Overlooked and Under-treated: Postpartum PTSD

Pregnancy and childbirth can be a joyous and exhilarating time. However, for some women, fertility struggles, high-risk pregnancies and unexpected childbirth experiences result in psychological trauma. Throughout the past quarter-century, research examining the impact of childbirth on maternal mental health has yielded valuable insights for understanding Postpartum Depression (PPD). Thankfully, PPD has become increasingly well-documented and recognized by the obstetric and psychiatric communities, and (for better or worse) has been much-publicized by the celebrity set. Worryingly though, less is known about another, equally troubling postpartum occurrence: the development of Posttraumatic Stress Disorder (PTSD) following childbirth. 

Women suffering from postpartum PTSD present with a set of symptoms similar to that of other traumas – symptoms of avoidance, re-experiencing, and hyperarousal. For example, ‘avoidance’ may take the form of requesting a tubal ligation to prevent subsequent conception, abstaining from sexual intercourse, using multiple forms of birth control simultaneously, terminating subsequent pregnancies, or requesting an elective C-section for subsequent deliveries.  Symptoms of ‘re-experiencing’ may include intrusive flashbacks of the birth, nightmares of dying during childbirth, experiencing birth-associated pain during intercourse, and re-living the traumatic birth on anniversary dates. ‘Hyperarousal’ may take the form of chronic muscle tension, a hyperactive startle response, or the experience of panic symptoms when faced with reminders of the delivery – particularly during gynecological exams and visits to doctors’ offices or hospitals. Further, the physiological arousal of posttraumatic stress may also intensify postpartum sleep disturbance and fatigue, and cause a mother to be overly anxious about the health and safety of her baby.

At Cognitive Therapy for Women Psychological Services (CTWPS), we comprehensively assess and monitor women for all forms of psychological distress as they navigate the journey through pre-pregnancy, pregnancy and the postpartum period. We seek to provide a safe place where you are free to explore your personal experience (be it traumatic or fantastic), without fear of shame or judgment. 

Through our work together, we will help you identify your thoughts and beliefs about your experiences that may contribute to increased feelings of sadness, fear, anxiety or depression.  Trauma naturally creates distortion in our thinking and in our emotional life. We support and challenge you to untangle and dismantle the parts of your personal narrative that do not currently support you well. While it may be natural for your mind to be pulled toward negative thoughts as a form of protection - we will help you master skills to shift these negative thoughts, and to move you away from fears and anxieties. It takes time and commitment to do this work – no doubt – but at CTWPS, we are committed to being your witness, your guide and your biggest cheerleader as you navigate the emotional complexities of your reproductive experience.  
 

Work-Life Balance

Women are receiving more encouragement than ever to fulfill their potential in the workplace. But paid work doesn’t always support a rich personal or family life.  Often, ambitious (and exhausted!) women find themselves over-extending in order to juggle all of their responsibilities. Some women even contemplate leaving the workforce entirely because they believe that their needs for flexibility at work, and for shared-responsibility at home, are impossible to achieve. 

We recognize that women continue to carry a disproportionate burden of labor across their work and family lives as compared with men.  Our goal here at CTWPS is to help women create more options so that they don’t have to choose between a career identity and a fulfilling private life.  If you’re seeking to cultivate a fulfilling work-life balance, consider these three tips:

1. Collect Data About YOUR Workplace 

Many women are too fearful to negotiate for flexibility in the workplace because of the belief that they will be unsupported or penalized for vocalizing their needs.  Sometimes this belief reflects a woman’s workplace accurately; other times, however, this belief may represent the deprivational way a woman already experiences the world.    

Let’s consider a new mother who is debating whether to stay at her job with demanding hours and travel requirements that are currently incompatible with her caretaking responsibilities.  How is this working mother likely to advocate for herself if she believes that negotiating for more flexibility would be met with a lack of support, or even a penalty? The odds are that she will either over-extend herself in all of her roles, or she might even quit her paid work altogether if that is a possibility.  

In our practice here at CTWPS, we would ask this woman to collect real information about her workplace in order to prepare her appropriately for a renegotiation of her role. What kind of information should she collect?  We would encourage her to consider whether anyone else in her workplace takes advantage of flextime, part-time, or the kinds of hours she would prefer.  If so, at what level of the organization are they?  Does anyone else acknowledge outside responsibilities as they leave work early?  What does the organization say they support in terms of work/life flexibility (even if no one takes advantage of it)?  Can she make a financial argument to the organization about why she should work differently?  What kind of changes in her pay and position can she afford to make?  Are there trusted individuals she can speak to who can guide her in her negotiation?

Ultimately, we encourage every woman seeking work-life balance to ask herself: How would my work need to change to meets the demands of my private life?  Alternatively, we may encourage her to consider the reverse - does something need to change in my personal life to better support my career?

2. Be Your Own Communications Director 

Once you’ve identified a specific way you’d like to shift your role at work, it’s time to manage your own public relations. After all, no one will ever advocate for you as passionately, or in such detail, as you can for yourself.  You can begin by creating a plan regarding with whom you will speak and how you will frame your concerns. Women working with us would likely create a thorough strategy about how they might assert their needs, as well as their value and commitment to their work.  

From an organizational perspective, women who experience their job as being compatible with their private lives are generally more confident in their roles and tend to stay in their job longer. This adds tremendous value not just for the individual woman and her family, but also for her company. 

3. Be an Active Manager of your Private Life  

Sometimes the biggest area of conflict for a woman is not in the workplace, but rather at home.  Outside of the workplace, women tend to devote many hours each week to managing their home-based responsibilities.  One of the most stressful issues women face is the unexpected excess of home-based work, regardless of their work situation.  We encourage our clients to develop skills in seeking support from their partners at home (if they have one) to lessen that burden.

At CTWPS, we fundamentally believe that there are extensive benefits to her work and family systems when a woman cares for herself well and seeks appropriate supports.  Conversely, the risk of a woman not accessing support is high – increased couple stress, mood problems, a lack of joy in mothering, or a tendency to “check out” at work (just to name a few).  In our work with clients, we take the long view, and encourage women to approach the management of their home-based work with the same level of attention and care that they devote to their paid work.  

We recognize that it takes courage and effort for women to experiment with establishing greater flexibility and balance in the workplace or in their home lives.  We can’t always guarantee that the organizations for which we work, or our partners at home, will be receptive to all of the changes we seek.  But without our engagement, we can assume that the status quo (whatever that looks like) will remain unchanged.    

 

 

New Year's Resolutions: Myths that Interfere with Action

We all seem to be compelled to set New Year’s resolutions on January 1st.  For many of us, January 1st provides an opportunity to reflect back over the previous year, and to set new intentions for the year ahead.  While nearly half of women making New Year’s Resolutions, remarkably few – only 8% of women – are actually successful in achieving them.

As cognitive-behavioral psychologists, we want to dispel the myth of willpower when it comes to setting and achieving resolutions.  After all, our willpower, or ability to “white knuckle” changing our behaviors with intense focus, may typically last a few weeks (because, let’s be honest, life interferes, we get distracted, and we may not continue to highly prioritize the original goal).  When this happens, we must rely on other mental and behavioral strategies to keep us on track.   We believe that most women are simply not set up for success with the strategies and skills necessary to persevere as they pursue their goals.  If you’re thinking of setting a resolution for yourself in the New Year, below are 7 ideas we encourage you to consider.

1.  Is my goal specific enough?

It’s no surprise that driven, motivated women tend to set highly ambitious goals, such as losing weight, increasing their productivity at work, or saving money.  However, one of the most common reasons that these kinds of resolutions tend to remain unmet is that they are actually not specific enough. So, our first task to select one goal and ensure that it is highly specific.  For example, a woman may refine her goal of “losing weight” by deciding that she will lose 5 pounds this year. 

2. Do I really want to commit to this goal?

Once we’ve identified a specific goal, it’s critical that we evaluate our readiness to commit.  This process often begins by first acknowledging that not meeting our goal does have advantages.  For example, the woman described above may note that committing to weight loss triggers anxiety or fears of failure (I’ve joined the gym before, only to waste my money).  She may also note that committing to the behaviors of weight loss may result in less time to do other activities that she believes are more enjoyable.  By contrast, in exploring positive ramifications of moving towards her goal, she may recognize that consistent exercise may increase her self-esteem and mood, which, in turn, may serve to increase her motivation towards weight loss.  In therapy, we would work with this client to realistically examine the pros and cons of committing to her goal at this time. 

3. How do I develop a plan?

Once we’ve identified our readiness to commit to a goal, we need a detailed action plan.  For example, the woman above interested in losing 5 pounds is now ready to break down that goal into specific actions.  In therapy, we would encourage this woman to step back and consider which specific days, at what specific times, and for how long, she can realistically expect herself to exercise, determine a weight loss plan, purchase and organize food, and so forth.  This longer-term goal can now be activated.  Additionally, we would encourage this woman to consider solutions to potential obstacles prior to implementing her action plan. For example, perhaps this woman walks by a tempting bakery on a daily basis.  One of her actions may be to commit to an alternate route so that she is not so easily triggered.

4.  The all-too-common problem of over-ambition in goal setting: 

Ironically, being too ambitious is likely to short-circuit our action plans.  It is our experience as clinicians that setting the bar low enough so that we are experience just enough of a stretch is the key to successful goal-setting in the long run.  Why? Because the negative and self-critical thinking that occurs when people inevitably disappoint themselves on occasion is the number one culprit interfering with our ability to stay on task with our goals.  The good news is that over time, we can expand that stretch, as new, helpful habits are formed that are congruent with our goal.

5. How do I stay positive and motivated?

The psychology of goal setting is just as important as the behaviors of goal setting. Whenever we try to change our behaviors, we may have negative self-talk that interrupts our process emotionally and behaviorally. In therapy, we teach women strategies to identify their negative thoughts in the moment, so that their thinking isn’t allowed to interfere with the incredible investment they are making in achieving their goals.  We help our clients to replace their “task-interfering” thoughts with beliefs that are more “task-oriented,” positive, and realistic.  For example a client might admit, “I was thinking about how unmotivated I was to go for a run, so I ended up blowing it off that day.”  We might help her reframe those thoughts going forward by saying, “Even though I TOTALLY don’t feel like going for a jog, once I get moving, I will probably have more energy and feel proud that I did it and it will have been worth it.” Reframing our thinking helps us keep on track behaviorally, which in turn, helps us eventually meet our goals.

6. Expect and welcome bumps in the road! 

Perhaps our greatest task as cognitive-behavioral psychologists is to help our clients debunk the myth of perfect linear progress in goal setting. We know that challenges and setbacks are to be expected, and that no change happens without a few bumps in the road. In fact, these “bumps” often help us learn more about situations that are particularly challenging, and force us to solve important problems around a specific goal.  So, it’s actually in our best interest to welcome these challenges for the critical information they provide.

7.  Success is not about being good! 

Women are so tough on themselves. As clinicians who work exclusively with women, our biggest concern is how often we see clients conflate success in meeting their goal with a type of moral goodness (and therefore, setbacks in goal setting are interpreted as a type of moral badness).  

Please keep in mind that reaching our goals has very little to do with the goodness of our character, and far more to do with our motivation for change, the specificity of our goal, and a thoughtful action plan.  

We wish you Happy Holidays and a Wonderful New Year!

Managing the "Mansplain" at Work

Rebecca Solnit aptly captured the essence of the “Mansplain” experience in her essay entitled, “Men Explain Things to Me” (2008).  Solnit described a time when she had been mansplained, or interrupted by a man, who then went on to explain the meaning of a book to her without acknowledging that she, in fact, had written it.  In response to her essay, the “mansplain” quickly became a cultural phenomenon, as it resonated with the experiences of women throughout the country who were frequently interrupted or condescended to by their male colleagues.

So how can we, as women, respond effectively to the mansplain?  As cognitive behavioral psychologists, we recognize that a woman’s internal experience of the “mansplain” has the power to exert tremendous influence over what she believes, says, and does, therefore impacting her professional identity. Let’s imagine, for example, that you’ve just begun to share an innovative idea during a weekly brainstorming meeting, only to be interrupted by a male colleague, who goes on to expand upon the same idea and take credit for it.  Although there are many possible reactions to this experience, below are three possible thought processes that may emerge for a woman in the face of this “mansplain:”

1. “I can’t challenge him, because the fact that he did that probably means I AM inferior.”

The gravest risk to a woman’s professional identity occurs when, in the moment she has been interrupted or dismissed, she becomes silenced beneath the chatter of her own self-doubt. This woman tends to personalize her colleague’s behavior because it resonates with an underlying fear of incompetence or failure that she harbors about herself. After all, she might think: why else would my colleague have had the audacity to mansplain to me? Behaviorally, the repercussions may be significant, as she may silence herself in meetings going forward, becoming complicit in the mansplain.  One way to address these kinds of issues in therapy may be to support this woman in challenging the unhelpful beliefs and fears that she carries about herself.  In turn, this woman may begin to experiment with advocating for herself at work, thereby utilizing more self-affirming strategies for collaborating effectively with colleagues on group projects. 

2. “I want to challenge him, but is it worth risking my professional reputation?”

A different woman may be able to depersonalize her male colleague’s behavior because she recognizes the validity of her ideas (and how important they are to the work itself).   However, this woman may still feel silenced by the sense of professional risk she experiences while using her voice.  In fact, research indicates that when women are assertive and advocate for their ideas, they are often labeled as more “aggressive” as compared to their male colleagues displaying the same behavior.   In the face of what has been termed the “likability penalty,” a woman may be apt to objectively examine the possible outcomes of speaking her mind. For example, if her colleagues do begin to see her as aggressive – or even bossy (oh no!) – can she tolerate their perspectives?  When, where, and by whom does being perceived as sometimes aggressive become problematic? One way we might address this issue therapeutically is by helping a woman develop cognitive strategies to tolerate that some colleagues will perceive her as aggressive some times (if she is indeed doing her work well), and that usually it is not catastrophic to her professional reputation.    

3. “I am going to respond because this man’s approach is not helpful to the completion of our work together or to my professional identity.”

A third woman may experience herself as competent, and as such, may recognize that her male colleague’s behavior is more reflective of his desire to be seen as confident and strong in the workplace than it is a conscious devaluing of her.  This woman, whose professional identity remains intact, is likely to feel empowered by the desire for her ideas to be recognized as having value, and for the work itself to be done well.  The challenge for this woman – and what could be reinforced in therapy – is to develop the facility in the moment to empathetically correct her colleague’s behavior, while also appearing collaborative.   However, what may be distinctive about his woman is her positive and accurate belief that she is already a relevant participant in the meeting and that her opinion matters (whether her colleague approves of it or not).  

The importance of depersonalization

As we can see from these examples, the more we can learn to depersonalize a colleague’s negative behaviors – that is, to truly understand that his inappropriate behavior has little to do with us and more to do with his issues – the more we are able to actively participate in group-based work projects without distraction.  Focused participation in the workplace is integral to a woman’s career success, and it begins with the assumption that her added value in the workplace is not dependent on constant approval by her colleagues. 

Why Cognitive Therapy for Women?

I am often asked how I came to work exclusively with women, whether I like it (I love it!), and why I use a CBT orientation specifically.  So I thought that I would share some of my background for our readers. I came to work with women exclusively after joining the Women's Mental Health Consortium in 2002, and meeting some pivotal reproductive psychiatrists who specialized in working exclusively with women (Catherine Birndorf, MD; Marty Altemus, MD; Karin Miller, MD to name just a few).  Meeting these esteemed colleagues let me know it was possible to build a practice working exclusively with women.   I found the idea of working exclusively with women very appealing as I had a feminist affinity for the issues women face, I tended to work predominantly with women already, and I believed that my CBT orientation would be especially helpful in the area of reproductive mental health.  

It's important to note that at that time in NYC, the therapy paradigm for reproductive mental health was still dominated by a psychodynamic therapy model.  However, many of the disorders that arise in the reproductive life cycle and for women overall - anxiety, depression, panic disorder, OCD, PMDD - have been shown to respond significantly to cognitive-behavioral interventions in the evidence-based research literature.   So while I knew no one personally who was specializing in using CBT for reproductive mood disorders at that time, it made clinical sense to specialize in this area.  And so I committed and founded Cognitive Therapy for Women.  I have never regretted that decision!

One of the surprising benefits of the CBT model has been that it "takes the shame out of the game" for mothers and prospective mothers.  So many of my patients have come to me frightened and ashamed of their symptoms in pregnancy and postpartum,  as if somehow their symptoms reflects their mothering ability or some deeper character flaw.  These patients did not make up this concept - this bias is sadly embedded in our culture. The CBT model challenges us to not make a bigger, or more nefarious story of the negative mood a women can experience during the reproductive phases of life.   So here at CTW it is important to us that we honor the complexity of women's mental health while striving to provide the most optimistic and effective treatment possible.