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Emily Writes on the couch with a clinical psychologist

Spinoff Parents editor Emily Writes is an anxious mess, which is why she’s constantly talking about mental health in mothers and the need to get help if you need it. She recently spoke to a clinical psychologist who specialises in treating mothers with anxiety and depression and other mental health issues.

This is the fourth in Emily Writes’ series of interviews with paediatric and parent-focused health professionals, including a dentist, a GP, a paediatrician, and a midwife.

Dr Sarah Bell-Booth is a mum of three and a clinical psychologist. I first discovered her on Facebook and I asked to republish a post that resonated with me. I thought it would be good to talk to her as part of our health professionals series.

Hi Sarah! Why did you decide you wanted to treat mums?

I was frustrated and saddened by the huge need for mental health support, portrayed through social media. Mums often describe feeling ‘lost’ about where to seek help with their anxiety or depression and unfortunately many who have mild to moderate difficulties slip through the cracks in community services. I felt it was my duty to use my skills to help this community. Of course, being a mother of three young children (including twins), I know too well the challenges of parenthood, which helps me empathise with my clients.

Sarah Bell-Booth

It feels like getting treatment for mental health issues in New Zealand is pretty hard. Maternal Mental Health services can be really good but getting seen quickly is really, really expensive. Do you have any thoughts on why that is?

It seems there are just limited resources and funding by government unfortunately. You’re right, Maternal Mental Health is a great service. Unfortunately, the demand is so high that they must prioritise those with a higher severity of mental illness.

Well-trained mental health professionals such as clinical psychologists may seem expensive but have many years (up to seven years) of specialist training and high registration and running costs, which are not subsidised by government. Not ideal at all but we do what we can to help those in need. It’s definitely worth checking out whether you can be subsidised by WINZ or health insurance though.

What do you think are some of the biggest issues you’re seeing with mums these days?

How long have you got? Modern society has got a lot to answer for when it comes to the pressures it places on mothers. It is a perfect storm of factors. It includes the expectation to make a quick physical recovery from pregnancy and birth and adjust to their new parenting role. This new role is often completely different to their previous life or career of freedom, control and predictability. This is especially true if the mother is older, which is common these days.

Often mothers are pummelled by conflicting advice, which casts doubt on their instincts causing worry. If they are in a Western culture, they will likely have minimal practical support and are instead forced into an autonomous role, leading them to feel lonely and disconnected. There can be enormous pressures to juggle everything well and make the ‘right’ choices regarding return to work, which may trigger uncertainty and guilt. Uncertainty can then lead to a search for answers which may include unfair comparisons with other mothers who ‘seem’ to cope, which  likely fuels further self-criticism.

Do you think more mums in 2017 have anxiety than mums in like, the 50s? I see a lot of people saying everyone has anxiety these days – and I just figured it was underground back then. Do you have any thoughts on that?

It is hard to compare prevalence rates of anxiety throughout history, often due to changes in insight and understanding of mental health problems, change in reporting from stigma, and other factors. As you can imagine, each era would present different challenges. In the past, communities were often more tight-knit due to transport limitations, leading to increased natural social support in raising children together. This would likely have prevented loneliness and distress. Although there were limited career choices and opportunities back then which may have been frustrating for some, mothers may have been spared the stress and pressure of juggling and meeting expectations in all domains. Technological advances are a double-edged sword. Social media can connect like-minded individuals but, as I mentioned, it can create unhealthy comparison, competition and criticism.

What’s the difference between cognitive behavioural therapy and dialectical behaviour therapy and other therapies?

I use both Cognitive Behavioural Therapy (CBT) and principles from Dialectical Behavioural Therapy (DBT) in my practice. They are both evidence-based, present-focused and help people to develop practical coping strategies for specific situations.

CBT focuses on how thoughts affect behaviours (e.g., avoidance or overcompensating), physiological reactions (e.g., panic symptoms or lethargy) and emotions. It is shown to be effective for treating many different mental health problems including depression, anxiety disorders, eating disorders and substance use disorders.

DBT is a specific form of CBT, which is said to have a stronger focus on social and emotional aspects. It was originally developed for more complex cases characterised by extreme emotions, unstable relationships, and self-harm/suicidal behaviour but is now used for many different problems. It focuses on mindfulness, distress tolerance skills, emotion regulation skills and interpersonal effectiveness skills. A full DBT programme can often be longer-term, sometimes with the inclusion of group therapy as well as individual therapy.

What kind of things do we need to know when looking for a psychologist?

When searching for a psychologist, the most important thing is that you feel comfortable with them. If you’re finding it difficult to establish a therapeutic relationship, it’s time to find another one. Of course, it’s also important to ensure they are currently registered and to check their level of training, specialities and current therapeutic approach to suit your needs.

Lots of mums tell me they feel they have PND but they don’t have babies anymore so they don’t know what to call it. Is that just depression? Or just anxiety? What would you advice a mum to do if she had older children and was really struggling?

Are you ready for my technical answer? According to the diagnostic manual we abide by, postnatal depression (PND) is actually called ‘Major Depressive Disorder, with peripartum onset’ – ‘peripartum’ meaning both antenatal and postnatal. But here’s the catch, it can only be diagnosed if you meet the criteria for clinical depression during pregnancy and within 4 weeks of delivery. This may be a surprise since, especially in clinical practice, we notice that mothers will often have an onset of significant depression and/or anxiety many months after the birth of their child. Fortunately, the community Maternal Mental Health service will accept anyone with severe mental health concerns within 12 months of birth. Also, some other health practitioners will even extend the diagnostic period up to two years due to the physical, emotional, environmental and biochemical changes that happen. So, these inconsistencies may explain the confusion out there in the community.

Also, the ‘Major Depressive Disorder with peripartum onset’ diagnosis acknowledges that there are co-existing symptoms of anxiety and panic attacks. Some mums just describe feeling ‘overwhelmed’ rather than anxious per se. There are also specific types of anxiety disorders for example, generalised anxiety disorder, social phobia or obsessive-compulsive disorder that require different treatment approaches. Too much information? Leave it up to us to decide but don’t let the specifics hold you back from reaching out for support. This includes mothers or fathers with older children. They should either consult their GP who may be able to recommend local mental health professionals or contact one directly, such as myself.

Sleep deprivation has such a huge impact on mental health – I was often told if I got more sleep I wouldn’t be crazy. And it made me just wait until I got sleep, which never happened. What can we do if we aren’t getting any sleep and we can’t get any sleep?

As we know, sleep deprivation can significantly affect mental health. Sometimes there are complex reasons for why you are unable to get enough sleep, like your child has physical health concerns which interrupts sleep. If you have tried enlisting help to get more rest – like getting friends or family to come over so you can nap, doing alternate night shifts with your partner, asking community services to give you practical support or breaks – and you still struggle, do not wait for sleep to return. Whatever the cause, it is certainly worth seeking help to develop coping strategies to better manage the mental health consequences. Why wait when you can be happier right here and now?

What can we do if we’re not coping? What should the process be if we realise we are depressed or anxious a lot of the time?

Often the first port of call is to consult your GP to rule out physical causes of low mood or anxiety or symptoms that look similar, such as hypo/hyperthyroidism or anaemia. Medication may be indicated for moderate to severe mental illness but this needs to be an informed choice in consultation with your GP or psychiatrist. Depending on the severity of distress, your will either be referred to a service or you can directly self-refer to a mental health professional such as a clinical psychologist like myself.

Emily outside being a mentally ill person with great hair

You also provide group therapy for mums – now that’s an intense coffee group. How does it work and who would it suit?

It can be a lovely way to normalise difficulties, learn coping strategies specific to your situation and gain natural support to apply those strategies in and between sessions. Group therapy members may be actual coffee group friends or acquaintances who I match up. I prefer to keep my groups small about four people max so they are more individualised and less intimidating. They suit mums who are struggling with stress and anxiety. I individually assess them first to ensure suitability for the group.

I like your blogs, which is why I’m interviewing you, but one of them in particular really meant a lot to me. You wrote about “normalising anxiety in parenthood”. I had never thought of the need to do this, but it makes so much sense. It feels so hidden and scary when you’re a parent with mental health issues – but it’s fairly common isn’t it?

Very common unfortunately. Statistics show that 10-15% of mothers have perinatal depression, 15-20% have perinatal anxiety and approximately 10% of fathers have postnatal depression.

You suggested thinking in terms of “Is my worry helpful?” and asking the following questions: Is my worry excessive, distressing, time-consuming, or overly focused on the future at the expense of present enjoyment? Are the events I’m predicting in my control or unlikely to occur? And: Is my body in panic mode as it responds to perceived threat.

Those questions are a really helpful starting point and it was also really good to read what the ‘fight or flight response’ actually is. Like, I’m not having a heart attack, it just feels like it. What do we do once we’ve identified those feelings?

To reduce the physiological fight-or-flight response, it is important to first use relaxation exercises such as controlled breathing. Some mindfulness mobile apps can guide you through this. This will calm your mind enough to think rationally and challenge your unhelpful thoughts and prevent you from engaging in unhelpful behaviours such as escaping the situation or being irritable with others. I can help with the specifics in session depending on the situation.

On your Facebook page you said “anxiety and avoidance are best friends” and I thought that’s so true. What are your tips for those of us who hermit when we are anxious? I find it makes me feel so much worse when I isolate myself but then I have such a strong desire to do that.

It can certainly be a strong desire to protect yourself from perceived danger – key word ‘perceived’ – your anxious mind might be tricking you. Often confronting a situation is difficult but ‘opposite action’ is best to test that you are, in fact, safe from harm or judgement. This exposure must be in a controlled, gradual way with support if possible, so as to increase your confidence and gain momentum for change.

I’ve spoken to heaps of mums with mental health stuff and for most of us our biggest worry is that we will pass anxiety or depression or panic on to our children. Is that a fear you hear from mums? And what would you tell those mums to reassure them?

Unfortunately it’s a common fear. We have to consider the research that shows that anxiety and depression develop from a complex combination of biological/genetic factors and environmental factors. The good thing is, you can influence some of the early learning your children experience. Specifically, you can reduce the likelihood that your child will be overwhelmed with strong emotions if you teach them to openly communicate their feelings and reach out for support. It is then important that you validate your child’s emotions and normalise them for their developmental stage or situation. You can also role model effective coping strategies such as self-care and reducing self-criticism and comparison with others.

Can you avoid antenatal depression or PND?

‘Avoid’ is a strong black/white, all or nothing term which may not be entirely possible if you have a strong genetic predisposition. However, there is evidence to suggest that if you learn your triggers, early warning signs and adaptive coping strategies, you can reduce the impact of depression on your life.

What can we do to support our partners or friends who have mental health issues?

If you notice any changes in their mood or behaviour, go to them rather than wait for them to reach out to you for support. Ask them how they are. Listen – really listen, without giving advice. Validate their concerns by saying things like “that sounds tough” or “that’s understandable”. Offer to go to appointments with them if necessary. Don’t give up on them – your support and kind words are important.

Finally, what is your advice to mums around their mental health?

Parenthood can be difficult, distressing and isolating. It is common to struggle during this time but it can change with the right support. Reach out to family, friends and mental health professionals. We all want to help.

Dr Sarah Bell-Booth is a mum of three (one girl and twin boys) and a clinical psychologist. She offers evidence-based treatment for parents with anxiety and depression. Emily Writes is editor of The Spinoff Parents.

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