Baby Steps With My CoffeeBlog by Forward Wellness Founder / Clinician, Jodie Hnatkovich
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 I feel like we have a systemic issue where no one is differentiating from fact, research, opinion and experience.
We are too busy preaching ‘facts’ that are not facts, but rather research, opinion, or experience. OR We are arguing against someone’s perceived ‘facts’. We do not get the whole picture. These are four very different meanings. Facts: Google defines fact as “a thing that is indisputably the case”. In theory, research with the same outcomes will become a fact – but research can not usually be done without external variables that could alter the outcomes. Experience might be your ‘fact or truth’ but it does not mean it is anyone else’s. Research: A hypothesis that was tested through controlled studies or by compiling several sets of data (that is usually not controlled). Academic Research is then reviewed by peers to find the external variables and navigate where future studies should be conducted to clarify the results. Opinion: What one thinks. Experience: What has happened to someone or a culture and can alter their actions in the future. Recently a well-known advocacy and education agency around stillbirth posted an image that stated, ‘Maternal obesity is a significant risk factor of stillbirth’. Is this fact, research, opinion or experience? It might be research or experience, but to me that statement sounds like a statement that is not helpful but rather shaming. I asked a simple question about the research and if this is due to other underlying issues (systemic – mistrust of doctors to not judge them or being treated dismissive when they do ask for care, physical – maybe higher blood pressure contributing to placenta issues, emotional -?). I was then dismissed, and someone told me this was ‘fact’. This is NOT fact. This is research – which can be used to do further research on the ‘why’. Research and experience also show that black infants are much more likely to die before their first birthday, than white babies. The fact is not the blackness causes babies to die. The reality is this is a systemic issue and we are failing. We need more research. We are not asking the ‘why’. Instead when given this information we use it to form causal relationships and then shame the victims or the perceived perpetrator. This is not helpful. Some might say I am too empathic and cynical. My mind always goes to the ‘WHY’. WHY are people acting the way they are? WHY do some people value one person’s opinions and not the other? WHY do we feel defensive when someone tries to point out flaws in our thinking? WHY does this power struggle exist in our society? WHY can’t we all just coexist in our ecosystem? I encourage you to take a step back before reacting and trying to navigate the intention or the WHY. Maybe if we could all take a minute to be aware of ourselves and take interest in others, we would all be a little calmer. Be Well.
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 This is week is Maternal Mental Health Awareness Week. The social media campaign that started today through The Blue Dot Project is asking moms to post on social media about #realmotherhood. You know, talking about the reality that we all yell more than we are willing to admit. We all think we are doing something wrong. We all want the best for our kids and worry about who they will be when they grow (or will they even make it that far). Being a mother is about a lot of pivoting and hoping that the last pivot is not going to damage our kiddos. We are all in this together. My goal is for all mommas to be able to support each other, even if the other person is choosing to raise their kiddo differently. The reality is that we are in a world torn and telling us to pick sides. We don't need to believe that. We are all doing our best. With that said, it is important to talk about, what I refer to 'glitches' in perinatal mental health. Perinatal Mental health issues are not something mothers can just get over. It is not something mothers are creating for themselves. It is not something happening to mother's because they are weak. Typically, when we hear a mother has 'postpartum' we immediately assume she is depressed and suicidal. **but how could a mother take her own life when a baby needs her *shame/guilt* or we assume she has psychosis and she wants to harm her baby **but how could a mother ever want to harm her beautiful baby*shame/guilt** "If you or someone you know is having suicidal or homicidal thoughts, please talk to someone! To the mother that is currently experiencing these types of thoughts, I say, “Do not let the shame of these thoughts stop you from reaching out for help. Shame will tell you not to talk to anyone. Shame will lie to you and tell you that you are a bad mother. But it is not true! You are not a bad mother. You are ill. You need help. There is hope and healing if you would only reach out.” - A warrior of Postpartum Psychosis that we lost in 2015, Naomi K. It does get better, with help. What does any of this mean: Perinatal – ‘around pregnancy’ Perinatal Mood and Anxiety Disorder (PMAD), Perinatal Mental Health (PMH) Antepartum – during pregnancy Postpartum – up to one year after pregnancy Maternal Mental Health – Duration of motherhood Baby Blues – 50-80% of women experience this. Last no more than 14 days (described as adjustment to new baby and cleanse of hormones) Here are a few symptoms of those with PMADs: Most women do not experience all symptoms, but may notice some from this list:
Risk Factors (The things that we should pay attention to and follow up quickly)
Then the Clinical Diagnosis.
I can go into more detail on what each is, including symptoms but I don't think that is the point of this post. You can find a TON of knowledge on the subject through Postpartum Support International and Mental Health America recently published an article full of great information. So, what is my intention with this post? To create awareness. To breed kindness. To support our mothers. To let struggling mothers know that is does get better with help and they are not weak. It does get better, with help. Please do not let the shame of feeling defeated keep you from reaching out. Please talk to someone about the feelings. The longer you remind silent, the longer it will manifest and all we want is for you to be yourself again. If you are currently feeling hopeless or not yourself, please reach out for help: Call the PSI Warmline at 1-800-944-4773(4PPD) For Crisis, call National Suicide Prevention Hotline at 1-800-273-TALK (8255). In Pittsburgh, call the re:solve crisis network: 1-888-7-YOU CAN (1-888-796-8226) Call your OB/ Midwife / Pediatrician/ PCP. Call a local therapist that specializes in perinatal mental health Call your PSI volunteer coordinator to find help. -Be Well.  In this post, I am referring to psychological trauma and not necessarily physical trauma. Though physical trauma can also hold psychological trauma. First some simple statistics according to PATTCh (Prevention and Treatment for Traumatic Childbirth) 25 – 34 % of women reported their births were traumatic. While the percentage that then develop PTSD (Post Traumatic Stress Disorder) is between 1.5 – 9%. “A birth is said to be traumatic when the individual (mother, father, or other witness) BELIEVES the mother’s or her baby’s life was in danger, or that a serious threat to the mother’s or her baby’s physical or emotional integrity existed” - PATTCh In other words, it is not up to a doctor or other provider to determine if a birth was traumatic to the mother or father. If the birth was deemed traumatic, it was. If the doctors pulled out the forceps and the mother felt like they were going to pull the babies head off… then it was traumatic. But a mom in the same situation might think it was amazing that she was able to avoid a csection. Most of us might view fourth degree tears as traumatic (ouch and holy recovery period!) but mom might feel empowered at what her body was able to do. “One’s perception of the event is what defines it as traumatic or not. As it pertains to childbirth, “Birth trauma is in the eye of the beholder” and whether others would agree is irrelevant.” - C. Beck Events that MAY be associated with a traumatic childbirth: -Stillbirth (death of baby prior to birth) -Infant death soon after birth: major organ deficits, trisomy 18, “diagnosis incapable with life” -“High risk pregnancy” -CODE O -Mom stay in Antepartum Unit or the ICU -Prolapsed cord -Uncontrolled pain -Unplanned C-section -Use of vacuum extractor or forceps to deliver the baby -Baby going to NICU -Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery -Women who have experienced a previous trauma, such as rape or sexual abuse, are also at a higher risk for experiencing postpartum PTSD. -Women who have experienced a severe physical complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3rd or 4th degree tear), or cardiac disease. So, why do we care?? “Birth Trauma NEEDS to be talked about. Post-Natal Depression (which, according to the American Psychological Association, affects approximately 1 in 7 women) is now widely known and accepted as a reality that many mothers experience. It’s time now for our awareness and vocabulary to expand once again. The fact that 25-34% of women come away from their birthing experience feeling some degree of trauma means that at least twice as many women struggle with this as with PND. And because of the lack of awareness about Birth Trauma, these thousands of women often struggle in silence. It's time for that silence to end, so that through awareness and preventative measures, the risk of trauma occurring can be greatly reduced.” – Jen Hannah – Advocate Having a traumatic childbirth is more prevalent than Postpartum Depression or Postpartum Anxiety – but we can assume that a correlation is present. If we are able to support the women or fathers to get the care or education, they need after a traumatic childbirth we might be to avoid some of the negative consequences for the family when these things go untreated. What are the Effects: Potential Effects on Mother – Feeling out of control, irritability Shorter lactation period Reduced sleep due to fear – not just baby not sleeping Difficulty with family relationships (avoiding family that might not understand) Avoiding friends and supports with small children Difficulty with ‘motherly’ roles: acting the part but feeling overly anxious/ protective OR detached / avoidant Difficulty with attachment to baby Feeling misunderstood, abandoned or isolated. Less likely to have more children Clinical Effects of: Postpartum Depression, Postpartum Anxiety, Postpartum OCD, and Postpartum PTSD Potential Effects on Father – Similar to the effects on Mother, Anxiety and OCD symptoms tend to be higher. “I felt like I was watching a car crash with the most important people in my life, and I could do nothing to protect them. She was screaming in pain - she was dying. Twelve doctors ran into the room. They wheeled her out and I knew nothing. I stood there (in the labor and delivery room) shaking, sweating, and then sobbing. I was terrified. She was dying and she was scared and alone and I was helpless. I couldn’t help her. I am supposed to be her person to help her… my job was not to leave her alone.” Potential Effects on Baby – We still have a lot to learn on how a traumatic childbirth effects a baby and their nervous system. Most of the research over the last decade has been contradicted with newer research. What we DO know is that attachment to a parent is key to reverse any upsets that might have happened. New research also suggests that the bond between baby and traumatized care giver is healing for both mom and baby. The attachment helps to reduce cortisol levels and help the nervous system regulate. (This is very exciting and empowering.) We also know the side effects of untreated caregivers can create developmental delays for the baby along with additional behavioral issues as they age. In my county (and hopefully the state of PA with Senate Bill 200), we can send a referral to early intervention and they can evaluate from birth to age 3 and set up for quarterly tracking to make sure any delays are caught early. What now? If you are a mom or dad struggling with the after effects of a traumatic birth, please know there is help and you are not alone. What you are feeling is normal. There are some ways to support: adequate sleep, message, brisk walk, exercise, support groups, psychotherapy – trauma focus, Smartphone Apps: PTSD Couch/ PPD ACT, self help guides to trauma recovery, Medication. There is help. You are not alone. You can get better. Other resources: Penny Simkin video on Birth Trauma: https://www.youtube.com/watch?v=IkVHUrhh_vY PATTCh: http://pattch.org/ Postpartum Support International (Learn more and utilize their supports): http://www.postpartum.net/learn-more/postpartum-post-traumatic-stress-disorder/ Jen Hannah, Advocate: http://jenhannahspeaks.com/  A few months back I finally got around to reading 'Option B' by Sheryl Sandburg and Adam Grant. It was a book that numerous people suggest I read and said they would be interested in hearing my thoughts. Ultimately, I think if everyone read it - but be warned there are a lot of trigger warnings (so maybe read this blog post first and navigate resiliency.)
Throughout the book Sandburg talks about her journey with traumatic grief and her initial belief that she will never feel joy again. Grant worked with her to navigate the research on growing more resilience through attempts to heal herself and her family. Grant summarizes that resilience as a muscle to strengthen rather than some fixed amount. When we don’t have life obstacles forcing us to be resilience, we never learn to strengthen it. A large part of the book revolves around the research of Dr. Martin Seligman. He labels the three pitfalls to resilience or the three beliefs that keep us from growing to be resilient. Because this is a topic that I talk about a lot, I wanted to share some of Seligman’s ideas and then how we can work to navigate them with self-compassion. The three P's that prevent resiliency after a traumatic event or loss are: personalization, pervasiveness, and permanence. Personalization is the idea that somehow the I event is your fault, or you could have prevented it from happening. Most of us tend to immediately ask blaming questions when we hear about something terrible happening. Why is our first response to someone getting mugged to ask what they were doing to cause this? It's because we WANT to believe there is a reason for bad things happening. We want to believe that some how we can control our lives enough to prevent the terrible from ever effecting US – those things happen to OTHER people. It isn’t a far leap then to point blame at ourselves when something traumatic happens. Doing this though causes us to be stuck in a cycle that doesn’t allow for growth or recovery. What about the mom whose baby died before birth? Guess what, it is not your fault. You only knew what you knew at THAT point in time and there was nothing you could have done, knowing what you did know. I know that is a hard sentence to process: you only know what you know. You are not to blame for not knowing things you did not know. The question of WHY you didn’t know – is a big question and this isn’t the blog post for that – but it is NOT YOUR FAULT. What about the girl that was violently assaulted? That was not your fault. It is the fault of the INTENTION on the perpetrator. It did not matter that you liked the guy; it did not matter that you wanted to be with him; what matters is that somewhere the partners intention became to cause harm to your body. It was not your fault. Pervasiveness is the belief that this event or loss will affect all areas of your life. The reality is the world keeps moving, as surreal as it feels that the rest of the world is moving forward while your world has just crumbled. In the days, weeks, months right after it is hard to get out of bed or take a shower or focus on anything for longer than a few minutes. Your world is falling apart, and you are trying to make sense of it and pick up the pieces. This is normal. The point is you keep going. You keep moving into this new and unknown world and every experience needs to be relearned as 'life after'. What you will find after the first few days back to work, is that it didn't really change. The first few days talking with friends will again feel familiar. You have changed. But you can find your new normal – even in situations that didn’t actually change. It is important to know that your grief does affect you in all aspects of your life, but those aspects of your life are still the same. I like to navigate this like exposure therapy - baby steps to reintegrate yourself back into your life. Give yourself a promise to go for 20 minutes, but permission to leave if all you want is to cry in the bathroom (this counts with work, social activities, volunteer roles, date nights, family gatherings, etc.). Baby steps forward are still steps forward. I will also add that if you are trying to push yourself to do something that you really just don't want to do, you don't have to do it. Maybe your new life after doesn't involve weddings or baby showers (or at least for the first year). If you are avoiding due to fear, then maybe we should eventually try steps forward. If you are avoiding because it is a thing you never liked to do in the first place, I would rather ask the question ‘Why?’. You don’t have to do anything you do not want to do – even if someone else doesn’t understand. Permanence is the belief that the intense emotions that come with grief will last forever. The goal of grief work is for the duration, intensity, and frequency of those "hit by a bus, can't get off the floor" moments to be less over time. What we want is for you to be able to talk or think about the event without a visceral body reaction. Step one to not have the visceral body reaction is to allow yourself to feel the visceral reactions and work through it. The fog and pain will not last forever if the work is done to honor your feelings as they come. I promise this intense pain does get easier. Those three ideas from Dr. Martin Seligman are vital to be able to name and understand. The point I need to add is that this is not possible if you can’t find some self compassion. In order to believe it will get better, you have to allow yourself time to not be ok. I often work with people that struggle getting through the 'not ok' stage because they just want to be 'OK' yesterday. We can't avoid the intense pain and we can't just wish it away. We need to be in it. We need to trust ourselves to know that pain is part of healing. Feel the intense feelings and take care of yourself in them. That could mean a warm bath with a glass of wine or talking with friends. But if you are overflowing with anger and rage, self care might look more like breaking $5 goodwill dishes in the basement or filling up a room with balloons to pop (cleaning up the mess is also therapeutic) or a batting cage or a shooting range. Unfortunately, time does not heal all wounds. Self-Love and Self Compassion can create growth over time. When navigating grief and trauma, I like to use the visualization of wading in the ocean. Sometimes we are meet with calm, refreshing waters but often we are met with big, angry waves that can pull you under. The more often you are in the water, the less energy it takes to stay afloat when a big, angry wave comes. This isn't because you have tamed the ocean, it is because you have gotten stronger and learned how to work with it. THIS is the ideal of resiliency. We get stronger and smarter. Trust that you will learn how to live your new life with this event on your timeline. Trust that you will place this event and it is not going to control your life. Give yourself some compassion to know that the hard days are the days you are doing the real work and it is not a straight line to growth. Hard days do not mean you are going backwards. One of my favorite quotes: Trauma creates change you do not choose, healing is about creating the change you do choose. -Be Well  This is a question I respond to regularly, due to my personal and professional connection to the topic. Just last week I received an email and follow up frantic text from a mentor asking for words. Words to give a group of young mothers, to help them support a mother whose baby had died unexpectedly. After some of my own processing I was able to write a few sentences, quoting Patton Oswalt’s late wife, ‘It's Chaos, Be Kind’ and allowing the grieving mother to be right where she was.
The next day, I came across this article, “When a Grieving Mother talks, Listen”. In the article Jen Gunter writes, “I can also leak my sorrow out into the ether ...If I do this, I know there will be a terrible pause because nothing sucks the life out of the room faster than telling someone you had a dead baby. The other person will quickly say, “I’m so sorry.” What do I say in reply? “That’s O.K.”? It is most definitely not O.K. As soon as the words that proclaim I had a third son leave my lips, I regret them. I feel responsible for the uncomfortable atmosphere generated by the sorrow I was not supposed to share. I do not want to be excluded anymore than I already feel, so I hastily gather the remnants of my sadness back inside where they can cut only me. " . . . The question remains: how to talk or listen to a grieving mother. What do you say or do? What if you say the wrong thing and offend them? What if you talk too much and they don’t want to talk? What if you make them cry? What if I don’t talk enough and that makes them cry? What do I do if they cry? What do I do if they just want to be distracted and avoid talking about it? So let’s talk… To quote Buddha: “Words have both the power to heal and destroy”. We need to be aware of the impact our words can make and choose words carefully. We want to avoid words that will work to diminish pain or unintentionally tell the mother that she should be ‘over it’ by now. Discussing what NOT to say, will come at another time – but a good rule of thumb is anything about lemons, not being given more than you can handle, comparing to the loss of a grandparent, or things happening for a reason SHOULD NOT BE SAID. . . . What to say: 1. “I can’t imagine what you are going through, but I am here if or when you need me.” It is good if you know what you are capable of handling. If you are not someone that can sit in heavy conversation, but are wonderful at distraction I think this is important to acknowledge. Offer to come over for the distraction – bring the snack tray, wine, games, etc. Can you randomly stop by for dinner (and then leave)? Can you occupy other children or clean the house? Can you plan a night out? Or can you be that person that can sit with them and let them cry? Knowing your abilities is so important to not put your pain of discomfort on her. 2. “I am so sorry for your loss. How are you? How are you really? What are you feeling?” Knowing that there is someone out there that actually wants to know how you really are is so important. Grieving mothers often say they feel like they are wearing a mask daily. Trying to act the part of a functional member of their family, work, society. But really, they just want to talk about the child they lost. They are craving a safe place to unload, a safe place to just be real. Maya Angelo said it best: “There is no greater agony than bearing an untold story inside you.” 3. “This really sucks and I hate that you are going through this.” That is all there really is to say. The emotions of grief are similar to wading in the ocean. Sometimes you are just floating on top but not exerting much force – other times you are using every part of your body to get back to the top. Eventually you get better at managing waves and learning how to use less energy – but you don’t tame the ocean. 4. Say their name. Don’t stop saying the child’s name for fear that you might ‘make them cry’. Their child is always on their mind and knowing that other people are thinking about them means the world to mothers. Knowing that the rest of the world has not forgotten them. And as for the ‘making them cry’ – I prefer the reframe of giving them a safe space and ‘letting them cry’. 5. Say nothing. Sometimes just being a welcoming space is all someone needs. Knowing they are not alone, but also that they don’t need to talk. 6. SHOW UP I can’t express the importance of showing up. And I don’t mean this as actually being at their home in a physical sense. I mean making the time for that phone call or sending letters or one-line text message saying, “I am thinking of you and (insert child’s name).” This is a moment in their life that they WILL NOT forget, and some relationships will never be the same. The excuse of ‘I didn’t know what to say’ or ‘it was just too much for me’ is complete bullshit. You take the time to realize they are drowning and your ‘discomfort’ for five minutes is nothing compared to their new life. 7. “I don’t know what to say” Because there is nothing that anyone can say to take the pain away. Being in the space to say this, is the most important part. It is ok not to have words. I regularly use the line, “I don’t know what to say, but this is the point that I wish I had a magic wand to take away your suffering for 5 minutes.” Our moms (and dads) are suffering. Their life is your horror story. Be kind and show up. Be Well. When navigating depression or anxiety loops (those thought patterns that we tend to go back to), it is good to remember that we don’t have to believe everything we think. Our loops tend to go pretty dark, pretty fast: “You never do anything right.” “You are a failure.” “You are too sensitive.” “No one likes you.” “What’s the point, you won’t ever get it right.” “You are a bad mother/ father/ friend/ daughter/ son/ spouse.” “You are worthless.” “You are unlovable.” Or the anxiety loops: “Your leg hurts - it is definitely cancer” “She is looking at you weird- she will never talk to you again” “He didn’t pick up the phone- he is hurt and suffering” Thoughts can contribute to our suffering. There is this idea of pluralism (my new favorite word) that two things can be believed as true at the same time. You can believe: “You never do anything right.” While also naming several things you can do right: “I do a decent job at work” or “I am a good friend”. An Idea, A solution: Listen to our bodies and try to figure out what we are feeling – the truth. Our feelings are true. You are sad, scared, angry, embarrassed, disappointed, jealous, frustrated, defeated. Name the truth – name the feeling. And THEN give yourself some compassion and self-love. Allow yourself to feel. Allow yourself to just “sit in it’. Allow yourself to name what you need in that moment: a hug, a TV marathon, a run, a warm bath, a good book, a good conversation with a friend, a nap, a glass of wine. All these are valid self-care and self-love acts – and there are hundreds more. Give yourself the PERMISSION to feel what you are feeling and the COMPASSION to take care of you. Stop beating yourself up, stop bullying yourself. Now, there is a reason those thoughts are there in the first place. Probably decades of negative self-talk that doesn’t just go away because you want it to (or because you read a blog telling you to stop being mean to yourself). There are ways to retrain your brain and the pathways to more positive thoughts. Professionals are there to help you navigate this journey when you are ready. To start, allow yourself to believe that you don’t have to believe the negative loops. You don’t have to believe everything you think. Be Well.  I feel like I am often on repeat when talking about the cycle of anxiety – so I figured, why not share my white board with everyone else to benefit as well. Here are a few [snapshot] steps to managing and accepting your anxiety.
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