Episode 68: Navigating Perinatal Mental Health with Emily Pyle & Mychal Riley

Bob Boland, MD: 0:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Bowen and Dr Kerry Horrell.

 

Kerry Horrell, PhD: 0:11

Monthly we explore intriguing topics from across the mental health field and dive into hidden realities of patient treatment.

 

Bob Boland, MD: 0:18

We also discuss the latest research and perspectives from the minds of distinguished colleagues near and far.

 

Kerry Horrell, PhD: 0:23

So thanks for joining us.

 

Bob Boland, MD: 0:26

Let's dive in. This is another great day for a podcast, right we have. We have an internal team. Super stars! And this is our kind of special.

 

Kerry Horrell, PhD: 0:39

And this is our kind of special. Mother's Day, Father's Day episode.

 

Bob Boland, MD: 0:44

Exactly yeah exactly. So we let me just do, should we just introduce?

 

Kerry Horrell, PhD: 0:46

Let's go, let's you go first.

 

Bob Boland, MD: 0:48

I'll go first. Okay, so our first guest is Emily Pyle. Let me tell you a little bit about Emily. She's a manager with Menninger 360, and she'll explain what that is. She specializes in working with adolescents, young adults and adults who are experiencing relationship or relational challenges, mood disorders, anxiety, attachment, trauma and personality disorders. Emily also enjoys working with women who are navigating life transitions and possesses specialized training in supporting parents during the perinatal period. Emily received her bachelor's degree in Psychology from Rice University and her master's degree in Counseling from the University of Houston. All right, how was that?

 

Kerry Horrell, PhD: 1:29

Amazing, and we also have the program director for Menninger 360. So we have our 360 kind of team here right now. This is Mychal Riley LCSWS. So Mychal is a program director for the Assertive Community Treatment, also known as PACT and Community Integration Program here at Menninger, called Menninger 360, and works with adolescents and adults. Mychal earned a Master's of Social Work and a Bachelor of Science in Brain, Behavior and Cognitive Science from the University of Michigan Ann Arbor. He completed a postgraduate fellowship with the Menninger Clinic in 2013, at which time he was hired as a staff clinician for the HOPE Program for Adults, In 2017, he became a program manager at the Pathfinder Program for Emerging Adults before accepting his role as program director for Menninger 360 in 2022. Mychal has specialized training in the Collaborative Assessment and Management of Suicide, which we call CAMS. Acceptance and Commitment Therapy, Adaptive Mentalization-Based Integrative… oh AMBIT. IAMBIT. I don't actually think I knew I like had a sense of that.

 

AMBIT. I'm gonna say that again… Adaptive Mentalization-Based Integrative Treatment and then Dialectical Behavior Therapy and the Gottman Method for Couples Therapy. But, like I said, this is our Menninger 360 leadership team.  Yeah, absolutely, maybe we can start there. Well, welcome.. first of all welcome. Can we start with how y'all ended up interested in PACT care? Also I think I missed the word "Program” in the PACT is a Program for Assertive Community Treatment.

 

Mychal Riley, LCSW-S: 3:05

So that's how Menninger talks about PACT as a program for assertive community treatment. Most times, the public programs that are doing what we do are just called assertive community treatment. They're active, but ours is a program because it's also the community integration.

 

Kerry Horrell, PhD: 3:19

Right.

 

Bob Boland, MD: 3:20

And while we're at it, why do they call it Menninger 360?

 

Kerry Horrell, PhD: 

Oh yeah, that's a good question.

 

Mychal Riley, LCSW-S: 3:24

You were there for that.

 

Emily Pyle, LPC-S: 3:25

Absolutely so. Menninger 360 is called that because we offer 360-degree wraparound care, really meeting clients where they're at, in their homes, in their communities, where they're living, working or playing, and so we're sometimes called the "hospital without walls” because of that. Yeah, it's a 360-degree approach.

 

Bob Boland, MD: 3:49

So tell us just a little bit about your careers. You know how you got interested in working with PACT care.

 

Mychal Riley, LCSW-S: 3:53

So, Emily, I'm going to let you go first, because Emily was actually -  fun fact - a part of Menninger 360 before I was. So she's been there pretty much since day one.

 

Emily Pyle, LPC-S: 4:08

So I stumbled upon community integration model when I was in graduate school, I was doing an internship at a community nonprofit counseling center and they were applying for a grant. That was for a community integration program that would be no cost for young adults and adolescents, where it would be home-based, community-based, school-based care, and I was intrigued, I thought that was incredible and I applied and I got it. And so I did that program as one of the clinicians for the duration of the grant. Really got to meet clients where they were at in their homes, schools, communities, and I really saw the power of that kind of model for adolescents and young adults. And when the grant ended, I learned right at that time Menninger 360 was just getting started here at the Menninger Clinic. When was this? So this was for Menninger 360. It was the end of 2017. Okay, and then I joined 360 in April of 2018. And, as well, I've been there for a year.

 

Kerry Horrell, PhD: 5:18

Exciting. Yeah, Mychal…

 

Mychal Riley, LCSW-S: 5:20

I mean part of it is I'm a social worker by training.

 

Mychal Riley, LCSW-S: 5:23

And so it just really naturally fits with what we do. I'm also pretty behavioral in my thinking and approach and so I love anything that's exposure-based and behavioral activation, anything that gets me out of the office. Folks who know me know I do not sit still very, well. So after working in the inpatient side and going to Pathfinder, which is our first community integration program, I saw how much I love just being out in the park. The other thing is you learn a lot, so I always tell people, whether they're an adult or an adolescent, especially sitting next to them in a car  when they're controlling the music. They start telling you what happened at school that day,  who's fighting with who…you learn a lot more than staring at them face to face. Don't get me wrong. I still love all of my traditional therapy, but community integration is a great model to learn more about people's strengths, and that's really what I love about Pathfinder.

 

It's really not an illness model. It's a wellness model saying ‘how do we help you live the life you want to live and move around the barriers that get in your way?’ So that's kind of how I ended up here. It was a natural progression from Pathfinder, my predecessor who started the program, stepped away and they asked me if I wanted to jump in and lead this team and so I was excited, and with Emily and the team members that were there, it was a piece of cake. It's just mostly kind of staying in community with the clients.

 

Kerry Horrell, PhD: 6:43

As someone who has been lucky enough to work with you all, I get to do some individual therapy for 360 clients I feel like it's such a good model and it's so helpful. And again I think, yeah, I think both your personalities fit with it really well too. I totally agree with what you're saying, Mychal. it's hard for me to imagine you just in like a traditional office all day long.

 

Kerry Horrell, PhD: 7:05

We’re talking specifically today that we wanted to get into perinatal care and specifically, and I don't know if this is actually even true, but my mind was going to …I wonder if there is a specific need for PACT care for this population. And I I've said this, I've like hinted at it for maybe a couple episodes. I don't think I hinted, I think I've said it, but I'm pregnant. By the time this episode comes out, I will have a bubbling baby boy.

 

Kerry Horrell, PhD: 7:33

But I imagine, especially being pregnant right now, I am so aware that it's like having a baby at home would make it very, very hard to even just go to regular appointments, especially not like hospital level care when people need more. So this is where my first question is coming from, which is, I imagine, when people are in that season of life when they're child rearing, especially having newborn babies, they need to probably be home, but some people still need more intensive care. So, to reframe my question, or say it one time, can you tell us specifically about what you've seen as far as a need for perinatal care in this population, working with the PACT programs?

 

Emily Pyle, LPC-S: 8:09

Absolutely. I'll go ahead and start, and so I'm also going to share kind of how this was an area of need and so I actually stumbled into this area of care. My first 360 family case was a perinatal family, and so I did that care with that family and it was a very effective model for this family. And then, not too long after I finished that family, I was assigned a new family therapy case with another perinatal family and it was very meaningful, especially being able to do the home and community-based care, given that I wasn't seeing other models or hadn't heard of other models that were doing this, at least in the local area.  I saw how it was decreasing some of those barriers to care that I had heard about, and so that got me doing some digging.

 

After these first two cases, I got curious. I wanted to know what the research was and what was out there. And what I learned is, first, that many new families are not accessing mental health care when they need it due to some pretty key treatment barriers, and the key treatment barriers that I saw were resources, that would be one, time, transportation and stigma. There are certainly others too, but those were the main ones. And so what I also learned is that wraparound home-based care was shown with research to be highly effective for mental health treatment with this population.

 

It makes sense to me.

 

Emily Pyle, LPC-S: 9:50

Absolutely. The tricky part is that very few places do it here in the United States, and I couldn't find any nearby, so that's where it became clear to me that we had a real opportunity to develop a track within our 360 program for this population.

.

Mychal Riley, LCSW-S: 10:07

Well, it was funny because we actually had one of our social work fellows who did a presentation right after we'd had a case and she was talking about the research overseas and how this is a model over there. And I went to Emily and said ‘ why aren’t we doing more of this?’ And she said ‘it's funny you say that ‘ and then it just kind of works from there. But we really are seeing that a lot of the data shows working with parents in the home with baby is an important part of the mental health work And that's the key part. Because even a lot of programs that people go to, baby is not there and so it's a little weird to say ‘we're going to work on your mental health and your stress that's related to baby,’  but baby's is going to be in a different room while we're talking and working.

 

That is pretty weird, yeah, but let's talk a bit about some of the mental health problems that come up around pregnancy and the postpartum period and maybe start with women, what kinds of things do you see?

 

Emily Pyle, LPC-S: 11:03

Absolutely so the main ones that I've seen have been depression disorders, bipolar disorders, anxiety disorders, and so particularly panic disorder and generalized anxiety disorder, psychosis, OCD and PTSD. That's not an all-inclusive list but those are some of the ones that…

 

Bob Boland, MD: 11:26

It's kind of everything.

 

Emily Pyle, LPC-S: 

Yes, right, and actually to that point to kind of encompass that spectrum of disorders within the perinatal period, there’s a term called PMADS, which is Perinatal Mood and Anxiety Disorders.

 

So I've never heard that phrase all …PMADS.

 

Emily Pyle, LPC-S: 

So it encompasses all of those, and PMADS collectively, actually are the leading medical complication regarding childbearing and the leading cause of maternal death in the United States. So one out of three pregnancy-related deaths is related to one of those diagnoses.

 

Kerry Horrell, PhD: 12:03

Whoa, I didn't know that. In a lot of ways it makes some sense to me. I'm following that. But yeah, I just don't think that that's talked about very much. I know I was just talking to another provider and we were talking about how bipolar and OCD seem like two, that if you've had it in your life, the chances that it gets flared up postpartum is really high. I was asking because I was like what are the chances I get postpartum psychosis?  They were like low, um, and I was scared that that's even a thing that  happen.

 

But yeah, I mean, you hear about postpartum depression, you hear about some of these things that, like, it is prevalent, it's, it's a leading cause of complication and even death. Yeah, that feels really huge to me.  I kind of just alluded to this, but are there certain women who are at higher risk? Is everybody just like, because you're going through the hormonal changes in regard to pregnancy and postpartum, is everyone at risk? Are certain women more at risk? Like, what do we know about this?

 

Emily Pyle, LPC-S: 13:04

So it’s a two-tiered answer. First, I would say that all women…not to scare you…

 

Kerry Horrell, PhD: 13:10

I promise I know I feel like I've definitely dived into this a little bit. Sorry, I'm not too scared…

 

Emily Pyle, LPC-S: 13:19

So there can be both for any woman who is pregnant. We'll start with that. There are biological and psychosocial risk factors for anyone in this period, and so I'll give an example of the biological ones for any woman, since we're talking about women first. So one would be hormonal changes. There are hormonal changes that happen in pregnancy and postpartum that would make any woman vulnerable to mood shifts, and also an abrupt discontinuation of breastfeeding is one based on research that can lead to a biological risk factor for which I thought was very interesting.

 

Didn't know that…

 

Emily Pyle, LPC-S: 

Yeah, and we've had some 360 clients who that as part of their story.  And then another one is lack of sleep. Sleep deprivation is huge. We  already know that from mental health work in general, that sleep impacts our mental health, and so those would be some examples of biological risk factors for any woman in this period.

 

Emily Pyle, LPC-S: 14:21

And then there's some psychosocial risk factors for any woman, and so these would include some social isolation, and this might be not intentional, right, so it might be. Hey, we're at home, we have to keep a tighter net because our child hasn't had vaccinations or doesn't. We need to protect the health and safety of our families. It also could be newfound stressors. So financial stressors, child care stressors, maybe changing roles and obligations in a relationship and, honestly, the social and cultural standards and expectations of parenting. That can be huge too. So those would be the first tier that I was mentioning.

 

Emily Pyle, LPC-S: 15:04

Then there's some of us who might have elevated risk beyond that. And so biological higher risk would be people who have had pre-existing endocrine issues, so maybe they've had diabetes, maybe they have hypothyroidism. Also abrupt discontinuation of breastfeeding, which I mentioned, and physical pain or inflammation. Those would be all biological challenges that could lead to higher redisposition. And then there are also psychosocial ones as well. So this might be family or personal history of PMADS or mental illness in general. A history of childhood abuse is actually one.

 

Other risk factors include complications in pregnancy, birth and postpartum, as well as breastfeeding. And  then the other one I was thinking about, because I'm not going to provide a comprehensive list, but the two others that really came to mind when you asked this question would be health challenges in the mom or baby and actually unresolved grief and loss, which is something that a lot of people don't hold on to. So, for example, perhaps a new mom has never really grieved the loss of her own mom, if her mom is no longer part of her story.

 

Mychal Riley, LCSW-S: 16:29

The two, I'll add, is kind of from the side. So one, the couples therapist and me.  we'll always talk about the times that we see stress in a relationship is around the time of the first child, um, and then the more children you add, you're starting to get outnumbered. So some of those stressors can also lead to increased depression, anxiety. So the couples therapy becomes very important. And then, as someone who's worked a lot with psychosis and mood disorders, one of our former colleagues, Dr Elizabeth, Nettich and I would talk about at times is: How do you stay on medication?

 

Kerry Horrell, PhD: 17:02

Oh my gosh yeah.

 

 

Mychal Riley, LCSW-S: 17:04

So you have a lot of clients who are really concerned about mood stabilizers, antipsychotics, and this is where having a perinatal psychiatrist can be really effective, because the OBGYN can work with them, because what we know is sure there may be some risk with some of these medications, but when you actually look at the data, the risk of someone having a manic episode or a psychotic episode is often much worse than the risk of some of these medications. So mom may need to change the meds a little bit, lower something, right, but taking especially for someone who's had multiple episodes before, taking them off the medication is actually increasing the risk of harm to the baby.

 

Mychal Riley, LCSW-S: 17:42

So that's one of those…that another stressor…that is just physicians and consumers being informed around like what are the actual risks.

 

Right, because even doctors can overrate the risks sometimes.

 

Kerry Horrell, PhD: 18:01

Or  they're not weighing like the risk versus the other risk, which is like well, here's the risk of that medication on the pregnancy. But it's like, what about the risk if you were to have manic episode, and like what's that look like?

 

Mychal Riley, LCSW-S: 18:09

And that's actually one of the things that is a stressor for a lot of parents. In our society, rightfully so, focuses a lot on baby, but there still needs to be some room for focusing on like, okay, but how do I take care of myself? Because we can't be successful parents if we aren’t functioning at as close to our top percent as possible.

 

We’re going to come back to this, but I also want to consider, what happens to partners of the pregnant person. You know we often think of husbands, but there's lots of different people who are going to be partners to pregnant people and because they're not going through the pregnancy, um, and so they're not going through necessarily like the hormonal shifts and some of the biological parts, I feel like they get missed sometimes in the perinatal conversations and what gets them at risk  So I'm speaking in generalities here. But for men, or again, partners of people who are pregnant, what are some of the considerations for them in regard to at risk or concerns around mental health?

 

Emily Pyle, LPC-S: 19:11

So one thing I want to start out by saying is I really appreciate you asking this question and this is something that really is tied into 360 because, candidly, the first two perinatal cases that I mentioned, the partner, the male in this case, was the primary client. The male in this case was the primary client and so 360, probably amongst all of our perinatal cases, probably 40% have been the partner as the primary client. So thank you so much for recognizing that with your question.

 

Kerry Horrell, PhD: 19:39

I wouldn't have guessed that.

 

Emily Pyle, LPC-S: 19:40

Yeah, and I think that there's so many reasons why people don't think that, so that again, I really appreciate you asking the question. Yes, there are definitely considerations for men, for partners, when they're expecting to become a parent and when they've become a parent. So I want to start out by saying that up to 10% of new fathers have symptoms of clinical depression and or anxiety, and so, and fascinatingly enough, the main predictor of those symptoms is if the mom has her own mental health issues that are happening.

 

Kerry Horrell, PhD: 20:14

Good, excellent.

 

Emily Pyle, LPC-S: 20:18

Because of the family system. Yes, impact each other, right? And it's also important to recognize that men have typically masked symptoms and so it can look differently, can present differently than like for women. So for example a male parent that has depression, it may appear as disinterest, distancing, increasing substance use issues, irritability, restlessness, and also the timing might be slightly different. So on average then male symptoms tend to spike three to six months postpartum. It's a little bit different. A lot of people don't know, and  I think it's really important too,  is there are documented paternal hormonal shifts that happen, especially postpartum, for dad.

 

Didn’t know. Didn’t know.

 

Emily Pyle, LPC-S: 21:16

I'll just focus on two that most people don’t know about is decreased testosterone and increased cortisol, so we were talking about hormonal.

 

Bob Boland, MD: 21:25

The cortisol makes sense.

 

Kerry Horrell, PhD: 21:27

Yeah, you're right, the cortisol I'm following.

 

Bob Boland, MD: 21:29

Yeah, testosterone probably would be a surprise.

 

Mychal Riley, LCSW-S: 21:33

See, it's not always just that we’re moody.

 

Kerry Horrell, PhD: 21:36

Mychal, I wonder if you have more to share.  Any thoughts on this question?

 

Mychal Riley, LCSW-S: 21:40

I mean, again, a lot of my knowledge comes from my experience working with couples

 

.

That’s typically what you see, and then there's a lot of really kind of like anxiety about what it means. There's often kind of like trying to find what your role is in the game. But you know we don't talk about this much. But for the first like three to six months, they get really dependent on mom and like even the dads that want to help, don't quite know how.  There are just certain things you need mom there to do, and then the other side of that is figuring out how to be a supportive partner in that situation. So a lot of that, a lot of it comes down to the conversations and taking on other responsibilities in the home. If there are other kids, helping with the other kids. But again, you see the same thing, things that lead to some of these depressions that aren't biological, or anxiety, is kind of the stress of a new problem and how do I move over?

 

Kerry Horrell, PhD: 22:36

That’s where my mind was. That was just like navigating that and like I imagine the resentment that can kind of come up around that, around how people are navigating it, and, yeah, just how messy it is. No one family is alike. You know, people's personalities in the partnership are going to look different.  There's just so many factors to consider, but I think it is important to think there's two oftentimes, not always.  like two people who are trying to navigate this endeavor and, making space for that.

 

Mychal Riley, LCSW-S: 23:05

And the last piece of this I would think about too, is the systems theory in me. There's some theorists in me that typically says nothing happens alone. So even for the partners who aren't clinically depressed or having anxiety, typically there's a lot of pressure to feel like you're wanting to take care of a child, take care of a partner. That's going to start to have an impact as well. So even just having support for being a caretaker, if you're not kind of having identified. sometimes can be really good.

 

Bob Boland, MD: 23:36

I was just going to say, and it just seems to me often that the partner, at least my experience, doesn't complain much, because they're not supposed to. You know, if you're like the dad or something like that, it's like look this, you know, your, your wife is going through all these things.

Or the mom is going through all this…and like who are you to sort of say that this is hard on you?

 

Kerry Horrell, PhD: 23:56

That's it. I was exactly what I was going to say. Well, my mind is going to. I have, for better for worse, spend a lot of time on TikTok these days and there's definitely a societal idea of like:  Partners, here's what you need to do. You need to do everything to support.  Don't complain… you're never going to be able to do enough to make up for what your partner has done …going through pregnancy.  And again, I don't. I see that perspective in some ways as a point, but as an end-stage pregnant person.  But I also like…that doesn't totally make sense to me as a psychologist. This is two people going through this and there's so many changes and there's so many factors that are impacting people. So, just glad we're opening that conversation and that's the thing.

 

Mychal Riley, LCSW-S: 24:39

So everybody has to have someone to complain to, right? Yeah, maybe it isn't the partner on, you know, week two after baby comes home… I'm not going and saying, ‘hey, I'm feeling bad too,’ but like, do I have friends, do I have a therapist, do I have a community around me? And especially when we look at the data on single parents. Having a community is just such a big important factor to parenting and keeping your mood and stamina and resilience up.

 

Kerry Horrell, PhD: 25:04

Before we talk about kids, the impact on the kid, for this just want to wrap up this section. I think one of the things I'm thinking about is how important it is just to name that this is stuff to look out for. I mean, I don't know it's hard because I'm a psychologist, and I'm a psychologist who's primarily researched women's issues, so like I feel in contact with this. But I feel like I've met tons of patients, people in my life, who are like:  I expected pregnancy to be glowy. I expected that when the baby came, I would immediately love it with my whole heart and I would never feel frustrated by it. I expected that I would feel great. I knew I'd be tired, but I didn't expect that, for some people,  I would feel so bad, and so I think, opening up the conversation about how there could be these complications.

 

There's help out there. It is not abnormal. It's not you're a bad parent or a bad person for struggling. There's a lot. I mean,

 

There's a lot of expectations. You should respond.

 

Yeah, and Emily like your list do feel very comprehensive of there's a lot of factors that go into why someone might end up with the struggle.

 

Mychal Riley, LCSW-S: 26:09

And you reminded me of the last thing I want to say which is we also sometimes skip over the fact that for a person and for a couple, becoming a parent is also a great experience. And as a society we say you should be so happy, there should be so much joy about having a baby, but it's also meaning I am giving up a part of my identity and sacrificing that to get this other thing, which is great. But there's also, like you can't go out as much as you used to do. You can't just escape. We were talking about this this morning with the team. Sometimes, especially with very young babies, it feels like there is no respite. You come from work to parenting and then it's leading back up again.

 

Emily Pyle, LPC-S: 26:49

 I actually wanted to add one more thing to this too, which is I also want to hold space for the idea that not every parent or parents have a planned pregnancy or desiring a pregnancy, and so that can also lead to grief and loss and also misunderstanding. Maybe everyone around them is saying, oh, you must be so excited, or, you know, have you been longing for this since you were 10 years old? And that's not everybody's story, right and so. And then the other thing is even if someone is, or a family is, very excited to embrace a little one and what I'm thinking about this, with Mother's Day in particular, and Father's Day coming up, they also might have had many losses leading up to that time. Right, so maybe they've already lost a child, maybe they've longed for a child for a long time, and so honoring that grief and loss, even in the midst of the joy, is really important.

 

Bob Boland, MD: 27:47

Fair enough, and of course, then you know you just worry about how it impacts everyone, including the child. I mean, obviously, if you have parents going through all this and are depressed and all that, I mean, you know, I mean it's a risk factor for children as well, right.?

Emily Pyle, LPC-S: 

Do you want us to speak more?

 

Bob Boland, MD: 28:01

Sure, yeah, no, I no, I thought I'd just show what I know. No, go ahead.

 

Kerry Horrell, PhD: 28:06

Especially I think, the idea of untreated. So if this stuff goes untreated or again it's like, well, you should need to, you know grit and bear it, because you can't be on the meds. You need to be on or you don't. You can't go to therapy because you don't have child care. What is the risk on the family and the child?

 

Emily Pyle, LPC-S: 28:22

Absolutely, so one thing that to me, is one of the biggest risks of untreated PMADS is that they are unlikely to resolve without treatment. A lot of people don't know that. They think it's just going to go away. That's not true.

 

So many risks of untreated PMADS, including that it is unlikely to resolve without treatment, and how this is going to impact the whole family system over time. There's so many ways it could impact the family system. For one, it could disrupt bonding and attachment, which, as mental health providers, attachment is huge in terms of predicting how a child is going to develop their sense of self and how they show up and how they experience relationships. It can also lead to unintended consequences like child neglect, substance use, suicide, which I mean all could impact a child with trauma, with grief, with attachment, unemployment maybe, or resource considerations. If your resource is to provide for a child, relational strain, and if a partnership is impacted maybe by divorce or separation because of untreated PMADS, then that's going to also have consequences for the children. And  ultimately, big picture. I believe, and I think research also supports this idea, that if there's an untreated PMAD, they're going to be less likely to be able to be attuned appropriately to a child's needs and attend to those needs. Attunement and being able to attend to the needs.

 

Mychal Riley, LCSW-S: 30:08

Yeah, well, that's kind of the stuff that I think about it. What we know is people learn to cope really throughout their childhood, so they're doing a lot of modeling and mirroring and so if they lose one of the parents there to support that or to show them, they start finding ways to do it that maybe are ineffective as adults. We talk about this a lot when we talk about personality disorders. A lot of times it's children who were coping the best they could, because that's how they got mom's attention or dad's attention or experienced attention.

 

Mychal Riley, LCSW-S: 30:41

And, if you know, if I have to act out, that might be something where you see more acting out as an adult that is not socially acceptable. Or if it's, I have to just do everything on my own. That's where you see the people who are learning ‘I can't count on anybody.’ So that's like, I think, more of the kind of psychosocial trajectory a lot of times you can see with some of the stuff that goes untreated. We see that in this clinic a lot where we hear about the parent that was like oh, actually your parent was really depressed or was probably unmedicated for a very long time and it wasn't you, but now they feel like they were crazy or or doing something.

 

Kerry Horrell, PhD: 31:21

I've had a number of assessment cases where ,you know, I'm doing my assessment of the person and their struggles and what I found is like they're like, well, I don't remember, I don't really remember, I don't have a ton of memories before the age three, so that must not have mattered. And we talked to the parents. I do a collateral interview and the parents are like, yeah, I was really depressed after I had them, I had really bad postpartum depression. It impacted and it's like, okay, that super matters.

 

Kerry Horrell, PhD: 31:49

And I think even just drawing attention to that, not in any and I know this is not how you guys think about this Not in any shaming way for the parent going through it, but to hopefully again say like there's treatment out there and that treatment is important and how we make it more accessible is important because this has a lingering effect on generations to come. It does impact the kid and I think that is the that's always my kind of like plea to the parent who's understandably,  just trying to be the martyr of, I shouldn't do this for my kid and just, you know, ignore my own needs. It's like when we do that, that does impact the child. So we consider all of it that like taking care of yourself, prioritizing that. That's not always possible. I know it's complicated, but when, where and when you can is good for them too absolutely

 

Bob Boland, MD: 32:33

So I you know a lot of people listen to this, are clinicians and you know.

 

Bob Boland, MD: 32:38

And what's your sense of like? What should people be looking for? To kind of recognize this, assuming that someone may not present saying they have these problems?

 

Emily Pyle, LPC-S: 32:46

Yes, so there are a lot of things. I'm going to keep it to be a short list because I don't want it to be too overwhelming for folks. I will say a couple of things, though. One would be if there's difficulty concentrating or making decisions, that might be something to look out for, or to ask the partner or the individual themselves more about.

 

Emily Pyle, LPC-S: 33:10

Isolation and social withdrawal will be a huge one. And, to Mychal's point from earlier, social connections can be very predictive for mental health, and so isolation and social withdrawal would be a risk factor or warning signs. Potentially difficulty caring for self and or family would be huge. And so if someone is no longer showering, if they're having sleep and appetite disturbance, those would be things to be attending to.

 

Irritability or agitation, describing hopelessness or worthlessness or guilt. This might seem obvious but intrusive thoughts that might be shared about harm coming to, even if it seems like they're they don't want this, harm coming to themselves or the baby, or maybe even hyper vigilance in certain spaces. If a new mom is suddenly really hyper vigilant leaving the house or being in the car or in certain spaces, that would be important to consider. And then significant mood changes, specifically ones that impact the decision-making process, because certainly there are going to be mood shifts that happen with all of those hormonal shifts and baby blues, which is up to 70% of women and baby blues in the first two weeks after giving birth.

 

Bob Boland, MD: 34:31

I'm glad you mentioned that, and I think often doctors have trouble telling the difference. Yes, right, exactly. Which is that usually it's just self-limiting and you know it's not a cause for clinical concern.

 

Mychal Riley, LCSW-S: 34:42

Right, and that's what I was going to say... is the two things that come to my mind are kind of getting a thorough assessment, because a lot of people downplay it. Like again for the reasons Emily was talking about before. Everyone's like you should be so happy. This is what's going on at this time. So even with clinicians, people are going to have a tendency to be like well, this is normal I heard this is baby blues... and so you really want to assess that. Particularly anxiety. So you'll get a lot of, a lot of clients say what their experience is is anxiety. But the more you start to talk to them about it and a part of that's because it is more acceptable to be anxious than to be less, yeah, and so when you start really digging in, you start learning more about like, about like. Oh, this person's not okay, and especially if someone is having psychosis, because it's pretty scary for them. Hopefully they will say but there are some people who won't, and so they'll say I'm more stressed, I'm more anxious, and they won't tell you they're getting a paranoid. The last thing I'll say, too, is getting a thorough history is really, really important, because people may have a whole other set of symptoms that they are not acknowledging or thinking about, and that are also playing a factor.

 

Emily Pyle, LPC-S: 35:48

Yeah, I have one more thing to add, which is if a warning sign to me would also be missing medical appointments, and so either for the parents themselves, and or the baby. There are multiple reasons why that would be concerning. One of which, though, is that, at the follow-up appointments with an OB-GYN and also with the pediatrician, those providers are supposed to provide screeners. They're supposed to provide evidence-based screening tools to help make sure that we're able to help catch if there is a PMAD, and so if they're missing those appointments, then they're not getting those screening intervention tools, and early intervention makes a huge difference.

 

Kerry Horrell, PhD: 36:27

There's. So again, man, there's so many more pieces of this, yeah, that I feel like we could dive into.

 

Bob Boland, MD: 36:34

It's usually just scratch the surface.

 

Kerry Horrell, PhD: 36:35

But I mean, I think one of the main takeaways I'm hearing, because especially the first warning signs you mentioned, Emily, I could just so imagine so many people being like "that's normal.”

 

Bob Boland, MD: 36:45

Yeah, well, it sounds like some of it, some of it could be normal, some of it sounds quite unusual.

 

Kerry Horrell, PhD: 36:51

Right, right and just knowing like you can reach out and there's help to help suss that out. Um, so, people again, I think that would be, that would be my thought. But I'm curious, as we wrap up, what, what would be your kind of like last say to clinicians, of like how to, how to help these families and these patients?

 

Emily Pyle, LPC-S: 37:08

Absolutely. So the first thing I'll say is I know there's a lot of information out there and we only scratched the surface today. I would encourage clinicians to lean in and to learn more. Uh, there are a lot of trainings out there, including free trainings for clinicians, that are available in this realm, and I would encourage looking into it. And secondly, tied to this, is being open to collaborating with specialists in the field and consulting with them, learning with them.

 

Emily Pyle, LPC-S: 37:39

When I was first starting to get involved in this area, I consulted with a lot of people at the clinic who already shared this passion and had this as a specialty area. I think also learning about the resources that are in the community which might be referral sources for families. That could be helpful. And then two more things. It's important to remember that these disorders can show up not only postpartum, also during pregnancy.  Sometimes I think people can forget about that. It's both pregnancy and postpartum. It affects the whole family system, like we talked about, so it can be partners, it can be other children. There's a spectrum of disorders. It's not only postpartum depression, as important as postpartum depression is.

 

Emily Pyle, LPC-S: 38:25

I'm so glad there's awareness about it. There are a spectrum of disorders, and they don't usually resolve without treatment. However, there are evidence-based treatment options that can help that are highly effective, and so there is hope. It's a whole matter of getting that information and those resources to these individuals when they need it.

 

Kerry Horrell, PhD: 38:47

Mychal, any last say for our clinicians listening?

 

Mychal Riley, LCSW-S: 38:50

I'm gonna leave it at that. I can't top that.

 

Bob Boland, MD: 

Yeah, well on that, Happy Mother's Day,

 

Kerry Horrell, PhD: 38:51

And Father’s Day. Thank you. again. I'm so appreciative not only of like the work that Menninger 360 does and going into homes and communities and being able to help people where they're at. I think that's huge, and especially, again, like your expertise and work with our perinatal population and again, your expertise is around here, so helpful, and I'm glad we're able to share it with our listeners.

 

Bob Boland, MD: 39:22

Yeah, so once again you've been listening to Emily Pyle and Mychal Riley and I'm your host. I'm Bob Boland.

 

Kerry Horrell, PhD: 39:28

And I'm Kerry Horrell.

 

Bob Boland, MD: 39:29

Thanks for diving in.

 

Kerry Horrell, PhD: 39:31

The Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

 

Bob Boland, MD: 39:40

For more episodes like this, visit wwwmenningerclinicorg.

 

Kerry Horrell, PhD: 39:45