Articles
MINDFUL BEGINNINGS: THE BENEFITS OF MINDFULNESS IN EARLY PARENTING
"This piece originally appeared in the Birthways' Newsletter in January of 2008 www.birthways.org"
When my first daughter was born, nearly 10 years ago, I remember a level of anxiety that I carried with me wherever I was, and whatever I was doing. Was I doing things right? Would my decisions as a parent serve her well? Would she grow up to be a well-adjusted person, at ease and self-confident? Being in the field of mental health, these things were of primary importance to me. I would often ask myself whether I was stimulating her enough, was I providing her with an optimal amount of external stimuli, or was I stimulating her too much, interfering with her ability to soothe herself? The answers from developmental and parenting experts were contradictory and confusing; from, never put your baby in a crib as this is the equivalent to being “put behind bars” to, if you do not teach your baby to soothe herself by the time she is several months of age, she will have difficulty developing a sense of independence and self-reliance.
I was, as many new mothers are, vulnerable to the “shoulds” and “shouldn’ts” that were expressed all around me, both from experts and from other new mothers. Our culture is one which places a lot of pressure on new mothers to parent their infants in a way that both provides a more advanced and fine-tuned form of stimulation than we were parented with, (from Baby Einstein to readings of Ulysses in utero,) while at the same time criticizing them for raising children who are “too needy” and “self- absorbed.”
What I wish I had known at this vulnerable time -- and which sadly seems all too obvious in retrospect -- is that more important than whether I was providing this kind of stimulation or that, or whether I purchased the car seat with the absolute highest safety rating or not, was my ability to be present with my children, and that giving them my presence was more important than any other decision I might make as a parent.
What does it mean to give one’s presence? In short it means to find moments, and more moments, to leave one’s thinking/analyzing/judging brain behind and to just be with one’s baby, staring into their eyes, smelling their scent, trusting one’s intuition, and being available to respond in a spontaneous and loving manner to the cues they inevitably provide us with.
In my work as a psychologist with pregnant and postpartum women, what I have seen repeatedly is women’s lack of ability to trust themselves and their babies to know what is right for this mother-baby dyad, and this particular family. Just like the birthing process itself, which has become so heavily “medicalized,” early motherhood and parenthood have become the domain of scholarly experts rather then living mothers.
So how is a new mother to protect herself from the commercialization and anxiety of motherhood? First and foremost, limiting external input from books, magazines, websites, and professionals, may be important, though perhaps it seems counter-intuitive, at this vulnerable time when your emotional membranes are unusually permeable. Rather than looking outside for generic advice and direction, it may well be better to turn inwards-- allowing yourself to listen to what feels right in this moment, for you, and your particular baby. Making time to sit with your feelings, paying attention to sensation, and making room to name the feeling and to observe how it may change with moments of meditative awareness. Asking yourself the question: “What do I most need in this moment, and what does my baby most need?” Trusting that babies are powerful resilient beings who need spacious mommies to give them the room to learn to communicate their needs, who model self-care, and who allow moments of spaciousness to color their days rather then lists of “shoulds.”
Below is a list of suggestions you may find helpful. What is right for you, however, is different then what will be right for any other new mother. Breath, pay attention to sensation, and …
1. Try to get enough sleep. (Enlist the help of a partner or friend to take over a feeding so that you can get an extended stretch of sleep.)
2. Try to have at least some time for yourself everyday.
3. Try to make time for connecting with your partner.
4. Combat isolation. (Join a mothers’ group, get together with other new mothers and go on outings, invite another new mom to your house for tea and nursing, schedule friends to call you to check in.)
5. Ask for and accept help.
6. Don’t compare your baby or your situation to someone else’s. (Jennifer’s baby sleeps for 6 hours and her husband works at home.) Everyone’s situation is different and comparing yours to someone else’s only sets you up for painful longing, as opposed to being present with what is.
7. Don’t blame yourself for your experience.
8. Be kind to yourself.
9. Allow yourself some luxuries. This is not indulgent, it is necessary.
10. If you experience yourself as overwhelmed by advice, sit still and turn inward. You are more likely to learn what is right for you and your baby by quieting the outside world and looking inside.
11. Identify and make use of constructive stress relievers. For example: exercising with or without your baby, taking a warm bath, reading a book, meditating, relaxation tapes, deep breathing exercises.
12. Seek professional help if you are feeling low or anxious. It doesn’t need to be a crisis. Better to receive some support before a crisis occurs. You can go in for a “well check” if nothing else.
13. Talk with other mothers and don’t assume that just because they look like they are having an easy time, that they actually are. Sometimes it requires persistence to encourage people to open up. While their automatic response may be “everything’s just great” - the answer they may feel they are supposed to give --if you share deeper details of your own experience, they will be more likely do the same.
14. Make sure that you don’t get into a pattern of “over-functioning.” Help facilitate and encourage a bonding relationship between your baby and your partner. Leave the house for an hour to go for a walk, or meet a friend for tea--and let your partner feed and change the baby. It is important to let them discover how to soothe the baby, and how to do things in their own way. You have had more time to learn about what the baby needs, but if you don’t let your partner learn these things for themselves, their confidence will suffer, and so will you. Caretaking is an important part of the bonding experience for both partners.
15. Prioritize what’s really important. Try and let go of the “mess,” etc. and standards of perfection. Don’t use your baby’s naptime solely to accomplish things. You will never get to the bottom of your list, and you will run yourself ragged. If it’s all getting to be too much, ask for help. It is important to use some of your baby’s naptime for restorative relaxation, whether that involves napping, meditating, taking a bath, or reading a novel.
16. If you don’t take time for yourself, you wont have anything left to give. Taking care of yourself will promote a healthier relationship with your baby and with your partner. Healthy partner relationships help grow healthy children.
EMOTIONAL CHALLENGES OF THE REPRODUCTIVE YEARS: PART I - INFERTILITY & PREGNANCY LOSS
GINA HASSAN, PH.D., DONNA ROTHERT, PH.D. & LEE SAFRAN, MFT
of Perinatal Psychotherapy Services - A collective of psychotherapist who
specialize in issues facing women during the Reproductive Years.
(These articles originally appeared in the Alameda County
Psychological Association Newsletter, Fall and Winter
issues of 2006, www.alamedapsych.org)
Daria is a 42 year-old woman who, along with her partner, has been trying to begin a family for the past 18 months. She has had two pregnancy losses and multiple medical interventions in an attempt to increase her chances of conceiving and carrying a healthy baby to term. Daria has a high stress career and she is tired and depleted as a result of the many months of hope and disappointment. She feels angry and isolated because all of her friends have had children without difficulty. She also feels ashamed of and frustrated with her body for failing her. Deeply pained by the multiple losses she has suffered, Daria is becoming increasingly isolated and feels that her friends and family are insensitive to her pain.
This vignette illustrates some of the complex issues that individuals experiencing infertility and pregnancy loss may face. With increasing numbers of professional women delaying childbearing, a factor that significantly raises the risk of both infertility and miscarriage, many of us are seeing women in our practices who are struggling with reproductive crises. The following is a brief overview of relevant issues and treatment options for those experiencing infertility and pregnancy loss.
Infertility
Infertility, defined as the diminished ability or the inability to conceive and have offspring after a year of regular intercourse without contraception, affects about 10-13% of heterosexual couples. (Medicinenet.com 2006) Infertility is first and foremost a stressful experience, often including physical, social, financial and psychological challenges. An infertility diagnosis can give rise to a profound sense of loss including: the monthly disappointment, miscarriages, the loss of conception being natural and without intervention, the loss of intercourse being spontaneous and romantic as opposed to on demand or technical, and sometimes the loss of the idea or dream of pregnancy.
Women’s individual experiences of infertility vary, yet there are a number of common factors which most women will experience: feeling that one is being left behind, that one is being denied a biological right, that one’s body is failing, that one is failing one’s partner, and that one’s sexual identity has become a merely physical identity - a constellation of sexual/biological organs which are prodded and probed and treated as scientific objects. Additionally, single people and same sex couples may face insensitivity and discrimination in their efforts to conceive. Given the sense of exposure during this process, both to the medical world and well-meaning friends and family inquiring about pregnancy status, many women feel like they are under the microscope.
Grief work may be an important component of working with women experiencing infertility; however, unlike grieving a pregnancy loss, which is a known outcome, infertility grief exists in relation to an uncertain outcome. It is one that involves recurrent hopes and disappointments which over the course of time can lead to anger, shame, vulnerability, feelings of hopelessness, poor self esteem, social isolation, anxiety, and depression. Acknowledging and making a place for women to speak about their anger, sadness, hopelessness and lack of control, are similarly important features of treatment with women seeking counseling for infertility. Stress reduction techniques such as meditation or progressive relaxation can be helpful for managing recurrent and ongoing stress.
Normalizing the tendency to feel envious of others and helping women find ways to address their need to protect themselves from painful situations, for example attending baby showers or children’s birthday parties, while not becoming overly isolated, will be important goals in therapy. Identifying primary triggers and helping each woman to identify and articulate the kind of support she needs is important, as well as helping her figure out how best to communicate her needs in a way that feels acceptable to her, and most likely to achieve the desired results. While individual therapy can address many of these issues, groups can be invaluable in helping women feel less alone and isolated during this struggle.
Couples work can be helpful in supporting healthy communication between partners. Men and women often experience and cope in different ways and it is important to make room for individual differences. Sex and money, challenging issues for many couples, may be particularly stressful for couples who are not only undergoing scrutiny of their sexual and reproductive life, but going into debt to do so. Therapy can also be helpful in supporting the strengths of the couple such that they do not become overly focused on family building, but can continue to make room for enjoying their relationship for what it is.
Pregnancy Loss
A significant number of wanted pregnancies end without a baby. Approximately 15-20% of known pregnancies end in miscarriage (before 20 weeks gestation) and about 1% of pregnancies end in stillbirth (a loss at 20 weeks gestation or later). Additionally, couples may decide to terminate a pregnancy after a prenatal diagnosis of serious illness or be advised to undertake a selective reduction of a multiple (twins or higher order) pregnancy for medical or other reasons. Although there are very significant differences in these experiences in terms of length of pregnancy and whether or not there is an element of decision-making, all types of pregnancy loss may lead to strong emotional responses and psychological complications.
As research since the 1980s has shown us, the vast majority of women become significantly attached to their babies prior to birth, and indeed, it is considered a major psychological task of pregnancy to do so. Although responses vary, and typically are more intense following later losses or recurrent losses, any neonatal death may lead to a significant grief response with a wide range of feelings including depression, guilt, anger and confusion.
In addition, aspects associated with many pregnancy losses (blood, shock, labor induction and the resulting labor and delivery of a baby that is known to be dead) may be traumatic and lead to complications such as dissociation and survivor guilt. The lack of bereavement rituals for pregnancy loss and cultural discomfort with emotional reactions to miscarriages, stillbirths and other types of pregnancy loss may contribute to one’s sense that these feelings are unacceptable.
Whether due to this perception that their feelings are intolerable to others, or because part of the early grief process often involves fear and a sense of being overwhelmed, people experiencing perinatal bereavement often minimize or deny their reactions. Unfortunately, this common strategy can lead to greater distress and longer lasting symptoms. Individual treatment may be beneficial to many people following a pregnancy loss, but is specifically indicated for those experiencing the most severe symptoms, especially if suicidal ideation and/or significant dissociation is present.
Group treatment may take place through hospital or other drop-in support groups or ongoing weekly therapy groups comprised of those who have experienced neonatal loss. Participation in such groups can decrease isolation, as well as normalize and validate the range of grief responses. Groups can also provide a safe place to process the individual meaning of the loss and consider future decisions. Couples therapy may be useful for coping with incongruent grief responses, decreased intimacy and feelings about trying to conceive again. All treatment options for those who have experienced pregnancy loss and/or infertility can make an enormous impact for people processing what is often a life-changing experience.
References
Kohn, I. and Moffit, P.L. A Silent Sorrow Pregnancy Loss: Guidance and Support for You and Your Family,
Peoples, D. and
Speckhard, A. Traumatic Death in Pregnancy: The Significance of Meaning and Attachment, Ch.4 in Death and Trauma: The Traumatology of Grieving, Figley, et. al ed.s, Taylor & Francis, Washington, D.C., 1997 Resolve: The National Infertility Association www.resolve.org
EMOTIONAL CHALLENGES OF THE REPRODUCTIVE YEARS PART II: PREGNANCY AND POSTPARTUM SPECTRUM DISORDERS
GINA HASSAN, PH.D., DONNA ROTHERT, PH.D. & LEE SAFRAN, MFT
of Perinatal Psychotherapy Services - A collective of psychotherapist who
specialize in issues facing women during the Reproductive Years.
Denise became pregnant with her first child at age 37. While she had a difficult first trimester with severe morning sickness, increasing anxiety, and sleeplessness, she was thrilled to be expecting a child. Her son was born 4 weeks premature following an emergency c-section. Six weeks postpartum, Denise was proud of how well things were going, despite a great deal of sleep deprivation and slow physical recovery. However, Denise began to have difficulty sleeping even when her baby was resting. She worried about not getting enough sleep and often felt preoccupied. She started checking on her baby frequently when he was asleep “to make sure he was still breathing.” She was horrified by images of him being attacked by dogs and felt frightened and overwhelmed at the thought of taking him out in his stroller. The other new moms she knew appeared at ease, or even elated with their babies, but Denise felt frightened by her morbid thoughts and feelings and too ashamed to share them with family and friends. She felt increasingly isolated and depressed and was worried that she had made a terrible mistake and was not fit to be a mother.
This vignette illustrates some of the confusing and overwhelming experiences that can be a part of a woman’s pregnancy and postpartum world. Given cultural expectations that having a baby is the happiest time in a woman’s life, it is often hard for a woman to recognize perinatal mental health issues and to seek needed support and information. Although mothers and pregnant women who are experiencing distressing symptoms during or after pregnancy often feel alone in their experience, women are more at risk of experiencing emotional difficulties following the birth of a baby than at any other time in their lives. Furthermore, these difficulties often begin during pregnancy. (Moses-Kolko, & Roth, 2004)
Pregnancy
Pregnancy can be a time of profound physical and emotional transformation, and a time rich with symbolic meaning. It is a time that may be filled with hope and expectation, fears and conflicts, growth and regression. For many women attachment begins instantly, for others fear and anxiety are predominant.
In our culture, pregnancy is most often perceived of as a time of bliss and happiness. Women who suffer from anxiety and depression may feel very isolated and may even be told by their physicians that this is normal. Differentiating the physiological symptoms of pregnancy from those of depression may be difficult as the symptoms overlap. The difference, however, seems to be in the degree of impairment. Suicidal ideation and anhedonia, for example, are not normal symptoms of pregnancy, but fatigue and mood instability are.
In addition to a growing belly and breasts, there are massive hormonal changes that may affect a woman’s mood during pregnancy. The rise in estrogen and progesterone during pregnancy, as well as the effects of prolactin and cortisol, will influence a woman’s emotional stability. Some women are more sensitive to these changes then others. For many women, the first trimester is a time of emotional upheaval, followed by a period of relative calm, even euphoria. For others, however, the hormonal changes can wreak havoc and set off a course of biochemical changes that alone or in conjunction with psychological factors may lead to serious depression or anxiety.
Untreated clinical depression or anxiety during pregnancy is very serious since the condition usually worsens over time. Women with untreated mental illness during pregnancy are two and a half times more likely to suffer from postpartum mood disorders then the normal population. Furthermore, it has been linked to increased risk of low birth rate, neonatal intensive care admissions, and increased rates of still births, retarded fetal growth, and poor maternal-fetal attachment. (Chung et. al. 2001)
Postpartum Spectrum Disorders
As in pregnancy, many women anticipate great joy after giving birth and are unaware of the range of emotional reactions they are likely to experience. Dramatic physical and hormonal changes, chronic sleep deprivation, new responsibilities and a new identity can provide a woman with one of the most stressful and anxiety producing life transitions she will ever experience. Other factors that are believed to contribute to postpartum emotional distress include; a history of depression or anxiety (either personally or in a blood-relative); a difficult or traumatic birth experience; a colicky, hardto-care-for baby; nursing difficulties or weaning; a predisposition to perfectionism and self-criticism; lack of social supports; and a poor partner relationship. Many women do not experience postpartum reactions right away, but may be surprised to feel the onset a number of months after delivery.
Up to 80% of women experience some emotional stress after the birth (or adoption) of a new child - “the baby blues.” For many these responses are brief and resolve themselves on their own. Up to 20% of new mothers experience stronger reactions which include: postpartum depression, postpartum anxiety or panic disorder, postpartum obsessive compulsive disorder (OCD) and postpartum psychosis (Bennett and Indman, 33). The overarching term “postpartum depression” is often used to describe all of these responses, which can be confusing to women who do not identify with the typical symptoms of depression. The more inclusive term, Postpartum Spectrum Disorders, will be used here.
Symptoms of postpartum spectrum disorders include: extreme irritability and restlessness, feelings of depression/hopelessness, intense anxiety (with or without panic symptoms), intrusive repetitive thoughts or images, difficulty sleeping (even when the baby is asleep), feelings of guilt, inadequacy or worthlessness, uncontrollable crying, and fear of harming the baby or oneself. While many people confuse the symptoms of postpartum OCD, as illustrated in the vignette, with postpartum psychosis, understanding the differences between these two disorders is crucial. Postpartum psychosis is an extremely rare and dangerous disorder that can lead to suicide or infanticide, while postpartum OCD is generally less dangerous and much more common. This confusion, however, may leave women with postpartum OCD reluctant to report their symptoms to family or professionals, for fear that their infant will be removed from their care.
Treatment of Perinatal Spectrum Disorders
There is clear evidence that early intervention better protects women and their babies from negative outcomes (Bennett and Indman, 42). Professional treatment of perinatal spectrum disorders includes medical evaluation (including postpartum thyroid tests), psychotherapy, support group participation and, at times, medication (depending on the symptom severity.) Most women feel that it is a combination of these supports that helps them recover and begin to feel like themselves again.
Educating women about what is happening and normalizing their experience is often an important component of working with women who are suffering from perinatal emotional dysregulation. Furthermore, individual therapy and support group participation can reduce stress through normalizing and validating a woman’s experience, acting to support self care and combating isolation.
For many women, a medication evaluation is necessary. It is helpful to frame this evaluation as a vehicle to weigh the risks of medication versus the impact of untreated maternal stress on the fetus or infant.
Depression and anxiety during pregnancy and the postpartum period may be tragic if not treated properly. Fortunately, there is clear evidence that early treatment of perinatal spectrum disorders alleviates more chronic problems and leads to better outcomes for women and their families.
References:
Bennett, Shoshana, & Indman, Pec. Beyond the Blues - A Guide to Understanding and Treating Prenatal and Postpartum Depression, Mood Swings Press, San Jose, CA, 2003.
Chung T, Lau T, Chio H, Lee D. Antepartum Depression Symptomatology Is Associated With Adverse Obstetric and Neonatal Outcomes. Psychosomatic Medicine. 2001; 63: 830-834.
Moses_Kolko E & Roth E. Antepartum and Postpartum Depression: Healthy Mom, Healthy Baby. Journal of the American Medical Women’s Association. 2004; 181-191.
Misri, Shaila. Pregnancy Blues: What Every Woman Needs to Know About Depression During Pregnancy, Bantam Dell,
Sichel, Deborah, & Driscoll, Jeanne. Women’s Moods: What Every Woman Must Know About Hormones, The Brain, and Emotional Health,