Occupational Therapy and Perinatal Mental Health

By Mauly Her Lo
Trigger warning: brief mention of stillbirth

I found out I was pregnant exactly one month after I graduated with my master’s degree in occupational therapy. Beyond graduation, there were plans to study and take the National Board for Certification in Occupational Therapy and be employed full-time. Plans changed when I was filled with repetitive thoughts and fears of losing my pregnancy. 

“You can do anything when you put your mind to it.” A phrase that we often hear too much. You can be pregnant and study, take the boards, and apply for a full-time job. I (my mind) did not feel healthy enough to take on too much. Witnessing my mother go through depression, a sister’s ectopic pregnancy, and another sister’s placental abruption that led to stillbirth was something I knew I did not want to experience. Fortunate enough to have an occupational therapy and healthcare education background, (1) I knew the risk of having depression increased because of my family’s history and (2) I had some knowledge of how to broadly care for my mental health. 

What is Occupational Therapy?

You are probably wondering, “What is occupational therapy and how does it relate to perinatal mental health? Is it about getting a job?” Or maybe you know someone who had a stroke and had occupational therapy to work on dressing, feeding, bathing, and toileting skills and don’t know how it relates to perinatal mental health. 

The mosaic beauty of occupational therapy supports the physical, psychosocial, and mental well-being of every individual across the lifespan – from those who are not yet born to elderly adults. Occupational therapy uses a client-centered, holistic approach to empower and support individuals to regain independence in all areas of their lives. By taking into consideration the whole person and their strengths and abilities, occupational therapy also recognizes the need for both the body and mind as well as other factors (age, gender, cultural values, beliefs, environment, etc.) that influence their participation in meaningful activities. 

Simply put, occupational therapy uses meaningful and daily life activities to enhance engagement, participation, and health at home, in the community, at work, and in other settings.

Where does Occupational Therapy fit in with Perinatal Mental Health?

Being a first-time mother or having a new baby is a major life event. This significant role change impacts the habits and routines that have developed over time. A mother’s sense of identity begins to evolve, as well as their beliefs and expectations of being a mother. The transitions during the perinatal period can influence their self-esteem and self-confidence with:

  • Self-care activities: personal hygiene, sleep, nutrition, or sexual activity
  • Parenting/Caregiver activities: feeding (bottle/breast/pumping), changing, bathing, positioning/holding the baby, or playing with the baby, 
  • Daily activities: meal preparation and cleanup, household chores, shopping, or religious and spiritual expression
  • Play/Leisure/Social activities: family and friend relationships, sports, exercises, reading, or arts and crafts 
  • Work/Education activities: bending, lifting, sitting, standing, typing, or writing

Occupational therapy practitioners have the knowledge and experience to conduct screenings, assessments, and evaluations, deliver treatment and interventions, and measure progress and outcomes. Considering their strengths and abilities, daily routine and habits, motivation, interests, meaningful activities, and social supports, we can collaboratively establish individualized interventions and goals.

Perinatal PeriodExamples of Occupational Therapy Practitioner’s Role/Interventions
PrenatalMaternal mental health screening, preparing for a change in role, facilitating home modifications before arrival, pain prevention, education awareness for perinatal mood and anxiety disorders, supporting groups for parents/caregivers
PostpartumMaternal mental health screening, postpartum recovery – personal hygiene after vaginal birth or Cesarean-section, enabling the development of healthy routines for themselves, functional and positional support during feeding, dressing, changing, lifting, and carrying the baby), breastfeeding support, supporting co-occupations between mother and newborn, self-regulation, and developmental milestones, returning to sexual activity, returning to work, supporting groups for parents/caregivers

Overall Benefits of Occupational Therapy in Perinatal Mental Health

With the support of an occupational therapy practitioner, mothers can 

  • Become more aware of perinatal mood and anxiety disorders,
  • Advocate for their health and well-being by identifying resources and community support,
  • Increase their self-esteem and self-confidence in their roles and abilities as a mother/caregiver, partner, worker, and/or student,
  • Establish a secure co-bonding relationship with their newborn,
  • Create a safe and healthy environment for themselves and their family, and provide grace for self-care, daily, play/leisure/social, and work/education activities

Through our holistic lens, we advocate and work on what matters to you, your health and well-being, and your family. 

Learn more about OT & Perinatal Mental Health! Join Mauly & MMHI for an Instagram Live on April 14th at 1:30 p.m.

On The Duxbury, Massachusetts Tragedy

Moms Mental Health Initiative is devastated to learn of the tragedy that occurred this week in Duxbury, Massachusetts. Our hearts break for the Clancy family as they navigate impossible grief following these events.

We’ve witnessed a robust conversation surrounding perinatal mental health following this tragedy, as Lindsay Clancy’s youngest child was eight-months-old. Social media posts and local media coverage reference perinatal mental health as a possible cause of these events. While we do not wish to speculate, nor are we familiar with the Clancy family’s situation, Moms Mental Health Initiative supports responsible discussions on perinatal mental health conditions. Furthermore, perinatal mental health is grossly under-supported and deserves more attention, education and resources.

What is Perinatal Mental Health?

Perinatal mental health conditions impact 1 in 5 mothers. “Perinatal” references the period of time from pregnancy through approximately 18 months postpartum, and is a high-risk time for mental health. While postpartum/perinatal depression is most commonly known, other conditions include perinatal anxiety, perinatal obsessive compulsive disorder, post traumatic stress disorder and, in the most severe cases, postpartum psychosis.

Learn more about perinatal mental health conditions

Postpartum Psychosis

Postpartum psychosis is an extremely rare manifestation of a perinatal mental health condition that separates a mother from reality and may include delusions and hallucinations (visual and auditory). This psychotic state makes her judgment irrational, believing these thoughts to be true (she doesn’t think anything is “wrong”). 70-100% of mothers experience intrusive thoughts- scary thoughts that may include harming themselves or their child. In these cases, a mother is not psychotic but rational in her judgment – she will feel embarrassed or terrified of these thoughts. Postpartum psychosis does not always lead to harm but is a psychiatric emergency in which the person deserves and needs immediate specialized treatment.

Perinatal mental health conditions may worsen if not treated and are the leading cause of death among perinatal women.

A Message to Moms: You Are Not Alone

To any mothers witnessing this discussion, suffering in silence, please know you are not alone. There is hope and there is help. In Southeast Wisconsin, Moms Mental Health Initiative connects moms to qualified providers with knowledge and experience with perinatal mental health conditions. Outside of the area, Postpartum Support International provides excellent resources.

If you or someone you know is experiencing a mental health crisis, you can contact 911 or 988, the National Mental Health Crisis Hotline.

For non-emergency Maternal Mental Health Support, you can call 1-833-943-5746 to reach the National Maternal Mental Health Hotline operated by Postpartum Support International.

Postpartum Anxiety Happened So Quickly

Trigger warning: Suicidal thoughts and ideation 

Stock Image by Jenna Norman via Unsplash

My perfect little boy was born in January 2019. Nothing was unusual about my pregnancy except, perhaps, the fact I seemed to have it pretty easy. No morning sickness, no real physical discomfort or pregnancy related ailments, low weight gain, high energy, no complications. Labor was a bit of a different story – it was long, slow, complicated and, at the end, even scary. But then he was here and, to be honest, I forgot about the unpleasant details within days. 

I was lucky enough to have a generous, paid, twelve-week maternity leave from the law firm where I had recently made partner and, once we were home, it took a little time but we soon hit our stride. I figured out how to fill a day – the Today Show is a bit of a guilty pleasure, I enjoy working out, I was able to make plans with friends to maintain a sense of sanity and adult conversation, and it wasn’t too hard to change my pre-baby, twice daily walking routine with our Goldendoodle into a dog and stroller regime. Being at home was so different from my work life, but I tried to enjoy the downtime while it lasted, and for the most part, I succeeded. 

Anxiety Sets In- Quickly

My return to work was pretty seamless and easy. I eased in but was quickly back to my pre-baby stride. I felt like I was making it as a young professional, wife and new mom. I can’t tell you the exact date things changed, but it happened so quickly. I remember feeling stressed (and now I know, anxious) when my husband and I went out to dinner to celebrate our wedding anniversary. The week leading up to that dinner I had reached out to some of my senior colleagues in the same practice group to express a willingness to take on additional work – the return-to-work buzz had sort of faded, and my plate wasn’t quite full, which any professional who has to bill someone else for their time knows isn’t a great thing. I got a positive response and plenty of cases in my practice area needed staffing. My excitement quickly turned to apprehension when I realized some of these cases were a bit different than most I had handled before. I spoke up and asked for support from my colleagues and, again, received a positive response. But, the first of many irrational or pathological anxieties had begun and they were starting to fester. 

My husband was concerned enough by my anxiety to suggest I talk to someone. Thankfully, I was able to snag an appointment with a psychologist’s graduate student the very next morning. I went, hopeful I could learn something or that she could say or teach me something to help nip this anxiety in the bud. At the end of my appointment, I also met the perinatal specialist for a few minutes. We agreed I was having at least some postpartum anxiety and would benefit from additional treatment; however, I also learned the perinatal specialist had a pretty significant wait period before I’d be able to see her again. Her perinatal psychiatrist counterpart had the same wait period. So, if I needed medication, I’d probably have to wait on that too. I left the appointment down, but feeling a little lighter and more hopeful. I had taken a step, what else could I do? 

By the time I got to work that day, my hopefulness had faded, and I was even more anxious than before. “I don’t know how to do this…How can I learn these things?…What if I make a mistake?” By the next day, I could not escape the anxiety and it had sky-rocketed. I had trouble concentrating on work long enough to get anything done. By mid-day, I was shooting out panicked texts to my husband and best friend. Feeling terrified, I told my office managing partner I was struggling with some postpartum issues and needed a day or two off work. He was surprised, but supportive, telling me to work it out with HR and let him know what I needed to make it happen. With a quick call to HR, I found I had more paid medical leave available and learned what I needed to do. I made a list of my cases, short-term case tasks and deadlines and I left, praying no one would see or talk to me. What would I tell them? 

Driving home, I was in a daze. On a whim, I called a friend who urged me to call my OB and suggested that OBs can often see women who are struggling with postpartum and get them started with treatment. I promised to call the next morning. I got home, and my very supportive mother-in-law greeted me and offered her support. I felt so appreciative, but I also felt ashamed for the first of many times. People have babies and are successful at work all the time, I thought. What’s wrong with me? 

The next morning I woke up with a pit in my stomach thinking I made a mistake by taking time off and might have even ruined my career. I called my OB’s office. She was off that day, but I spoke to a nurse who contacted the on-call OB. Within an hour, I had an appointment with him for later that morning. He listened to my story and agreed it sounded like postpartum anxiety and depression. He prescribed a standard antidepressant and suggested I take two to three weeks off work, if that was an option for me, to give the medication time to work. “You’ll get back to yourself,” he assured me. Relieved, I headed home, armed with a plan. The relief was fleeting, though. How could I take more time off?

I was hardly able to function

Unfortunately, things got worse. I was lucky that my mom and mother-in-law were at our house and able to help because I was hardly able to function. I had my first appointment with the perinatal psychologist late that week, and she honed in on my irrational thoughts and gave me some reframing exercises – a facet of cognitive behavioral therapy – to work on. I felt better leaving the appointment but that hope barely lasted the drive home. What I was feeling felt so overwhelming and chaotic that it was hard to believe it when those I loved and my healthcare providers told me that things would get better. I couldn’t believe them. My next vivid memory is experiencing my first suicidal thoughts. I was so sure that everyone could see the anguish I was feeling. How could life be moving as normal? Doesn’t everyone see that I’m about to explode, that I’m hurting? Time passed and I started having trouble sleeping. 

I woke up after the weekend hoping and praying for relief. I had asked for two weeks off, and this was week two. I could focus on myself this week and on getting better. I could go back to work next Monday. But, my hopeful plan didn’t even last that day. I contacted the psychiatric hospital that had been recommended to see what sort of outpatient groups they offered, and I “failed” the intake process for outpatient therapy. This meant I was sent to the psychiatric hospital for evaluation, where I admitted to the providers and to my husband that I had begun to develop a suicidal plan that day. 

Admitted to the Psychiatric Hospital With Postpartum Anxiety & Suicidal Thoughts

I was admitted for the standard three days, which I know now wasn’t enough. But, the minute I got there, I realized that I had to say whatever they wanted to get out. Most of what I felt inpatient was shame. The women I was with were dealing with some horrific issues and circumstances, and I was sad, anxious and suicidal five months after having a baby. I couldn’t come to terms with it. I participated in my individual and group therapy sessions, but there was no true breakthrough. I was scared, and I was numb. 

By the end of the three days, I realized I’d have to lie or exaggerate the “betterness” I was feeling to be discharged. I know my husband knew it was too soon, but he trusted the experts who said I was ready. Unfortunately, it was enough for me to tell them I no longer had suicidal thoughts. I cycled through a few different psychiatrists and the various medications they were trying weren’t working, but I had to get out of there. I would have said anything.

The next step after inpatient was an intensive outpatient program (IOP), which I started the next day. I felt immediately that it wouldn’t help me, but what other choice did I have? My husband and I agreed I had to try. I had a lot of support but, if I’m honest, it was hard to take at the time. I didn’t feel like I deserved it. 

I alternated between pretending I was ok and being unable to pretend. I could hardly stand being with friends and trying to act normal. “Can’t you see I’m in pain?” was a constant refrain in my head but I didn’t feel like I even understood my own struggle, as raw and overwhelming as it was, so I didn’t expect that anyone else could either. Yet, all I wanted was for someone to help me – to save me from this anguish. One evening a few days later, I began to fear I had (and began obsessively researching) postpartum psychosis. While it didn’t seem to fit, I saw no other postpartum anxiety (PPA) stories like mine. I wasn’t worried about the baby. It was me, it was work, it was everything. 

I continued IOP going through the motions and feeling worse and worse. Soon, there was a plan in place for me to finish IOP and return to work on a reduced schedule so I could continue group therapy. I was part of the plan making, but I didn’t believe it could work. I didn’t know what else to do so I convinced myself I had to move forward. I completed my second and final week of IOP with the plan to go back to work the next Monday. The baby started daycare and he did great. I was embarrassed to meet his teachers and see the other moms. I felt like a fraud. If they only knew what was going on in my head. By Sunday, I was a wreck with the thought of going back to work. I actively considered and researched ways to commit suicide. 

Another Return to Work

Monday was horrible. I was almost childlike, refusing to go to work on my own and forcing my mom to drive me there, pick me up and take me to partial therapy that afternoon. I did my best to get through, but felt panic and doom almost every minute. I made it 15 days. The weekend before the 15th day, a close friend visited for the weekend. We sat down and talked about my work anxieties and how I could take small steps to get through them. We made a plan. I wanted so badly to be able to follow the plan the next day, but I didn’t believe it was possible. That Monday I sat in my office with the door closed for 15 hours, completing about 1 hour of work. My mind raced, but time crawled. My husband and friends finally convinced me I had to go home, and that I needed to take another leave.

Thankfully, I had an appointment the next morning with the original perinatal psychiatrist, returning to her after shifting to the psychiatric hospital and IOP program who were not perinatal specialists. She decided to try a very different medication, one that my mom had been on for thirty years to treat her obsessive-compulsive disorder (OCD). She told me she couldn’t accept what I’d told her about feeling hopeless and that, for this to get better, she needs me to have at least a small amount of hope that we can get through this with the right treatment.

Another Leave, A Glimmer of Hope & Healing

With the perinatal psychiatrist’s guidance, I was off work for a second leave, this time, fully removed from work (i.e. no email access) to allow myself time to heal. About a week into the new medicine, I had an appointment with the original perinatal psychologist. We made a plan involving cognitive reframing exercises and I committed to trying to practice the reframing exercises daily, maybe even hourly, over the next few weeks. I felt the smallest glimmer of hope again that night. While it still felt a bit like “faking it”, it was different. I believed her that maybe this could work. The next day I woke up and felt just the slightest bit better. I told my family and close friends, but I was scared to be hopeful. Could the new medicine be working? 

Over the next few weeks, I had regular visits with the perinatal psychologist and perinatal psychiatrist. Things were trending up and we were all hopeful. Of course, I was scared of being disappointed if I was not actually getting better. The final week before returning to work had a few roadblocks. It was tough, but I felt ok. My debilitating anxiety was starting to ease and everyday life was becoming more manageable. I had my final perinatal psychologist session before I was set to go back to work and I went in armed with a notebook. I told her my coping plan and went through all my reframing. She told me I was ready and I actually believed it that time. 

I was Ready, I was Better

I returned to work that Monday, and things were so much better. I followed the plan and it worked. That afternoon was my last day of group therapy, and we had a substitute. The substitute was one of the therapists I had had while I was inpatient, and it felt like I may have come full circle. Things fell into place at work and I continued regular visits with the perinatal specialists – psychiatrist and psychologist – for months, and I still take a low dose of the OCD medication that finally helped me. 

I’ve been back to work for over a year-and-a-half and all is well. There are even some days that I forget about what I went through. But, truthfully, I don’t want to forget. I’m hopeful that I’m a better mom, wife, family member, friend and even professional because of what I went through. I certainly don’t take anything for granted. I feel an amazing sense of gratitude for the resources and support I had in helping me through the hardest thing I’ve had to deal with in my life. I’m also certain that whether you call it luck, God, or some other higher power, it played a huge role in me making it to the other side. The least I can do is share my story in an effort to pay it forward or help even one other woman in a way she may not even realize she needs. 

Help is available- click here to find the right resources for your healing journey

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