Fourth Trimester Podcast Episode 33: Pinpoint Where You Are on the Spectrum of Mental Health
This is our second and brief interview with Jane Honikman, a founding member of the Postpartum Education for Parents resource (www.sbpep.org) as well as Postpartum Support International (postpartum.net) that includes a telephone support line and partner with Dr Shoshana Bennett in Postpartum Action Institute.
Jane gives us an overview and outline for finding ourselves on the spectrum of mental health. Listen to the episode to find out how to identify different parts of the continuum and better understand where you yourself might fall on that spectrum.
She talks about her time studying with Dr. James Hamilton who was interested in maternal mental health at a time when it might have seemed as if no one cared or understood, much like today in many women’s experience!
The point is made in our interview that Partners/Dads are also sufferers with mood disorder and need support and guidance, therefore it is preferable to refer to Maternal Mental Health Week as Parental Mental Health Week.
Finally, in this episode, Jane outlines self-care activities and recommends conversation and engagement, offering the plausible hope that there is support and healing that is within reach.
About Jane Honikman
Selected links
Connect with Jane Honikman janehonikman.com | Santa Barbara PEP
Recommended books | Postpartum is Forever: Social Support from Conception through Grandparenthood | Community Support for New Families: Guide to Organizing a Postpartum Parent Support Network in Your Community
Learn more Postpartum Support International | Postpartum Recovery Plan | Self-Care is Critical to Caring for Others
Connect with Fourth Trimester Facebook | Instagram | About & Contact
Episode Transcript
Esther Gallagher: [00:00:05] Hi, everybody. This is Esther recording this week. We are so interested to have Jane Honikman again because we are interested to promote and raise awareness because it’s Maternal Mental Health Week. So we’re going to launch right in. Hi, Jane. How are you?
Jane Honikman: [00:01:18] Great. Esther. Pleased to be asked to come back. I’m always delighted to talk.
Esther Gallagher: [00:01:24] Great. So, Jane, you were telling me that you’d like to talk a little bit more about the history of maternal mental health in America, And so I’m just going to let you go. Go right ahead.
Jane Honikman: [00:01:37] Okay. Thank you. Yes, I, of course, am eager to continue to help and support and spread the word that’s going absolutely viral these days. It’s remarkable what’s happened over my lifetime and see how much change has taken place. But I want to share that a lot has not changed at all.
Jane Honikman: [00:01:59] And so I dug up an old brochure that I wrote in 1989, and I wrote it as after I had been educated by one of the world’s experts, Dr. James Hamilton, and he wrote the first definitive book in America in 1962 called Postpartum Psychiatric Problems. He was both a psychiatrist and a psychologist based out of San Francisco. And he was my mentor, my guru. He was a remarkable man who was way ahead of his time. And because I am grounded in what he taught me, I think it’s important to share again and again how much we have progressed.
Jane Honikman: [00:02:50] On the other hand, how little has made leaps and bounds, because what I want to do is share the very simplistic way that he verbalized to me and I wrote it down and tried to come to encapsulate this very complex topic and try to make it simple, because again, my background is not in medicine or in biology. And I really was very much a neophyte at his knees, so to speak. But he taught me about what he called the continuum of reactions to child birth, and I ended up calling it postpartum emotional syndromes.
Jane Honikman: [00:03:31] He approved of this idea of getting people to understand that these are syndromes, that there are these clusters and constellations around the emotions that occur because of pregnancy and actually in child bearing. So I thought it would be kind of interesting for me to share how I grasped the complexities of then. And I think it’s the same today. It is complicated. We throw more names around, we call it mood disorders. We do all sorts of different things, breaking down and this is reaction, reaction, this, then that. And I think it’s just confusing.
Jane Honikman: [00:04:12] So I wanted to share that he expressed it as a continuum or a spectrum of severity. And the syndromes range from mild to severe. And I think this is a good way to explain this. It’s very important not to ignore when somebody is having a reaction after delivering the baby that we now know is called the baby blues.
Jane Honikman: [00:04:37] And if you can visualize those of you who are listening and visualize or write this down as sort of put the word baby blues or mild on one side of the piece of paper or in your mind on the left and then on the right put the word severe so that the range of reaction is, is we don’t want to ignore somebody having what we call less than wonderful. And it may be even just an adjustment, but it’s certainly the baby blues we know is some way biological.
Jane Honikman: [00:05:06] And we don’t want to ignore the fact that we have an in between. We have mild to moderate in between the very mild and the most severe cases that can happen to a woman. So I think that’s to me, it’s very helpful because then you can do these symptoms and see how they are the same symptoms. And then if you put them in context of this like a chart which is mild on the left and severe on the right and in between, we can call it depression and anxiety in the middle and on the severe side, we know of psychosis.
Jane Honikman: [00:05:44] But what I also learned from him is that we also have severe depressions and we have psychotic depressions. And these things are on the very far right of our piece of paper. But listen to this overlap of some of the the symptoms that occur under baby blues, insomnia, exhaustion, tearfulness confusion. Overwhelmed feelings.
Jane Honikman: [00:06:13] Now in the middle are mild and moderate depression anxiety symptoms. We have depressed mood, tension, irritability, loss of sexual interest, physical complaints. And they are actually what we call the exaggeration of the baby blues. It includes all the others we just listed insomnia, exhaustion, cheerfulness, confusion and overwhelmed feelings. Now, the tricky part here is that on the far right side and under severe, we very rarely do we see somebody who is so disoriented because of fatigue. But it is an agitation.
Jane Honikman: [00:06:56] It can be delusional behavior. It can be through hallucinations. We can have excessive disorientation. And this is, again, related to insomnia, exhaustion, tearfulness, confusion and overwhelmed feelings. So that’s why we get so confused by all of these things. It’s complicated and it’s an overlap. These are syndromes that are overlapping, not clear cut.
Jane Honikman: [00:07:26] So what do we do to sort it out? Well, we can easily think of it in terms of when it is happening. So we call that onset and how long is it lasting. So if we just again, look at our little symptoms list and this continuum of reactions and on the left hand side again is under baby blues or mild reaction, it happens within the first day or up to six weeks. And then if you go to the far right under severe, we know that it’s between day three and within the first month.
Jane Honikman: [00:08:01] This is, again, generalities, of course. And in the middle, we know that we call this the week six up to first year. But again, we need to not diminish and ever ignore this onset idea. But then think about again to go to the top and think about onset related to how are these symptoms relating to you and whether it’s very mild, is it moderate, is it severe? And I think that that’s helpful. And then we have to think about another simple word, which is duration. How long has it been going on? And we need to know onset can now we are well aware of the research into pregnancy and so we need to also acknowledge that this is not just reactions after the baby is delivered.
Jane Honikman: [00:08:55] We also, in terms of rates, it’s interesting to look back in 1989 and when I wrote this, it’s based on all the research that had gone up until that time and I attended and continued to attend these conferences with the very finest researchers and researchers in the world who get together and share their research. Our rates of then 1989, I wrote down rates of Baby Blues, the mild response anywhere between 39 to 85% and the rates of mild to moderate depression and anxiety 10 to 15%.
Jane Honikman: [00:09:37] And of course, the most severe are 1 in 1,000 and very rare. And it’s all about being conservative to estimate these numbers. I’ve always been very comfortable with saying 1 in 10, even though we tend to want to up it. And I know that a lot of people are saying a lot more people are suffering. It’s all about going back to those researchers and really looking at how they studied their populations when they did their research. But it doesn’t really matter when it’s happening to you, it’s happening to you. And that’s 100%. So I think it’s important just to be able to delineate this in that way. So what do you think, Esther? Is that helpful or not?
Esther Gallagher: [00:10:22] Well, I think that it’s a great basis with which people can sort of look at where they might be at and kind of put themselves on the continuum somehow if they have the presence of mind. I think that understanding that this is it doesn’t matter whether it’s super common or not common at all when it’s happening to you, right, you deserve to get appropriate support, from everywhere that you can get it. That’s exactly right.
Esther Gallagher: [00:11:11] The good news is that it’s being studied. I do think that it’s a sad commentary on our culture that to this day, women are being met at every turn with comments like, but you have your baby or everything’s going to be okay. What’s your problem, basically? So I’m one of those people who went without support. I am distressed when I see clients going without support. I live somewhere where I think that resources are being cultivated, but too slow, in my opinion. I myself have felt like there’s a lack of resources for people like me who are working with moms everyday and don’t know quite how to help moms assess themselves and then get appropriate resource and referral.
Esther Gallagher: [00:12:26] However, having said that, you have a wonderful website that you and your peers have put together, and we’re here this week to help enlighten people about the facts on the ground and help people feel more resourced if they’re. Finding it difficult to be a new mom or a new parent, for that matter, because I think partners can experience postpartum mood disorder if we want to call it that, or just, are going to find themselves somewhere on the mental health spectrum themselves. So everybody counts.
Jane Honikman: [00:13:18] And that’s exactly right. And it’s very important at this point in this conversation between us is that I’m a proponent of changing our emphasis on maternal to parental, because we do know that the research is coming in from the fathers, that the men are having high rates of depression as high as the women at 10%. So it’s a very important thing that we make sure that we’re including everybody.
Jane Honikman: [00:13:48] But I wanted to then respond to this idea of getting help. And of course, you know that I’m the biggest proponent there is about social support, and that doesn’t cost anything and it doesn’t have to be difficult to find. But that’s what we need to have conversations around.
Jane Honikman: [00:14:07] So if you’ll allow me, I’d like to go back to this idea of seeing this on a spectrum or this mild, mild to moderate and severe and have a good grasp that what does it take to get well, and again, I want to put this in a historical context. We’re talking, 30 years ago I wrote these things and it’s the same today that no matter where you are on the spectrum, you have to be educated.
Jane Honikman: [00:14:37] And that’s number one. And we are doing a better job about that. There’s absolutely no doubt that we’ve made leaps and bounds around the world. I mean, everybody now has this flashing light about we do need to pay attention to how dramatic and this change in our biology and our psychology and our social status is when you have a baby and also remember adoption. So I don’t want to exclude that. It’s just pure biology.
Jane Honikman: [00:15:08] So education, education, education across the across the spectrum. And the next word is always important. And you already said it Support, support, support. Because again, it doesn’t matter whether you’re tearful or hallucinating, you need support. And we just have to get comfortable. And I think the overarching issue is stigma, stigma of mental illness. Again, no matter what and when, when behaviors change, people are uncomfortable. And so that’s the biggest obstacle of all of this. And then if we again, go back to our looking across this spectrum and this continuum of reaction, the next word is sleep. And we talk about this in terms of steps to wellness, sleep, sleep, sleep is our greatest form of healing for all, all, all animals and for all life. Right.
Jane Honikman: [00:16:05] And then that is, again, critical in the severe reaction because we know that the direct correlation to not sleeping in insomnia and becoming psychotic. So when you see the severe side professional care comes in after an education is support and then professional care, but not at all. In the mild cases, the referrals to professionals is absolutely not necessary. When we have baby blues, right? We all understand that now.
Jane Honikman: [00:16:35] But again, the onset, the onset on that continuum of baby blues is the same as psychosis and severe depression. So you can’t diminish those early weeks when you are. adjusting. So that’s really important. And again, when we have the mild to moderate in the middle, our depression and anxiety syndromes, professional care still isn’t up there. We still look at education and support and are you sleeping and how can you get more sleep if you can get more support? And then we have a nutrition. Again, we have exercise and way up there again is sharing how you’re feeling.
Jane Honikman: [00:17:21] Now, this is the kind of stuff that just is without a doubt simple. If we start paying attention to having the opportunity to share and not be judged. Now, a lot of the judgment is so internal, and we have this message that plays in our brains when we’re not sleeping well. And it doesn’t matter whether you’re a teenager or elderly.
Jane Honikman: [00:17:47] Depression has that tape that goes in our brain. And when you’ve just had a baby, we know that you’re not sleeping. So that’s why this gets so doggone messy. And that’s when we would definitely want to turn to professional care medication for those who anyone’s on the spectrum that is not sleeping and not eating needs to be seen by a professional who understands what’s going on. And we don’t ever diminish that.
Jane Honikman: [00:18:15] But remember, we absolutely must hospitalize those women who are in the severe range with their syndromes. And we absolutely never, ever minimize that. And we need to get them sleeping on medication. But there’s so many things that we are doing well there and now and it’s not easy, but it’s there. And then again, exercise and sharing the this just a moment.
Jane Honikman: [00:18:41] I want to say that we are not doing as good a job as we should for those who are suffering in the most extreme cases, they need more support that they are so stigmatized from having been hospitalized and separated from their babies that I really want to do a shout out here about the importance for us to destigmatize and work more closely with families who are having that because it impacts the family so, so, so powerfully. When mother leaves and goes to the hospital. Okay. How does that reaction what’s your reaction to my reactions? Well.
Esther Gallagher: [00:19:21] My reaction is I think it’s a wonderful summary. I think it helps. It’s potentially very helpful for people surrounding new parents to be able to, get a grounding in how they might be able to reflect with new parents about what they’re observing and, ask the right questions about how new parents are doing. I also, though, I think that one of the emotional states that doesn’t get spoken about so much, we talk a lot about feeling overwhelmed, feeling anxious, and tearful, sad, blue, all of those. But I think that what we maybe don’t talk about quite enough is feeling anger as an indicator that somebody might be depressed.
Jane Honikman: [00:20:28] And it should always be talked about. And we do our trainings in our workshops. We need to make sure we highlight the fact that anger is a symptom as part of the syndromes of depression. And we need to deal with it. And we don’t. We go into conflict and we start fighting and we think it’s all somebody else’s fault, right?
Esther Gallagher: [00:20:55] Yeah. And kind of get stuck in that loop. Right. It’s just sort of our, if we were thinking of it mechanistically, we kind of think of it as the default mode. And we don’t think of it as reactivity. We think of it as reaction. When in fact, it’s fueled by. A, a kind of. Mental health experience, which may be a little more like anxiety, but that’s that’s the strategy. That’s the mental health strategy is to go to anger.
Jane Honikman: [00:21:43] Well, we really don’t understand what goes on in the brain. But we know it’s not normal. We know it’s not okay to be feeling those feelings. And that’s back to sharing it. If you can start allowing people to express these things and then give them feedback and I want to throw in a new word that I think is missing in this conversation. It’s conversations. We use the word sharing, but conversations count. When you have a conversation with anybody, it matters what you say and how you say it. And when you say it. And I would say we’re out of practice. We need to be doing better.
Jane Honikman: [00:22:31] And this is back to what I believe in is face to face contact. And then if we have to, it’s over the phone or like we’re doing now is have a conversation and feeding back to each other. How are you doing and what do you think and how do you feel and what did you hear? So conversations are critical and I don’t think we do enough role playing. I don’t think we practice this. I think professionals are extremely uncomfortable on this topic because they don’t know what to say. Well, they don’t know what to say because no one’s ever taught them to just be natural and compassionate and loving and caring. And that helps a lot. It’s very healing. It’s very therapeutic.
Esther Gallagher: [00:23:08] Yeah. That, engaging your curiosity and your creativity can go a long way when you’re witnessing somebody who’s having difficulty. Yes. and it’s hard to have a conversation if you haven’t engaged your curiosity.
Jane Honikman: [00:23:29] Let’s throw in here the piece that makes this period in our lifespan is the baby and the baby is angry and cries and the baby is crying out of needs and needing. We don’t know. It’s hard to learn to interpret those cries. And then, of course, it triggers these internal things inside of us. That includes anger, frustration, all those sensations of being overwhelmed. And those are normal.
Jane Honikman: [00:24:03] I mean, we have to have the conversation that it’s not an illness to at times wish you hadn’t gotten into the situation. Right. And we don’t have that conversation enough. We’re not frank and open enough. And I, I have the privilege of going and giving workshops and being with people in settings where with those who go in and do home visiting and they are the front line and they themselves don’t even understand depression and what are our perceptions of depression.
Jane Honikman: [00:24:36] And they really don’t know how to have that conversation. We tend to let’s go check on the baby and oh, yes, how are you doing, Mom and dad? But, it’s very interactive. It’s dynamic, it’s complex, and everybody’s sleep deprived.
Jane Honikman: [00:24:55] So did you want to call attention to resources more, or have we done that enough?
Esther Gallagher: [00:25:02] I would love it. Yeah, if you’d like to, give a shout out to the things that you like to promote as resources, and we’ll also post those on in the newsletter and on the Facebook page. So yeah, why don’t you, why don’t you let us know what you think are your favorite resources out there in the world?
Jane Honikman: [00:25:26] Will you be shocked to know that I’m not going to give out one website or one phone number because I believe this is where our biggest gap is, is that people do not have a place to turn to naturally in their own community, that they’ve identified that this is helping with this these syndromes, that these reactions in Santa Barbara where my girlfriends and I got this whole thing started and it’s 40 years ago that we started our warm line and our parent discussion groups with PEP, which is postpartum education for parents.
Jane Honikman: [00:26:03] And the dream I still have is that there should be something just like that everywhere. But it’s not designed to bring people together under duress or distress. But under the wellness model of I just had this baby, now I need to make new friends because those are your resources, those are your best resources and everyone should have them. We don’t have to create them. They should be there naturally because you’ve already been in because of pregnancy. You get caught in a system, right? Yeah. And then people find but the system failed me. I have this baby. I’m sent home and I’m clueless.
Jane Honikman: [00:26:43] So that’s why we started PEP. And there should be something like PEP everywhere around the world. And in some cultures there, it never went away because mothering the mother and being there as a family and a clan is just integral into who they are. This is where we need to look around and say, Where is something like a PEP in my community? Did my childbirth educators tell me to come back and have a reunion? Did I have a phone number with my midwife? Am I going to have a home visit with somebody coming to see me? every every day, every week for a year.
Jane Honikman: [00:27:18] I mean, you know what’s going on. There is a lot going on. And I think in America, we tend to underestimate how well we do try to approach this and not very successfully. But public health is a success story in America. And the problem has been that public health is overwhelmed, but they also only reach out to those in the lower income. And there’s been a lot of wonderful, wonderful work. And we need to make sure now that we expand that and it shouldn’t be on, How much do you make? I need social support, right?
Jane Honikman: [00:28:01] So again, we need to be looking into our communities and saying, okay, looking around the I’m pregnant, what’s going to happen? Is there going to be somebody I can call? Do I call my doctor every time I have a question? Whose doctor is it? Is the obstetrician my midwife or is it the pediatrician? Oh, I can’t bother them. And that’s why we started this idea of a warm line. But again, it’s not around. Oh, I’m depressed. I need a call. Because when you’re depressed, you don’t call. I can tell you that for a fact. But the other people around you who are you’re in a well situation. They’re your network of support. And that can lead you to good professional care.
Esther Gallagher: [00:28:39] Right. Yes. Because somebody knows somebody who knows somebody. Right? Right. Yes.
Jane Honikman: [00:28:45] That’s how it works.
Esther Gallagher: [00:28:46] That is how it works. We were interviewing Maureen Fura and talking about, identify that friend who is not the friend who’s going to be the first to empathize with you and go, Oh, gee, yeah, that sucks. But the friend who can maybe engage compassionately and say, I see that you’re suffering right now. Let’s talk more about it. Let’s see if we can be creative about finding you some resources that you might need that go beyond what we have right at hand. But who can listen without judging. And not fall into the pit with you.
Jane Honikman: [00:29:39] Right. And again, they’re usually the people we live with. Our family members need to be the first in this conversation. And that brings me to always remind people that this is hereditary. The brain is something we don’t fully understand yet, but we do know we see severe mental illness and certainly the range of reaction, even mild to moderate. It runs in families and it’s something to, again, destigmatize that during your pregnancy or even hopefully before you get pregnant, you’ve already identified. Look, we know what’s going on in the family. I already had this trauma. I had PMS. I’ve had these other things happen to me. I’m probably at risk. And it’s okay to say that.
Jane Honikman: [00:30:23] And then that’s when you also pull everybody together in conversation and the conversation with your care providers beforehand. They want to know. They really do want to know, but they won’t. Can’t know without asking. And that’s about you tell it before anything happens and then but that’s again embarrassing and that you know that now takes us to screening.
Jane Honikman: [00:30:47] I’m a proponent of conversation and not necessarily a check off list because we lie a lot. We cover up. We put on happy faces. And so I’m not so sure that we need conversation. And that could lead to let’s take a look on a scale, let’s do a self screen. And those all need to be interpreted with care with people who understand and that’s back to conversations isn’t it.
Esther Gallagher: [00:31:20] Absolutely. If parents have access to, your wonderfully described continuum model and maybe to the checklist that midwives and obstetricians use and at the six week check when you may already have fallen off the cliff. Right. But they could assess themselves a little bit and then say their friends. Well, I’m feeling like I’m having a lot of difficulty. I looked at this checklist. I’m curious what you think, how you think I’m doing. Here’s how I’m feeling about it.
Esther Gallagher: [00:32:05] You could start a conversation if you have these resources available and they don’t just hit you, in a kind of sterile environment like the doctor’s office. I’m not saying that doctors shouldn’t be doing these screenings, but I will say that I think you’re correct that we don’t always know the answer to give in those moments. And there is a strong tendency to minimize in those very environments.
Jane Honikman: [00:32:37] That’s right. The other is that people will score very high and a trained professional will see that this person is indeed not doing well. But the person who just filled that out doesn’t identify and self identify as that’s just their normal. So that’s again, really a complicated conversation to have. The other people always say, well, there’s not enough time for conversation, but yeah, there is. It has to be.
Jane Honikman: [00:33:06] And the conversation doesn’t begin when you walk in the doctor’s office. I mean, you have to have already had conversations with those who are around you before you even make the appointment, right? So we again, need to keep it up and keep it going. And it’s all about destigmatizing our feelings that are not necessarily nice and say it’s all wonderful, but it can be. Remember, if 10% are not feeling well, 90% are. And they are the ones who help us, surround us, give us support and share and take us through these troubled times. Because once you’re out of this, you’re back into the swing of it.
Jane Honikman: [00:33:48] There’s other things that we remember when we self-screen. The idea is so simple and this is self care. Just ask yourself, have I eaten? What did I eat? When did I last eat? Am I getting my period for the first time? Am I lactating and diminishing milk supply? All these things impact. If I do, I have to go back to work. have I just relocated? Yeah.
Esther Gallagher: [00:34:19] Yeah.
Jane Honikman: [00:34:20] So it is complex, but the best part is that it’s something that is treatable. People get well, we move on and we’re all healthier because of this experience.
Esther Gallagher: [00:34:36] And there’s every good reason to engage with it rather than ignoring it. Correct. Jane, thank you so, so, so much for being with us again. I immediately thought of you when I was made aware that this coming week was going to be a special week for parental mental health, acknowledgement. So, I’m so pleased that you were able to eke out the time to give us your wisdom on the subject.
Jane Honikman: [00:35:15] No, you’re very sweet, Esther. It’s always a pleasure. And say hi and bye to everybody who’s listening and stay in touch.
Esther Gallagher: [00:35:22] All right. We will. Of course. And to our listeners, just know that you’ll be able to find connections with these wonderful websites that Jane is in part responsible for creating that have been around for a long time, these wonderful resources. So we’ll make sure to put everybody in touch with those.
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