The Broken Metaphors of Treating Mental Illness

28h

Psychiatric medication prevents you from drowning.

I love Acceptance and Commitment Therapy and third-wave psychology. I love how it is a full-circle throwback to ancient wisdom traditions, reconfigured without all the confusing esoteric, and presented so that an everyday person in the 21st century can understand and use practically.

It sounds simple, but the meaning and application of Acceptance and Commitment Therapy is profound.

ACT teaches you skills such as defusing from your thoughts and feelings without repression, how to develop a sense of self built on your core values, and how to accept the things you cannot change. It shows you how to develop a worldview based on peace and empathy and compassion. It teaches that experiential avoidance – of fear, sadness, panic, anger or unwanted thoughts – is what compounds the problem, and the remedy is to be openhearted and welcoming to commonly perceived “negative” private experiences. Instead of finding ways not to have panic attacks, just have the damn panic attack, and sit inside it with a brave, curious heart. It is to accept that you are human, to have compassion and forgiveness for yourself, and to push forward with what you want to do in life anyway – get on that plane, host that meeting, give that speech, walk out the door to your house. ACT is the existential cousin of Exposure-Response Prevention. It is absolutely brilliant.

But, like my Dad loves to say, “People only tend to meet the middle when they cross it.”

I fight hard for the middle. I try to be a moderate in principle (an extreme moderate?:/ )  I think the healthiest, and yet most challenging and complex, place to be is in the middle. The middle is really the straddling of ideologies, the ability to have one foot planted on seemingly opposing sides of an issue. It is like standing on the tip of a pyramid – it’s hard not to feel like you will be pulled in two. You feel compelled to pick a side. But when you do, what inevitably happens is a gradual sliding descent to ground zero. To me, the middle – while resisting the forces of gravity that pull you in an extreme direction there on the summit of that very slippery iceberg – is where true acceptance of human reality is to be found.

Because the curious thing about “the opinion” – that the ONLY WAY to mental health is by radical acceptance and openness to experience with no shortcuts whatsoever (and we’re talking the no-taking-of-medication), is counterintuitively what tips you toward extreme thinking.

Mental and philosophical muscles are not made while sliding further away from the other side of the human experience coin.

And the problem with Acceptance and Commitment Therapy advocates is their tendency to be so impressed with its efficacy that they risk slipping into evangelicalism. They become ACTivists. This beautiful philosophy built on time-tested wisdom becomes rigid and separated, and even troubled or phobic, towards more than one approach to getting better.

This is a problem with any value system that looks down its nose on the use of “quick” or man-made” answers to address a problem in society. Secularism looks down on religion. Liberals with their flexible points of view look down smugly on the perceived narrow-minded dogma of conservatives. Generations of yore shake their heads at millennials and mutter “in my day we didn’t give kids the iPhone when they misbehaved at the table” (irony: we spanked them). Paleo and Atkins dieters roll their eyes at carbohydrate-consumers. Every member of society at one point or another, consciously or unconsciously, holds the opinion that people who are homeless, or addicted to drugs or alcohol or tobacco, are doing it because they are lazy and lack the “cobbles” to be resolute against their desire to use. An anti-crutch or anti-quick-fix attitude, in the absence of openness to multiple truths or ways of being, begins to feed upon itself. It becomes its own crutch – even sometimes its own delusion.

And then there is the so called quick answer that everybody loves to hate and prohibit and finger-wag at: psych drugs. And despite all of the disapproval and admonishing – one in ten people uses an antidepressant. Just like the War on Drugs or Sex in the Media – what is resisted persists. Isn’t that precisely what Acceptance and Commitment Therapy has been trying to get across?

Not that taking antidepressants gives you a quick fix anyway – most take up to four weeks or longer to have an effect. And considering that the initiation of medication is something that is fraught with stigma and difficult emotions, especially if you are pregnant or breastfeeding, it is neither quick nor easy.

The neurosis over medication in some drug-free human-to-human therapy circles is best encapsulated by the gigantic error in the following analogy:

Giving somebody medication for mental illness is like giving medication to someone drowning in the ocean. It’s not addressing the root problem, therefore it doesn’t make sense.

Well, for fuck’s sake. You thought they would be saved if a psychologist leaned over the side of the boat and covered “The 12 Thought Distortions” with them?

Because one problem with this metaphor is that medication is still being used in its literal sense. It is not being translated into a metaphorical device, and so what happens is the integrity of the entire analogy is broken – and the use of medication for a drowning person ends up looking ridiculous – because it is ridiculous!! Even counselling someone on how to resist coping and checking compulsions looks ridiculous in the context of a drowning person – because you are not translating it into a metaphor first.

The other problem with this metaphor is that “drowning” is being substituted interchangeably for 1) the subjective feeling of suffering with mental illness and 2) the specific behaviours you are engaging in to perpetuate the illness. These things are causally linked, but not the same exact thing. So “drowning while medicated” doesn’t really make sense if the problem (suffering) is supposedly being remedied by the medication in the first place (something that is lifting your head above the water).

If the metaphor for suffering from compulsive shopping was “drowning” in one’s “ocean” of problem spending, teaching them how to make a budget and stick to it would be like “teaching them how to swim”. But you can’t just tell them that over the side of the boat! They’ll scream “How?!” and go under and leave nothing but bubbles.

You can’t teach someone to swim – who has never swam before – in the midst of drowning.

First you need to pull them out of the water.

Sometimes that means the water is actually not so deep. Sometimes you can tell them how to swim over the side of the boat and tell them to just stand up. And it turns out their problems actually have solutions – in metaphor: there is a sand bar beneath their feet and they can stand up and breathe.

But sometimes (many times) those problems are not little. Mental illness happens to intelligent people and can even haunt exceptionally intelligent people the most. Sometimes it’s not the shallow end of the ocean – sometimes it’s grief and trauma and upheaval and the deep dark mire of existential human problems.

And you can’t literally throw pills at a drowning person. No one would do that anyway. It’s stupid so let’s not even talk about it.

So to preserve the integrity of the metaphor we have to convert “pills” to a device in the metaphor.

Which would be:  a flotation device.

Giving someone medication when they are drowning is like throwing them a pool noodle.

I feel this is apt because you can directly compare aspects of floating on the noodle (a life-saving “crutch” -and here I’ll even highlight the stigmatizing of the word “crutch” when in fact it is referring to something that helps you walk and perform in your life when one of your legs doesn’t fucking work).

The pool noodle is doing spectacular work – it is keeping this person’s head above water long enough that a plan of rescue can be made. They can be pulled out of the lake and reintroduced into a swimming pool (and eventually a lake or an ocean) where swimming lessons can occur.

But the pool noodle without “counsel on how to swim” has limitations. The water can have swells that may eventually capsize the inexperienced swimmer. If you hang onto the pool noodle for too long and float, your swimming muscles may atrophy and become useless, and you may slip off the pool noodle (this can be remedied by throwing out a bigger pool noodle or one that supports you from a different angle and switching things up from time to time). You find when you are not expending energy you start to become cold and hypothermic in the water. Other swimmers pass by you – floating on their own – and you realize you could never travel as fast as they can through the water because of this stupid pool noodle you push everywhere.

But drowning is a crisis. No matter the amount of very correct and wise swimming instruction in the most compassionate of manners you deliver to a drowning person (whether you the therapist are swimming in the water next to this person or still sitting in the comfy-ass boat they fell out of – the boat being a metaphor for the privileged position in the genetic, financial, gender, race, or socioeconomic lottery of society).

And I can still hear the “but, but, but” of the anti-medication crowd. They are now clamoring that the metaphor should never have been used in the first place. Because you can die from drowning and water inhalation but you can’t die from mental illness.

I can’t even type that sentence without cringing. People absolutely die of mental illness. In the United States, someone commits suicide every 15 minutes. I am forced to use an image of Kermit to convey just a tiny portion of my disdain for the opinion that years and years of struggling with mental illness is not the suffering equivalent of drowning in the freezing waters of the ocean.

kermit

 

Let’s examine another metaphor. One that anti-psychiatry proponents bully people over constantly when it’s used in debate:

Diabetes.

You wouldn’t withhold insulin from a diabetic, so why shame people for using psychiatric medication?

“Because, dummy,” says XYZ Internet Couch Skeptic. “Mental illness is fixed by addressing your thoughts and behaviour. Mental problem = mental treatment. Physical problem = physical treatment (pills or insulin, you know, because you can physically see them).”

So if it’s something we “can’t see”, you treat it with something else we “can’t see”? If it’s a problem with abstract roots, then the intervention has to be similarly abstract? ‘Fix your thoughts, if the thoughts are giving you problems’, right? And wow, don’t we all wish we could fix stupid.

I can’t even begin to cover the number of physical diseases like Metabolic Syndrome (Type Two Diabetes, Heart Disease, High Cholesterol) in one post that have roots in a person’s thoughts and behaviour.

Dismissing someone with mental illness who is asking for medication is about as unethical as dismissing someone with type two diabetes asking for medication, on the grounds that the Diabetes was not caused by an inborn genetic defect, but because “fatty just needs to put down the fork” and then they would get better.

Yeah, but they’re in crisis now. They’re in diabetic ketoacidosis. Why are you sending them off in a wheelchair to nutrition counselling when they need insulin, they’ve been wasting for days, and now they can’t remember their last name or keep their eyes open.

“But there’s no blood test for mental illness.”

Yeah there is. It’s called fMRI.

fnhum-07-00302-g006

Image Source: Disparity between dorsal and ventral networks in patients with obsessive-compulsive disorder: evidence revealed by graph theoretical analysis based on cortical thickness from MRI (2013), Seung-Goo Kim, Wi Hoon Jung, Sung Nyun Kim, Joon Hwan Jang and Jun Soo Kwon.
Column A = Healthy Control. Column C= OCD-affected person.

 

Those who feel psychiatric medication has no place in mental health are inclined to make prejudicial errors by using broken metaphors and oversimplistic analogies, without even being consciously aware that they have done so.

Avoiding and pushing away subjective experience in yourself is a sign of mental illness. The widespread systematic repressing of the subjective experience of others… is still mental illness. It is cultural anxiety. It is grief – and denial – in the heart of our communities over the fact that without medication some people just can’t get better. Having to rely on help outside ourselves feels like a threat to our wholeness, and reminds us how imperfect and human we are.

The healing begins when we are able to move past our hesitation to accept the place medication has in mental health treatment, to mindfully expand our awareness and, in the words of Thich Nhat Hanh, make a “serene encounter with reality”.

 

Cheers,

 

Jess

What Pisses Me Off About Kegels: They Don’t Cure

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I tire really fast of patronising health messages. And the only thing worse than mainstream health advice with a patronising tone, is health advice that is not giving the entire story or is even entirely correct.

Stress urinary incontinence (or pee leaking when you jump or laugh) in women in their childbearing years is vaguely reported – like many stats on women’s health problems. Some studies say 4%-35%. Some say 25%-40%. Some say 45% of women have it to some degree after childbirth.

I would bet my firstborn (LOL, no I wouldn’t) that at the VERY LEAST, 50% of women who have had a baby, probably have SUI. I think that 1 in 2 seems like a safe guess – just speaking from my own field research. I have given birth. I sneeze. I work in a female-predominant workplace. I have groups of all-female friends.

Why are studies not estimating more prevalence? Probably because women have heard by now that ‘it just happens’ and there is already a gold standard at-home treatment, so they refrain from even bringing it up with their doctor or ob-gyn. Because they already know the answer. Kegels have been pounded into us as the panacea for stress incontinence since we started prenatal classes – and earlier. We all know what the solution is. Our doctors, nurses, doulas, and gynos have all made it loud and clear. So naturally, the persistent lack of control we feel is because we’re just lazy and forgetful and not doing enough Kegels.

Not a single internet info page or article will come out and say it like that. But seriously, if you don’t do your Kegels, you are one lazy mother.

I don’t like this implied message. And I am suspicious of any school of thought that believes that any condition is due to a patient’s laziness to control a problem, regardless of how it got there in the first place.

I’m not just interested in urinary stress incontinence and pelvic floor exercises because I have had a baby, either. When I was a nursing student my heart got pretty sad after seeing firsthand the disease burden of chronic incontinence in elderly people. Older women tend to be more affected, and sooner, than men. So I wrote a paper about it for one of my Public Health classes. Here it is in my portfolio.

IMG_0767

 

So why do women ‘slack off’ on Kegels?

My hunch is that we know -deep down – that it’s probably not going to work – unless an extreme amount of time and dedication is spent Kegelling and it is kept up at that pace for the rest of your life. Basically super-pumping your pelvic floor. Sounds great, but is it achievable or realistic? Is this any different from other messages like ‘if you just ate this…’, ‘if you just worked out more…’?

The written wisdom on this subject is usually introduced to the reader with the same example. First, two unrealistic mommies on the park bench get talking – with about the same amount of stiffness and lack of candor as two moms in a bad example of female relationships can be (like those insurance ads where one mom realizes she picked the wrong company for her family’s health and dental, and the other one rubs that shit in). The one woman has tried everything – limiting water intake to the point of being thirsty, peeing before every activity (and several times during), not missing a bathroom opportunity, buying the dreaded “period pads”, avoiding trampolines, and leaning on one hip when she has to sneeze. Nothing helps, so the woman confides to her friend. Her friend giggles (and pees) and says, “It’s just what happens after having babies.” and they carry on with their day and put their pee problems out of their minds. Enter the Kegel expert (often a dude) to save these women from their deplorable lack of knowledge.

This is what I think of as the subtle ‘silly woman’ health message. Where a health expert writing for a health website or creating a patient handout is assuming patients with SUI are total ninnies or ‘silly women’ who skip off into the setting sun together with grocery bags of pads swinging from their arms. As if stress urinary incontinence wasn’t a huge embarrassing deal when going for a run or doing a Crossfit WOD. As if it doesn’t happen to intelligent people who know that limiting water intake is not a good idea, and they should probably do some more Kegels like the most current recommendations say. It is an embarrassing, private, ongoing struggle. It is difficult to ignore. It is uncomfortable. And women everywhere Doctor Google that problem like crazy, looking for something that could make it better. But the same thing comes up over and over – SUI is due to weak muscles and you need to Kegel that shit.

Well too bad for those assholes, I can read.

About 6 months ago an article, meant for doctors and other healthcare providers, was published called Urinary Incontinence Relevant AnatomyAnd in case you were wondering about the credentials of the authors of this article, I will block quote them here for your skimming pleasure. Because science.

Contributor Information and Disclosures

Author

Bradley C Gill, MD, MS Resident Physician, Department of Urology, Glickman Urological and Kidney Institute; Clinical Instructor of Surgery, Cleveland Clinic Lerner College of Medicine, Education Institute; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic

Bradley C Gill, MD, MS is a member of the following medical societies: American College of Surgeons,American Urological Association, Societe Internationale d'Urologie (International Society of Urology)

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Martha K Terris, MD, FACS Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society,Association of Women Surgeons, American Society of Clinical Oncology, Society of Urology Chairpersons and Program Directors, Society of Women in Urology, Society of Government Service Urologists, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, Society of University Urologists

 

Well-stocked résumés aside, I will now tell you what I got out of reading this publication. Sorry in advance for the dry medical terminology in the direct quotes. All anatomical depictions belong to the aforementioned authors of this study, and are not mine.

Below is a side view of the female pelvic anatomy. See the pelvic diaphragm? It makes what is called the pelvic floor or basement.

That is the muscle you contract when being good and doing your Kegels.

 

This is the side view of the pelvic diaphragm. The

Image Source

Wrapped around the lower end of the urethra (not visible here), are the muscles of the voluntary external urethral sphincter (or pee-squeezer-offer).

Here is a close-up. Note there are two sphincters. One is external – voluntarily controlled during Kegels. The higher one, the internal sphincter, is “…more of a functional concept than a distinct anatomic entity”. It gets its shape from the tissue surrounding it and cannot be voluntarily controlled.

The female urethra contains an internal sphincter

Image Source

Regarding the muscles of the external urethral sphincter:

Because they are composed primarily of slow-twitch muscle fibers, these muscles serve ideally to maintain resting urethral closure. The muscles probably do maintain resting urethral closure, but they are known specifically to contribute to voluntary closure and reflex closure of the urethra during acute instances (eg, coughing, sneezing, laughing) of increased intra-abdominal pressure. The medial pubovisceral portion of the levator ani complex also is a major contributor to active bladder neck and urethral closure in similar situations.

Got it. The little sphincter around the outer portion of your urethra AND the pelvic floor muscles are in charge of squeezing shut when we laugh or cough or sneeze or run. The rest of their day is spent just hanging out and providing tone.

But if they are supposed to stop urine from leaving your bladder in the first place (because urine can’t just float in limbo once it’s in the urethra while you red-face squeeze your Kegel muscles like a fiend), why are these voluntary, consciously controllable pee-stoppers located at the end of the urethra like an emergency hatch?

Like, if I wanted to haul some dirt with a shovel, why would I place my hands at the furthest end of the handle?

Like, if I didn’t want to be catching my son while he jumps off the Ottoman fifty times, shouldn’t I move the Ottoman into our spare room instead of just standing there catching him only after he jumps fifty times?

Like, if the Titanic didn’t want to leak all over the place and sink into the Atlantic, shouldn’t it have just slowed its maiden voyage instead of hastily running into the iceberg?

You get it.

So either someone put those muscles in the wrong place. OR they are in the right place, and doing the best they can given the circumstances, considering that some kids did pass through them.

And why are we putting all the blame on this outer muscle group when something further upstream is clearly not working, either?

Your pelvic floor muscles and voluntary urethral sphincter are not the main bouncers at this club. Your pelvic floor muscles take up the basement of your pelvis but there are a lot of very crucial tenants living above it – smooth muscle (not under conscious control – like in your intestines), fascia, ligaments, and connective tissue.

The pelvic floor is the on-call back up security guard when you actually hit the softball and now have to run to first base, or you didn’t expect to find a certain joke so funny. The problem is is that mainstream health experts expect you to make those muscles like John Dalton from Roadhouse (besides, John Dalton never had to push out a baby).

So lets talk about connective tissue. Because around your urethra, vagina, and rectum there is a LOT of it, and it usually gets left out of the whole Kegel conversation.

Histologic examination of the striated urethral sphincter indicates the muscle complex largely surrounds the urethra in an incomplete fashion. Fibers have been observed to be deficient along the posterior aspect of the urethra. Thus, the shape of the muscle complex can be described as resembling a horseshoe or an omega symbol. Investigations using ultrasonographic imaging of the urethra also have confirmed a paucity of muscle bulk along the posterior urethra.

Translation: When looking just at the muscles that make up your external urethral sphincter, the front of your urethra (you know, like, the front of your body) has all the muscle bulk. The backside of your urethra has scarce to no muscle bulk. So the urethral sphincter muscles only partly surround the urethra. Like the verandah on the front of a house. Like a house that only has a front deck, but no back deck.

Sometimes, after childbirth, your urethra gets drunk and falls off the back step. This is what is called a urethrocele – when part of your urethra herniates through this weakened and damaged connective tissue into the vagina. When your urethra pulls your bladder out the door as well, it is called a cystocele. Those conditions are often corrected with surgery (but if you do not have a diagnosable herniation, any other urinary symptoms mean you should keep squeezing your Kegels, right? LOL).

The posterior wall of the urethra is embedded in and supported by the endopelvic connective tissue. This sheet of connective tissue consists of collagen, elastin, and a small amount of smooth muscle. The connective tissue envelopes the anterior vagina. This supportive tissue has been likened to a sling or a hammock around the urethra and bladder neck. Recent research has highlighted the importance of hormones and genetic factors as determinants of connective-tissue integrity in stress urinary incontinence and pelvic organ prolapse.

Note: smooth muscle is not under voluntary control. Not like striated muscle, which you use in your legs and arms to do things.

Firstly, I have heard that dainty little description of a sling or hammock, before. Kegel pushers (squeezers?) like to throw that one around a lot in describing the pelvic floor muscles. It’s a correct description – the pelvic floor also looks like a hammock, forming the undercarriage of all the pelvic organs.

But CLEARLY WE’RE FORGETTING that other nice hammock that supports our urethra a little higher up the channel. All that nice connective tissue cocooning the banks of the pee stream.

So why didn’t God spare a few more human cells and make that damn muscular sphincter go all the way around? Why all this elastic connective tissue instead?

Because Baby.

And at the back of the urethra is also the front of the vagina. And that puppy has got to stttttrrreeeeetttttccchhhhh during childbirth. And muscles do not stretch as well as elastic connective tissue.

Which brings us to the final clincher: opposing all this connective tissue is a hard-fastened and fixed ligament: the pubourethral ligament.

 

The pubourethral ligaments suspend the female uret

Image Source

 

See it? Right there. So while a hammock of connective tissue sits behind your urethra, and ends up quite battered and loose after childbirth, this lovely little PU ligament acts like a bellboy, holding the front wall of your urethra open when straining your abdomen. Like when a bunch of angry Black Friday shoppers break down half of a double door, and the other one still automatically opens.

The previously described endopelvic connective tissue, when intact, provides support to the urethra as a whole. With increases in intra-abdominal pressure, some believe that the urethra is compressed shut against this firm support. Stress incontinence may be associated with a deficiency in the hammocklike support of the endopelvic connective tissue coupled with relative preservation of pubourethral ligament anterior urethral support. This may partially explain the commonly observed complex rotational descending motion of the bladder neck associated with stress incontinence.

As the pubourethral ligaments limit downward motion of the anterior urethral wall, they may provide a pivot point for rotational motion around the pubic bone. Furthermore, some theorize anterior wall support may also serve to pull the anterior and posterior urethral walls apart during straining, thereby directly contributing to bladder neck incompetency and stress incontinence.

 

So there you have it. Stress incontinence can be functionally observed by medical imaging – as a downward slippage of the bladder neck (or base). Abdominal pressure increases + lack of support from behind the urine channel (thanks, childbirth) + and your urethra is held open by a ligament in the front. Pee escapes.

So despite factors during the birth that have very likely damaged the connective tissue around the urethra (by lots of stretching or trauma to the vagina sharing it’s posterior wall) through forceps or vacuum intervention, traumatic delivery, straining, having a large baby….

Nope, says mainstream health advice. Wasn’t the pregnancy. Wasn’t a permanent side effect of vaginal delivery. Wasn’t the forceps intervention. Wasn’t pushing the mother to push when she wasn’t ready to push. Wasn’t the actions of the healthcare team.

Let’s review some other bad advice for women after having babies that finally got archived. Not a surprise, both of these examples involve placing fault on women for having weak muscles, when connective tissue had actually been permanently altered during pregnancy and birth.

Unhelpful High School Teacher - Breasts not so perky after breastfeeding? better pump that shit up with some chest flys

 

Unhelpful High School Teacher - rectus diastasis and loose abdominal skin after pregnancy? better do some crunches ya fatty

 

Healthcare has a sexist history. It is known for minimising the impact of natural forces beyond the patient’s control, minimising actions of medical practitioners, while magnifying the patient’s fault in acquiring their present situation.

It is easier to put 100% burden of responsibility on the woman because there is one thing she can control – Kegels – regardless of how effective they are. Patients are kept so busy trying to fix the problem at home that they are distracted from the larger problem: that her gravid belly was enormous and put strain on her bladder during pregnancy, that labour was long and difficult, mostly in a hospital, and the doctor had to pull the baby out with a vacuum. Elastic connective tissue was irreversibly stretched and altered, if not battered and torn, in the process.

Connective tissue plays a crucial role in the pelvic anatomy, and it cannot be ‘bulked’ back up like a muscle. But since when do doctors like delivering bad news. Kegels not working? Get out of my office already, lady.

Oh yeah, and your husband probably isn’t complaining about you maybe doing a few Kegels here and there. Wink wink. Motherly and wifely duties!

So bottom line, don’t do Kegels?

No. Do some Kegels. They will help. And they are good for everybody. Do them after each time you use the bathroom, for example, as apart of everyday healthy habits.

But for god’s sake don’t beat yourself up if they don’t make the pee stop coming after you’ve given birth. All things considered, they probably won’t do that.

This definition is one of the few I have read, from a reputable healthcare source (a healthcare region in Pennsylvania), that acknowledges BOTH the role that pelvic floor muscles and connective tissue damage play in SUI.

And also – try some squats!! And get to know Katy Bowman – who wants you to do them in the shower… while you pee.

 

Cheers,

 

Jess Cooney

 

 

 

You Can Keep Your Gendered Lenses – #elbowgate needs a clear-eyed review


I am not a political or social scientist. I have no formal education in feminist theory, or the history of gender and race disparities in western society. But I do have common sense.

Ottawa and company is still in a lather about an incident that occurred in the House of Commons on May 18, 2016. In summary, the PM took it upon himself to leave his seat, bust up a group of NDP turkeys who were in the midst of a stall tactic to hold up parliament, firmly steer a conservative whip to his seat, and accidentally/less-than-accidentally elbow a female NDP MP in the process.

There are theories as to why this stall tactic occurred in the first place. The passing of Bill C-14 is deadlined for June 6 and the opposition feels the Liberals, through certain motions, have turned over too much power to the ministers – who could call a vote at really anytime. According to the opposition, this limits debate. To you and me this means less shenanigans and foot-dragging antics like what we just saw – and I suspect the Liberals are taking a leaf out of the Harper government’s book for this reason. Less squabbling, more business, and a majority government that can actually do their job. Hence why the house is a little butthurt and the razor sharp tensions that morning. 

Keyboards were flying as the internet hashed #elbowgate to pieces. Reactions varied from sensational, to irritated, to laugh-out-loud funny, politically charged, thoughtful, hostile, to just plain weird. Nothing unexpected from the word vomit that is the comment section of every clickbait and news story that gets passed around social media.

And I certainly have my own thoughts. What do I care if a bunch of narcissistic politicians can’t get along on a hill 2500 km away from me?

I don’t care much for the players in this drama – but I am invested in the social commentary that runs through it. I am a woman, a voter, I have worked as a palliative care nurse, and I am paying for these goons to get something accomplished at the end of the day, namely, a bill that would outline more rights for terminally ill people. Perhaps in fleshing out C-14, the need for more government support in the areas for palliative, hospice, and home care would be realized. Now because of said immature shenanigans, all of this got totally off track and delayed.

One opinion that I was surprised received so much consensus was the view that Ruth Ellen Brosseau was certainly making a huge deal of getting elbowed -and in doing so – took the validation that feminists and advocates for victims of assault have worked so hard for, down a major peg.

Ruth Ellen has every right to be pissed off, but I wonder if some of her anger is misdirected. Her party pressured her into physically intimidating a colleague. Someone called this out and felt moved enough to physically intervene. She got elbowed and shoved, as far as we can guess, with about as much force as a typical passenger gets on a city tram going to work. Emotions are high, and she seriously can’t believe the PM’s elbow just knocked her breast; the camera is rolling, so she decides to head to the lobby. She’s embarrassed and probably by now realizing none of this would have happened if she just hadn’t been a part of the gang blocking Gord Brown – so she’s feeling a little set up by her party. Everyone including her own family has seen the footage and is making their own judgements of her. And when she goes for her last card – victim of gender-violence – nobody buys it. She feels like a victim, and she is, but certainly not of gender violence. At least she wasn’t – until the angry masses reached her Twitter account and unleashed an unprecedented amount of malice and shaming. 

Nonetheless, the internet seems to be overly preoccupied by the issue of how hard Ruth Ellen actually got hit, and if that correlated with the reaction that followed, both Ruth’s and that of the House.

I’m not here to debate whether Ruth Ellen was grazed or jabbed by the well-selfied elbow of the PM.  We can only guess, since someone’s body happens to be standing between the incident in question and the video capture. We can replay the tape as many times as we want, like reviewing a misdemeanor in a soccer game, but we still won’t know what really happened.

Concerning the video footage in particular, I have to admit I watched a slowed-down version first – posted by YouTube user Jaro Giesbrecht. After seeing this, my reaction was more like, “Ppppphhhtttt. There’s no harassment here. A bunch of politicians were impeding progress on a huge bill, and the PM wasn’t above getting up to help the whip get through them….”

But then I watched the original footage in real-time. And I changed my mind.

Because the video in slow-motion has a curious effect – it highlights to the viewer the amount of harassment NDP members are giving the whip, by slowing down the blatant side-stepping and blocking behaviour. The YouTube poster also provides a play-by-play so we can catch every smirk. But the video does one more thing – it minimizes the aggression shown by the PM.

Because Justin arrives on the scene hot – a little too hot. He is not nearly caffeinated enough for this bullshit, and could seriously use a Belvita because he is not about to make a ‘morning win’. He books it fast and angry into the centre of the brouhaha and removes the whip like a drunk blocking the door to the club. And just like at the club, someone is standing in the wrong place at the wrong time and ends up in tears. Now the other patrons are all amped up and want a fight. Chests are puffing. A few peacekeepers move in and out of the drama, asking “can’t we just get along?”

And then there’s Elizabeth May like….
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 … who just happens to be the only non-partisan member of the House that day who could comment sensibly on what happened. Someone should motion to call it Elizabeth May Day. 

The whole thing is ridiculous. To be clear, workplace violence is not funny. But human behaviour in its predictability is hilarious.

Enter the now-infamous comment made by Niki Ashton that made women all over the country do a facepalm.

“…if we apply a gendered lens, it is very important that young women in this space feel safe to come here and work here,” she said.

First off, MP Niki Ashton is absolutely correct in that people should be free and feel safe from harassment while at work. Period.

Secondly, nobody should be applying a gendered lens, or in other words a bias, to anything here, so just stop. A gendered lens does not give you super powers for spotting misogyny, or enhancing your spidy senses for sexism.

Focusing more on the fact that a young, pretty, white woman standing behind someone’s back got elbowed, and not how conservative whip Gordon Brown didn’t just get totally steered to his seat by the arm like a three year-old, despite telling the PM (in his words) “Let go of me – now”, is doing nothing to further a discussion on gender equality or how to make the workplace free of harassment.

Because what if whip Gordon Brown was Gloria Brown and Ruth Ellen Brosseau was Ricky Allan Brosseau – their personal reactions being the same, but their genders different. It’s the gold standard exercise for spotting unfair gender issues, but everyone seems to be forgetting this.

I have a feeling Ricky Brosseau, as a dude, would be absolutely mocked and hung out to dry for not being a little tougher after an accidental elbow. Furthermore, the public would be beyond horrified that the PM just intentionally grabbed a woman by the arm and steered her. Faces would be melting. Actually, I’m pretty sure that would be JT’s last day as Prime Minister. It’s worth mentioning here that feminists’ main objective is to reduce toxic attitudes that pigeon-hole people in expected gender norms, and to achieve fairness for everyone. And there is certainly unfairness here. 

So to close, a gendered lens is already applied to this whole issue. We don’t need any more.

Here is a a gem from the comment section I particularly enjoyed.

Your Kid Can Touch My Kid

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The playground is not just where kids run, shriek, climb, knock each other down, and accidentally run over somebody’s fingers with the Little Tikes baby coupe. It’s also a battlefield for parental styles; a floor for the awkward dance of release and restraint of our kids around others.

Bringing Up Bébé, since 2013, has been a book du jour of ways-parents-get-it-wrong-in-America (and Canada, we’ve resigned). According to Pamela Druckerman, the kids go to the playground, and the mommies employ a laissez-faire approach by relaxing on a park bench in their high heels together to visit. The mommies do not go onto the playground.

I need not describe the opposite – the mom that non-stop hops up from that park bench as if it’s hot with a wire, calling her child by name again and again not to ‘go over there’, and cheering ‘yay!’ when their kid reaches the other side of the monkey bars – while carrying them across. These are sometimes the same parents that are ‘no-touch’; refereeing all interaction between their kids and others on the playground. They are horrified and apologetic if their kid touches another kid’s face, or pats them a little too hard on the arm. They’ll say something like, “Parker, be nice!” and laugh nervously with the other parent.

I fall somewhere in the middle. My rules are: as long as no one is crying, there is no touching of genitals, and there is no exchange of body fluids (kissing on the mouth, picking someone else’s nose and eating it) pretty much all is fair game.

Let kids touch each other.

I can already feel the heat of the mommy-blogger rebuttal: Why your kid shouldn’t touch mine: And why if you do, I’ll f-n cut you. Of course my child does not have special developmental or cognitive considerations, a history of receiving abusive or unhealthy physical contact, or an immunocompromising  medical condition. He is current on his vaccinations, and my corner of the world is not going through a serious outbreak of communicable illness. Insert other special considerations here.

But haven’t you noticed toddlers and babies crave physical contact with each other? They like to pat, squeeze, cuddle, and yes, push each other down. A lot of times, toddlers get right back up and keep on toddling after the group, or their older siblings. How many times have we seen that?

But if older children get pushed down (and adults for that matter), now then there’s blood. Because we have learned from our parents and society that being pushed down or touched roughly is a personal attack and highly offensive.

I wish I could tell other parents, sometimes, it’s okay. My 14 month-old has been walking for nearly 4 months, and now runs. He can hold his own, and often seeks out older toddlers and kids on the playground. At home he is exposed to lots of wrastling. We roll him on the carpet until he giggles, tickle and bounce him on the bed, swing him over our shoulders, and even turn him upside down while he shrieks with delight. He is by all definitions a rough-and-tumble little boy.

So I can see the confusion in his eyes when another child reaches out to touch or pat him above the waist, and the parent quickly whisks the little one’s hands away with a gentle scold and a nervous laugh directed at me.

I find this scenario delicate to navigate. I would love to say something – and sometimes I do – something like, “It’s okay. J loves other kids. He likes to be touchy-feely too, so it’s okay if Harper is with him.” But the big issue in this case is that telling the other parents what my child (and by extension myself) is comfortable with may sound like I am giving my opinion on what they should decide is acceptable behaviour in their child. I could also be undermining that sacred authority they have with their child, by telling them in front of their own child that a behaviour they have just said is not okay, is okay with me.

No one wants to see anymore of these grim Collapse of Parenting-type news stories, but a lot of it is sadly true. Angela Hanscom, a pediatric occupational therapist who wrote an article for the Washington Post in 2015, says kids are losing what is called their proprioceptive abilities – which means the expertise to control and perceive their own bodies in the environment. When we became teenagers our proprioceptive skills were not at their hottest – with our legs and bodies getting longer every day, until things eventually settled out and we got used to our new adult physicality. But interestingly, because young children are becoming more and more reined in these days – less climbing tress, exploring, manual labour, and most of all, less permission to touch other kids – they are losing their ability to gauge appropriate touch. Instead of touching someone in tag (which does require sophisticated skill because you are running at the same time), Angela has observed some kids clumsily whacking each other across the back – which leads to crying, the recess supervisor having to mediate, and the eventual ban of tag on the playground by the school.

Throw in the general message we give kids who encounter difficult peer situations today, and things go downhill really fast. Previous generations said, “Yes he hit you, but you’re tough. No big deal. Dust yourself off and keep playing” (which could invalidate emotional hurt that should be addressed). But we say something just as bad; “Yes, he did hurt you! Hitting is very bad, and it is understandable that you no longer want to play tag! Let’s go tell an adult” (which undermines the kid’s ability to cope with challenge independently and their emotional resilience). Instead of discussing them as two children learning how to touch, or not touch, appropriately as they grow up, one is now labelled the aggressor, and one the victim, and it becomes a serious health and social issue.

Babies and toddlers with limited verbal skills have their own built-in language of consent, and they use it with less hesitation than we do: back off if I cry or push you away; proceed if I reciprocate. I think us adults read into their interactions too much, confusing that look of raised eyebrows for alarm, instead of novel interest or curiosity in another person their size.

We almost need a code word. To tell other parents, “it’s okay, I don’t mind if your three year-old just got down and hugged my child, whom he just met.” Like ‘roughhouse’ followed by a wink, or something. But less obnoxious.

For the record, your kid can touch my kid. At the McDonald’s play yard, the park, or at the daycare drop-off. Your little one can hug, squeeze, and even enthusiastically pat my child on the head. He may be little, but in his own way, he can permit or deny physical contact as he is comfortable with, and I will be present in the room in case he needs help. Just no fingers in the mouth.

Cheers,

Jess Cooney

First, Put On Her Shoes

  
If you want to truly help someone, you have to get down in the ditch with them.

You can’t stand at a pulpit.

You can’t wag your finger.

You can’t pity.

Everyone seems to get all ruffled at some point about this – how to be helpful. We’re familiar with the ‘new baby’ etiquette tightrope. At what point does my offer to help cook or clean or hold the baby become imposing? Am I neglecting or smothering? Was my little parenting ‘tip’ more like unsolicited advice? Is it my place? Am I doing too much? Not enough? Should I do/say anything at all?

First, put on her shoes. Stand in her place. 

Want to say the right thing? If you were the recipient, how would your advice sound?

Want to do the right thing? If you were the new mom, what would you need most from those around you?

That’s only ONE RULE to follow. It’s not easy – it requires you to stretch your empathy. But all that should be expected of you is that you try.

Just because it’s hard sometimes to know how to help, does not mean it’s right to avoid offering your services, or asking if everyone is doing OK. Assuming everything is fine over there at the house of a new baby, might help you dodge the awkwardness of a complex social situation, while meanwhile a new mom could be drowning.

The costs are too high. When we add maternal mental illness to the mix of new motherhood, silence and inaction are harmful.

If you proceed with concern and respect, it is far better that you screwed up than the alternative, which is – you didn’t ask how things were going; you didn’t pop your head in; you didn’t offer to wash some dishes or make dinner or give Mom a break; you didn’t ask if a mom was needing to reach out to a doctor or professional, and harm was done by your inaction. And if it turns out that what Mom truly needed most at that time was space to breathe alone with her family, then perfect. Affirm that with her, and feel good knowing you did your job as a decent human being – which, believe it or not, includes a shared responsibility for looking out for the well-being of mothers and their families.

Organizations that advocate and raise awareness of maternal mental illnesses do this, of course, on a wider scale. 

They have two important responsibilities, 1) to educate the public, and 2) to build up and protect the community they stand for.

These groups or organizations have to be particularly careful with how they help, because their reach is broader, and their actions have more repercussions.

Therefore, they need to get it right. They need to be able to exist between the people they protect and the rest of the world, and portray the most accurate representation of the issue they are working to raise awareness about.

That is what led me to respond to a post on the Facebook page of Saskatchewan’s leading provincial maternal mental health organization, in which a media release by Fox News was shared about an American mother who experienced postpartum psychosis and took the lives of her three children. It is a devastating, heart-breaking, shocking story. It has high emotional impact. Therefore, it needs to be shared responsibly by parties that are invested in its subject matter.

Thank-you Motherfirst for your continued efforts to raise awareness, and for keeping the conversation going on postpartum mental illness, but I strongly feel the need to clarify for some readers who may not know about postpartum depression and anxiety vs. postpartum psychosis

Infanticide is extreme, horrific, devastating, and tragic. It is the ultimate example of a breakdown in our system meant to protect both mothers and children.

It is also blessedly rare.

Postpartum psychosis is a health emergency. A mother can experience delusions, hallucinations, and a complete disruption in thought process.

Postpartum psychosis occurs in about 1 in 1000 postpartum women.

The rate of psychosis leading to infanticide is about 4% of the 1 in 1000.

Postpartum depression and anxiety on the other hand are EXTREMELY common. Some studies of western countries like ours, such as Australia, estimate that it may occur in as high as 25% of all mothers.

No doubt we all need to do more in our communities to prevent tragedies like this. But this one is an extreme example. Postpartum mental illness is not present exclusively or defined by the mental state of women who hurt their children. It happens to nearly 1 in 6 women in Canada – your mother, sister, neighbour, or friend.

Unfortunately, public perception of postpartum mental illness remains heavily influenced by headliners like this one – a disproportionate stereotype that further embeds a culture of silencing, shame, and fear, preventing women from recognizing their symptoms, or seeking help. It may also be highly triggering in mothers at risk for perinatal anxiety or OCD – conditions sensitively covered by Karen Kleiman and Amy Wenzel in their book Dropping The Baby and Other Scary Thoughts.

As advocates we have a responsibility to portray an accurate and representative image of maternal mental illness. It’s not just the women like Andrea Yates and Carol Coronado. It’s also the young mom you might know who just can’t stop crying, or who hasn’t slept in three days because she’s afraid the baby will stop breathing in the night.

As long as the dominate public perception remains fixed on the extreme tragedies, we need to expertly bring the conversation back a little closer to home, and not overrepresent stories based on what garners the most media coverage. Thank-you.

Community organizations need to remember that these news stories are not only emotionally disturbing to the public, but they are even more so to parents of children, perhaps way, way more.

They need to be shared with care because they are highly triggering. They can create fear – in the general public and in those struggling with mental health disorders.

To mothers with anxiety, specifically postpartum OCD, these news stories are bombshells. They are terrifying; gut-wrenching, day-ruining, paralysing. They take on the form of intrusive thoughts, dreaded what-ifs.

“If it could happen to her, what-if.”

“If I got that sick, what-if.”

“I just CAN’T stop thinking about that thing on the news, what-if.”

To an audience of mostly individuals who have suffered or who are suffering postpartum mental illness, how would the casual sharing of a news story like this be received? Like a punch in the gut, maybe?

Does that mean censoring? NO. Does that mean perhaps instead making a short reference to the incident and then promoting a discussion that is open, honest, accurate, and inclusive? Yes.

And we need to bring to light the stories that don’t make headline news. We need to provide a voice to those who are marginalized. That means giving a voice to the silenced victims of postpartum psychosis, so that they can share their story. That also means giving a voice to the suffering silent majority who are not sick enough that the media cares, but more importantly, whose quality of life is impacted.

Sometimes it’s tough to know what’s best to say. 

But having postpartum mental illness is tougher.

Memes That Moms With Postpartum Depression or Anxiety Can Relate To

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I created these to put into words the thoughts all moms with postpartum depression are thinking at some point; about a system that is so broken, at times, it’s almost funny. PLEASE FEEL FREE TO SHARE.

 

 

When you’re a vulnerable, tender, brand-new mommy, feeling the rawest you have ever been,

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Marianne Williamson, American best-selling author, on PPD:

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Moms who’ve been there are like,

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The healthcare system responds like,

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When you finally get that appointment, and the specialist either has never worked with postpartum women, you have to drive over an hour, or…

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The room-clearing effect that mentioning postpartum depression research, funding, underestimated prevalence, or the need to do something has on an audience,

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A wholly untrue piece of crock,

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False beliefs still linger about pregnancy and mental health too,

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Moms with perinatal OCD giving other moms advice on wrangling perinatal OCD,

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That f****** stupid doctor everybody gets,

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Yay for pediatricians, general physicians, and nurse practitioners for screening when they think something is not right!

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When moms of the internet see a stigmatizing message,

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And the best way to handle an anxiety attack, courtesy mom-blogger Constance Hall

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How Common is Postpartum Mental Illness, Really?

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We see the numbers all the time. They swing from 5% to 25%, from ‘one in ten’ to ‘one in five’. They differ by country, by social status, by income, by ethnic background, by neighbourhood.

But does anyone really know the true prevalence of postpartum mental illness?

And what of the words we use when asking? Are postpartum anxiety and OCD misrepresented, because we ask only about the oft-referenced postpartum depression? Are illnesses like postpartum mania and psychosis so scary to go through, that mothers choose not to disclose?

I invite you, as a visitor here, to anonymously enter a response in the poll below. The so-called ‘experts’ may be unable to give clear answers, but small-scale surveys like this one might give an idea where we stand, where work needs to be done, and most of all, that we are not alone.

*** IMPORTANT TO NOTE: You may check all that apply. Illnesses like depression and anxiety are often co-morbid and exist together.

If you are unsure what the symptoms are of postpartum depression, anxiety, OCD, mania, or psychosis, please refer to the excellent descriptions at Postpartum Progress®.

 

The Community Maternal Mental Health Professional

There is a big hurdle that women seeking perinatal mental healthcare have to cross to get help. And the hurdle is more like a gap. A gap in the system that exists between the mom needing help and actually getting help.

This fact seems so obvious that it almost washes over you – a supposedly meaningful statement that seems lacking in meaning. So let’s break it down, because understanding this black hole is important, and could mean everything.

A key word is Points of Contact. Points of Contact in healthcare need to have both quantity (enough of them to meet the healthcare needs of the community) and quality (they need to be effective at detecting illness).

PPD

When considering perinatal mental illness, POC to the healthcare system need to be a) large in number, and b) familiar with perinatal mental illness.

In the Western World, with good access to healthcare, the first criterion is often met. There are usually enough points of contact to go around, with of course the exception of many rural and remote communities. After having her baby, moms come fact-to-face with the healthcare system and other community supports, starting right in the hospital: the delivering doctor, her obstetric nurses, the public health nurse, the lactation consultant, the lab technician at 7am, the Welcome Wagon lady, etc.

But that’s where the ball seems to get dropped. Despite due diligence to mention ‘the baby blues’ at discharge, distribute pamphlets, ask the right questions, and so on, many healthcare teams are just not that skilled at picking up on perinatal mental illness. And even when the Nurse Practitioner at the 6 week checkup, the LPN checking the caesarean stitches, and the public health nurse conducting the well-baby visit feel something is off, many times nothing really ends up getting done. The entire process is awkward and full of healthcare desk-shuffling:

 “The causes of postpartum depression can be complex, but… call this number.”

“If your symptoms last more than 14 days… call your doctor.”

“I’m not really the expert on that, so… here is an appointment in 4 weeks.”

THEN WHAT???

What if I do *that* and they take my child away from me?… And put me in the hospital?… What if everyone finds out I’m sick?… What if they don’t understand that I’m having scary thoughts but I would never do anything to hurt my child?… But those aren’t really my symptoms… so do I not have PPD?

There is such grayness of information given out on postpartum mental illness, and a lot of quiet tip-toeing around the honest truth. Possible symptoms to watch out for are given out in hints and clues. Not a lot of dig-down-deep descriptions are really available unless you go online and find a comprehensive and compassionate list like The Symptoms of Postpartum Depression and Anxiety in Plain Mama English on Postpartum Progress.

I will use a statistic from my own health region. In 2013, 40.6% of at-risk mothers screened for postpartum mental illness DECLINED referral to a professional.

The obvious next all-important question is: Why?

Because healthcare does not deserve the trust of its patients, that’s why.

I’ll say it again: healthcare does not deserve the trust of its patients, least of all its female patients. As to why this would be, go and read this book this book or this book.

Healthcare needs to repair this relationship. And earn the trust of the people it serves.

Burden of responsibility cannot be placed on a suppressed minority of sick women.

And when patients don’t seek help, the system must not be allowed to simply shrug its shoulders at those who are too scared and ashamed to get help and say, it’s not our fault they should have said something. 

Not good enough. Not Good Enough.

We need a new Point of Contact for perinatal mental illness. Not another faceless hotline. Not another pamphlet. We need more mental health trained professionals on the ground. In some communities (mostly large ones with resources and a garden of educated professionals) this is already being done or piloted.

Because a lot of family physicians and nurses are tapped out. The disease burden of chronic illnesses in older generations is taking up a lot of their time. They are doing the best they can, but you just cannot be a generalist and a specialist at the same time. Public health nurses, for one, already have a library of black and white papers to give new parents on vaccinations, and vitamin D drops, and breastfeeding tips, and how many wet diapers a newborn should be having, and on and on and on. Maternal mental health gets put on the back burner again and again.

Healthcare responds to fires, and works in dollars. In the eyes of the healthcare system, if you don’t vaccinate your children, there could be a measles or mumps outbreak. If you don’t practice healthful eating, you are at risk for developing obesity or diabetes. All of those things are expensive. They are also relatively easier to trace from behaviours to outcomes.

But the consequences of untreated perinatal illness? Much more subtle and insidious. It has both roots and branches. The repercussions can echo through generations. Until it can no longer be determined where the health of a family or a community began to turn down.

The good news is that the wisdom of primary and preventative healthcare has been gaining ground in the last few years. Community mental health is deterministic of many health outcomes. Sometimes illnesses seen in the hospital are just end results of bigger problems that human beings medicate for years with food, alcohol, smoking and other coping behaviours. You could compare those illnesses to symptoms of a broad condition. And though focusing healthcare delivery on acute care is necessary to stop the bleeding, at times it is sort of like mopping the floor before someone walks over it with muddy shoes again, and at worst, a bandage solution to a deeper problem.

So where is a great place to start? Where is a great place to focus preventative efforts that will have a big impact?

Mothers.

Politicians and ‘new baby’ cards pay great lip service to moms, but when statistics like 1 in 7 get thrown around, many healthcare providers look away. They avoid that awkward conversation and remind mothers of their scheduled bloodworks and ultrasounds and checkups. Because those are things they can control.

Mental health is much more slippery. Like a can of worms. And a can of worms is the end result of a problem going untreated for too long. Healthcare might not be able to support the overwhelming need and cost of everyone suddenly receiving the mental health treatment they deserve. That is the dirty little secret of the system.

Because mental illness doesn’t result in direct injury or mortality, it gets ignored, unless someone is sick enough that they need urgent care. Dollars are saved on the backs of moms quietly suffering. That phenomenon is what colours the gap in even darker – how mothers go from being at home to acute psychiatry overnight with no health history in between.

So what do we do?

I’m a nurse so my background is going to influence this answer. Other disciplines will have great solutions. I will speak to the idea I can visualize best, given my personal experience.

Enter the Community Maternal Mental Health Nurse/Counsellor/Social Worker/Physician/Doula

Teenage Girl Visits Doctor's Office Suffering With Depression

Who can:

  • disseminate updated informational material
  • postpartum well-mother visits/follow-up care
  • leading or joining an existing collaborative action team of postpartum mood disorders in the community
  • leading a patient mom-and-baby peer support group
  • speaking at or holding a forum/class/telehealth conference(s) on postpartum mood disorders for the public or other healthcare providers
  • mental health history and intake of mothers
  • referral to other disciplines in the healthcare team
  • introducing and offering care/information to mothers who have delivered in hospital or at home (much the same way a lactation consultant or public health nurse would check in)
  • supporting and providing women with information on mental health medications and reporting back to prescribing physicians on how it’s going

These practices are indeed today filled by many professions, and this hypothetical person is just an example of someone who could specialize in delivering this kind of care. Because of their specific and expert role, mothers might be more comfortable in disclosing to them and beginning to receive help. It also increases quality of care. Less mothers falling through the cracks. Less misdiagnosing. Less misunderstanding. More trust. More compassion. More outreach.

More lives saved.

Oh, Shut-Up WebMD

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As a Registered Nurse, I love WebMD. It’s a great resource for people on both sides of healthcare, and it doesn’t usually let me down. I even subscribe to the e-newsletter.

The slideshow I received in my inbox, with the attention-grabbing title 10 Ways to Wreck Your Liver: Is Your Liver in Danger? as a part of the special Your Most Pressing Health Concerns, could not have been more perfectly timed. It was a day filled with candy, food and a booze-soaked Raclette at my house, while my in-laws were visiting for the holidays. When I saw the subject line I thought maybe it was a sign and I leaned in closer.

As it turns out, I was disappointed after following and viewing the link in the e-mail (if clicking and waiting for a slideshow to load isn’t less than impressive already) so I dropped WebMD a little shit-o-gram to express my views.

I was a little annoyed to see antidepressants on the list of “Ways to Wreck Your Liver” in the newsletter just sent out.

The list seemed to include mostly elective lifestyle choices like consuming sugar and MSG – things a patient can safely reduce on their own. Antidepressants on the other hand are oftentimes life-saving prescriptions and should not be stopped abruptly unless a doctor is supervising. They are not an herbal supplement a patient can just ‘quit’.

True, they are known to rarely cause hepatotoxicity, particularly with the older MAOIs and tricyclics that are less prescribed. In fact many medications for serious chronic conditions can cause liver damage, but I didn’t see them on this list. And I feel that listing antidepressants here may cause unnecessary alarm in a group of patients already known to struggle with compliance.

I suspect antidepressants’ special mention is a residue left over from the attitude that those taking these drugs are just participating in cosmetic psychopharm and are not really ill.

Can we stop the out-of-proportion reporting of the adverse effects of antidepressants where it is not warranted? Information is power, but finger-wagging just creates more shame. Thank-you.

Acetaminophen toxicity is the leading cause of acute liver failure in the Western world. That’s Tylenol.

Overdose on Tylenol may be intentional or accidental, especially if you are an older adult, or your liver is already compromised. This is something all nurses and doctors know because it is one of the more common medication-related injuries seen in hospitals. It continues to be a major problem in ERs and, in the case of accidental overdose, people are not warned nearly enough of the dangers of taking more than what is recommended.

Liver failure from a daily antidepressant medication? I would have to argue is less common. If a publication was to cover the adverse effects of one drug, why would the subject of focus be a prescription medication for a serious, chronic condition over and above a non-prescription pain reliever that the public has universal access to from infancy through adulthood in their medicine cabinet? Editorial bias? Bad journalistic priorities?

My tone here mirrors my reactionary thoughts I had to the well-covered findings of a recent study which showed a weak but statistically significant link between SSRIs taken in pregnancy and autism.

And this article sums up in a more accurate, cool-headed manner why we all don’t need to start freaking out and tut-tutting at other moms.

You may have heard this study reported in early December on your local news or radio station while you were driving. It probably was squeezed in at the end of the program and went something like this: “And a recent study has shown a significant link between SSRIs taken in pregnancy and childhood autism…. And that’s all we have for today, folks….” This type of quick-digest reporting is not harmless. It creates misunderstanding, alarm, and guilt.

I guess what I’m trying to say here is, if you smell bullshit, it’s best to call it out. No one is arguing where the smell is coming from, but its placement in the middle of the sidewalk may not be appropriate.

Moody Bitches: Book Review

I have officially become a Julie Holland fangirl.

A few days ago I walked in the bookstore alone, with the pleasure of sinking into a hot bath. Dr. Holland’s book title jumped off the shelf. I flipped through its pages and I was won over by her intimate, down-to-earth writing style and wisdom, and of course the subject matter. But I had to know: what was Dr. Julie’s verdict on medication to treat mood disorders? Appropriate in the right circumstances or just another ‘cure’ worse than the disease?

She seemed very grounded in today’s reality for women. The book appeared well-researched, referencing studies that had been popular when they were first reported, and also ones I had not heard of. Her voice was compassionate; not at all patronising. Working in a psychiatric ER for 20 years, with a private practice thereafter, should give you some solid street cred. But I needed to find a passage first that proved what I hoped:

“I’m not suggesting that all use of psychiatric medicines is counterproductive. People who don’t really need these meds are taking them, while people who are genuinely psychiatrically ill remain undiagnosed[…]. Clearly there are times when we need to pull out the big guns.”

Perfect. So I bought the book. Not cheap either – $35 Can. for hardcover!

The look of this book might scare some people off, who have experienced the nightmare of a severe mood disorder – we don’t need any more guilt heaped on our full plate. But Dr. Julie makes her message clear – our proper treatment of mental illness is so important, but we cannot let that slip into a war on emotionality. Our moods in all their highs and lows should be honoured as a rich human experience and respected for their wisdom. Being a woman sometimes means being a tiger or a growly mama bear. As Dr. Julie put it best, “Being fixed and rigid does not lend itself to survival. In nature, you adapt or you die.” Sometimes that means showing your teeth and voicing unhappiness.

Recovering from a mood disorder means making peace with the trauma of having your mind betray you deeply. In recovery you are hypervigilant for the return of that black beast – when we are tearful or sad, obsessive or anxious – what is healthy and what is worrisome? This book is a good start for someone looking to repair that relationship with their emotions.

It is smart, feminist, and scary – like Girl Interrupted read  Lean In. It discusses the dangers of direct-to-consumer marketing by pharmaceutical companies, and the advent in the ’90s of disorders that are not really disorders. Cosmetic psychopharmacology is another bull in the arena that women have to fight in the workplace. How do we stay authentic and taken seriously? Our expressed emotions are a call to action – spurring growth and change. How does our sadness and anger and anxiety remain dynamic, when everyone around us is taking Xanax and just floating by on the status quo? Our emotions are the root of our empathy, our ethics, our humanity.

Moody Bitches is practical, too. The appendix is great for anyone who feels they aren’t getting enough straight talk on medication options from their doctor. Cover to cover is packed full of information and helpful instruction for women with our unique biology in mind. It is a reliable resource that doesn’t just throw the experience of being female all in a messy pile and call it ‘raging hormones’. Dr. Julie tidies up, and makes our hormones and their role in our lives and bodies more clearly understood. Women who suffer from misunderstood conditions like Premenstrual Dysphoric Disorder or Postpartum Mood Disorder will feel refreshingly validated. Getting sunshine and exercise or not just presented as ‘complimentary’ but necessary for our bodies to feel well. And so importantly – she hits home that medications like seratonergic drugs and oral contraception can potentially knock your libido out – something doctors usually skirt around in their office.

I highly recommend this book to everyone – women and men, moody bitches and even stevens. It’s a resource for the average girl, and not just that, it’s a great reference for healthcare providers, too. It contributes to a tremendously relevant conversation that we should be having. One that I hope I am helping to bring more to the table, too.