothers Day was one of the worst days of the year- when I was going through infertility. Since that experience, I work hard to be mindful that Mothers Day can be very painful to some. 

In my practice, as a therapist who specializes in perinatal mental health, there are three common categories of women that Mothers Day is hard for (and some men too!). 

1. Women going through infertility (and their partners)

About 12% of women (1 in 8) and couples struggle to get pregnant. It makes sense that a day that celebrates being a mom can be difficult for these people. We need to be aware of how painful it can be for a woman who so desperately wants to be a mom cannot escape that our culture defines success as a woman as being a mom. You can't escape it, especially around this time of year. Go to Target, and right when you walk in the door is the HUGE sign above the card display for Mother's Day. Commercials on TV. Pregnant women with their bellies and young babies going out on walks, as the weather warms. I remember wanting to just stay in bed with a blanket over my head for the month of May. But we have to live. So, if you know someone in your life who is struggling to get pregnant, make sure you acknowledge that Mothers Day is hard for them. Offer to get together and do something fun anyways. Or let her talk, cry, yell about how unfair it all is. And if you or your partner are struggling, it is OK to let people know you are sad. It is OK to be sad for you and happy for the women in your life who are mothers. 

2. Women who have had a pregnancy or infant loss (and their partners)

Here are some statistics from www.hiringforhope.org:

• 90,000 children die annually in the United States before their first birthday.
• Nearly 2,500 babies are lost/year in the United States due to S.I.D.S.
• Nearly 30,000 babies a year are born stillborn. The number of stillbirths that occur worldwide jumps to more than 4.5 million/year.
• More babies die as a result of stillbirth than all other causes of infant death combined.
• Stillbirth occurs ten times more frequently than S.I.D.S.
• 15-20% of all clinically recognized pregnancies end in miscarriage each year.

This means that it is very likely that you have experienced or know someone who has had a miscarriage or lost a baby. For the same kinds of reasons mentioned with infertility, pregnancy and infant loss is invisible. You can't tell just by looking at someone if they don't have kids by choice or not. And there is still a lot of misinformation and ignorance that some people don't consider miscarriage "a baby", or if a family has had other children, the one that was lost is forgotten. But moms don't forget. Moms remember every year how old that child would have been. Or how differently their family would have looked if that child had survived. So again, be kind, because we don't know what anyone's story is. But if you DO know someone, remembering that baby to them can be so so kind. Tell them Happy Mothers Day. Validate their sadness. And if you are a partner, talk with her about how she wants to acknowledge Mothers Day. Please don't ignore it or pretend it's not happening. 

3. Those who have lost their own mother, or have a poor relationship with their mother 

Stepping outside our own feelings of Mothers Day, about if we are a mom or not, and remember that we all have a mom somewhere. Some of our moms have died. Some of our moms are cut out of our lives for numerous reasons. And some of us still have our mom with us, but the relationship is very complicated and makes Mothers Day a challenge. 

If you have lost your mom, the first Mothers Day will be particularly difficult. Think about how you would like to spend this day, and honor your mom. Share this with your partner or a close friend. Don't go through it alone. 

If you have relationship challenges, make a plan. Do you need your partner or a close friend to take you out and keep you distracted? Let you share your emotions about it? And if you do still see your mom on Mothers Day, set very clear boundaries. It is OK to limit the amount of time that you spend with your mom. It is OK to feel sad, hurt, angry, or frustrated (or all of the above) that you don't get a happy Mothers Day with your mom. Try to plan something to do afterwards to vent and debrief. 

This post is not intended to take away from the joy that Mothers Day brings. If you are a mom, you are to be celebrated. Just know that it is a very emotional day for many people, and to be kind, because we never know what people's story is. 

Best Books of 2014... In my opinion

Happy new year! I'd like to start off the year by recapping a list of self-help books and memoirs that I found very readable this past year. Some of them are serious, some of them are funny. Note: this is only MY opinion, and in no particular order...

Self help

"Just Tell Me What to Say" by Betsy Brown Braun is a nice quick read on very common parenting concerns about discipline, friendship issues, sexuality, and conflict resolution. It gives readers a script for ways to navigate these difficult issues. It is geared towards those who have kids in the preschool through high school ages. This book would also be helpful for anyone in a profession that works with kids this age. One of the easier reads that tackles difficult parenting conversations.

"Change your Brain, Change your Body" by Daniel Amen, MD  This is not the first book I have read of this authors, nor will it be the last. What I love about his books is he is a advocate for people who choose treatments of all different modalities. He talks about Western medications, but also eastern integrative medicine, such as homeopathic treatments and supplements. He also emphasizes the importance of good old self care: sleep, diet, exercise. He also includes nifty brain scans that show the science behind his research, and how it literally can change the structure of your brain. He includes wonderful mental health information as well as other physical ailments.

"The Secret of the Shadow: The Power of Owning your Whole Story" by Debbie Ford This is not a new book, but one I finally just got around to reading this past year. I fell in love with one of Ford's previous books, and had to read this one as well. I like this one better. It takes the information from some of her other books and makes it more about using it to improve your current and future life. This book will help people who struggle with low self-worth and self-esteem. Through guided exercises, you will learn to like yourself better, and except that even if bad things have happened to you, you are still a great person.

"The Gifts of Imperfection" by Brene Brown This is another wonderful read about self-esteem. In a culture that values perfection, we need to learn how to handle the reality that we are not perfect. But how do we embrace that? This book walks you through Brown's ideas of how to do that in a simple straightforward way. If you would like to get a flavor of brown before buying, she also has a video on TED about shame and imperfection.

Memoirs

"Dad is Fat" by Jim Gaffigan Not only is Jim Gaffigan hilarious, but he is also the father of five very young children. This memoir is filled with short essays about his experience as a dad and son are laugh out loud funny. This would make a wonderful gift, not only for dads in your life, but for anybody who appreciates parenting humor.

"Battle Hymn of the Tiger Mother" by Amy Chua A controversial read, I really liked that the tone of this book was not about "this is how you should parent" but about how she did follow the cultural mores of her family's parenting style, and how it went wrong in some ways. She also shares the challenges of having a blended cultural marriage, and how they made that work. It is a good breed that makes you think about your own parenting style and about how the American culture can be a challenge for people living here from other cultures.

"How Starbucks Saved My Life" by Michael Gates Gill Okay, I'll admit it: the reason I picked up this book was all about being addicted to Starbucks coffee. However, I was pleasantly surprised by this memoir written by a man who basically loses everything. He was raised in a wealthy family, and had a very wealthy lifestyle until the market crashed. I won't give anything away, however I will say that what I loved about this memoir is that it shows that people can be happy without all of the material things that are culture tells us we "need". He makes a very difficult new start and is inspirational. PS. It's also not a very long book, so good for even those who do not like to read.

Motherhood Comes Naturally, and Other Vicious Lies" Jill Smokler  As someone who works with postpartum moms, I am always looking for books that talk about motherhood in a realistic way. Smokler, founder of the blog Scary Mommy published this book a very funny essays about the realities of motherhood. If you are looking for a gift for a new mom, or you are a new mom yourself, pick it up on a bad day and just read one essay. It's a great reminder that motherhood does not come naturally.

Happy reading! 

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?