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Health & Fitness

Postpartum Depression Can Be Rebirth: Talking with Dr. Susan Benjamin Feingold

Dr. Susan Benjamin Feingold's groundbreaking work on postpartum depression shows that it can be one of the most positive, transformative experiences of a woman's life.

The story broke moments before my interview with Highland Park psychologist Susan Benjamin Feingold, PsyD. A New York City mother had thrown herself from an eighth story window with her ten month-old son strapped to her chest. Miraculously, the baby survived. Tragically, the mom, who suffered from postpartum depression, did not. Dr. Feingold is the author of Happy Endings, New Beginnings: Navigating Postpartum Disorders, a unique and essential guide to what can be one of the most challenging times of a woman's life.

Dr. Feingold's contribution to the field is original and potentially lifesaving. According to Feingold, tragic endings are the exception. With proper guidance, postpartum depression and related disorders (there are several) can be one of the most transformative and productive experiences of a woman's life. Sound impossible? According to Feingold, it's a real and even likely outcome. Happy Endings, New Beginnings takes readers through the healing process to a life that's meaningful, rewarding and full of reasons to live it.

Dr. Feingold's treatment protocol focuses on four principles:

  • Tools to address symptoms, including coping strategies, setting manageable goals and identifying illness triggers
  • The power of hope even if it's initially a leap of faith
  • Religious or spiritual tools to the extent one is comfortable with them
  • Telling your story, a surprisingly effective tool for diffusing shame and embarrassment, alleviating grief and connecting with others

 

Readers of Happy Endings, New Beginnings will find an expert and understanding guide in Dr. Feingold. Her own battle with postpartum depression twenty years ago inspired her to specialize in treating the disorder. She has since successfully treated thousands of patients and teaches her methodology at the Chicago campus of Argosy University. The book is populated with inspiring first-person accounts from her patients who generously share details of their struggles and ultimate triumphs. It also covers facts and myths, deflecting unsolicited advice, the effect of postpartum disorders on dads, guidelines for partners and friends, and includes an extraordinarily thorough resource guide. Other bonuses include "paper and pencil" screening tests.

Dr. Feingold kindly took time to speak with me about this most inspirational guide.

Q: Your book offers such hope to anyone with postpartum disorders. Even the most despairing reader will see the possibility of coming out the other end even better than she could imagine.

A: And that's why I wrote it, for women who feel so hopeless. The first thing is just to have hope that they can get through this, that it's not a life sentence. I think many women feel that it's a life sentence and being in that much pain think, "I don't want to stick around like this."

Q: In the midst of intense pain it's hard to imagine coming out of it.

A: That's the challenge as a therapist: when a woman is so down and so desperate and hopeless, to have them even believe me. One of the things I have going for me is that I've been there. This happened to me. I've treated thousands of women. I've been doing this for twenty years now. I can say, "You will get better. I promise." Even then sometimes it's a challenge because it can be hard to see the forest for the trees.

It's a very intense illness, but with help it can be treated in a short-term way. The therapy very often is brief. It's not the ten-year plan. Patients get better and they leave treatment. There are people that I continue to work with because they want to work on other issues or they continue to stay in touch and come in periodically. But for many people, it's very short term.

Q: When did you know you wanted to write this book?

A: I started writing it maybe five years ago. I don't remember the exact point because I wrote and re-wrote. There were other books out there and I struggled with what do I have to say that's different? It was at a time when I was ending treatment with a couple of different patients and sometimes you see patterns.

I had two patients [completing treatment] the same day. When treatment terminates, we review our work together, say our goodbyes and "good luck and call me if you ever need anything." And what occurred to me is both of the women mentioned that even though it was the worst time of their life, they learned so much or changed so much that they were almost glad it had happened to them. And it triggered the thought for me: that's what people don't get and that's what they need to know.

So often we read about the terrible tragedies, but they're rare. The media makes it sound like everybody who has postpartum depression is going to kill themselves which isn't the case. It is a possibility because it can be such a painful and dark illness, but what I started realizing was that nobody was talking about the majority of women who not only get better, but grow. If women only knew that not only would they survive this, but that it might be the biggest growth experience of their life, that this would help them to change and transform, then maybe they wouldn't feel so desperate to take their life. They would have hope.

And so I started looking at the other books out there and nobody was covering this. Nobody was saying anything about the positive outcomes. No one was looking at the long-term picture instead of this brief point in time.

And then, of course, I felt my own experience was life-transforming. And it clicked. It was an epiphany and it seemed like now I had something important to say and that got me moving and feeling that I really needed to write this book.

Q: What sort of "new beginnings" do people experience?

A: One of my patients was very successful, very driven, but didn't enjoy the little things, the simple things, and her life was passing her by. So for her, her new beginning was seeing and experiencing her life with fresh eyes. Sometimes out of these very hard experiences, not only postpartum depression but other things, if somebody has a car accident or a near death experience, they start to perceive things differently. It's like something shifted. The new beginning is that in this transformed state they perceive things differently and change the ways they do things.

Q: What are the causes of postpartum depression?

A: There are multiple causes. There's always a hormonal piece. Certain hormones increase significantly during pregnancy and then within two to four days after [delivery], decrease to pre-pregnancy levels, so there is a big hormonal shift, an enormous falling-off-a-cliff thing. It's the same shift for all women, but the difference is that some women's brains are more sensitive to hormonal change. There are other things as well. It may be that your life isn't working for you. Oftentimes there are other things going on.

There are biological factors. Perhaps depression runs in the family. There are what we call psychosocial factors which could be sleep deprivation, adjusting to change. Some people don't have good coping mechanisms and are not so resilient. There may be relationship issues. So those are things you work on in therapy.

As I'm seeing someone, I'm putting it together. What's not working besides the fact that they're hormonally sensitive? I visualize it like a pie chart. How much of it is this? How much is that? What caused them to get here? And what do they need to work on besides their symptoms? What are the issues that would help them to grow?

Q: Is there always a biological predisposition?

A: No, I don't think so. Women are at the highest risk of any time of their life for some kind of mood disorder during childbearing years. They're adjusting to probably the biggest change of their life. Plus, it's a total shift in identity to take on this idea of "mother." We have all these myths and societal expectations about what that means.

This woman in New York left a note castigating herself for being a bad mother. There is this idea of perfection, of everybody else does it better, that there's one way to be a mother. It's like how we have this idea of what beauty is and then if you're a little chunky and you see all the magazines with women with perfect shapes you can feel "less than." And so people have this idea of what being a good mother is and feel very ashamed if they feel they don't measure up.

If a mother comes in talking about being a bad mother I work with her on [the question], what is good enough? You don't have to be perfect. Who's perfect? Was your mother perfect? None of us are. And if you think other mothers are perfect? Hey, they're either not being honest or you just have this as an idea in your head. We're all doing the best we can. It's a learning process. No one trains us how to be a mother. It can be especially hard on somebody who is a professional and feels competent in their profession and then feels so incompetent in this new role as a mom.

Patients come in and say, "Well, when I go to the mall, the other mothers all look so perfect and they're managing their kids and they don't have any problems." I say, "How do you know? How do you know they didn't just leave my office?" We have these ideas about things when really we have no idea.

Many of the women I see look really together. They put a lot of effort into looking okay. Maybe because they're not feeling okay. So that can be a real fooler because sometimes it's a way of wearing a mask. It's a way of hiding how they're doing on the inside.

Q: So having postpartum depression, of course, doesn't mean one is a bad mother?

A: There's nothing that says women who have postpartum depression are bad mothers. They are suffering. But they might be doing just as good a job as another mom who does not have postpartum depression. But certainly there are some who are not functioning and they need to get help.

Q: When does feeling understandably overwhelmed turn into a postpartum disorder that needs attention?

A: Well, there's a spectrum. I do a lot of education with my patients because I think the more they know, the more they understand that they have an illness, not a character flaw. It also gives them more control. They become a better informed consumer.

There's a spectrum based on intensity and severity of symptoms. Normally, [motherhood] is a hard adjustment. But at some point, there's a crossover. It's not only a hard adjustment, but their level of distress is affecting functioning and significantly impacting their life.

We talk about three postpartum emotional disorders: postpartum blues, postpartum depression and postpartum psychosis.

Many people look at postpartum blues as the mildest of the postpartum mood disorders. I don't necessarily agree that it's a disorder because it's very common and transient. With the "blues", women feel more emotional, maybe more anxious, maybe more depressed. It usually starts right after the baby [is born] and it can last about two weeks. It doesn't really require treatment. It just requires women understanding that this is a hormonal change and it affects 75-80% of women. When something affects most people, how do you say it's a disorder? It's sort of normal. So I don't consider that one of the postpartum disorders.

For me, the first and mildest postpartum disorder is postpartum adjustment disorder. That's just having difficulty making the adjustment to being a mom.

Postpartum depression is more severe and can last weeks or months. It requires treatment and certainly it affects people's functioning. Postpartum depression can come in many forms and may include panic disorder, anxiety or obsessive compulsive thoughts. The most common statement women make is, "I just don't feel like myself."

There's a subgroup of women who don't even feel depressed, they just feel anxious, but because of the name "postpartum depression" they often don't realize they have it. Unfortunately, some healthcare providers also don't realize it because they think, "She's not crying. She's just calling me all the time. She's neurotic." It may be a form of postpartum illness known as postpartum anxiety disorder.

Q: How do you know when to ask for help? Is it after a week or two weeks or is it based on the intensity of symptoms?

A: If a woman is just feeling emotional in a way similar to PMS and she's not having panic attacks or obsessive thoughts or so much anxiety that she's feeling scared, then it's probably okay to wait. But there are other times where a woman feels very depressed, very dark or highly agitated or anxious. Certainly, if they have panic attacks or obsessive thoughts, they should be evaluated because that doesn't come with the "blues."

Sometimes it's obvious that you don't need to wait two or three weeks, that you want to get treatment started because, and this is probably true of other illnesses, the sooner you get treatment, the sooner you're done with treatment. There are exceptions where it goes away on its own, but it's chancy. More often, the longer you let it go, the worse it gets and the more the ripple effect. You start having problems with bonding. You start having problems with relationships, or you've cut off all your friends. And then treatment takes longer and is more complicated.

Q: What about when fear of judgment is a barrier to getting help? Or maybe a mom is afraid that if she tells the truth her child will be taken away?

A: I think that's part of the stigma that causes people not to get help and not to tell anyone; partly, the societal stigma and partly their own thinking that "If anyone knew, they might take my child away." I've had patients say that and usually I can assure them that DCFS doesn't take away kids just because someone is not being the mother she wants to be. DCFS would be taking away almost every child if that were the case.

When a woman has obsessive thoughts she can have negative thoughts of harming the child. Those aren't the same women who harm their children. It's more of an anxiety symptom. They know these are crazy thoughts, but they can be gruesome and scary thoughts.

I've had plenty of patients with those kinds of thoughts, but I once had a patient who told her young, new pediatrician about the thoughts and the pediatrician freaked out and she did call me, but she called me after she called DCFS. It created such a mess because this woman was not at risk to hurt the baby, but the fact that DCFS got called in created more anxiety for the woman as she thought, "Oh my god, maybe I really could do something if she's calling DCFS."

Unfortunately the pediatrician triggered more anxiety, whereas what I want to do in situations like that is bring anxiety down. If someone is going to hurt their kid or they are hurting their kid, it's different. You have to protect the child. But these were purely thoughts that were creating anxiety for the woman that she wasn't going to act on. It really made a mess. The woman ended up going to the hospital because she became so anxious. It exacerbated her anxiety and she was so mad at the physician that her husband wanted to sue.

But this certainly doesn't happen all the time. That was one instance. But that's why we want healthcare providers to get it. I think there is a fear in getting treatment. Women can be secretive about this illness. They don't want anyone to know. Maybe people will judge them. In some way, there is a stigma, so they are kind of right. Until we understand more about mental health issues, maybe some people will judge. But it's still worth it to get treatment and get well.

Q: It sounds like if a mom suspects she is suffering from a postpartum disorder, she should contact one of the resources in your book or a healthcare provider who understands.

A: Certainly it's best if they can get somebody who either has expertise or at least who has treated this disorder and has some experience.

Q: Who should make the decision to prescribe medication, a physician or a mental healthcare provider?

A: It's good for a woman to go to her physician unless she's already being seen by a mental health provider. [But] physicians need to be aware that everybody's got their expertise, and there are many tools that can help women with postpartum illness. We live in a time when, thank goodness, we have these medications as some patients need medication as well as therapy. But it's not the only answer. Sometimes I see a patient who has seen her primary care doctor and been put on antidepressants. I listen to her and think, "She didn't really need that."

It's not all brain chemistry and it's not an exact science. There are many things that can be done in addition to medication. Medication is only part of the answer. Therapy is essential in treating postpartum illness. In fact, medication is not necessary in every case, it depends on the severity level and symptom picture.

Q: You write that you haven't healed properly if you're embarrassed or ashamed of your story. Can you ever be completely rid of those feelings?

A: Yes. Yes, you can. I think you can be left with feeling empowered. It's a very different ending to feel that you not only survived but you've grown than to feel you've survived but you don't want anyone to know and it's this dirty little secret.

In 2001, I was doing a lot of interviews. I did an interview for the Tribune and they published my phone number. A woman called me. She was in her seventies and said she wanted to talk to me. I had talked about postpartum OCD (obsessive compulsive disorder) during the interview. She had had it fifty years ago and never realized what she had and she never told anyone. She also never got treatment. It did go away, but she was left with this sort of secret that she was a bad mother and that no one should know. She never even told her husband.

She had had twins who were now fifty years-old and she was in fact a good mother. She was a nurturing mother, but she felt that because she had dark thoughts about hurting them, she was really evil. It eroded her self-esteem and it was something she never shared.

So we talked. She said, "Oh my god, I didn't know there was a name for it." We ended the conversation and I encouraged her to talk to her husband and to call me back and she did. And he was very sweet. He said, "Why didn't you tell me? I could have helped you. You suffered all these years."

Q: I can really understand that, how the shame can be so heavy that even if you come through it, the shame lingers.

A: Right. That's what I mean. You haven't totally healed. Even though she was well past postpartum depression, it was fifty years earlier and she did apparently get well. I don't know if she got well as quickly as if she had gotten treatment, but there was a piece left over like a scar. This could be something that makes you feel bad, if you think, "If anyone ever knew what I really was like …" It doesn't need to be.

Q: That's a powerful story. Does that mean that when you heal, the pain of the memory stops also?

A: That's an interesting question. You might always feel some pain when you think back. There's a loss issue. The last stage of treatment is grieving the loss of the perfect mothering experience that you had expected.

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Even for myself, there's one picture of me with my son, who is now going on twenty-one, when he was an infant, maybe three months-old. It's a nice picture in some ways. I think I look pretty good in this picture and I usually don't like pictures of myself. But I was so vacant and when I look at it, it makes me sad. It brings me back to how depressed I was. I'm holding him and he doesn't look happy, either, to tell you the truth. He looks all chubby and cute, but I can see my depression and being vacant when I look at my eyes. I don't remember where I was or who took the picture. But I remember that feeling. Many patients have expressed this; that you're mentally checked out.

The picture makes me a little sad because it reminds me of what a painful time it was and how I was so not present and that I missed that time, that I can never get it back, that I did not enjoy him at that time and I didn't enjoy being a mother. I was so in my own world. It's sort of like you're living this nightmare and you're not even aware of what's going on around you. So that's another reason to get well faster because there's less missed time.

Q: Can postpartum disorders affect a baby's emotional development?

A: Yes, absolutely.

Q: Can a baby sense it?

A: They probably do sense it. But also if the mother is doing the motions, they're changing them and feeding them and maybe they're doing the best they can, but they're not as engaged as they would be if they weren't in a depression. There's a lot of literature that suggests that babies of depressed mothers have a higher incidence of affective disorders, of learning difficulties later. Sometimes they're not gaining weight. Sometimes the babies become depressed.

We need to help the mother for the mother's sake so she can enjoy the baby, but there are also good reasons to help her for the sake of the child and for the sake of the couple. But certainly it can be bad for things like bonding. There's a lot of [research] now about people who grow up with attachment disorders. They have trouble connecting with people. Well, this is your earliest connection. There are so many reasons to help women at this time.

Q: Can a depression during pregnancy affect the baby?

A: It's a delicate thing to talk about because women feel so guilty that to tell them they might be screwing up the baby in utero is not going to help their mood. We don't know for sure, but a mother who is depressed might not be taking as good care of herself. There may be a higher incidence of drugs and alcohol. She may not be eating as healthy or taking as good care of herself. So that's one way the baby could suffer.

But there's also some work by an English researcher, Vivette Glover, on the mother's anxiety and how it changes the blood flow to the baby. That's something I'm really careful talking about with my patients because certainly I don't want to make them feel worse. It's not going to help them get better.

Q: So if a woman feels anxious or depressed during pregnancy, should she get help at that point?

A: Absolutely. That is the highest risk, other than prior postpartum illness, for postpartum depression. At the same time, we don't know everything about this illness. There are times when someone has significant depression or anxiety during pregnancy, then they deliver and they're fine.

But talk about myths, there's a myth about pregnant women that your skin is glowing and your hair [is beautiful] and, well, it's all from the extra hormones. But there's also this myth that in pregnancy women are insulated from mental health problems which is totally untrue. But it makes it more shameful when you have a society that says you're supposed to be on top of the world.

I saw a patient who is very depressed last night. She is pregnant. Young mom. She's concerned. She said, "I'm not excited. I feel like I'm not bonding." But everyone keeps asking her, "Aren't you excited?"

And she said, "I mostly lie because I'm embarrassed to tell them, no, I'm not excited. I feel very blah. I'm not looking forward to this. I feel like it was a big mistake." So I suggested we come up with a statement that would make her feel more comfortable than, "Yeah, I'm excited." She also said, "I have a friend who's having fertility problems and I don't even want to talk to her because she's like, 'you should be thrilled. I can't even have a child.'" And that only makes her feel worse. You can only be where you are. Somebody telling you that you should feel some way doesn't make you feel it more, it only makes you feel worse.

Q: Do adoptive parents ever feel a version of postpartum depression?

A: They can just like fathers can. An adoptive mom or a man can have a clinical depression or adjustment disorder and it can look just like a postpartum disorder, but because there are no hormonal changes, I don't call it postpartum depression.

Q: What is the effect of living on the North Shore? On the one hand, we have a lot of resources and people tend to be educated and aware. On the other hand, there's a lot of pressure.

A: The pros are that people are more psychologically minded. There are times I'm with a patient and she'll get a call from a friend and say, "I can't talk with you now. I'm with my therapist." There are more resources. There are more therapists. There are more services. There are more new mom groups and postpartum groups. Whereas if you're in rural Indiana and it's an underserved area, there's no therapist to be found so it's hard to get treatment.

Cons are that there is more pressure here. There are higher levels of depression. Expectations are higher. Some of the things I hear are, "Moms are taking their kids to twelve different activities." "All the other moms have it so together." "All the other moms …" There is also a lot of pressure to keep up with the Joneses.

Q: Is there ever such thing as a hopeless case when it comes to postpartum depression?

A: I think people believe that, but I don't believe it. There are people who have such treatment-resistant depression that we might have to go to more extremes in terms of treatment but that doesn't mean that I would lose hope.

I made a choice not to work with long term chronic patients because I guess I personally need the gratification of feeling like I can make a difference so I don't tend to work with a long term schizophrenic population where maybe the improvement is the person buttons their coat. That's not enough for me. I need to feel like, wow, I've helped to change things for them.

So that might be my own thing but no, not only do I not lose hope, but even when I see someone in a very depressed state, I can picture what they'll be like or what they were like and see through to what's on the other side.

So even though they may look depressed, I can see that there's a vivacious person in there. I can get a handle on what they were like before this cloud of depression was on them. So even though they're feeling hopeless, I see the ending even at the beginning and that puts me in a different position. It allows me to remind them that I don't see this as hopeless. Sometimes I'll even say, "I don't mean to be disrespectful, but this is a pretty classic postpartum. I've seen it hundreds of times. No problem. We'll get there."

Q: So every case of postpartum depression has the potential for a new beginning.

A: I think it does.

Q: What did you find most challenging and most rewarding about writing your book?

A: What I found to be most challenging was my own tendency toward wanting quick results. I like short term therapy and this area works for me because I guess I like immediate gratification. And writing a book is so not like that. I had to write and rewrite and finally send it out and find an agent. Once I found an agent, it was a pretty quick turn-around for her to find a publisher who was interested so I was really lucky in that way.

Then there was another challenge. When I got a publisher, my book was a very small book. It was about 150 pages. The publisher sent me an email saying, "We are interested and we want to sign a contract." But what they required was if I wanted to sign the contract, I had six weeks to more than double the size of the book. I thought, "I've been writing this book for five years! In six weeks I'm going to be able to do that?" So my first thought was, "I can't do it. It's impossible! I'm not going to sign a contract to say I can do something I can't do."

And then I had to do my own mental shift, that if this is a story that needs to be told, could I -- just like these women, in some ways it was a parallel process, like they feel it's impossible to get well -- could I take on this impossible situation? I felt like it was hopeless. Could I take on the attitude that I am going to commit to it and I'm going to make it happen? That was a big challenge.

And so I started working three days a week and writing four days a week and I signed the contract with the idea that I'm going to make it happen and did a lot of work on myself with "I can do it!" and I posted slogans around and I talked to friends who would encourage me, "You can do it!" And I got myself on the schedule of getting up early, exercising and start writing; not taking calls unless it was a crisis from a patient, not going out to lunch with friends, kind of pulling in and writing all the time.

I also posted a lot of little sayings which are still all around me like, "Challenge comes to teach us things. It will make us stronger." "There are no obstacles, only opportunities." There's a quote by Georgia O'Keefe, "I'm absolutely terrified every moment of my life and I'll never let it keep me from doing a single thing I want to do." There's an Einstein quote, "There are two ways to live your life. One is as though nothing is a miracle and the other is as though everything is a miracle." I focused on, "I need a miracle."

Q: That is a wonderful story. I feel encouraged just hearing it.

A: It felt like a parallel process. I had an epiphany that it was like my own postpartum experience and the postpartum of other women in that this book is my baby. I have to birth this baby. It's an enormous challenge. Can I take it on and make it happen?

Dr. Feingold will appear at The Book Cellar, 4736 N. Lincoln Ave., Chicago on Thursday, May 23, 2013, 7 p.m. Joining the author will be Nili Yelin, an award-winning children's storyteller who will read a true-life account by a patient who emerged from "postpartum darkness" and changed forever.

For more information about the reading and signing, call The Book Cellar at 773-294-2665, or go to its website, thebookcellar.com.


Happy Endings, New Beginnings: Navigating Postpartum Disorders was published by New Horizon Press in February 2013 and is available at independent booksellers and on http://www.amazon.com , http://www.barnesandnoble.com.

Dr. Feingold also writes a blog:www.post-partumdepressionblog.com.

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