Mental Health Stigma Suicide

How I Started Treating Pregnant and Post-Partum Mental Illness & Why It’s Important

I’m going to preface this post with…nursing school was horrific. If any one reading this is a nurse; you feel me. If any one reading this wants to become a nurse…being a nurse is better than nursing school. Hang in there.

Maternity was mid-way through nursing school. Right when I felt like I was never going to get through the program but also feeling I had come so far and couldn’t go back now. I hated maternity. There were many reasons why but it was not my jam. First day in post partum I was given a patient with a fetal loss. I had to take pictures of the mom holding her dead baby.

Writing that now, I’m like wow that was definitely messed up. They had a nursing student manage this incredibly intense case on my first day on the rotation. Looking back I can see the rest of the time I was overwhelmed, and disengaged. Not only was I not interested but I felt somewhat traumatized by my first day there and felt shut down by my clinical instructor when I mentioned how intense that experience was. It didn’t get better. In fact my last day my clinical instructor pulled me into her office and said “I was this close to failing you.” Then proceeded to berate me. It was pretty awful. Aside from that one experience my grades were stellar, I graduated Magna Cum Laude, and I had glowing reviews from every other clinical instructor.

I think the instructor didn’t like me. I think I didn’t like maternity. And I think my first day on the unit having to deal with a dead baby and grieving mom by myself for nine hours straight with no support from the nurse or my instructor set the tone for me.

That entire experience left a bad taste in my mouth. Through the rest of my nursing career I steered clear of anything maternity based.

My first experience with post partum care after nursing school was years later on an inpatient psychiatric unit. I had my first patient with postpartum psychosis. I treated her the same as all my other patients and honestly didn’t think much of it. Psychosis is psychosis. Needed to be stabilized and discharged with a plan in place. I had a few pregnant patients inpatient and then a few more postpartum psychosis cases. Enough that I felt I had some exposure to perinatal and postpartum mental health care. I learned what medications are safe-ish for pregnancy and medications for post partum with a nursing mom. I can’t say I loved it. I just did it.

Then I started outpatient care. I was young (28?) and I think as a result I saw a lot of young female clients. I don’t remember the first one who told me she was pregnant. I do remember several different times though. Some were teenagers disclosing looking scared and ashamed. Some had abortions. Some didn’t. Some were young women who were newly married and glowing with excitement.

I do remember trying to convince the first two of my pregnant clients to see a different psychiatrist or APRN who has more of a specialty in peri-natal care. They asked who that would be. I asked the psychiatrist I worked with at the time who had far more experience than I did. He gave me two names. I gave them to my clients. One of them actually called. The other didn’t. They both came to their next follow ups and essentially told me they didn’t care that I didn’t have a specialty in peri-natal care that they trusted me. They liked me, and one of them said, “I’m sure you’ll figure it out for me.”

I remember going back to the old psychiatrist I worked with. I reviewed their meds with him. I talked to the pharmacist on staff at the hospital. And for the next few pregnant people I continued to seek regular supervision and took some continuing education courses specific to peri-natal and post-partum psychiatric care. Fast forward seven years.

Probably a third or more of the caseload of my entire practice is peri-natal and/or postpartum clients. I know the postpartum specialty therapists. They all refer to me for medication management. I get calls from OB-GYNs and therapists asking if I can fit in a post partum case. I never advertised this part of my practice as it developed. I think it’s all been word of mouth. There are very few psychiatric practitioners willing to treat pregnant women and even fewer who will take on acute postpartum cases. I honestly didn’t realize how hard it is to find a provider to treat pregnancy and post partum until I started doing it.

I carried my own biases into this part of practice back when I first started not just from my first bad experience in nursing school. I thought of postpartum illness like many probably think of it- as an illness where Mom’s don’t like their babies, and maybe even try and kill them. I had a case in the pediatric emergency department when I was two or three years in. I remember it was a five week old with a head injury. There was a clear handprint on the baby’s head.

It ended up having a skull fracture. The Mom sat stone faced. Blank. The dad looked like he wanted to puke. The baby just lay on the bed until I picked it up and cradled it when it cried. I remember glaring at the parents. Why are they just sitting there? Why would they hurt this beautiful baby? Eventually the Dad broke down and told us it was his wife who did it. She hadn’t been right since the birth. Looking back now I can recognize that she clearly was psychotic at the time, and she was ultimately transferred to the adult hospital and admitted for psychiatric evaluation. I think we knew that she had postpartum but I didn’t truly understand what that meant other than her being cold and her baby having skull fracture.

These were the experiences I brought with me into my career as mental health APRN. When that client told me to figure it out for her. I remember thinking, what the hell am I getting myself into?

At some point during the following few years I got pregnant and had my own kids. I did not experience postpartum. I experienced twins. Twins who required exclusive breastfeeding. I had a C-Section. I went blind (my vision came back). I had pre-eclampsia/eclampsia. All in all pretty shitty time. But I wanted those little dudes. I worked so damn hard to have them. I kept them in through 36 weeks and 3 days of puking daily often multiple times daily. I was sleep deprived. But I was so incredibly happy to have them. I remember staring at them. I should have slept. But I couldn’t look away. Post partum time sucked because I was sleep deprived, I was sore, I had twins, and I had to breastfeed. But I didn’t have any overwhelming depression or anxiety on top of it. For that I am grateful.

Now I’m seven years into outpatient work. I’ve had many, many, pregnant and postpartum patients. I’ve treated depression, anxiety, mild to moderate to severe. I’ve treated post partum psychosis and post partum anxiety and post partum mania. While I’m writing the diagnoses though I’m picturing the women.

Because the women touched me and taught me. I’ve treated women who have had severe post partum illness but still felt incredibly bonded to their babies. What I found more common is women feeling bonded to their babies versus not. The clients who feel not bonded are definitely less common. Some times the only relief for women with post partum depression and anxiety is the time with their baby.

The women who struggle with bonding tend to have significantly more guilt, more shame, and in my experience are higher risk to develop more severe symptoms. When I have some one come a year before they want to get pregnant I want to do a happy dance. I reassure them that 1. there are medications safe for pregnancy and 2. in my experience the clients who figure out the meds that work for them before pregnancy and before post partum do much better in the long run.

The clients I’ve treated during post partum; some of them I’ve now treated through two and three more pregnancies and two and three more post partum time periods. I’ve counseled women who had severe illness who want to get pregnant again. Such deep fear exists and also such hope and longing. I’ve never counseled against a pregnancy. I do review the data, and the pro’s/con’s, risks and benefits. I had one woman start crying and look at me, and ask me “If I do this I’m just scared you won’t treat me because I was so sick before and it took us so long to get me better. Please just promise you won’t stop treating me. I’m so sorry. I just want this so bad but I can’t do it without you.”

People who know me, know that I am not someone who cultivates dependence on me. If anything I do the opposite. I want people to be flying free and never feel that I was solely responsible for healing them. Because they do all the work. I’m more like the tour guide. They are the driver. But treating post partum illness has made me appreciate the provider-patient relationship in a way that I haven’t with any other types of clients or illnesses.

There is not another illness that makes women feel so raw, so vulnerable, so shamed, and isolated as perinatal and post partum does. Because pregnancy is supposed to be a happy fun time. To feel like you’re breaking inside is not socially acceptable. Because post partum is stressful, and you have a new baby, and people think maybe your overreacting and why are you so sad, just take a nap and it will be fine. Why are you sad? You have this beautiful newborn baby to love on?

This has all been said to me. “My life is perfect. This is what I wanted. Why do I want to die?”

I watched When the Bough Breaks on Amazon. It’s heartbreaking and incredibly accurate.

Everything leading up to my career in psychiatry made me think I would never have anything to do with pregnant women and post partum women. But honestly it’s one of the most rewarding aspects to my career and it’s a lifeline that my practice and the providers here have all embraced this as part of our mission.

I’ve held a lot of fears, a lot of pain, and a lot of those deep dark scary thoughts that are not voiced anywhere but my office.

I think back to the mom in the emergency department who broke her child’s skull (the baby was fine, as skull fractures go it was mild and no long term issues). I think of her so differently now. I see her as ill and clearly not engaged in treatment. I wish she had a provider who could have intervened sooner. Some one who could have hospitalized her sooner and medicated her sooner. I think back to that mom and I think she’s why I figured it out. Because somebody needed to. Because mental illness strikes pregnant women and postpartum women too. She needed treatment. Not judgement.

The best part about telehealth is intervening fast with post partum illness. I can see clients 3, 5, or 7 days post partum because we do the appointment remotely. But for my established clients we already have a plan. Usually I see their smiling face come on the screen at 3-4 weeks post partum. They’ve already restarted the med they stopped during pregnancy, or doubled the dose we decreased for the last few weeks before delivery, or whatever the plan was they did. They weren’t terrified of post partum because we had a plan. They still struggle at times and sometimes I still have to refer out for higher levels of care. But they have support and we know what works and what doesn’t.

I had one client call me from their hospital room because they were fighting with their nurse who was trying to give them their lower dose of the anti-depressant and she knew we were supposed to go back up immediately after delivery. The poor postpartum nurse had to deal with me and the postpartum Mom telling her this was non-negotiable. Increase the dose and if she can’t do it then get me on the phone with some one who can. With my client intermittently yelling the birth weight and that she was able to have a vaginal delivery, and I had to tell her to stop yelling I’d talk to her later, let me talk to the nurse.

I’ve been texted pictures of newborns and I’ve been texted pictures of positive tests. I’ve been mid-telehealth when a client got a call from her fertility doctor, asked me to stay on the line to hear the result with her, and was there for her positive test result. I got the call when that same mom went into pre-term labor and delivered early. I saw her weekly until the baby came home from the NICU more for reassurance than anything.

I’m grateful I’m not the one catching the baby. Because good lord that’s just disgusting. I’ve had to be there for a few childbirths including my own kids, and I’m all set. But I am this peripheral support through entire pregnancies, post partum, more pregnancy, and more post partum, and sometimes infertility thrown in the mix also. It’s a journey that is incredibly intimate and to be a trusted component is incredibly rewarding.

Post-partum illness has a mortality rate. Women with less supports, family history of mental illness, and a history of their own mental illness like anxiety or bipolar disorder are at higher risk for psychotic symptoms which increases risk for suicide or infanticide.

Ask Mom’s how they are doing. When I ask mom’s how they are doing. Really ask. Eye contact and everything. They usually have tears well in their eyes and say, “No one’s asked me that,” because it becomes all about the baby. Ask them. And don’t dismiss their sadness as fatigue. Don’t dismiss their fatigue as just due to having a newborn. Ask if they have talked to their doctor. Ask if they have a therapist or mental health provider. We as a society need to open up the dialogue. We as a society need to support new mom’s and dad’s better.

Telehealth needs to remain permanent. Just as there are set in stone follow ups for baby and Mom with pediatrician and OB-GYN there should be a set in stone follow up for a psychiatric professional to meet with every new mom at least once in the first four weeks of postpartum.

Mental health has to become part of the pre-natal, peri-natal, and postpartum dialogue in doctor’s offices and in our communities.

The statistics are that 1 in 7 women will have clinical post-partum illness. Roughly 600,000 women a year in the USA. Approximately 50% of women with postpartum illness develop symptoms during pregnancy. IT’S NOT JUST HORMONES!! That infuriates me when I hear that clients have been told they are just being hormonal while they are literally breaking inside. 1-2 women out of every 1000 will develop post partum psychosis. 10% of Post partum psychosis cases result in suicide or infanticide. Suicide is the seventh leading cause of death in the first year after giving birth.

Educate yourself. All my clients love to be Dr. Google. This is one area I encourage googling. There are personal accounts that are heart wrenching. The more you know the more you may be able to help a friend or family member during and after pregnancy. Know that these women are not just hormonal. They are suffering from a mental illness with a biologic basis. There is treatment. 80% of cases are remitted completely with medication and therapy.

I think back to my first day in maternity at the ripe age of 21. I think back to all the emergency department cases that were so messed up. I think of all the cases that could have been prevented if they had adequate treatment. I think of my clients and their struggles that are so raw and courageous.

Just like I never went looking for nursing, it sort of found me. I never went looking for maternal mental healthcare. But it sure found me and I’m not sorry it did.

#COVID-19 · Divorce and Separation

When Life Feels Good (During COVID and Divorce)

There are certain moments in life that feel right. The last few years those moments felt few and far between. Some one asked me recently if I missed my ex. Some one else asked me specifically what ended our relationship. Those are some loaded questions. People who know me know I am uncomfortably direct and honest with myself and others. I did some introspection and answered honestly.

I miss feeling not alone. I miss having some one who gives a shit as to why I’m running late at work or having some one who even knows when I work. I miss getting a checking in text from some one who cares how my day is going. The little things that people in pairs take for granted. That’s what I miss.

Do I miss our marriage and relationship? No. I don’t. Because toward the end we were both miserable. I would never go back to that. I do miss having some one. Between being a mom to twins and running a mental health practice I deal with a lot on a day to day basis. I essentially hold it all. I feel like I hold up everyone else and I have to just keep on holding myself up too. Because there’s no time or space to fall. I miss having some one who could catch me if I felt like I was falling. But somewhere in our relationship we lost that. So no. I do not miss the last year of our marriage.

What ended it? I answered “What ends a 13 year relationship? It wasn’t just one thing. It can’t be pared down to a pretty one liner. And honestly now it doesn’t matter. Because the end result is that it is over.”

A few weeks ago I walked into our new office space and two of my employees were there seeing clients, there was a client in the waiting room and I could hear our office manager on the phone with a client in the back office. We had our yoga music playing on the tv in the waiting area and all my gay books were on the coffee table staring happily at me. I stopped and took a breath and smiled. I thought here are all of these people employed because I built a business. Clients getting mental health treatment because I had a dream. Some times running a mental health practice is the least crazy part of my life. Ironic I know.

It felt right in that moment. Through my dad’s death, through COVID, through a divorce I’ve poured blood, sweat, and tears into that business. I’ve had weeks I couldn’t get paid. I’ve interviewed many, many, clinicians. I’m selective in who I’ve hired and I’ve been burned in many ways. I kept going.

To date we’ve provided services to over seven hundred clients and rough estimate is that half are Queer identifying. I walked down the hallway at our new suite of offices with the noise machines whirring, the music playing, and distant muffled voices of providers and patients. Then the not so distant voice of my admin as I went to shut her door as she now yelled at an insurance company. I felt pride. I did that. I made this happen. I fought through grief, hate, discrimination, a global pandemic that shut down in person visits for a year, and so much more to keep it going.

I take being an employer seriously. I never want my employees feeling like the way I’ve felt working at other agencies and hospital systems. It’s easy to devalue employees. I find it’s harder and more rewarding to support them. I still have hard conversations at times. We don’t always agree. But this weekend, I had them all with families in tow at my house by the pool. It was another one of those moments.

Smiling, laughing, swimming, and genuine enjoyment of each other and our families. It’s a beautiful thing to build a business that serves clients. It’s even more special to build a business that has employees who feel valued and happy to spend a Saturday hanging out with each other and our crazy kids and partners.

It was another moment that felt right. We all know we do hard work. When we walk out our office door it makes a difference to be surrounded by people who you want to work with. Who bring you up instead of pull you down. We have all been in bad work environments. Building a good one was just as much my mission as building a great practice. We are not all cookie cutter. Every one is a little weird and has stories and after seeing us all in swimsuits we mostly all have tattoos. But I like weird and backstories and tattoos. I am all of those things. So it works.

After a lot of bad moments since 2019, it feels good to know that through the bad I can still build good.

Of course I ended the day explaining to my sons at bedtime not to be scared of getting a new parent because all the sudden they realized that I could apparently get married again, give them a new parent, and in Declan’s words, “And it better not be a man Mama!” Wow. Judged by my 5 year old. I said, “No one’s lining up baby so don’t worry.” Then he got into bed muttering, “Well no one better line up, and not a man, Jackson imagine if Mama marries a man?” Those are stick my palms in my eyes moments and try and kiss them goodnight and run out of there.

To all my people who keep showing up for me and for my sons, with wine, sushi, zucchinis, folding laundry, helping me move my office, and continuing to invite me places even though I’m the third wheel now…Thank-you. I would not have survived the last year without you. Life isn’t perfect. Life is change.


The Scent of Grief

Some things still catch me off guard. It’s been over two years since my Dad died. But Father’s Day this year snuck up on me and I got the email from daycare at the end of their day. “We will be talking about Dad’s this week!” it said cheerfully.

I shot an email off to the director knowing I was already too late as they had circle time already that day. They were on their way home to me with my ex. “The boys do not have Father figures. Please do not try and force them to find a male figure during this week’s discussions about Father’s Day. My sister has a wife, the boy’s have two mom’s, my dad died in 2019, and there are no extended male family members they have any ongoing relationship with especially in light of COVID. We literally haven’t seen any one for over a year in our extended family who are male. Do not try and find a substitute father figure for them. Just acknowledge they have two Mom’s who love them and Aunt and Auntie, Gramma, and cousin who love them very much.”

That night at bedtime one of them cried and they talked about how they miss Poppy (my Dad) and I asked if they were upset because they talked about Father’s Day at school. They were. I reminded them of all the people who love them. I reminded them that some people do not have Dad’s and that’s okay. Meanwhile I was trying not to be irrationally angry and Mama Bear wild tempered at their preschool teacher for trying to place a male figure into their lives when they do not have one.

They told me they didn’t have to do the Father’s Day craft. I said why don’t they do it for Mommy or Mama? They didn’t want to. I didn’t push it.

I realize this is going to be a yearly event unless Father’s Day happens to fall late enough that they are not in school by that time in June.

Single Mom guilt can be bad. In that moment hugging my sons as they bemoaned their Dadless lives I felt lower than dirt. Not only do they not have a Dad, but they do not even have intact parents. Their two mom’s couldn’t cut it. I realized I was disproportionately angry at preschool (it’s called displacement or projection in mental health) because I was really angry at myself for 1. forgetting about Father’s Day and not having a discussion beforehand with their teacher 2. for being smack dab in the middle of a divorce with their other Mom and 3. for literally having no male family members for them and for missing my own Dad so hard.

Dude. It was a rough week. I had a client who said she had trouble setting limits with her kid because of single mom guilt. I reflected that I am a single mom. I definitely feel guilt. A lot. But I still make the boys clean up their toys, put their clothes in the laundry, and most recently clean all the bathrooms with me because they climbed over the back of the couch for the hundredth time after me telling them not to for the ninety-ninth time. We laughed that Mom and I. She totally understood what I was saying and she felt seen. I validated that single mom guilt is a real thing. Because lord it is.

The Spring is the anniversary of my Dad’s death, Easter, Memorial Day, Father’s Day, and my Mom’s birthday and then the 4th of July all in quick succession. It feels wrong still. All these holidays without my Dad. He was disorganized and often didn’t plan my Mom’s birthday until the last second. But he managed to pull through usually. Not with the same attention to detail when my Mom plans birthday parties, but he got the job done. The last two of her birthdays with him alive were not fun as he was in the throws of Dementia and we all were watching and waiting as he declined.

What I wouldn’t give to give my sons the experience of my Dad. But I can’t. Instead I have to tread carefully around Father’s Day because I am grieving and my sons are questioning why they do not have any one to celebrate. It’s a hard thing. And it’s freaking yearly. Couldn’t be biennial or triennial. Nope yearly. In the past I’ve tried to celebrate their other Mom on Father’s Day and we called it second mother’s Day. But honestly this year we were in the midst of mediation sessions that haven’t all been super amicable and I just wasn’t feeling like I wanted to do anything. Sundays are her days with the boys so they were with her anyway.

My sister invited me over to her house with her family and my Mom and her in-laws who are just lovely and who I actually like very much. But I stayed home. I painted my fence. I thought my Dad would nod in approval to that. I had to stain it this year. It’s a lot of fence and deck. I made some heavy progress that day. I blasted my music and painted up and down the fence and rolled it on the deck. My Dad wanted above all else for us to be happy. I’d say I’m seeking happiness and that I am at least on the other side of unhappiness.

I try and practice gratefulness. I am grateful for my sons, and I hope one day they can be Dad’s to their own children. I am grateful for the time I had with my Dad pre-Dementia. I am grateful for the stroke he had during Dementia because for some bizarre reason that was one of the last truly lucid conversations I had with him was in the emergency department as he was recovering from the stroke. It was like having my old Dad back. It was bizarre and wonderful and heart wrenching and I ate up every second of it. He laughed. Actually laughed. And cracked jokes and was his old self.

I am grateful for my marriage because without it I would not have become who I am. I am grateful for divorce because without it I would not be able to be who I am. I am grateful for my cats because those rascals keep me company when the boys are gone on Sundays. They keep me sane with their insanity. I am grateful for my mom, my sister, my sister-in-law, and my niece who have been a constant presence in my life and supported me unflinchingly through this divorce and who love my sons as much as I do.

I am grateful for the intense and sometimes debilitating grief I feel for my Dad because it is a reflection of the love I felt for my Dad the truly unconditional love he felt for me. I wish he were here. I wish I could talk to him about my divorce and mediation and hear him tell me he would support me no matter what and ask me what I need and tell me to just keep moving forward because that’s what we have to do. And he’d make some comment about how at least I’m not Catholic because when he got divorced the fucking priest told him to get the feck out of the church. (He was still a little bitter about that). He’d tell me he met my Mom after he got divorced from his first wife, and look at how lucky he was to have my Mom and me and my sister. He’d tell me he’d never have had me in his life if he hadn’t gotten divorced.

I know he’d say these things because I knew my Dad. So well. We had all those conversations. He always told me he was grateful for divorce because it gave him me and my sister. He told me he felt lost after his divorce felt like he was a failure and that he missed his kids from his first marriage so much. He told me he loved my sister and I and he was always so incredibly proud of us both. He told me he didn’t know how I came from him because he admired me.

It’s been raining the last few days and so I did a 550 piece puzzle. I don’t think I’ve done a puzzle since before the boys were born. I listened to an audiobook and actually had time to do it because the boys occupied themselves with toys, games, and tv. They would intermittently pop in and “help” me with the puzzle and also make me take breaks to play Memory with them.

The audiobook I listened to had a line about grief. It hit me.

“Smells are the worst. Smells can put you right back into the belly of grief. When you love too hard you can lose the will to live without them. Nothing feels right and everything cuts.” I remember giving my Dad hugs and digging my face into his left chest. If he was wearing his army uniform there would be a pocket there and maybe some pins or his name pin. It always had a starchy smell to it mixed with his deodorant. If I hugged him on a holiday he’d smell of cologne and still have a pocket on his left chest that I would rub my face into. If I close my eyes I can almost feel his shirt, smell his scent, and feel like I am with him.

Dear reader if you take nothing else from this post: remember that grief is a reflection of your love for someone. True grief is a reflection of true love. Do not run from it, do not hide from it, let it in, little by little so it can be felt in pieces and can help you remember how deeply you loved. For what is a life without love? My Dad would say it is a life that is empty. My Dad would say “You have to do it Muffin, because you might just get lucky like I did.”