The act of growing, nurturing, and birthing another living being remains one of the most mysterious and affirming acts of humanity, but being a new mother while maintaining an identity and navigating daily challenges can be one of life’s greatest hardships. Millions of mothers have walked this path, yet society is quick to diagnose their challenges as character flaws or a weakness in their capacity to love.
Karen Kleiman, a licensed clinical social worker, holds a different belief: she argues that postpartum distress is normal—and should be normalized more in our society. She also believes more therapists need to be trained to work with postpartum anxiety and depression. She founded The Postpartum Stress Center in 1988 in Rosemont, Pennsylvania, and has written several seminal books, including This Isn’t What I Expected, Overcoming Postpartum Depression, and Good Moms Have Scary Thoughts: A Healing Guide to the Secret Fears of New Mothers.
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Ryan Howes: How did you became interested in postpartum work?
Karen Kleiman: When I had my own babies and had to stop breastfeeding because of a medical complication, I didn’t know whom to ask for help. That’s when I became aware that the needs of postpartum women were falling through the medical cracks. You can ask your mother for help, or your sister-in-law, but you may not get the best advice. You can ask your doctor, but she’ll send you to a pediatrician, who will send you to a breastfeeding specialist. You get kicked around.
In the early ’80s, I was doing hospital social work, and I became a breastfeeding counselor because I wanted to help more moms. It turns out that once you talk to a woman about her nipples, the doors of conversation often swing open. Women started telling me about their stressed marriages or how depressed they were, even though they’d waited for this baby their whole life.
I put out this little ad in a local community paper: “Social worker interested in researching postpartum depression. If you’ve recently had a baby, call me and let’s talk.” I got three phone calls. Two of the women were over 70 years old, and they each told me stories of sadness and shame. Even decades later, they remembered feelings of not wanting the baby and thinking, “I’m a terrible mother. They’re going to take my baby away.” They didn’t tell their husbands. They didn’t tell their mothers. They didn’t tell their friends. They sat in the shadows of silence until it went away by itself. Both of these women said I was the first person that they’d ever told.
I started knocking on the doors of OBGYNs, who were mostly male in those days, saying, “Hey, doctor, do you know what’s going on here? Are you aware?” Back then, almost 40 years ago, people weren’t keen to talk about moms who don’t feel good about being moms, not even the pediatricians I contacted.
Even today, there’s a societal message that says the postpartum period is supposed to be the best time of your life. When I questioned this in a childbirth education class, I was told, “We don’t want to bring the mood down.” But the moms I was working with were already down. They were saying, “Nobody’s listening to me. Nobody’s taking me seriously. Everybody’s focusing on the baby. I sit in bed and cry, and then get up and put on lipstick on and tell people I’m doing wonderfully.”
I knew I needed to create a safe space where moms could say, “Actually, this sucks, and I don’t like myself very much. Some days when it’s really, really bad, I feel like killing myself.” I became a pioneer on behalf of women who weren’t speaking and sometimes killed themselves. It felt essential.
RH: You started writing books to get the word out?
Kleiman: With my then sister-in-law, I wrote my first book, This Isn’t What I Expected, because I found myself saying the same thing over and over: women need to be validated in their postpartum experience. They need psychoeducation. They need somebody who isn’t a male, authoritative, I-don’t-have-time-to-listen person saying, “What you’re feeling is okay.” I wanted to tell as many women as I could: here’s what’s going on, here’s what’s okay, here’s what’s not okay, and here’s what you can do.
RH: I think there’s some confusion about the terms we use. Are we talking about postpartum depression or postpartum anxiety or some other iteration of that?
Kleiman: I’m from another generation, so I find myself continuing to use the term postpartum depression, which was previously the umbrella term for all postpartum mood, and anxiety disorders, including mild to severe to OCD. In This Isn’t What I Expected, we coined the term postpartum stress syndrome for an adjustment disorder that requires support but not medication. Today, people use the term perinatal mood and anxiety disorders or PMADs to describe all forms of distress that occur during pregnancy and the first postpartum year.
RH: Do you think that term carries less stigma?
Kleiman: No matter what you call it, there’s stigma. Postpartum depression is a very agitated depression, and so much shame is attached to that anxiety and not feeling like the perfect mother. Thirty-five years ago, women were told, “Take a pill. Relax!” It was a joke how we helped moms who didn’t feel good. Even today, many doctors respond dismissively: “Oh, she’s just an anxious new mom.”
If you don’t create a safe space for women, they aren’t going to reveal how bad they’re feeling or the extent to which they’re suffering. And if they don’t disclose that, they run a greater risk for worsening symptoms. Even when moms are given the Edinburgh Pregnancy Depression Scale in the hospital to assess mood, they often think, “If I put down that I feel like hurting myself, they’re going to take my baby away, so I can’t do that.”
It’s tricky. We have to be careful not to overpathologize and not to underpathologize. Yes, we want to pay attention to mood and anxiety disorders during the postpartum and prenatal period, but we don’t want to normalize everything.
RH: How do you distinguish between normal amounts of anxiety, depression, and exhaustion experienced by new mothers, and postpartum depression?
Kleiman: Good question, and it’s why I wrote Dropping the Baby and Other Scary Thoughts. The goal was to let women know that every mother has scary thoughts, like, “Not only could I drop my baby, but sometimes I want to drop my baby.” There’s a normal scale that’s often hard to understand because you can’t believe it’s normal, which asks the question: if you say this is normal, how do I know if this is not okay?
Because anxiety is normal and suffering is subjective, what bothers you may not bother me and vice versa. So we have no real test to say that your suffering is not okay and mine is. It’s a matter of frequency, intensity, and duration. All new mothers cry. Their hormones are out of whack; they’re sleep deprived. So we can say that it’s normal to cry, but not if you’re crying all day, not if you’ve been crying for six weeks, not if you’ve been crying so much that it’s interfering with your day.”
Some women can function very well with high levels of distress. Do they need medicine? Maybe; maybe not. We say, “It’s okay if it’s okay with you. And if you’re not functioning, that’s not okay.” If you have a history of anxiety, that’s when we can see the development of anxiety disorders and OCD.
RH: What then?
Kleiman: If she’s not eating, not getting out of bed, not getting dressed, is confused, is having panic attacks, is experiencing suicidal thoughts, then she needs state-of-the-art treatment with medication and supportive psychotherapy.
With milder to more moderate depression and anxiety, psychotherapy is important, and antidepressants to treat biological symptoms are a possibility. We know that CBT works, and I wrote a book on CBT for perinatal distress, but honestly, most moms in severe distress aren’t interested in reframing their thoughts: they really want to go to sleep and have somebody take good care of them. So I’m currently working on a book about the art of holding perinatal women in distress. It’s sort of like taking Winnicott and putting him into the perinatal population.
RH: Do moms get concerned about medication and breastfeeding?
Kleiman: We have enough research now for clinicians to comfortably say that medications are compatible with breastfeeding. Still, many mothers don’t want to take medication after they’ve had a baby, whether they’re breastfeeding or not, because they find it pathologizes new motherhood: “I just had a baby and now I’m mentally ill?”
For the most part, we defer to what her preference is. But if too much time goes by and she’s still feeling bad, we may want to reassess. There’s no real downside to starting the medicine. If it doesn’t help, we’ll get you off. And if it helps, that’s great.
RH: How can therapists help?
Kleiman: All the clients we see at our center are moms who are feeling bad, and we’ve got a waiting list of 200 people. It’s unfortunate that more family therapists aren’t trained in these issues. Someone who’s had a baby within one postpartum year runs an extremely high risk of having a problem. The numbers are staggering, and they’ve tripled with the pandemic. So if a client mentions having a new baby, you need to do some rapid screening. You need to ask, “Are you okay? You’ve been hormonally compromised and sleep deprived. Is there depression or anxiety going on that might be influencing your marriage?”
One of my books, Tokens of Affection, is about the emotional residue that can simmer and infect a marriage, even after somebody’s postpartum depression has resolved. The baby might be two years old now, and the couple’s wondering why their marriage feels so bad. Maybe mom’s still angry with dad because she felt abandoned. And he’s angry with her because he couldn’t figure out why she couldn’t do what she needed to do and was crying all the time.
Having a baby is hard on a marriage under the best of circumstances, even when nobody’s experiencing postpartum issues. Simply having a six-month-old is a reason why many people go into therapy. We want to screen for an untreated depression or anxiety disorder, but even without that, having a baby can wreak havoc on a relationship.
RH: What is the field not talking about enough?
Kleiman: My mission has always been to say, “Please, don’t put added pressure on a new mother to feel good; she’s under so much pressure already. Let her do the best she can, and let her be okay with having a bad day.” This Isn’t What I Expected was one of the first popular-press books to emphasize that it’s okay to not feel okay about being a mother.
If a mother with a seven-month-old comes in to see you, for example, the response is often to say, “Oh wow. Congratulations!” Instead, try asking, “Are you doing okay? Are you sleeping? Do you still feel good about yourself?” Sometimes I hear, “I no longer know who I am. My identity and who I thought I was for 30 years is out of my reach. I’m sleep deprived. I’m spit upon. I’m yelling at my husband. I’m crying. I’m not working. I’m bleeding. I’m lactating. And I don’t know who this is.”
Our culture needs to change. Women need to talk openly about these things without being shamed, about their bodily functions and their bodily changes. Many don’t even talk about it with their partners.
RH: You wrote a book about dads, too?
Kleiman: One of my books is about helping dads help new moms. It’s a very scary time for the dad too, and it can seem like no matter what he does, he can’t do anything right. If he leaves her alone, then he’s abandoning her. If he asks her too many questions, then he’s in her way. If he says, “I love you,” he’s told, “You don’t understand how bad I feel.” Dads can get postpartum depression as well. People have only recently started talking about that. Therapists also need to make sure that dad is okay.
RH: What’s on the horizon for postpartum treatment?
Kleiman: We have promising treatment options for severe postpartum depression, such as Zulresso (Brexanolone), which is intravenously infused in a medical setting and closely monitored over the course of two and a half days. Currently, it’s extremely expensive, with significant side effects, but it’s exciting to see small trials of women recover so quickly from significant depression. At this point, while this is a positive step forward, several barriers still need to be overcome.
The larger complex issue is the enduring societal pressure on moms to do everything and do it all with a smile. Fortunately, there’s impressive momentum in the right direction. There’s greater advocacy, new legislation, more education, better trainings, so we have a reason to be hopeful that we’re going to continue to pay attention to this issue and save lives.
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