. Distraction: think of a very relaxing place, listen to some music, count backwards from 100 ^ whatever works for you!

. Do not avoid or leave a panic situation: the feelings will go awayquickly but will be worse next time. If you stay in the situation, the symptoms will eventually subside, as the feared catastrophe does not occur.

If you have been avoiding this problem for some time, you will need to start by identifying the situations that you have been avoiding and gradually face these events, starting with the least feared ones first.

Identify sources of stress Take a realistic look at what you can change and what you cannot.

Remember you cannot change other people; you can only change yourself and your own way of life.

Don't try to tackle everything at once: start with things that are easy to change, then you can build on your success.

Learn new life skills and ways of coping See the section below on depression.

Understanding and coping with depression In the previous chapters it has been highlighted that depression can be experienced throughout the life cycle but that becoming pregnant and having and caring for a baby may be times when women and their partners experience periods of depression. In previous chapters the experience or symptoms of depression have been looked at and there was also discussion of some of the things that might lead to depression at these times: a labour that wasn't what you were expecting, a sense of loss for former aspects of your life, a poor relationship with your own parents, and so on.

You should always go and see your doctor if feeling depressed and try and get as much help and support as possible. Depending on the nature of your difficulties, the doctor may recommend various treatments ^ possibly medication or that you should see a counsellor or therapist or he Understanding and coping with depression 167.

or she might just monitor your progress.You might also get support from your family, friends or your church.

As well as seeking help from a professional, there are ways that you can begin to understand and cope with your depression and some of these ideas are introduced below. You can use these ideas while taking medication, while waiting to see a therapist or alongside any other supportive discussions that you might be having. If you are referred to see a counsellor or therapist, you can tell them about any self-help work you have been doing. This will help you to decide together what needs to be done next.

Challenging depression Some of the factors that contribute to people's depression cannot be changed: if you are living in extreme poverty, if you had a complicated labour or a very poor experience of parenting in your own childhood, then these factors in themselves cannot be changed. However, there usually are aspects of your depression that can be changed. People do recover from awful experiences and depression is not inevitable and this is partly to do with how they view themselves and the world around them. For example, a child who is bullied at school may grow up to feel that he is 'not someone that people like' or 'not someone that people want to be friends with'and therefore he is less likely to try to make new friends or change his situation. His lack of a social life confirms his belief about himself and means he is isolated, has no-one to confide in and is more likely to be depressed. Another child who was bullied at school may think that the children picked on him for a specific reason: because he wore gla.s.ses or joined the cla.s.s later in the year, for example, and that the children were inadequate in some way themselves if they needed to bully him. He may have learnt from this that he needed to be tougher and more determined to put his point of view across.This may mean that as an adult he is much more a.s.sertive because of the experience.

Therefore, bad life experiences do not necessarily mean that we will get depressed (obviously, though, the more bad things that happen to you, the more difficult it is to keep being positive). Partly it is how we attribute meaning to what has happened.

Research has shown that people can improve their depression by tackling some of the negative thoughts and feelings that contribute to keeping us depressed.The ideas presented below are meant to help you explore and understand your feelings of depression.

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Step 1: 'Why am I depressed at the moment ?'

Identif ying problems One of the reasons that sadness turns into depression is because people fail to understand why they are feeling unhappy or what exactly their problems are. Sometimes people have been feeling slightly depressed for most of their life. Therefore, the most important step to getting rid of depression is trying to understand the reasons that it happened. Depression changes the way we think and feel and usually when we are depressed we do not stop and think about what is happening to us.

Keeping a diary When you are feeling depressed, life can just rattle on in a monotonous way: you are feeling miserable but haven't really got the energy to try to understand what your depression might be about. This is why it is extremely useful to keep a diary of your thoughts and feelings. You can do this in whichever way you like but it helps if you decide on what you are going to record, otherwise it can become too onerous a task.

One useful way, similar to the drinking diary in Chapter 3, is to try and record the following information every time you feel low or upset by something: 1. Triggers/situation: what was happening, what you were doing, who was there, any incident that might have caused you to feel low or upset.

2. Thoughts and feelings: what was going through your mind at the time?

How were you thinking and feeling?

3. Consequences: what did you do next/in response to these thoughts or feelings?

This might then read: (1) Monday p.m. ^ lying in bed trying to get to sleep; (2) thinking about the day ahead tomorrow, wondering if I will be able to cope, feeling guilty for having been so cross with the children today; (3) was awake for a long time and felt even worse the next day.

Just keep the diary for a week or two in the first instance. Don't allow the diary to become a ch.o.r.e. Carry on with it if you find it really helpful.

What's the point in keeping a diary?

There are lots of other things that you might like to record or different ways that you could do it. You may feel depressed all of the time, if so, then you Step 1: 'Why am I depressed at the moment?'

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could just record incidents where you feel worse or upset or even when you feel a bit better.The idea of the task is to try to learn something about your depression.

Quite often when I set this task for people they come back saying they couldn't do it because they're only just coping with all they have to do or they are just too depressed to think.They inevitably see this as a failure and this confirms their belief that they are 'useless'. However, you can learn something even from an empty diary.What stopped you doing it? How did that make you feel about yourself? Useless? Fed-up? Feeling like a failure? This is the depression 'talking'. This is one of the things we are looking for in the diary: how the depressed part of us affects how we see the world.Through exploration of why the diary wasn't done, how you felt about the task and what thoughts and beliefs this reveals about yourself, you can learn an awful lot about your depression.

What am I looking for?

There are almost an infinite number of things that can be learned from a diary and everyone seems to find out something different. Some of the things that you might look at are as follows: 1. Things that might be generating the problems, patterns that emerge from the diary. 'Whenever I stay at my parents' house we end up arguing and I feel depressed the next day'. 'Whenever the baby has been feeding a lot I start to feel worried that the baby isn't getting enough milk, that I'm not doing it right and eventually everyone will realise I'm not capable of looking after a baby.' 'At the station when I wait for the train to work in the mornings, the panic starts.'

2. Are there common thoughts that accompany these situations?: 'I'm going to embarra.s.s myself'; 'I'm not as good as . . . (or as clever as, as thin as, as pretty as . . .)', and so on. Here you are trying to identify critical or negative thinking: 'Clare never seems stressed with her baby, she's a perfect mother.'

3. Are you allowing your depression and negative thinking to restrict and control your life?: 'I didn't phone Clare and ended up feeling lonely all afternoon.'

What do I do next?

Well, that really depends on what you find out from your diary! If your diary has identified some triggers for your depression, then you may 170 need to explore these situations in more depth. Are there unresolved issues in your relationship with your partner, a parent or colleague? If your diary is full of negative and self-defeating thinking, it may be that this is causing your depression and you may need to learn to change this (see later section on challenging negative thoughts). Have you stopped doing things that give you pleasure or a sense of achievement? Often depression can manifest itself in the'tired all the time'syndrome. People explain their avoidance of activities as being due to tiredness and this avoidance leads to a less enjoyable life and more of a negative sense of self or lack of purpose. If you are caring for a new baby and getting up at night, you may well justi-fiably feel tired all of the time but do try and make some time for yourself to do something that you enjoy, even if it is just reading the newspaper for half-an-hour.

It may be that after identifying some problems that you feel a bit stuck.

If so, try to sit down with someone you trust and discuss what you have found out. You can ask them for their perspective: 'do you think I'm very critical of myself ?' 'I feel depressed when my mother is around, what do you notice when she is here?' If you can't get any further perhaps now might be a time to seek out some professional help.

Step 2 looks at some general solutions to the sorts of problems that people identify as causing their depression. In reading through these, you may find some that seem to be right for you and your situation.

Step 2 : Learning new skills Problem solving Often when people are depressed, they feel completely overwhelmed by their problems or find it difficult to identify what their problems are: 'I'm just feeling bad.' Hopefully if you have managed to keep a diary you will have begun to identify things that you need to change. Usually there are two reasons that people stop solving problems: first, they fail to identify what the problem is and, second, they set themselves too complicated a goal.

So, first, when identifying the problem, try to sort out what you can change and what you cannot: if you are fed-up with a lack of support at home because your partner has a very demanding job, then how can you get support from him when he is there? Who else can support you? What are the specific things that you need? Is it someone to talk to or someone to take the baby out for an hour while you have a sleep?

Step 2: Learning new skills 171.

Try to make a list of all the things that you think would make you feel better and how you might go about achieving these. Try to be realistic: don't try to be the perfect mother, just try to be good enough.

Set yourself some goals One way of moving forward is to try and set yourself some targets or goals.

These goals need to be simple, achievable and realistic. If you have been very depressed for some time a realistic goal might be to phone a friend or get out of bed before lunchtime. If you set complicated or unrealistic goals: 'I want to change my career and be earning 30,000 by the time I am 25', you may well reinforce your sense of failure. Goals also need to be measur-able, so that you can tell whether you have achieved them or not. For example: 'I need to be more a.s.sertive', is too vague. Break this down into a number of easily achievable steps: 'I want to say ''no'' once to my friend when she asks me to look after her children.' The next time she asks, you will know whether or not you have achieved that first step. If you don't achieve the goal, then break it down into smaller steps. If you ended up saying 'yes' to your friend again, then next time set yourself the goal of saying 'Yes, but I can only have the children for an hour because I have to go out later'.

Once you get going on the small steps, then the big challenges gradually become more achievable.

Expressing feelings/dealing with anger/a.s.sertiveness It has been argued that depression can result from problems of dealing with powerful feelings such as anger. It is certainly true that when people are depressed they can have a number of strong feelings and thoughts that feel jumbled up and in need of unravelling. Learning to be more open and willing to discuss problems and feelings can help to resolve those problems and release pent-up anger and tension. Sometimes people need specific help with managing their anger but more often than not it is the exploration of the problems that are generating these feelings that lead to the feelings resolving. Often people fear that they will lose control or 'explode' with rage if they begin to talk but this is rarely the case.

We all deal with anger in different ways but if you think that you never get angry, then perhaps you need to think again. How do you deal with life's frustrations? Often it can feel easier to say nothing about small irritations but these can simmer away causing a great deal of stress and possibly boil over in a destructive way.

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Roza's story Roza was referred to see me for help with managing a chronic pain problem. She had a pain in her ankle that at times stopped her from walking. The doctors could find no clear cause for this pain and felt that she needed to learn some relaxation techniques. Roza had four children, two of whom were at school but her eldest son had recently started 'staying home'and she was finding it difficult to get him out of bed in the mornings. Roza had come to live in England to marry her husband who was born in this country. He had worked in the family catering business for many years but had not worked for three years since he had fallen out with his father. He usually stayed in bed until after she had taken the children to school. Roza was responsible for the care of the children and the housework. She said it would be inappropriate for a man to help her with these tasks but she did wish she had more support particularly concerning managing their eldest son's behaviour.

Roza expressed no anger or frustration towards her husband and said she was very sympathetic to his plight. However, she said that since her leg troubles she had suggested that he would have to walk the children to school as she often could not stand on her foot in the mornings.

Many people come for help with depression and realise that they need to be more a.s.sertive and say 'no' more because the cost is too high if they don't. However, this is always a difficult choice to make since it comes at a cost.When people are used to you behaving in a particular way, they don't want you to change. For Roza there were complicated cultural pressures and personal expectations about a relationship that made it hard for her to ask her husband for help. Learning to be more a.s.sertive is something that needs to be practised and often when you try to change your behaviour, the people around you only intensify their behaviour because they want you to stay the same. If you really want to change, then start with an easy situation and practise saying 'no'. After all are you really helping your family if you are left completely exhausted and irritable by their demands?

Identifying and challenging negative thinking So, how we deal with our feelings and problems may be an aspect of becoming depressed. Research has also identified that depressed people Step 2: Learning new skills 173.

are p.r.o.ne to thinking negatively about themselves and their life. This seems to be particularly apparent when faced by new challenges or difficult situations: 'I'll never do this as well as the others.' This negative thinking seems to reflect an underlying set of negative beliefs about themselves. Basically,'my life is going badly because I am a useless person' or a 'bad' person or 'stupid'.You may not be aware of holding such beliefs about yourself or even that you are p.r.o.ne to thinking negatively. This is often because this is such a habitual way of thinking that you don't notice it. It is often keeping a diary that makes someone realise that they are making life twice as hard for themselves. If you are constantly criticising yourself and predicting failure, then you make it very hard to succeed at anything.

Try to become more aware of negative thinking (use your diary to monitor your thoughts) if you keep saying 'I'm useless at this' then you are likely to feel stressed, demoralised and give up easily.Try to replace them with more helpful thoughts: 'If I keep practising, I'm sure I'll get the hang of it.'

Changing the way that you view yourself certainly can be an immense undertaking and not something that you can do overnight. If negative thinking appears to be a big factor in why you get depressed, then you might find it useful to look at one of the self-help books listed in the Further reading on p.188.

Self-care When experiencing either anxiety or depression it is very important to learn or relearn how to look after yourself. Depression may be a psychological problem but it is more difficult to have a healthy mind in an unhealthy body. As previously mentioned, feeling 'tired all the time' or unable to initiate activities is all part of being depressed. Again, try to start off with an easy step: it might be, for example, cutting out coffee or alcoholic drinks (particularly important for those with anxiety problems).

People often falsely believe that these drinks make them feel better, either calmer or more awake but in fact they contribute to the experience of anxiety symptoms even in fairly moderate doses.

Activity and exercise are important factors in trying to recover from depression. Very often depression makes you lethargic and yet restless.

Some form of activity or exercise can be an important first step in breaking out of this. Again, don't set yourself unrealistic goals:'Ican't do anything at the moment because I'm not able to afford membership of the gym.' Just going out for a walk to the local shop every morning can give you a boost of energy. Exercise can be a very important factor for many women after having a baby. Most women are keen to return to their pre-pregnancy 174 state but may find it difficult to make time to go for a swim or do the things they did before they had a baby. Walking with the baby in the pram instead of driving everywhere is good for both of you. Going for a walk can help you in the early days to set a routine with the baby or to settle him if he is fretful.

Often women give their lives over to their baby in the early days and it may be important for you to identify some time for you to take care of or nurture yourself.That might mean a meal out or a relaxing bath or a trip to the hairdresser, whatever makes you feel a bit better or special.

Relearning how to enjoy yourself and feeling a sense of achievement Enjoyment and a sense of personal fulfilment are two aspects of life that tend to disappear when someone is depressed.When depressed, people tend to avoid certain social situations or friends because they feel they will 'spoil it for others' or because they don't want people to know that they are depressed. We all need to enjoy ourselves, to have contact with other people and to feel that we do some worthwhile things. Consequently, this avoidance makes us feel even more depressed.

When setting yourself some goals, it is really important to identify at least one activity that you can start to try doing again. When you have been very depressed, this may need to be a very small step initially. You might just want to call a friend, take a walk through the park, or make a shopping trip. This will help your depression in other ways too. Often when people are depressed, their lives lack structure and they find it difficult to initiate activities. After having a baby you may feel your day is completely full up but try and make some s.p.a.ce to do just one special thing for yourself each day.

As well as trying to have some positive social experiences, it is also important to remind yourself of what you are good at. Make a list of things that give you a sense of achievement and look at trying to reintroduce some of these into your life. Again, where you have been very depressed you may feel you aren't good at anything. Your initial objective should therefore be a small easily achievable goal, even if it is just reading a maga-zine, so that you can look back at the end of the day and feel you have achieved your task for the day.

After having a baby, particularly if you had a very active life before, depression can manifest itself in an enormous amount of frustration about what you cannot achieve now that you have a baby. The important factor here is really about adjusting to your new situation and accepting Step 2: Learning new skills 175.

that for the moment things have to be different. If you have no expectations of having free time, then every time your baby goes to sleep it will be a bonus. However, if you start the day hoping to clean up the house, make dinner, catch up on some phone calls and sort out your paperwork, then you are likely to continually feel frustrated.'Time management' is not about being shown the secret way of trying to fit more things into your day, it is about trying to be realistic and prioritising your tasks so that you do what you really have to and don't keep'beating yourself up'about what you haven't achieved.

Deciding to change n.o.body wants to be depressed or gripped by fears and panics but moving away from these symptoms can be a frightening prospect. Once you have accepted that there is no magic wand and you cannot simply have your depression or anxiety 'taken away', you will begin to realise that you need to make changes if you are to get better. These will be different for each person. This might mean recognising your role in your relationship problems or deciding that you have to confront a difficult situation. In order to tackle your anxiety problems you may need to start going back to situations that you have avoided. Sometimes with all these challenges it can seem easier to do nothing and just hope that soon it will all go away. Sometimes you need help to motivate yourself to do anything differently. Try setting yourself the task of imagining life if you do not change.

Try to write a description of your life in five years' time if you continue to be depressed.What will you be doing? Where will you be living? What will family life be like? Alternatively, try to write a list of everything that you feel your depression or anxiety stops you from doing.What things have you missed out on in life since you have had these problems? Have you avoided taking career moves, lost contact with friends, missed out on social events, and so on? Then make a list of any of the positive benefits of being like this.

For example, 'I get to avoid another argument with my partner', 'I don't have to feel uncertain' or 'I don't risk feeling optimistic and then being disappointed.' Take a look at the benefits of staying the same and ask yourself if these outweigh the benefits of change.

Looking forward from depression and anxiety The different ideas in this chapter may all seem very complicated at the moment and it is important to remember that you can take just one step at a time. When you have had a baby there is an enormous amount of 176 change going on and it may take you some time to catch up with the changes. Sometimes when things are getting a bit better, you may experience a setback and then feel even more hopeless.The early days of trying to change can be very difficult so try to rally as much support as possible when things become difficult.

Who can help ?

Experiencing stress, especially panic and anxiety symptoms, can be extremely distressing and demoralising. Trying to do something about it requires a lot of hard work at a time where you probably feel least able to find the energy. However, you may find that taking the first few steps can bring an enormous sense of relief and quite quickly you may feel hopeful about changing your life. If you can't get going on your own, speak to your GP who should be able to recommend a psychologist, counsellor or possibly an anxiety management course.

There are also self-help organisations that run groups or offer individual support over the phone (see the list of addresses on p.181). Many local councils also run 'stress management' courses within their adult education programme. Always try as many different options as you can to try and find the right one for you.

9.The journey that never ends.

Looking ahead.

In the course of a year you will have made an incredible transition from an individual to expectant parent through to a family.You are now the parent of a baby who is growing and developing rapidly. When you look back, you will probably wish you had done certain things differently and wonder why you didn't realise other things. Hopefully, though, the pleasures will have outweighed the disappointments. If you have had a difficult or disappointing time, then it is perhaps important to remember that the relationship between mother and baby is not a static one: it is constantly changing and evolving. If you have struggled in the first six weeks, this doesn't mean that you are doomed to be a bad parent or that your baby will always be unsettled or whatever your worry may be. No one is a 'perfect mother' or gets it right all of the time. Clearly, some parents find it easier, and some infants offer more complex challenges.

Often as soon as you have established a routine with your baby, or feel that you are getting on top of things, a new challenge comes along: perhaps your baby catches a cold and his feeding and sleeping go awry.

Outside events may change your situation: your partner loses his job or a close relative dies. Suddenly you have to deal with the outside world again and manage your own and your baby's life around these new circ.u.mstances. Just as you will experience further life events, so too will your baby.This can come as a bit of a shock for parents who hope that they can simply avoid their baby ever being frustrated or upset. For example, your baby might develop eczema and your usually content baby may become 178 distressed and frustrated. You will have to help him manage this experience. Separations can also be difficult for mothers and babies. If you return to work, you will have to leave your baby in the care of someone else and deal with the feelings that this stirs up in you and with the feelings and reactions it generates in your baby. Even if you don't return to work, your baby will have to learn to manage at times without you there.

Donald Winnicott introduced the idea of the'good enough' mother and that is what we should be aiming for. As with any relationship, you cannot always get it right and at times there will be misunderstandings, disagreements or external pressures that make your relationship with your baby difficult or unpredictable. Sometimes you will have to wait and tolerate uncertainty until you work out the way forward together. It is important to remember this as you struggle with each new challenge. If your baby wakes frequently at night after months of 'sleeping through', if he cries a lot because he is frustrated in his attempts to crawl or if he refuses to give up the breast, then it may take time for a solution to develop and you may have to tolerate distress in your baby and yourself.

The new 'me'

This process of development continues for all of the family and each developmental stage brings new challenges. Often it may feel as if nothing stays the same for long: as soon as a family has found some equilibrium or routine, then the baby develops and everything changes again.

These developmental changes are more apparent in the baby: as he begins to take solid food or begins to crawl. However, the changes are continuing for you too. You can never really return to the same place as before. Even if you take a short maternity leave and return to the same job, it will feel different when you have a baby. Having to leave your baby stirs up complicated emotions but also, on a practical level, it makes life more complicated. Your priorities are split. In time you may have more children, your baby will become a toddler and eventually go to school.

All along he will need you but in different ways at different times.

In becoming a parent, your view of yourself will have changed. Now you are 'mother' and 'parent' as well as all the other roles that you may perform. As you move into these roles you will be continually faced by dilemmas over priorities. Again, it is about finding what is right for you and your family. For some women, over time that might bring a recognition of having made sacrifices: perhaps missing out on times with your child or perhaps having given up the idea of holding the 'top job' at work.

The new 'me'

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Looking ahead you probably don't want to miss out in any areas but what is important is to make your own decisions over time.

For many fathers, especially those who have been less involved early on, feeling that you have become a father may take a long time. Finding your role as a father can often be difficult, especially where a mother is breast-feeding for long periods of time.This role may develop more slowly and it may seem difficult to be still making mistakes if the mother seems so competent and keeps telling the father what to do. Some fathers may have taken a much more active role especially if a mother has struggled with post-natal depression. Becoming a father may have made the partner review his own 'life plan' too. He may ask himself, 'Do I want to be away from the home so much as I used to? How can I become more involved in family life?'

The journey for your family continues with all its ups and downs.With good communication between all of you, hopefully the journey will be unforgettable.

Addresses of useful organisations British Acupuncture Council 020 8735 0400.

www.acupuncture.org.uk British Pregnancy Advisory Service Helpline 0845 730 40 30 www.bpas.org.uk Child Bereavement Trust 01494 446 648.

www.childbereavement.org.uk Information and support for parents and children who have lost a family member.

Contact a Family 0808 808 3555.

www.cafamily.org.uk Information and support for families caring for a child with disabilities.

Support group contacts.

Cruse Helpline 0870 167 1677 www.crusebereavementcare.org.uk For advice, individual and group counselling for bereavement.

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Addresses of useful organisations Eating Disorders a.s.sociation Helpline 0845 634 1414 www.edauk.com Foundation for the Study of Infant Deaths Helpline 0870 787 0554 www.sids.org.uk Independent Midwives a.s.sociation 01483 821104.