Alyssa:  Hi.  Welcome to the Ask the Doulas Podcast.  My  name is Alyssa Veneklase.  I am co‑owner of Gold Coast Doulas, and today, I have Jessica Kupres, one of our postpartum doulas, with us, and we are both so excited to talk to Dr. Ladd.  She is the author of a book called Transformed by Postpartum Depression.  Hi, Dr. Ladd.

Dr. Ladd  Hi, guys!

Alyssa:  Hi, Jessica!

Jessica:  Hi!

Alyssa:  So, it’s still COVID.  We’re still in a pandemic.  We’re recording via Zoom, so if we hear any — you know, I have a dog and who knows what else.  Bear with us, right?  So, Dr. Ladd, I have to start — so Gold Coast Doulas is a doula agency, and I read that you were a birth doula.

Dr. Ladd  That’s correct!

Alyssa:  Are you still actively working or not?

Dr. Ladd  No.  I miss it.  I miss parts of it.  I decided to become a doula — I had a doula for my first birth, and she was wonderful.  And after I had my experience with a traumatic birth and then postpartum depression, I decided that I wanted to be a birth doula and did the DONA training.  And when I did the DONA training — this is all related, I swear – I saw in the syllabus, and Jessica, you can probably relate to this.  This was back in 2000ish – 2001, 2002.  So I was doing the training for birth doula certification, and I saw on the syllabus that there was nothing about perinatal mood and anxiety disorders.  Nothing.  And at the time, it wouldn’t have been even called that, but we didn’t – there was no training about depression or anxiety or any sort of mental health other than this kind of vague emotional support.  So I asked the trainer if I could bring in my own materials and do a presentation at the doula training.  I was so obnoxious.  And I took the PSI information with me and some basic statistics and basic, you know, what I had been through and shared my story.  And so my doula practice ended up being – I got breast cancer shortly after I was certified, so I took a hit in terms of how many I was able to do, but I did specialize in working with moms and partners who had had some sort of a trauma.  Either previous birth trauma or other; military.  I worked with some military couples.  And I absolutely loved being a doula.  It was hard physically.  I don’t think people realize how hard it is in terms of sleep deprivation and physical stuff.  But yes, I was a birth doula.

Alyssa:  Yeah.  I thought that was amazing.  Well, and it’s really amazing that you – they let you do your own presentation on mood disorders at that time, and I almost wonder if maybe you were a catalyst to adding some of that stuff to the DONA training, I wonder.

Dr. Ladd  Well, I’ve since been lucky enough to know Penny and Phyllis and work with them.  I was the founding president of PATTCh, which is dedicated to preventing traumatic childbirth.  And I’ve had many conversations over the years with Penny regarding whether or not doulas, birth doulas, should have what she would consider, I think, a scope of practice issue, because her amazing vision and belief was that anyone should be able to get the training to be a doula.  And along those lines, she felt that anything that kind of went into mental health needed to be handled by a professional.  So she and I have had those conversations throughout the years, and I’m hoping that the more the doulas nudge, that we can handle the statistics.  We can wrap our head around how to help somebody get to the Edinburgh Postnatal Depression Scale.  It’s fairly straightforward.

Alyssa:  Yeah.  I think we’ve come a long way in 20 years, right?  It’s been almost 20 years since that training.  At least we’re talking about it more.  I mean, that’s a step; a huge step in the right direction, that mothers are talking about this.

Jessica:  Yeah, getting the word out there so they don’t feel alone.

Alyssa:  Right.  So one question I had about even just the title of your book, Transformed by Postpartum Depression,  I was wondering – you know, that word “transformed” is so powerful.  And then I read in one of the chapters that you had – you were reading a book yourself about – I forget who the author was, but it had something to do with mental illness and mental health for mothers, and you read that word and it just, like, hit you.  So I’m guessing that’s why that word is so powerful to you and why you used that for the title of your book?

Dr. Ladd  Partially, yeah.  I mean, the title – that word did jump out, and it was Jeanine Driscoll, and this was a book that I had been given in my clinical training as a therapist.  And her story of postpartum – at the time, this was, for her, in the ’80s – she used the word transformed, and it’s the first time, I think, I had aligned the idea of transformation with perinatal mood disorders because I felt so different.  And when I, years later, went forward to do research in this area, the original title of this study was Changing instead of Transformation.  It was Changing Depression.  And my thought there was that what I was finding from the women’s own lived experience was that there’s a certain nature to postpartum depression.  Like, it has its own entity, and it is a changing kind of depression.  It’s so forceful.  It’s so sudden and comes on so strong, like a trauma, that it has its own sense of power.  It can change you.  And then I came back to the word transformation, and I think now, to be honest, I still grapple with that word a little because I think it has – I don’t want it to only be seen as a good thing or a bad thing.  It’s just that, gone untreated, these disorders change women.  They change women.  And for some, that change can be powerfully positive, and that’s where I got more – you know, I got involved with posttraumatic growth, but not everyone.  Not everyone.  So, yes, it’s a transformation, but I’m also kind of hinting at – which I don’t think I’m quite there yet.  I want to keep working on it.  I want to transform postpartum depression itself.  I mean, in the very back, I put together that graphic at the back page, which shows what we’ve called postpartum depression since the beginning of time, and we haven’t really gone very far.  It’s around birth.  It’s always related to some sort of reproductive event.  So I want, like you guys, to transform not only the experience that women have, but what we say about it, what we know about it, and the language that we use.

Alyssa:  Yeah.  You had mentioned that your husband at the time just kept telling you, this is all in your mind.  You’re making this choice.  Right?  And I think, you’re not the only one who hears that.  And maybe even if we as mothers aren’t hearing it from someone else, we’re hearing it from ourselves.  Why don’t you just do this?  Why can’t I just be that?  So I think you’re right in transforming not only what we call it but what we think about it and what we know about it, and I still think we don’t know enough about it, even though we’re talking about it.  It’s very surface level.

Dr. Ladd  Why do you think that is?

Alyssa:  You know, I didn’t know about it when I had my daughter.  I didn’t really know what it was.  And I would say, oh, no, of course I didn’t.  But then I think back, the more I learn, I’m like, oh, my gosh.  I remember sitting in the nursery just in tears in the rocking chair, and breastfeeding was so much harder than I imagined, and your hormones and your emotions are all over, and, you know, granted, for me, it slowly got better, but I don’t know.  I guess, was I in a depression?  Did I just have some anxiety?  Was this all just normal?  It’s hard to put a name on something.  And then the stigma of that is also what hinders a lot of mothers.  And, Jessica, I think you had a question specifically about postpartum depression, too.

Jessica:  Yeah.  But to go along with what you guys were just talking about, I think that part of it is, a big piece is that stigma, and going with my question in just a second, is that moms are afraid.  If they speak up and say something, their baby will be taken from them.  I did have postpartum depression pretty severely, and I didn’t seek help for eight months because I was, like, these horrible thoughts, which I now know were intrusive thoughts: they’re going to take my baby.  I don’t want to lose my baby.  And I think that that’s a big message that has to get out there, is that seeking help doesn’t meant that you’re a bad mom, and it doesn’t mean they’re going to take your baby.  It just can help.  And so I think that is a big piece of it.  But talking about this and this language, I wonder – you’re predominantly saying postpartum depression and focusing on the depression.  Why don’t you include more of the other things that go with it?

Dr. Ladd  Good question.  And I do, but it’s all because of language.  What we’ve known in common society – I think postpartum depression is the most identifiable.  So anybody who’s a possible reader or a clinician who hasn’t full training in the full spectrum of perinatal mood and anxiety disorders might identify postpartum depression.  And I also use it as an umbrella for all of the disorders because the language hasn’t filtered out to – I mean, we’re talking, all three of us this morning, about not knowing what to call our own issues when we have them.  So somebody with intrusive thoughts is not necessarily going to know that they might have postpartum OCD or postpartum panic disorder.  So I use the language that we’re most familiar with.  And I want to tag team on something you said about stigma.  You know, stigma – I did a study about how women who are diagnosed with bipolar disorder in the first year of postpartum, how they experience stigma.  And, basically, for all of us, any sort of the way we make decisions about the world is we observe how people are behaving, and if we perceive something to be outside of the norm – this is based on Goffman’s stigma theory – we kind of mentally categorize them as different.  Right?  And that different space is over, away, from what we’ve come to recognize as everybody else being normal.  Right?  So that different space lingers, and if we perceive them as either physically different or behaviorally different or emotionally different, we’re going to put them – our habit is to put them over in the “different” space.  And gone unchecked from just basic knowledge, that “different” group of people, we will build assumptions and beliefs about what they are capable of or how they fit in society, and it’s usually negative.  That creates the prejudice.  A prejudice; a preknowledge belief that, okay, that person who is behaving or looking different is going to potentially do things that are unpredictable.  And then if that goes unchecked, we can actually unconsciously build this implicit bias where we will discriminate.  We will discriminate in micro ways against or away from people that we perceive to be different.  So let’s take a mom who is crying a lot, and in the book, one of my participants referred to it as leaking.  You know, it’s like this kind of leak.  It’s like an involuntary crying.  Like the stomach flu, but you’re crying.  There’s no control over it; it’s just coming out.  So let’s say this mom is crying.  She feels that those symptoms are out of – they are out of the range of normal for her, and all of the baby stuff that she’s seen, from the minute she peed on the stick, didn’t show anybody crying inconsolably.  So when she goes out into the world, if it’s to Walmart, if it’s to the care provider, if it’s to the postpartum doula, there are no representations of that as normal.  So she moves herself into that “different” space and can start to believe that maybe there’s something seriously wrong with her.  And if that goes unchecked and she is at a family event crying, it gets validated because everyone’s like, why are you upset?  You have a new baby.  Everybody’s great.  So that process of stigma happens for women constantly.  And we unfortunately do it to each other.  When I was a doula, I once had a mom ask me to go to the supermarket for her to get formula because she was so afraid that some of her neighbors would see her buying formula instead of breastfeeding.  So that’s just one example.  So that stigma piece is – and the media certainly doesn’t help.

Alyssa:  Right.  And I had a question about one excerpt from your preface, and maybe I’ll just read it, because it stuck out to me.  Again, it’s the whole stigma, and it’s the idea of what do we call this.  So it says: “I reject the notion that objective truth is inherently real or measurable but rather constructed by multiple entities, including society, culture, history, and individuals, all coexisting.  So from this perspective, the reality of postpartum depression can’t be known, defined, or quantified.  By definition, it is constructed in real time, every time, in multiple ways, by multiple people.”  So it’s dynamic and changing, and to me, this pinpoints exactly why this is so hard to define, because postpartum depression, for one, doesn’t look – you know, for you doesn’t look like it does for me, and a lot of how we feel about, you know, if I had it, maybe it’s the way my family’s talking to me about it.  Maybe it’s, you know, not going to the grocery store for fear of my friends finding out I’m buying formula.  Or maybe I don’t care about that, but I have to post all the beautiful Instagram photos.  There’s just so many different layers and levels that I think you just hit the nail on the head with why this is so hard to define and then so hard for others to understand.

Dr. Ladd  Exactly.

Alyssa:  So when a mom has it, I feel like she’s – you know, maybe her partner doesn’t understand.  So like you, getting the whole thing about well, just change your frame of mind.  Just do something different.  Get your head out of the hole and, you know, you have a baby who’s beautiful, so what are you so sad about?  If people don’t understand, then we just dig ourselves into a deeper hole.  Well, I know I feel this way.  I shouldn’t feel this way.  I don’t want to feel this way.  But now they’re making me feel worse, so now I’m probably digging a deeper hole, and it’s just getting harder and harder to get out.

Dr. Ladd  Yes.  And part of what you’re saying, really, it speaks to how do we fix this, and I think the more we can normalize that – we have no trouble talking about a clogged milk duct.  No trouble.  We’ve made that okay.  And women have said, I need help.  So there’s been this agreement between science and society to allow women to talk about things like sore, cracked nipples, for God’s sake.  We can do that.  We can talk about how to care for an episiotomy repair.  I think maybe if we could talk about the range of that for every birth, there is a range of physical and emotional recovery and experience, and within that, I mean, we do know that 80 to 85% of all birthing women will experience postpartum blues, that kind of – you know, shortly after birth, two or three weeks.  It lasts for a few days and then moves out.  But we’re not even comfortable talking about that, and when I say we, I mean all of us.  But predominantly care providers.  So when you’re discharged after having a baby and you have all those pamphlets about how to lactate and breastfeed but there’s nothing in there about how you can identify if you’ve got some things going on with your brain, there’s a miscommunication.

Jessica:  So what would you suggest?  And this – I just really am interested.  What would you suggest as care providers that we do to get the word out?  How do you think we could improve that so more moms would know about it ahead of time and can be better prepared for it so it doesn’t just hit them like a ton of bricks?

Dr. Ladd  I think there are a couple of things, one of which is public health.  And on the public health level, we need more support for mandated screening.  And ACOG is close, but not there with the mandate to screen.  And even asking a woman about her family history, we’re not – if it’s not on the checklist for an intake for the OB nurse, for any sort of prenatal or perinatal care provider to say, so, tell me about your family history with any sort of mood or anxiety disorder.  If that’s not on the list, that’s something we could add quickly.  We’re not shy, and ACOG is not shy, about saying that we need to test your urine.  We need to test your blood.  We need to test your blood pressure many times to screen.  But yet even though we’ve got these validated screening tools, it’s not mandated, and that sends a message.  I’m not even sure that would fix it.  But on the public health level, organizations like National Perinatal Association, NPA, PSI, who are saying, we have to change it by asking women.  That’s one way.  And then I personally believe, and that is my personal belief, that the more women can talk about how they’re feeling, regardless of what they think might be happening in response to that, the better.  So in my research, all 25 women ended up having to get themselves treated because providers failed, even when women were saying flat out, I’m not sure I want to be here, or I think I shouldn’t be my child’s mom, or I can’t sleep.  And providers miss it.  And I don’t want to bash providers; I really don’t.  I want them to get the support from their certifying bodies that it’s important; important enough to take 5 minutes out of the 15 minutes that they’re given with a patient and ask.  So that’s part of it.  And I think as the birth community, the mom community, that’s so huge now online.  Maybe we just need to lighten the load on the language.  I mean, the women in my book speak very frankly, and I think all women speak very frankly when they’re not under the – you know, when they’re not being analyzed.  We all have those private Facebook groups where women are throwing down.  So when a participant will say to me, I don’t know why we don’t just tell each other.  It sucks, man.  That resonates on a level to any mom, regardless of their perinatal mood or anxiety disorder.  Why don’t we tell each other it sucks?  And that’s the last piece.  And it seems to be that we have a lot of trouble allowing – I’m going to use the word allowing – women to be ambivalent about motherhood.  You’ve got to love it all, or you’re horrible.  Every moment of it, every diaper change, every ear infection, all of it.  And that’s – who loves all of anything?

Alyssa:  Right.  That’s not fair for anything, let alone a screaming toddler or a sassy teenager, right?  With each new stage, I feel like – you know, I always tell my postpartum clients that every developmental stage, you lose something that’s so hard, and then you go onto something that’s easier, but then this new hard thing is going to come.  Like, there’s always going to be this new hard thing, and you won’t be prepared for it, and it’s okay.  It will suck for a while.  But yeah, I think it’s hard to – you know, I have whole days that I’m just like, oh, my God.  This is awful.  What in the world?  Why?  I read something the other day where this mom said she had one kid, and it was – you know, the pain of it and just the exhaustion.  It was, like, a two-day induction or something.  She goes, my only thought was, why in this developed world where contraception is available do we have so many humans?  Like, why are people doing this again and again?  And she was so real.  I loved it.

Dr. Ladd  Yes!  And the last piece of this, and not everyone – you know, I will just share that I think Bowlby and attachment theory has done a number on us for six decades because, on some internalized level, guys, we are buying the notion that maternal deprivation will harm the thing that we love more than anything.  That if we sneeze in the wrong direction or have a thought about, God, I’d really like to not be doing this right now, we will harm our child.  Not only once; for their lifetime.  And while we do have, you know, years of science about maternal attachment and development, we have yet to really clear the debris of what attachment theory can also do, which is to shame women out of their reality.

Jessica:  Yeah.  I feel like that’s a lot of mommy wars type of stuff.  There’s so much information on how to be a good mom, and whichever way you choose, every other way is going to say you’re wrong, and I think that’s just really hard, that we just don’t – I mean, it’s all this pressure to be this perfect mom.  Yeah.  I think that’s a big piece of it.  And then we have, on that, that if you have depression, if you’re not happy, if you don’t enjoy every minute of every day, now you are destroying your child for the rest of their life.  Now you’ve not only given them depression because you have depression genetically, but now you’ve given them depression because you’re depressed and you didn’t bond with them appropriately.  And so let’s just add a little more stress and anxiety to someone who’s already stressed and anxious.  And I just think that’s – I mean, it’s good to know.  Like you said, it’s research.  We know that there’s not that – it’s not going to be as much bonding and that it can cause more depression, but I feel like sometimes it just adds more.  It’s another way to feel like you failed.

Alyssa:  Well, and I think – I have the same thoughts about the attachment.  You can always go too far.  You know, and of course the oxytocin that you can get from the skin to skin, but sometimes even now, and my daughter’s 8, I just feel touched out.  Everyone just needs me all the time, and if I were a depressed mom with a newborn baby, and everyone’s saying, oh, you’re feeling depressed.  Just hold your baby all the time.  Wear your baby all the time.  Breastfeed more.  That’s just more touch when I need my own space.  And then sometimes babies – I see this a lot because I do sleep consultations, and I get those depressed moms who haven’t slept for months.  They are so sleep-deprived, and then they think, I’ve been holding my baby to sleep for three months straight or all these things.  They don’t know that their little babies are developing these personalities, and they might not want to be touched all the time.  Just because you’ve been told that they need to be picked up every time they cry – your baby doesn’t always need that.  So really listening and being in tune with what you want as a mother and what your baby is actually asking for – I think we’re just getting – like you said, the attachment thing.  We’re just getting too touched out.  We don’t necessarily need that all the time.

Dr. Ladd  This is such a great conversation, and it makes me think about how it loops into the stigma.  It loops into what we said about needing to let women speak to their own experiences.  And I think there’s something about redefining attachment as – or this idea of motherhood as, you can communicate to your baby and to your child: Mommy’s struggling, and I’m right here.  I had a conversation with a mom this week, a colleague of mine, who’s got a boy who had to have a tooth extraction.  And as anybody listening can imagine, a child having a tooth extraction is incredibly anxious, and it was long and very difficult.  And I said, you know, it’s okay to tell him that you – it was hard for you, too.  And that you went through it together, and that you’re okay.  Yeah.  I was there, and because it validates to your child, yeah, that was pretty crazy, wasn’t it?  That was pretty hard.  It was hard for me, too.  And I’m okay.  And maybe we can allow each other to say, you know what?  I see that you’re an amazing mom, even though you have these experiences that tell you that you’re not.  And we can start to say to our children, you know, I went through this, and I rock.  It didn’t screw me up in terms of my connection to my child.  It actually made it stronger.  And I’ve had women, lots of women, tell me that, that the connection with that child with whom they went through a mood disorder is unique and tight.  In other words, I think women – we love our kids, no matter what.  It just doesn’t have to always be positive.

Jessica:  I love that you said it doesn’t always have to be positive, and I think that’s really important for moms to know, that it doesn’t always have to be positive.  That there will be ups and downs, and it’s the hardest job in the world.

Dr. Ladd  And we’re able, in other areas of society, to really honor struggle in a way that’s noble.  Veterans: we’ve gotten our heads around honoring the nobility of somebody who’s sacrificed and paid a price emotionally, physically, et cetera.  And yet we’re not able to do that for moms in terms of honoring their suffering nobly.

Alyssa:  I love this conversation.  Two more things.  We’re going to end with how people can find you and your book and tell us anything else about your book, but let’s say not everyone is going to be able to read your book.  What’s one thing you think every mother, parent, would need to know going forward, either about motherhood or mental health or…

Dr. Ladd  I would say about any woman who is of childbearing years should be talking, should be telling, their provider about their sleep, their appetite, whether or not there’s a history in their family of mood or anxiety disorders, and for women of color, it is so much harder to get the message across, so I would say we all need to support our women of color to have an ally, to possibly go with them to the provider.  Without a doubt, we need to be telling – because they’re not asking right now.  They’re not saying.  They’re just not asking.  For a number of reasons; put COVID on top of everything else.  So we need to be encouraging.  I would love to see – there’s this concept called a reproductive life plan where doctors could be asking young girls and young men about their emotional and mental health very early on.  So a pediatrician who’s doing a well‑check for a kid who’s 11 could be planting the seeds that that’s a safe space to say, I am not sleeping.  I’m having intrusive thoughts.  Or I can’t stop thinking about this, or I’m any of the symptoms that would come forward.  So to wrap that one up, I would say – and for anyone who’s pregnant and/or just had a baby, I would say, know the language of mood disorders to be able to say it to your provider to get help, and that would be how your sleep is affected, how your appetite has been affected, and how your sense of hope or interest in life, anhedonia, has been affected.  Just being able to say, I’m not sleeping.  I’m not eating.  And I feel like I don’t want to do this.

Alyssa:  Yeah.  I think that’s beautiful.  Well, thank you so much for doing this.  It’s such a pleasure, and I look forward to finishing the book.  We got quite a ways into it.  But tell people about your book; maybe say your name and the title again and where they can find your book.

Dr. Ladd  Sure.  So my name is Walker Ladd, and you can go to my website.  And the book is Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth.  And that’s on Amazon or at my publisher, Praeclarus Press.  And I also wanted to give a shout-out to anybody interested in the book to think about – I was able to get interviews with amazing experts, so a part of the book is dedicated to – I ask, you know, Karen Kleiman and Jane Honikman.  I had such a great experience interviewing these leaders to see what they think about the idea that untreated postpartum depression or any disorder could be experienced as a traumatic life event, and it was a very interesting response.

Alyssa:  Great.  Well, thank you so much!  We’ll talk to you soon.