How Women of Color Can Manage The Impact of Acculturative Stress and Discrimination During Pregnancy

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dr sumner acculturative stress and discrimination during pregnancyToday I’m thrilled to have Dr. Lekeisha Sumner with us to share insight on two very common types of stress women of color may experience during pregnancy and tips on how we can manage both. Dr. Lekeisha Sumner, PhD, ABPP is a board-certified clinical psychologist with specialization in both clinical psychology and medical psychology. She is currently an Associate Professor in the Department of Psychology at Alliant International University and Assistant Clinical Professor in the Department of Psychiatry & Biobehavioral Sciences at UCLA. A frequent commentator on psychological science, she has written extensively on trauma and the intersection of culture and gender in health and well-being. Dr. Sumner maintains an independent practice in West Los Angeles where she was recently commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment to serve on the Strategies for Improving Outcomes for Peripartum Women committee.

With so many changes in one’s body, daily routine, and responsibilities, it’s typical for many women to feel overwhelmed at times both during pregnancy and after the birth of baby. And yet, for some women, these feelings can be compounded by stressful experiences related to their cultural backgrounds or ethnicities, which increases their vulnerability for emotional distress.

Take for example, Olivia, a bright and compassionate 28-year old woman who was in the second trimester of her first pregnancy when we met. She had moved to the United States several years ago from her native country and was elated to finally have the opportunity to be with the man of her dreams and start a family. Her husband, a US native, was supportive of her adjustment to life in a new country and particularly attentive to her needs during pregnancy. She was especially grateful for the comfort he provided now that she lived without her extended family.

Despite all the wonderful changes that were happening in her life, Olivia felt chronically overwhelmed and was stunned by the recent discovery that she had developed hypertension during her pregnancy. She had already unsuccessfully tried the home remedies her mother suggested which included taking a walk around the block and listening to relaxing music. But, at the urging of her husband who observed her increasingly distressed mood, she decided to enter psychotherapy.

Olivia began experiencing stress on her job long before she became pregnant but things only intensified once she disclosed her pregnancy to her boss. Since that time, she began to experience difficulty sleeping, little appetite, constant worrying, and difficulty concentrating and had even begun to grind her teeth during sleep. Given the severity of the symptoms, Olivia was concerned that they would negatively impact her pregnancy. As she began to delve into the underlying sources of her stressors and the contexts in which they occurred, it became clear that many of the experiences she described are common among women from some ethnic and cultural groups (especially women of color, refugees, immigrants, etc.) yet rarely discussed: acculturative stress and discrimination.

Acculturative stress typically refers to the emotional strain of having to alter one’s cultural attitudes, beliefs or behaviors to adapt to and navigate a distinctly different culture. For Olivia, acculturative stress presented as the strong social pressure she felt to quickly learn English and lose the accent of her native language. She also experienced discrimination on her job as her boss would often humiliate her by making snide comments about immigrants within earshot. He would keep constant tabs on her, would make embarrassing “jokes” about people of color and her accent, and routinely give her lower performance evaluations than her colleagues even though her productivity was equal too or greater than theirs. After disclosing her pregnancy, these incidents worsened. Although working in a hostile climate resulted in her having performance anxiety, ruminative thoughts and nightmares, she was too intimidated to report this behavior to human resources and believed she would have been labeled as being “too sensitive,” “playing the race card” and perhaps worse, risk further alienation and stigmatization.

Over a period of time, intense and chronic stressors like the ones Olivia experienced can wear on a person and leave them feeling emotionally drained and depleted. The stress brought on by discrimination and acculturative strain during pregnancy can quickly erode one of the most sacred and enjoyable periods of a woman’s life and render women at risk for symptoms of depression and anxiety, and poorer lifestyle choices (e.g. eating habits, nicotine use) as they attempt to cope. For some groups, these stressors may alter the release of bodily hormones that may affect the outcomes of pregnancy. For example, African American women across the economic and educational strata have the highest rates of preterm birth in the United States. Studies confirm that these findings are in part due to the high levels of chronic stress and ethnic discrimination they are exposed to throughout the lifespan. While research shows that these stressors do not affect everyone or every group of pregnant women exactly the same, they can certainly diminish mood mood, energy, and confidence in caring for baby.

There are some ways to help lessen the impact of acculturative stress and discrimination. For instance, women who use healthy coping strategies (e.g meditation, walking, journaling, asking for help), those with a strong belief in their ability to overcome obstacles and those who have pride in and a connection with their cultural heritage and cultural values all seem to have better emotional responses in the face of these types of stressors than those without. Also, women who feel a sense of belonging and receive support from their partners throughout pregnancy and post-partum also tend to respond better. For Olivia, getting involved in an on-line support group, a local church that appreciated congregants from diverse backgrounds and engaging in psychotherapy were all beneficial in helping to restore her well-being and equipping her to improve her ability to cope.

For all women, the pregnancy experience is shaped not only by biology but also by psychological and cultural influences. While you may be limited in eradicating all stressors during pregnancy, given the suffering that severe culture-specific stress during pregnancy can cause for you and baby, it’s a good idea to discuss with your doctor as soon as possible any concerns in your life.   You will also want to monitor your stress levels not only during pregnancy but also in the many months after your bundle of joy is delivered. Taking a few extra steps can help you better prepare to be the best warrior mom you can be.

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Not All Situations Are the Same: My Four Stories

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postpartum depression storiesTrigger warning: This post contains some references to miscarriage.

Often, I find myself telling my story of life with and after postpartum depression (and postpartum OCD, and postpartum anxiety, and postpartum PTSD… darned comorbidity). I love to tell my story. I also love to listen to the stories of other people. Over time, I have come to realize that it’s easy to fall into a trap of saying or insinuating that [this] is what worked for me and so you should do what I did; it worked for me and it will work for you.But one of the things I have come to realize is that no two stories are the same. And it’s not just that no two people’s stories are the same, no two stories are the same even for an individual person. Even if there are similarities, there will still be differences. This certainly holds true for treatment options and strategies.

I have had four pregnancies. Three of those ended with live births, one ended in miscarriage. They also all had different mental health situations, outcomes, and treatments. I have one story, in the sense that it is the story of my life, but that one story contains smaller individual stories, and they don’t all follow the same template.

The first story

My first story is that of my oldest child. In April 2009, after a very long and difficult labor, I gave birth to a beautiful little baby girl. Unfortunately, life was not the idyllic fairy tale of storybooks and I found myself suffering a nasty case of postpartum mood and anxiety disorders. I was officially diagnosed with postpartum depression and anxiety, and had missed diagnoses of postpartum OCD, postpartum PTSD, and hypothyroidism. I believe I also had some antenatal depression that went undetected. (I didn’t even know that was a thing until a while down the road). That story involved 2 inpatient hospital stays, 9-ish months of Celexa, Ativan, and Ambien, and seeing a therapist. That was what was necessary and what worked for that story. Ultimately, an overdue diagnosis of hypothyroidism resulted in me starting on Levthyroxine (thyroid medication), which resolved my PPMD about as promptly as you could hope for, almost literally overnight.

The second story

In April 2011, I gave birth again, to another beautiful little baby girl. This time, in consideration of my history, I had started on Zoloft at 38 weeks pregnant as a prophylactic measure, and also had my thyroid levels (TSH and T-4) checked pretty much monthly during the pregnancy and again after giving birth. This second time, there were no problems and life was pretty rosy.

The third story

In September 2012, I gave birth to a very unexpected beautiful baby boy (let’s just say that it’s important to keep in mind that a 99% effectiveness rate for birth control still leaves 1% for whom it is not effective). This time, I had a number of things going on during pregnancy that were extremely stressful, and ended up starting Zoloft at about 35 weeks instead of the planned-for 38 weeks. However, I still didn’t really have major issues afterwards and everything resolved itself fairly quickly without further intervention.

The fourth story

The fourth story is my ongoing one, which I wrote about yesterday. In April 2014, I miscarried the twins I was carrying as a gestational surrogate. It’s been a tough road. The emotional aftermath of pregnancy loss is no joke. I haven’t had a need for medication this time; therapy alone has been very useful in helping me deal with postpartum adjustment and the grief and trauma that 2014 brought me.

Four different stories. Four different treatment plans. Four different outcomes. And that’s all for the same one person: me. If my situations don’t even follow a predictable formula, why would I expect that anyone else would have the exact same situation/needs as me or even the exact same situations for their own individual different situations and stories? I can’t. We can’t.

It is so vital to remember this. My story isn’t yours and your story isn’t mine. Our brains, bodies, and situations are different. It’s okay if and when we react differently to similar circumstances and situations; it’s even to be expected. The danger is when we start to insist that someone should follow our advice and not consider any other method because it worked for us. There is no guaranteed cure or prevention for PPMD (dear GOD do I wish there were). We must all keep this in mind and be gentle in dealing with ourselves and with other people. We must remember that we are all unique individuals with unique brains, situations, needs, and stories. We must love each other and ourselves to remember that not all situations are the same.

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Dealing With Grief, Trauma, and Intrusive Thoughts

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Close-up of ribbon and pearl

Trigger warning: This post contains references to miscarriage, D&C, and intrusive thoughts. If you are feeling vulnerable, you may want to skip this post for now. 

Last year, I posted about my experience with the emotional aftermath of a missed miscarriage. Quick recap: I was carrying fraternal twins as a gestational surrogate. At my 8w5d ultrasound everything was good. At my first OB appointment a few weeks later, I was told neither one had a heartbeat and they had both stopped growing a couple of weeks prior, shortly after the ultrasound where everything was good. The end result was a D&C.

It was rough. It was REALLY rough. Not only was there the guilt and grief and normal hormonal nonsense of a miscarriage, I had the added emotional complication associated with miscarrying as a surrogate. However, I pushed on and kind of stuffed it all down as my intended parents (IPs) and I moved forwards with the checkups and testing the reproductive endocrinologist (RE) recommended to clear me to try another round of IVF and have a second go at making my IPs parents. Unfortunately, my anti-thyroid antibody labs came back (ridiculously) highly elevated which my RE said could potentially indicate an increased risk of miscarriage so he recommended they find a new surrogate.

As was their right under our contract, my IPs terminated the contract. Unfortunately, they did so in a very abrupt manner that violated trust and hurt me badly. It really ripped the bandaid off the wound from the miscarriage. I told a friend that it felt emotionally like I was experiencing the miscarriage all over along with the sudden and unexpected loss of another relationship I had been assured would last no matter what.

Time went on and I tried to go on with my life since there wasn’t really anything else to do. Unfortunately, I dealt with it by continuing to stuff everything. Really, I didn’t deal with anything. You would think that by now I would know that’s a really bad idea and that not processing things and not getting help just makes things worse, but apparently I have yet to learn that lesson as thoroughly as I would like. As time went on, I wasn’t sleeping well. I was stressed and irritable. I was moody and cried a lot and was really grouchy and short-tempered. I put it all down to stress and normal fatigue from taking 16 credits in college along with dealing with 3 small children, a husband in the military, and a generally full plate.

One night though, it got really bad. It was September 28, 2014. I was driving on a windy road in the hills and suddenly started to have some really nasty and terrifying images and questions/thoughts pop into my head. I beat it back and hightailed it out of there and started to head out to a particularly beautiful scenic area to take some pictures, but the thought of the windy roads along the coast that I was about to encounter had thoughts and pictures in my head again. I turned around and headed home. Suddenly I realized, “These are intrusive thoughts and I am changing my activities and behavior to avoid the trigger. This is familiar… @#%$!!! This is a symptom of postpartum OCD.” Let me tell you, the thought of going through PPOCD again had me terrified. And I do mean terrified. Like, pulled over in a parking lot sobbing and hyperventilating, unable to breathe, having an honest-to-goodness, would-take-an-Ativan-if-I-had-a-prescription-and-one-on-me, panic-attack terrifying. I started pm’ing my short-list of Warrior Mom friends trying to find someone I could talk to and help me get calmed down and worked through it. I got ahold of Lindsay Maloan. I adore her. She talked me through it, helped me formulate and talk out my plan for calling a therapist ASAP, and sent me funny links/pictures to help me laugh until I got ahold of a friend who lives near me (who was kind enough to let me come cry on her couch). Katherine Stone and Lauren Hale were also fantastic over the next few days about helping me talk through things and generally supporting me. All 3 of them kept telling me that it wasn’t my fault and that it was GOOD that I recognized what was happening and got my butt in to see a professional to deal with it.

I was fortunate to find a therapist who has quite a bit of experience and specialization with grief and loss, postpartum adjustment/PPMD, and infertility. It’s been a great combination and nice to not have to explain everything like I would with someone who doesn’t have experience with infertility or PPMD. We’ve done a combination of eye movement desensitization and reprocessing (EMDR) and talk therapy and it’s been working great. At this point, we’re pretty sure that my problem this time isn’t PPOCD or any other type of PPMD so much as it is just straight grief and trauma. She told me that it’s perfectly normal to need help working through what I went through. The official diagnosis for insurance purposes is postpartum adjustment, or needing help adjusting after pregnancy (specifically with the loss of the pregnancy and everything that’s happened since). She also pointed out that lack of sleep can exacerbate or even cause intrusive thoughts, so that combined with some other anniversaries/milestones (such as my due date) may have been the culprit behind that nasty little bugger.

I think there are a couple of main points I hope people take away from this post.

  1. Even without postpartum mood and anxiety disorders, it’s perfectly normal to need some help working through thoughts, feelings, and emotions, especially after a miscarriage.
  2. Don’t put off seeking help.
  3. Have a network of at least a few people you know you can turn to if you start to have a rough time. For women who are postpartum, especially those with a history of PPMD, it can be especially helpful if you have a few women who have experienced PPMD themselves, who are educated and know what’s up, who understand where you’re coming from. Lindsay was my lifeline that night. She got me through a REALLY bad spell where I was having trouble breathing (you know that whole my face is getting tingly and it’s making me panic even more thing? Yeah. I was there). And she, Lauren, and Katherine, and my friend here at home, and another friend who is working on becoming a social worker, gave me support. I can’t even express the value of that in words. I would love to give them all huge hugs.
  4. When you seek out a mental health professional, try to find one with experience/training in your situation. Having seen mental health professionals before who were PPMD clueless (it’s disconcerting to be explaining postpartum depression to the person who’s supposed to help you work through it), it has made a HUGE difference to be working with someone who knows her stuff.

I’m still not totally “there” yet, but I’ve made a lot of progress with my therapist, and it’s been a big relief to feel power in actually dealing with things on MY terms instead of just letting it happen to me and not have anything in my arsenal of “what to do.” When I had PPMD after my first baby was born, I felt so helpless and powerless. This time, I took control. That alone has made a difference.

If you are reading this and you’re in a bad place, know that you have a community ready and waiting with open arms, wanting to support you. We send you our love. I send you my thoughts, prayers, warm vibes, crossed fingers, and whatever else helps. There are resources. There are people here to support you. You are not alone. You do not have to go through this by yourself. We are here for you, we want to help you. Let us help you. As we support each other, we learn how to better support and help ourselves.

What advice do you have in how to help yourself or how to help someone else?

Photo credit: Esther Dale

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3 Ways We Can Improve Maternal Mental Health Care For Women of Color

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women of color Earlier this week, I shared my growing concern with women of color and their maternal mental health being underserved by professionals and those in the mental health advocacy space. (Note: “Women of color” refers to women who are not considered to be Caucasian: Hispanic/Latina, Black or African-American, Asian/Pacific Islander, Native American, Indian, of biracial heritage, etc) Today, I’d like to offer just a few ways in which I think we can improve our efforts, and make maternal mental health advocacy more inclusive of mothers of color, our experiences, and our needs.

Believe Us

I mentioned in my earlier post that many of the women I’ve spoken with expressed frustration and dismay that they were not taken seriously when they told their doctor, social worker, pastor, or a mental health professional that they were struggling. Their symptoms were minimized, their concerns and lack of awareness about what they were experiencing dismissed, and some even stated they were degraded by the professionals they reached out to. That’s unacceptable, and does more harm to women already suffering. One mother, who is African-American, described her experience to me as this:

“When I FINALLY went to a therapist, after my second child, I was dealing with PPD then. We began talking about my life (two kids under 3, stressful full time job, lack of support from significant other), and her response was to ask me if I was on birth control so I wouldn’t have any more kids.”

Her experience mirrors my own. After the birth of my second child, I knew something was wrong but couldn’t identify what. I was depressed and anxious and my moods were out of control. When I mentioned it to my OB at 8 weeks postpartum, he said I just needed more sleep. When I told him how out of control I felt, he wrote me a prescription for an anti-depressant, said I should discontinue it in a few weeks once I was feeling better, and told me to follow up with my primary care doctor. The medicine didn’t work. I was still a wreck. I went to my primary care doctor and she just told me that again, I was just tired. When I finally realized what I was experiencing was PPD and anxiety (thanks to Postpartum Progress’ Plain Mama English Guides), I called the NJ state PPD hotline. It took two days for a call back, and I was told that because I was on Medicaid, I’d have to see a social worker who was also a therapist from the state’s mental health program. At that appointment, I unloaded everything to him: my swinging moods, rage, intrusive thoughts, depression, fear. He asked me questions about my “living situation” and his next words I remember to this day:

“Well, you know, I mean what you’re experiencing isn’t postpartum depression or anxiety. You’re just experiencing the stress of being an unwed mother to two children who’s in a rocky relationship. Women like you…in your type of situation…in your culture, experience it, you know? Of course you’re stressed. You’re young, with an infant and toddler, going to school and working full-time…there are plenty of other Black women like you who face these kinds of daily challenges, you know what I mean? You just have to shoulder it and keep going the best you can. I think you’re going to be alright once you figure out how to manage it all.” 

Despite taking down my family and personal history where I detailed several things that placed me at risk for PPD (family history of mental illness, personal history of depression and anxiety, single, unexpected pregnancy, early childhood trauma, minimal support from family and friends), this therapist ignored all of it and said what I was experiencing was expected because of my cultural experience. This (White) man was not helpful nor was he culturally competent and a good match for my particular needs. I struggled to find adequate help for two more months.

Tell Us, Talk to Us, Become Culturally Competent

During my first and second pregnancies, I wasn’t screened for PPD or told anything about it, despite being at risk for developing it.  I didn’t even know PPD was A Thing. Other mothers of color have told me they’ve had similar experiences:

“I wish my doctor had told me anything. I had no information whatsoever.”

“When I had my daughter I was 20 and unwed (but my boyfriend was present). I got lectured from a social worker about my elevated risk for shaken baby syndrome. But no one asked about my mental health, either at discharge or at my follow up appointments.”

” I was upfront about my bipolar disorder with staff at the birth center. In the office, they even said, “You know you’re at increased risk for postpartum depression, right?” Then after the birth, the midwife attending just went about her business doing paperwork and asked me to sign to accept financial responsibility. Another midwife came in to check on me and asked me how I was feeling in front of family and friends. I was NOT about to say that I was having intrusive thoughts (I didn’t even know what to call it then). A lady who wasn’t a midwife (I think she was in billing) called to ask how I was doing. I broke down in tears on the phone. She called me weekly for several weeks. She gave me more care and concern postpartum than any of the midwives did.”

“She (my doctor) mentioned it, I just wish maybe she talked about it more in depth with me- signs/symptoms, etc.”

We need those in charge of our pregnancy and postpartum care to do a better job of informing us about what the signs and symptoms of postpartum mood disorders are. We need to be made aware of how they can manifest in our lives, and what places us at particular risk for occurrence. Providers need to become more culturally competent on how issues such as racial and gender discrimination, racial profiling and harassment, the high rate of domestic violence in our communities, our high rates for chronic illness, violence, poverty, and other sociopolitical aspects of our lives impact our mental health. Treatment plans then need to stem from an understanding that takes all of these factors into consideration.

Advocate for Better Access, Better Quality of Care, More Awareness

Reports have shown that there are disparities in mental health treatment, quality of care, and access to services when it comes to minority mental health, especially for women of color. Aside from cultural stigma, barriers to treatment include lack of insurance coverage post pregnancy, the costs of mental health services, and very little community resources in neighborhoods with significant minority populations. Educational literature and books on maternal mental health are hardly written with our experiences and needs in mind. Research on women of color and maternal mental health does exist but it is not extensive. Many awareness campaigns lack a multi-cultural focus, despite pregnant mothers of color facing significant and unique physical and mental health risks .

How can we do better? I’d like to see more literature featuring women of color distributed in doctors offices and where social services are located. It would alleviate a huge burden if mental health offices had childcare so we could safely leave our children in the care of others while we are seeing a therapist. We should create more spaces for mothers of color to gather and discuss their struggles and experiences with each other to gain support. More mental health professionals should offer reduced rates or at least accept Medicaid. There should be collaboration between cultural institutions our neighborhoods trust and national mental health organizations to raise awareness and eradicate cultural stigma on an ongoing basis. I’d like to see the expansion of Medicaid so more mothers can have comprehensive and longer coverage that enables them to access mental health services.

I think while some strides have been made, we still have much further to go to help women like myself. I’d like to see a more concentrated effort made in advocating for better care, easier access, and more awareness that empowers mothers of color. Doing so will help us give our families and ourselves the strong starts we deserve.

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