153.

eventually reflect that it had been a difficult year. Her father had died suddenly of a heart attack not long after she had become pregnant. She was terribly sad that he had not seen her baby. Her mother had no longer felt able to run the bakery that the couple had owned throughout their life and it had had to be sold. Janet had worked in the bakery throughout her life and all of the family were struggling to come to terms with the new situation.

Do fathers get post-natal depression?

There is much research now that highlights the difficulties many fathers have in coming to terms with their new role. Many men do experience emotional difficulties in those early months and as in Karen and Colin's situation, often when one parent becomes depressed, the other then experiences emotional difficulties. As discussed in Chapter 3, although men are less likely than women to develop depression they may increase their consumption of drugs or alcohol, stay out of the home or experience any number of other difficulties in response to their new situation.

Craig's story Craig was referred for help with depression that was affecting his training to be a doctor. His depression began following the separation from his girlfriend and his five-month-old child. She was adamant that the relationship was over although she was happy for him to see as much of his daughter as he wanted. The trigger for depression was not the separation itself but the unbelievable sense of failure he felt. He had come from a single parent family himself and his father had never acknowledged him. His father had many children, with various mothers and he had not maintained any relationship with Craig. His mother had found him difficult and he had ended up in care repeatedly.

He had been determined not to make the same mistakes as his father whom he bitterly resented for his absence. However, now he felt he was repeating the mistakes his father had made and therefore Craig could no longer simply be mad at his father as he felt he too was letting down his child.

154.

Getting help with post-natal problems Admitting that something is wrong The first step to getting help with post-natal problems is recognising that there is something wrong and that there are things that need to be changed about your situation. Most women do not like to admit that they are depressed, particularly so early on after the birth of their baby, and when there is such a great sense of expectation around them.When you have just had a baby, you can feel that the spotlight is really on you and that everyone is a.s.sessing how you are getting on. To hold your hand up and say 'Help, I'm not coping' or 'I'm really unhappy' can seem like too much of a failure.

For many women it takes a while to acknowledge that there is a problem.

There is often the feeling that 'Well, I just need a good night's sleep' and everything will be OK. It may be that you are so consumed with anxiety about how the baby is doing or so preoccupied with trying to sort out a 'routine' for the baby that you fail to notice that you are crying every few moments.

Beginning to talk The first step should always be to try and talk to someone whom you trust about how you are feeling. This might be your partner or a relative or friend. It may be that you can identify the source of the problem: perhaps you still have dissatisfaction about your birth that need to be talked through with someone, perhaps you just need a break away from the baby to get some sleep or phone a friend for a chat. However, these post-natal weeks seem to be a time when women find it difficult to reflect on their experience partly because there is so much new learning going on that there really isn't much time to think about how you are feeling. Sometimes it may be that you need to speak to a professional to have the time and s.p.a.ce to sort out what the problems are.

Getting help Many women will need extra support at this time and your GP, midwife or health visitor should all be able to offer information and support. The type of help you might need will vary from person to Getting help with post-natal problems 155.

person so the best place to start is to sit down with someone else and try to identify your difficulties. Sorting out your difficulties may be something that you feel you can do for yourself or you may feel that you need the help of other professional or voluntary organisations. It may be that your partner has to explore these options because he is concerned about your well-being.

Self-help The emphasis of this book has been about being aware and informed and, therefore, trying to prevent problems developing. However, if you do feel you are not coping or feeling fed-up with things you may find that Chapter 8 of this book 'Dealing with anxiety and depression' helps you to understand and approach the problem slightly differently. Part of getting rid of depression is about identifying what the actual problems are that you face and what the emotions, thoughts and feelings are that are holding you back from changing your situation. There are many problems that you usually cannot solve for yourself: ill health, poverty, poor housing, violence in another person or marital breakdown.There are always things that you can do to improve your situation but unfortunately depression doesn't let you think like that. Isolation is not good for new mothers but depression tells you 'I'm too fed-up to go anywhere new'. Organisations such as the National Childbirth Trust (NCT) provide opportunities to join groups and meet with other new mothers. Many local churches have 'mother and baby'groups and usually you can just turn up on the day without being a member.

Where depression has been a feature of your life for a long time, you may need to see a therapist who can help you to work on these ideas. It's always worth speaking to your GP to see if he or she can recommend a therapist either through the NHS or privately.

Health visitor support Many health visitors are now specially trained in supporting and listening to new mothers. Some health visitors will ask you to fill out a questionnaire at around six weeks after the baby is born. This questionnaire, the Edinburgh Post-natal Depression Scale or EPDS, helps to identify women who are depressed or struggling. You may find that the questionnaire helps to open up the discussion about how you are feeling and is meant to convey to mothers that health visitors are interested in 156 how you coping not just how the baby is doing. Your health visitor may be able to visit you regularly at home and give you some time and s.p.a.ce to explore how you are feeling. Health visitors can also offer specific advice about other types of help you might need and may introduce you to, for example, a post-natal support group. If your problems seem more deep-rooted or where you have had previous emotional difficulties your health visitor may ask you to see your GP or suggest you see a member of the mental health services.

Support within the NHS The health visitor and GP are the first line of contact within the health service and they will have access to other services where needed. Many GPs now have counsellors, community psychiatric nurses or psychologists working at the surgery who can become involved where necessary. They may offer individual or group therapy following an a.s.sessment. They may also recommend the support of voluntary organisations or groups.

The support of other mothers and parents Most studies looking at depression in mothers highlight a lack of confiding relationship or social support as a feature of the problem.

Being together with other mothers-to-be in pregnancy has also been shown to be effective in the prevention of post-natal problems. It can be very difficult if feeling depressed to think about going along to a mother-and-baby group or joining a post-natal support group but for the women who do take the step, it can be an incredibly supportive experience. It may be that you need to go and talk to someone first about how you are feeling and then maybe you will feel able to take that step.

There is a list of addresses of organisations on p.181that you may like to contact for specific types of support, for example, mother-and-baby groups.

Who can help ?

The section on post-natal problems has highlighted a number of types of support but it is important perhaps to highlight the range of different people you may come into contact with and the services that you may be offered in the first six weeks.

Discussion points 157.

Care of your baby Your midwife may remain involved in your care for up to 28 days after the birth of your baby. In practice, they tend to hand over to the health visitor in the first couple of weeks if all is going well.

Your health visitor will carry out a 'new birth visit' within the first month. She will be there to hear all about your experiences so far and to explain her role with your family until your child goes to school.The health visitor will invite you to bring your baby to the Baby Clinic once you are able enough and here you can have the baby weighed and discuss your progress or any problems with the health visitor or GP. You will also be offered a programme of immunisation for the baby in due course.

At around eight weeks you will be offered a 'developmental check' or 'review' of your baby's progress with the GP or health visitor.

Support for you You will be offered a'post-natal check' with your GP at around six weeks to discuss your recovery and any concerns that you have about your own health: physical or emotional.

When you do feel that you are not coping, you may be offered extra support from your health visitor, possibly visits at home.Where problems are more deep-rooted you may need to speak to a counsellor or other mental health professional.

Organisations such as the National ChildbirthTrust run many supportive post-natal groups or drop-in facilities where you can meet other new mothers.

Discussion points 1. Getting to know your baby. Try describing your baby as if you were describing him to a stranger. How do you think the baby takes after you/your partner: looks, personality? How does your baby let you know how he is feeling? Crying? Wriggling? Cooing? Does your baby have any routines/predictable patterns yet? Are there any concerns about your baby you feel you need to discuss with someone?

2. Are you feeling well? Do you feel you have physically recovered from the birth and, if not, what are the problems? How are you both doing in terms of sleeping, eating and relaxing?

3. Are there any concerns about how you are feeling?

4. Do you need any more help or support from others?

8.Managing anxiety and depression.

The journey through pregnancy and into parenthood brings with it psychological risks. The previous chapters have outlined different types of psychological difficulties mothers might experience and why. The emphasis of this book has been about trying to prevent problems by being more aware and informed about the emotional pressures that you might experience when you embark upon having a family. However, for some women the events of pregnancy and childbirth will lead to significant levels of anxiety or depression or these may have been around for most of your life. Each chapter has tried to highlight issues specific to problems at that stage; such as the reasons for depression in pregnancy; what follows here are some general points about dealing with these problems whenever they occur.

Understanding and coping with stress and anxiety Everyone experiences stress or anxiety at some point in his or her life. It is usually viewed as a problem but moderate levels of stress actually help us to perform better. If about to have an interview or raise a difficult issue with a friend, it is perfectly normal to feel 'b.u.t.terflies' in your stomach or to breathe faster than usual. Our bodies are preparing us for action or to face perceived challenges. At times we have all felt 'panicky', been preoccupied with worries or avoided something we would rather not deal with.

160.

However, when these signs become regular or intense or in the 'wrong'

situation, then anxiety can be a cause of much dread and misery as well as being detrimental to health in the long term.

The aim of this chapter is 'coping'and 'understanding' NOT 'avoiding'

anxiety. Many people I have worked with have wanted to know how to avoid the problem. Avoiding the problem only ever makes things worse in the long run. Anxiety can only be solved by learning to cope with the symptoms so that you can begin to explore and understand the problems.

The following areas will be covered in this section: 1. What are the signs or symptoms of anxiety?

2. How does anxiety affect peoples' lives?

3. What causes these problems?

4. How can I cope with anxiety/manage my life better?

What do we mean by 'stress'or 'anxiety'?

Most people don't need to be told that they are under stress or what stress means to them. However, 'stress' is a word used in many contexts but generally refers to a situation where the demands that you experience in your everyday life outweigh the resources that you feel you have to cope with those demands.

Anxiety has also come to refer to many types of experiences. Here it will be used to refer to a type of problem or experience that can be divided into the following three aspects: 1. 'physical' ^ bodily experiences and sensations 2. 'thoughts' ^ negative thinking, fears, worries, tendency to catastrophise 3. 'behaviour' ^ avoidance of the situation or problem.

How do you know you are stressed?

The list of signs or symptoms is endless and each individual has their own unique set of experiences. Generally, these experiences fall into the following categories: . chest pain or tight feeling across the chest . palpitations . dizziness . sweating . hot and cold flushes . blushing Understanding and coping with stress and anxiety 161 . shortness of breath . hyperventilation . difficulty swallowing . shakiness/trembling . tingling sensations . tension; muscle cramps; aches and pains, especially backache and headache . nausea . dry mouth . diarrhoea.

There are probably many other types of experience that you can add to the list. But what causes these physical symptoms? In order to understand, this it is helpful to look at what happens in a panic attack.

Understanding the reasons for bodily symptoms ^ the panic spiral When we find ourselves in a situation that we perceive as threatening, our body prepares us for action: adrenaline starts to pump around the body and therefore our heart begins to race; breathing becomes more rapid.

This is known as the fight or flight response. This physical response can be traced back to our prehistoric ancestors who needed to flee from predators.When you are stressed, your body goes into a state of high physical arousal and these bodily changes prepare us for action ^ to'flee' from the situation or 'fight'. However, in a panic attack these symptoms occur in a situation where there is no obvious danger, such as on a train or at the supermarket. This we call a panic attack. An a.s.sociation is made that this situation is in some way threatening and the symptoms return whenever we return to a similar situation.

Karl's story One morning as Karl stood on the platform waiting for his train to arrive, his heart began racing and he started to sweat heavily. He sat down on a bench as he thought he was having a heart attack. He remained there while the pa.s.sengers boarded the train and when he felt a bit better, he managed to walk home and spent the day in bed.

Next morning he went to the station as usual but found himself 162 sweating profusely as he approached the platform and his heart began to race. He was convinced that he was on the verge of a heart attack and went straight to his GP. His GP sent him for various tests but eventually said he was physically quite well. Karl stayed away from work and was now terrified of going anywhere near the train station.

Karl needed help to manage his symptoms of panic. He gave up his job rather than face the journey to work. As he began to manage his panic attacks, Karl recognised that he had hated his job and had felt that his life was going nowhere. He needed to rethink the direction of his life and as he began to do this he gradually regained his confidence and eventually was able to use the train again.

Panic attacks can seem to come out of the blue but are generally a sign of an increasingly stressful situation or set of events. Naturally we interpret these symptoms as signs of something catastrophic, i.e.: 1. 'I'm going mad': some form of imminent psychological breakdown.

2. 'I'm having a heart attack': serious or fatal health problems.

3. 'I'm going to make a fool of myself': the fear of terrible loss of control/ embarra.s.sment in front of others.

The natural reaction is to avoid the situation in which the feelings occurred: to get out of the meeting or leave the supermarket. However, the panic attack will not harm you. If you can stay in the situation, the panic will subside.

These three factors: physical symptoms, frightening thoughts and avoidance behaviour together create a vicious circle. The experience of panic is so frightening and unpleasant, there is usually a desperate attempt to avoid it happening again at all costs. Therefore, we tend to look for any physical changes; avoid the situations where it has taken place and fully believe the frightening thoughts that occurred during the panic: 'If the train stops in a tunnel, I'm sure I'll not be able to breathe and I'll collapse.'

Many people who come for help with anxiety problems are caught up in their'fear of fear'.They are so terrified of panicking that they are constantly looking for signs that they might panic.When they feel like this, people will avoid any situation that has been a.s.sociated with panic, any event or activity that might make their heart race, make them feel nervous or even avoid rushing for a bus in case it triggers a panic. Ironically when someone can get to the point where they can say 'I really don't care if I have a panic attack', this is the point where the panics will usually subside.

How does anxiety affect people's lives?

163.

April's story April, who was 28 years old, only managed to get to her first appointment with me because her mother had brought her. She had rarely been out of the house since she had given up her 'stressful' job as a travel agent, three months previously. She had been repeatedly panicking at work following an incident when a customer had become angry and abusive towards her. At first she had enjoyed the safety of being at home with her mother. However, now the symptoms had started to happen at home whenever her mother left the house. This had made life almost impossible for both of them since every time her mother went out April would become tearful and resentful.

April made significant progress by learning to face her panic and managing to go out again, starting with very small journeys. She also began to think about the underlying reasons for her anxiety. She had lived with just her mother since her father had left when she was five.

It was very frightening for both April and her mother to think about her becoming an adult and leaving home at some point.

How does anxiet y affect people's lives ?

As well as the immediate and distressing symptoms of panic, anxiety can have more subtle or longer-term effects. These we would call the secondary symptoms of anxiety.

Changes in behaviour . Sleep problems . Appet.i.te loss or over-eating . Drinking/smoking/drug use . Avoidance of certain situations/people/places/problems . Over-activity/inactivity.

Changes in how we think . Poor concentration . Problems making decisions 164.

. Memory problems . Negative thinking/more rigid thinking.

Emotional changes . Increase in a range of anxiety problems: panics, phobias, obsessions . Increase in depression: sadness, apathy, fatigue . Mood swings . Problems with anger/irritability/aggression.

Effects on health . Can cause or worsen certain health problems such as hypertension or asthma . Digestive problems . General feelings of ill health.

What causes anxiet y problems ?

. Stress is a very individual experience, therefore the sources of stress for any individual will be different.

. Sources of stress can be everyday demands or major life changes.

. Every aspect of life can be a source of stress for a particular individual at a particular time.

Here are a few examples: . Family life: raising children, looking after an older relative or grandchildren; marital breakdown, interpersonal disputes, moving house.

. Work: work overload, unemployment, problems with colleagues, financial problems.

. Illness and disability.

. Accidents and trauma.

. Personal/developmental: boredom, lackof personal fulfilmentor direction, few interests.

Research has shown that the more of these life events we experience, the more likely we are to experience stress. Also we are not just talking about negative events, positive changes can also bring stress: getting 'How can I cope with anxiety/manage my life differently?'

165.

married, having a baby, moving house, Christmas and holidays can all bring stress.

Overall, then, it is our ability to adapt and change in response to these events in life that will predict how much stress we experience.

Adapting to life events can mean having to let go of the past, possibly facing a period of uncertainty and self-doubt. It may mean learning new skills or being open to new ideas. Research shows that if you can embrace and enjoy change, then you will experience less stress. Therefore, what changes can we make to manage life differently and therefore reduce our stress?

'How can I cope with anxiet y/manage my life differently ?'

Once you have started to identify signs and sources of stress in your life, you will have already gone a long way towards dealing with them. It is important to believe that you can change and not allow these feelings to overwhelm you and make you feel powerless.

Below is a list of ways of tackling stress and life problems generally.Try out different things as some may be more helpful to you than others.

Identify and understand your symptoms . Keep a stress diary and monitor when, where and how you are feeling stressed. Look for patterns of symptoms or particular situations that bring them on (see Designing Diaries on p.186).

. Check out with your doctor anything that you feel might be undiagnosed ill health.

. If you have anxiety symptoms (fight and flight as discussed earlier), try to follow the steps outlined below: Learning to cope with feelings of panic . Relaxation: learn the techniques of relaxation so that you can put these into action before you start to panic (see the relaxation ca.s.sette discussed on p.188).Try to visualize relaxing scenes.

. Monitor your panic thoughts. As you learn about what is happening to your body in a panic, try to recognise that what you are saying to yourself increases the panic:'I'm going to faint';'I'm going to run screaming from the cinema', etc.

166.

. Positive self-talk: try to replace these panic thoughts with more rational ones: 'my breathing will slow down if I sit down for a minute'. Or focus on the word 'calm'.