One of the things that I always heard about private practice before opening mine is that it can be isolating work. But, I haven't found that to be true.
I've relished the opportunity to meet with other practitioners: sleep consultants, chiropractors, therapists, midwives, doulas, lactation counselors, massage therapists, acupuncturists. I've been challenged, shared ideas, and brainstormed some exciting future goals with these friends and colleagues.
The conversations that I've been a part of in the wake of the NY Times maternal mental illness articles (see my reaction to those articles here) about how to expand screening for depression and anxiety for women in pregnancy and throughout the postpartum year; how to facilitate better connections to treatment; and how to expand the innovative programs that are being developed here in MA to reach more women have been especially invigorating.
I'm in the process of developing a couple of exciting projects in collaboration with some of those other practitioners to expand what I'm able to offer women and families in the Cambridge area. I'll be sharing more information as it all gets finalized!
What are you excited about in your professional life? What partnerships and collaborations energize you?
On 6/16/14, the NY Times published two articles on maternal mental health. This was above the fold, front-page media coverage for the emotional complications that mothers face. Let's talk about the cover story: 'Thinking of Ways to Harm Her': New Findings on Timing and Range of Maternal Mental Illness.
First, a quick point about language. I don’t love that the headline led with the attention-grabbing reference to intrusive thoughts of harming a baby. And the article fell into the pattern of referencing either “postpartum depression,” which it makes the point of saying doesn’t accurately encompass the range of experiences, or “maternal mental illness,” which can come across as very medical. But the alternatives, like "perinatal mood disorders" or "emotional complications" have their limitations as well. So, I try to use a range to best speak to women's experiences. But back to the article...
Women and families shared their experiences with depression, intrusive thoughts, and anxiety, demonstrating incredible vulnerability and courage. Writer Pam Belluck discussed the new research that backs up what clinical experience tells us: that emotional complications often start in pregnancy and are not easily identified as "just” depression, but frequently include overlapping features of depression, anxiety, obsessive compulsive disorder, and bipolar disorders. She touched on some of the factors that are associated with these experiences, the prevalence, and the range in timing when symptoms arise (during pregnancy and throughout the postpartum year). And there was mention of treatment: medications, therapy, support groups, and help to address impacts on bonding and attachment, though I wish there was more exploration of what treatment looks like for women and families.
Belluck highlighted efforts to increase screening for postpartum mood disorders and the frustrating fact that more screening does not necessarily mean improved health: "A study in New Jersey of poor women on Medicaid found that required screening has not resulted in more women being treated...the law educated pediatricians and obstetricians, but did not compensate them for screening."
I am thankful that in Massachusetts we are taking some steps to increase screening. A 2010 law authorized the Department of Public Health to "develop a culture of awareness, de-stigmatization, and screening for perinatal depression." But changing a culture and eliminating stigma take time.
Even if they are given a questionnaire, new moms often hide the truth of how they're feeling from their doctors and pediatricians out of shame and fear of judgment. And an OB who sees a woman for a mere 15 minute follow up appointment at 2 or 6 weeks postpartum may feel reluctant to ask further questions because they're unsure of where or to whom they would even refer her. The Massachusetts Child Psychiatry Access Project (MCPAP) aims to address some of these barriers by expanding its focus to include maternal mental health. Starting next month, doctors will be able to call a toll-free number to speak to a care coordinator to help find a mental health provider for their patient.
MCPAP for Moms will be a great resource for doctors, but what about for mothers, their partners and families, and other providers? Granted there are some resources like the Massachusetts Postpartum Support International warmline (866-472-1897) and regional and community task forces creating systems of care for maternal mental health, but there are still gaping cracks women and families can fall through.
What I’m most hopeful about in Massachusetts is a relatively small pilot project focused on preventing postpartum depression by putting postpartum doulas who can provide support and screenings in a few community health centers. A friend and colleague, Divya Kumar, Sc.M., is a certified postpartum doula and certified lactation counselor who works in one of these community health centers. Excited about the integration of services to address maternal health, Kumar says, “We need to change the way we do this...it's not just about preventing postpartum depression, but it's about promoting postpartum wellness and overall emotional health in new moms.” When a new mom brings her baby in for his well baby visit, Kumar is able to spend time with her helping with breastfeeding challenges, screen her for postpartum depression, and if needed, refer her to the mental health clinician down the hall who can see her that same day. And this is true even if the mother is not a patient of the health center.
Plus, the community health center has midwives who also provide prenatal care so there’s the possibility for connection during pregnancy – important for the women who experience depression and anxiety during pregnancy and/or those who have a known mental health history.
"Timely screening for perinatal emotional complications can save lives—especially in a community health center lucky enough to have comprehensive postpartum support AND mental health services right under one roof. [I am] so thankful for this pilot money and for centralized, accessible services," says Kumar, "We are offering services to families where the baby is seen at the clinic even if mom is not...We have caught a couple cases of PPD that way--huge, huge victories!"
Until this pilot project can be replicated to reach more women, a woman (or someone in her family) needs the knowledge to recognize that what she's feeling isn't just new mom exhaustion, the courage to ask for help, and the resources to be able to find/afford/get to treatment. On top of all that, treatment must be specialized, connected to community-based supports, and welcoming. Dr. Kozhimannil, quoted in the article, speaks to the barriers: "There are also not enough treatment options…If a woman comes with a baby, and it’s a place treating people with substance abuse or severe mental illness, she may be uncomfortable.” (And yet, let's not forget that these are not mutually exclusive groups).
When everything falls into place, it works. Timely, accessible treatment can help. As Jeanne Marie Johnson was quoted saying, once she received help, “It’s just a whole world of difference.”
When I was looking for my office space, I thought about what it would be like for pregnant or new moms coming to see me. I looked for an office with an elevator, easy bathroom access, and parking. A chair that rocks for a breastfeeding mother, a hidden box of toys to distract an infant, water or a cup of tea to offer some comfort and hydration: these are all small ways I hope that the environment welcomes pregnant women and new mothers. And my connections to other resources—psychiatrists, acupuncturists, sleep consultants, lactation counselors, groups—form the foundation of a potential community of support for isolated new mothers and families.
Ultimately, national media coverage of perinatal emotional complications like these NY Times articles helps to decrease isolation and stigma. I hope that this leads to more screening, more treatment, and more health for mothers and families. A bow of gratitude to the women who shared their stories and to Pam Belluck for writing these pieces.
What's your take on the article? Please share in the comments.
In 2007, Massachusetts implemented the Children's Behavioral Health Initiative (CBHI) in response to a class action lawsuit on behalf of Medicaid-eligible children with serious emotional disturbances to provide improved screening, evaluation, and access to behavioral health services for youth up to age 21 with MassHealth.
One of the services created was Intensive Care Coordination (ICC) to "help get all the adults in your child’s life to work together." In my previous work as an in-home family therapist, mobile crisis intervention supervisor, and point of contact for families entering the CBHI system, I can tell you this is one of the biggest challenges and most important factors in providing effective care that wraps around and buoys a child and the family. While some families I worked with had a dedicated Intensive Care Coordinator, others relied on the family therapist or outpatient therapist to provide the coordination. Too often, it fell on a parent who was already approaching or well past the stage of burnout trying to decipher acronyms and navigate an incredibly complex system all while dealing with anxiety about finding help for their child. Throw in a doctor, a teacher, a special education services coordinator, an occupational therapist, or a mentor and it's not hard to imagine the benefit of making sure everyone's talking to each other.
In my private practice, I see children and families, as well as individual adults, and I always consider who else is working with whoever is sitting with me in my office. Together, we review the pros and cons of signing releases allowing me to communicate with those other providers. Here are some common themes that arise:
One of my strengths is looking at the bigger picture and navigating larger systems. When we think together about who is currently involved in your life and how you'd benefit from working with other providers, we have the best chance of efficiently meeting your goals, but it's critical that appropriate communication happens to ensure everyone on your team is working together.
Do you have any success stories or cautionary tales of collaboration among providers? Therapists, what makes you hesitant or excited to take on the role of coordinating care? Please feel free to share your thoughts in the comments.