For this 3-part series on postpartum depression, we interviewed Mary Wise, MA, MFA, BSN-RN, who is the Chief of Maternal Health Services for Delaware Health and Social Services’ (DHSS) Division of Substance Abuse and Mental Health (DSAMH). Mary will talk about what postpartum is, common and myths, and how to get help.

3. What are some common myths? What do you think people should know about it?

One common myth about postpartum depression is that birthing people just experience depression or have “the baby blues,” and it’ll just pass. This often comes packaged with the myth that the parent is just “adjusting” to things being harder and they just need to “get the hang of it.” There’s a wide spectrum of disorders a birthing person could experience at any point of their pregnancy and up to one year beyond its end. It also is not something that untrained people can treat. They can’t “make them feel better.” The person needs a trained professional and possibly medication, other interventions, and supportive resources. While the untrained person’s heart is in the right place, it is dangerous to try to help someone who has symptoms of a PMAD without a professional’s involvement. This is because the situation can go downhill and become catastrophic very quickly, so it’s important to allow a professional to determine the person’s needs and closely monitor their progress. It is very human to notice something and wait because it’s scary and we hope we’re wrong. It’s also very human to notice and just not realize the significance or know what to do. It’s safest, though, to always seek the guidance of a professional.

Another common myth is that this only happens to certain types of people in certain situations, but PMADs can affect everyone regardless of ethnic background, family dynamics, financial status, or anything else. There are some outside factors, and internal genetic factors, that can increase risk, such as having a history of depression or trauma, but no one is immune.

And that includes partners of the birthing person. Many people believe the myth that they couldn’t possibly have PMADs. But the reality is that fathers and partners absolutely can. Although their risk is lower, when we think of “Maternal Mental Health” we should most definitely include the fathers and birthing partners in that as well. Their mental health and well-being directly and profoundly affect not only their lives but the lives of the birthing person and their children. A possible example of how it affects the family unit is the increased risk for pregnant and parenting birthing people to experience domestic violence or be the victim of homicide during the perinatal period.

4. Do you think there is stigma around postpartum depression? If so, what are some examples?

I absolutely think there is stigma around postpartum depression and PMADs, just as there is stigma and discrimination around all mental health and substance use diagnosis. The reasons for them all are similar. They result from a lack of knowledge, which causes a lack of empathy. In general, the way we commonly use language and the way media portrays this subject matter directly contributes to that lack of knowledge and empathy. Some cultures from other countries also hold deeply ingrained beliefs that perpetuate stigma as well. And we can add to those cultural factors, the personal and familial histories where negative stories grew out of very real pain and fear, perpetuated by experience and lack of evidence-based knowledge.

All stigma, no matter where it’s experienced, grows shame and shame grows illness. We can easily look to the work of shame researcher Brene Brown, a mother with lived behavioral health experience, for the evidence base to show the negative effects of shame. Shame causes people to avoid seeking treatment and also causes them to engage more in unhealthy behaviors.

Stigma can be experienced by birthing people and their partners in all of their social circles. It may be experienced as daily reminders from cultural or religious norms that may say it’s shameful to have a mental illness or take a psychiatric medication. They may also experience it indirectly at a holiday meal while family members or friends talk negatively about someone else with a behavioral health diagnoses or another parent who has symptoms of one. From there, moving outward, they may also experience it at their job in similar ways, or an employer may not allow the needed time off for self-care because they don’t believe their employee actually needs the time or care. It may even go as far as jeopardizing their employment, along with housing and food security, if an employer calls out the person’s signs and symptoms in a putative work evaluation. In another instance, co-workers may use hurtful language, express annoyance, or avoid working with the person because of their diagnosis or symptoms. And medical professionals who lack the knowledge needed to support these individuals may use judgmental language, such as “difficult,” “non-compliant,” “drug-seeking,” or “attention-seeking,” when documenting or discussing these clients. As a result of stigma and judgement, these individuals also may not receive the treatment needed in a timely manner, or they may not receive the needed treatment at all because their signs and symptoms are not taken seriously.

If someone experiences stigma at any of these points in their social circles, it can create enough shame to prevent treatment. If they experience it in all areas of their life, this barrier to treatment can become a huge mountain to climb. Broken trust and can be very difficult to rebuild and shame can be very difficult to heal. That’s why it’s so important to educate and be vigilant about how we interact with all people. Our words matter as much as our actions.

When we look at the pregnant and parenting population, there’s an added layer of shame and stigma. Our culture, just as many other cultures, equate behavior with morals. For that reason, when someone behaves in a way that isn’t healthy or we don’t understand, regardless of the reason for their behavior, some automatically feel it’s a moral defect of character and there’s something “wrong” with that person. They forget that it’s the behavior that’s the problem, not the person. The person is human and doing the best they can with the tools they have at the time. And so is the person who is judging for that matter. That’s why education is needed. They need tools too. If someone asks me to build a dollhouse and gives me 3 blocks of wood, a saw, a hammer, and a box of drywall nails, what I build will not be a very nice doll house. It may not even resemble one. No matter how hard I try, no matter how many hours I put in, I’m only going to give you what I can give you with my knowledge and the tools I have. I’ve never made a doll house, and I’m pretty sure you need more than a few blocks of wood, a saw, a hammer, and drywall nails.  Does that mean there’s something wrong with me because I can’t build the dollhouse with those tools? Does that mean that my moral character is off? Of course not. That’s easy to see because it’s obvious to anyone that the tools I had were inadequate.

What’s more difficult is looking at a person who lives in a house with dirty dishes piled high, trash overflowing from the cans and scattered around the room among the various piles of clothing and papers, etc. Someone may say, “What’s wrong with them? Why don’t they just take a day and clean it up? They have cleaning tools, after all.” What they don’t have, though are the tools we can’t see.

They don’t have the chemical’s in their bodies they need to think clearly and motivate them to do these things. They also may not have the tools needed to feel supported and not get stuck in the emotional swirl of shame, guilt, and overwhelm. This is their version of the “dollhouse.” Looking at this version, some may think there’s something wrong with this parent. They may think the parent is just being lazy or doesn’t care. And this is because they don’t realize the parent is missing essential tools or is struggling with traumatic memories, anxiety, depression, hallucinations, etc. And because they’re parents, they’re held to an even higher expectation; it’s not just their life they’re responsible for, it’s also the life of the child they’re carrying or the ones who are crawling through the unsanitary, unsafe living conditions and going to school in the same dirty clothes they wore for the last 3 weeks.

That parent needs empathy and tools, not judgement and shame. And yes, the children need support, but they need someone to do the laundry and help their parent get well; they don’t need be removed from their family as a result of stigma, which may have contributed significantly to these conditions becoming so unhealthy. That’s just a band-aid for the symptoms and it perpetuates the feelings that are already setting that person’s world on fire. Taking away their children, takes away their hope and maybe the only reason they’re still alive. That said, if children are in imminent danger, it’s necessary to remove them. If they’re not, however, it’s better to give the family the support they need and help them all get back to baseline or create a new baseline. Removing stigma is the foundation for that.

Guest Blogger: Mary Wise, MA, MFA, BSN-RN

Mary Wise, MA, MFA, BSN-RN, is the Chief of Maternal Health Services for Delaware Health and Social Services’ (DHSS) Division of Substance Abuse and Mental Health (DSAMH). In this role, she leads initiatives designed to support the mental health and substance use disorder (SUD) treatment needs of birthing people in the state of Delaware. She is part of the core faculty for the Peer Recovery Specialist ECHO series, created in partnership between the Weitzman Institute, DSAMH, Help is Here Delaware, and the Substance Abuse and Mental Health Services Administration (SAMHSA). Mary also provides subject-matter expertise to inform policy and standards and to support grant-funded projects. In addition, Mary serves as a Commissioner for Delaware’s Maternal and Child Death Review Commission (MCDRC) and is a participating member of the Commission’s Maternal Mortality Review Committee (MMRc).

She is an active member of the Delaware Perinatal Quality Collaborative (DPQC), the Delaware Healthy Mother and Infant Consortium (DHMIC), and DHSS’s Multi-divisional Perinatal Workgroup and Advisory Committee. She is also a writer and has previously worked as a registered nurse and as an educator of children and college-level adults. Adding to her professional background, Mary is a single mother of 2 teenagers and has a wide variety of lived experience that informs her work in all areas. These help fuel her passion about reducing maternal mortality and morbidity, eliminating health disparities and stigma, and supporting the mental health and substance use disorder treatment needs of this population. She believes the path forward is through a holistic approach that addresses the needs of the entire family unit. This ideally incorporates a web of multi-disciplinary care and resources, which address not only behavioral health and medical needs but also social determinants of health, including those nuances well beyond what is traditionally thought of as basic needs.