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Motherhood as Rite of Passage

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For Partners: Navigating the Land-mines of Postpartum and Eating Disorder Recovery

I just finished reading The Postpartum Husband, by Karen Kleinman.* This is hands down the most fabulous book I have seen for partners (except for the non-PC title that excludes same sex or unmarried partners) supporting women through Postpartum Depression. It is basically the Men are from Mars Women are from Venus of Postpartum Depression Recovery sourcebook. The style is direct, informative, non-shaming and concise. The chapters are 1-2 pages long- perfect for men and partners wanting bullet point versions of information that are most likely sleep-deprived and potentially in-crisis-with-a-depressed-new-mom-and-baby. Some gems that stood out for me were: YOU CANNOT FIX THIS.

And also:

What works for you may not work for her:

You’d want to be alone; she wants you there all the time

You’d get up and out and run yourself through this; she stays inside and can’t get up and go

You’d isolate yourself at work; she craves support and comfort from others

You’d turn your sadness into anger; she feels inadequate and worthless.

As a pragmatic clinician and eating disorder specialist, I am always asking the question, how does this apply to eating disorder recovery? Here are Karen Kleinman’s thoughts on supporting women in PPD recovery followed by my thoughts on supporting women in eating disorder recovery:

  • The single most important thing for you to do to help is to sit with her. Just be with her. No TV, no kids, no bills, no newspaper. Just you and her. Let her know that you are there. (DITTO)
  • This isn’t easy to do, especially with someone who seems so sad or so distant. Five minutes a day is a good place to start. (DITTO)

Here’s what you’re up against:

  • If you tell her you love her, she won’t believe you (Ditto)
  • If you tell her she’s a good mother, think you’re just saying that to make her feel better. (Substitute “good person.”)
  • If you tell her she’s beautiful, she’ll assume you’re lying. (Ditto. If you tell her “you’re not fat,” she will think you are lying or are minimizing her distress.)
  • If you tell her not to worry about anything, she’ll think you have no idea how bad she’s feeling.(Ditto)
  • If you tell her you’ll come home early to help her, she’ll feel guilty. (If you tell her you will eat with her to help her, she will feel guilty, ashamed, anxious)
  • If you tell her you have to work late, she’ll think you don’t care. (If you tell her you have to work late, she will think it is to be with someone else because you hate her company or are sick of her.)

You may (as the partner) be thinking, THEN WHAT IS THE POINT? Anything I do is fruitless. That is where I would encourage you to be aware of the cognitive distortions rampant in depression and eating disorders that you are up against: all or nothing thinking, personalizing, perfectionism, minimizing, control fallacies… However, there ARE things you can do. Here are some examples:

  • Tell her you know she feels terrible. (Ditto)
  • Tell her she will get better. (Ditto)
  • Tell her she is doing the right things (therapy, medication) to get better. (Ditto)
  • Tell her she can still be a good mother and feel terrible. (Substitute “person.”)
  • Tell her it’s ok to make mistakes she doesn’t have to do everything perfectly. (Ditto)
  • Tell her you know how hard she is working right now. (Ditto)
  • Tell her to let you know what she needs you to do to help. (Ditto)
  • Tell her you love her. (Ditto)
  • Tell her your baby will be fine. (Tell her that her eating disorder is not destroying you and that you can handle all of her feelings.)

For eating disorder recovery, I would add the following DO’s and DON’t’s:

  • Do NOT try to be “the food police” or try to be her nutritionist/dietician. DO redirect her to her nutritionist/dietician for advice on her food plan recovery.
  • Do NOT bring up emotionally difficult conversations during meals when she is already struggling. DO know that meals will most likely be uncomfortable for her and keeping conversation “light and polite” or simply giving her a kind look that acknowledges you know meals can be tough for her, but you are right here beside her. DO ask when a good time to talk about difficult things is for her and for you (ex in the morning, at night before 8pm, on the weekend).
  • Do NOT assume she is feeling or will feel better if she is eating according to her food plan, gaining/losing weight as a result of her recovery action steps. Do NOT comment on her body size, even if you think she looks “better” or “healthy.” . She is most likely feeling WORSE. DO validate that she is most likely feeling worse and know that she will cultivate tools for managing these distressing emotions without using her eating disorder behaviors as she continues her recovery (therapy, group, nutrition) work.
  • Do NOT comment on her appearance or “level of fatness,” even if she asks (ex “Do I look fat in this?”) DO instead say “How can I support you through this difficult feeling right now?,” “I trust your ability to find the right outfit that feels comfortable to you,” or “I’m not going to comment on that but love you.”
  • DO access your own support system or if you don’t have one, develop one! CODA and Al-anon are great 12 step resources for partners.

For women recovering from eating disorders/body image difficulties AND postpartum depression:

DO remind her that you love HER and that her body made a baby. Remind her that postpartum media images are NOT realistic. Remind her she is a whole person that you love, not simply a body. Remind her that you are with her as a partner and friend with all of your own age-ing postpartum imperfections.

Above all, try to hold a big picture of this time as limited and it will get better. Take very good care of yourself and put your own oxygen mask on first.

As always, this blog is not intended to diagnose or treat any mental illness or eating disorder. Please contact your therapist for individualized diagnosis and treatment. If you would like to schedule an assessment with Dr Linda, you can call 415-335-2596

Resources:

* Kelinman, Karen, MSW (2001) The Postpartum Husband: Practical Solutions for Living with Postpartum Depression

http://www.postpartumdads.org/ is a support resource for Dads run by Postpartum International.

Motherhood, Body Image, and Disordered Eating in Middle Age

I remember going to my first ObGyn visit when I was pregnant. The Doctor put “AMA” in my chart. Having worked in treatment settings for eating disorder recovery for many years, I thought she meant “Against Medical Advice,” the term clinicians use when a client is choosing to leave treatment despite their providers’ recommendations. I quickly said to my Doctor:

“I just want you to know am willing to implement any medical advice that you give me regarding my pregnancy!”

She gave me a blank stare.

I explained that I noticed she had written “AMA.”

She smiled. That means “Advanced Maternal Age.”

“Oh.” Long pause. “Oh.”

Being a mother of “advanced maternal age” is becoming more and more common in developed nations, as women work toward completing higher education, solidifying their careers, finding the right partner, and doing personal growth work prior to having children. The Center for Disease Control and Prevention reports:

Delayed childbearing in the United States is evident in the 3.6-year increase in the average age at first birth between 1970 and 2006…The dramatic increase in women having their first birth at the age of 35 years and over has played the largest role in the increased average age of first-time mothers…many other developed nations have observed increases in average age at first birth with some now averaging near 30.0 years of age. 1

What does this phenomena have to do with disordered eating and body image?

Although data regarding body image in middle aged and older women remains sparse, a study published just this past month in the International Journal of Eating Disorders suggests that body dissatisfaction and drive for thinness do not diminish with age. In a survey of 715 women just out, of which 76.5% were married with children, 4.6% met full diagnostic criteria for an Eating Disorder and 4.8% met criteria for Subthreshold Eating Disorder (SED). 2 Together, that makes roughly 10%. So that means 71 of those women with children are suffering with disordered eating.

And yet the myth persists that eating disorders primarily affect adolescents. Why?

There is a reason why the myth that eating disorders affect young women in adolescence exists. According to the National Association of Anorexia and Associated Disorders (ANAD): Over one-half of teenage girls…use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.3 Adolescence is a huge rite of passage for a woman. When a rite of passage is not celebrated, ritualized, or supported, the growth required to complete crossing the threshold of this rite of passage goes underground. Mary Pipher, author of Reviving Ophelia: Saving the Selves of Adolescent Girls (2005), writes:

“I think anorexia is a metaphor. It is a young woman’s statement that she will become what the culture asks of its women, which is that they be thin and nonthreatening…Anorexic women signal with their bodies “I will take up only a small amount of space. I won’t get in the way.” They signal, “I won’t be intimidating or threatening. (Who is afraid of a seventy-pound adult?)” 4

Similar to adolescence, both parenting and middle age are rites of passage in a woman’s life. When not honored, seen, and embraced, these can also turn into eating disorders and body image distress. Ageing women also face the cultural taboos of not taking up too much space, speaking too loudly, or being seen and valued. They face the task of loving themselves and embracing aspects of the beauty of mortality, power, and wisdom that western media culture is terrified of in women: wrinkles, thick middles, saggy boobs, gray hair. I remember reading one article on “objectification theory” in my doctoral research that linked media and female body image obsession with western culture’s fear of mortality. Female body objectification may veil unconscious existential fears. 5 Other stress factors that affect women in middle age that are similar to adolescence are hormonal changes. However, middle age women also face different stressors such as: medical scares, death of a parent or a spouse, divorce, and career challenges. 6 Margo Maine, co-author of The Body Myth: Adult Women and the Pressure to be Perfect, writes:

Women in their 30s, 40s and beyond face increasing pressure to look slender and youthful despite years of childbearing, hormonal changes at menopause and the demands of careers, parenting and caring for aging relatives…Some researchers call it the ‘Desperate Housewives effect,’ referring to the cultural influence of the hit TV series, in which improbably thin women in their 40s prance around in short shorts. 7

It is an interesting journey being “advanced maternal age.” Sometimes I look at young(er) women or young(er) mothers and I think You look so not tired. Or Wow your stomach looks so not stretched. I remember that. That feels like a long time ago. Or I envy younger moms who are more likely to have their grandparents be present for their children’s growing up. My child will already never meet one of his Grandpas. He died before my baby was born. However, there are gifts I have being “middle aged” that I couldn’t have come by earlier in my journey. I had not yet solidified my eating disorder recovery in my twenties. I had not earned a doctoral degree in Psychology in my twenties. I had lots of ideas and lots of difficulty with follow-through. I thought being earnest would pay the rent. The concept of income needing to match or be greater than outgoing expenditures was not a concept I truly understood or felt applied to me. Because I now have financial clarity, I don’t have to “deprive,” “restrict” or  “binge” or “purge” with money, like I used to do with food in my twenties. Interestingly, though I hated my (flatter) stomach in my twenties, I now love my (stretched) stomach in my early middle age. I also have much more capacity to pause and come back to difficult interactions in relationships rather than avoid, hide, or leave. I would not have been ready for marriage in my twenties. I would not have had the “distress tolerance” skills to go toward a young child and stay emotionally present through individuation-attempting tantrums. I would have been inadvertently shaming or stuffed the discomfort with food. I can tolerate it now. I would not have been a good, or frankly even good-enough, mother in my twenties. I wasn’t ready. I remember studying for the Psychologist licensure exam learning that the executive function of the brain (the part that fully understand cause and effect and is able to therefore pause impulsive actions) is not fully developed until the late twenties, or even 30. Does that mean all women should only have children after age 35? Or that only women over 35 are good (enough) mothers? Of course not. And not all women are able to. One always has the potential to become a good (enough) mother. In fact, the eating disorder recovery process mirrors the journey of becoming a good enough mother to one’s self: allowing and embracing imperfection, listening to and honoring emotions, communicating clearly, getting enough sleep, eating in a balanced way, practicing mindfulness or spirituality, connecting with support. And THAT is always possible and always a work-in-process, regardless of one’s chronological age.

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Dr. Linda Shanti McCabe is a Mom and Licensed Clinical Psychologist who works with women recovering from Eating Disorders, Body image difficulty, Depression/Anxiety, Perinatal Mood Disorders, and New Mommy “boot camp.”You can read about her work professionally at www.drlindashanti.com

Resources:

1. T.J. Mathews, T.J. and Brady E. Hamilton, “Delayed Childbearing: More Women Are Having Their
First Child Later in Life,” Center for Disease Control NCHS Data Brief, Number 21, August 2009. http://www.cdc.gov/nchs/data/databriefs/db21.htm

2. Mangweth-Matzek, Barbara, Hoek, Hans W. et al, “Prevalence of eating Disorders in Middle-Aged Women,” International Journal of Eating Disorders2014; 47:320-324.

3. National Association of Anorexia Nervosa and Associated Disorders websitehttp://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/

4. Pipher, Mary, Reviving Ophelia: Saving the Selves of Adolescent Girls (2005).

5. Grabe, Shelly, Routledge, Clay, Cook, Alison, Anderson, Christie, and Arndt, Jamie “In defense of the Body: The Effect of Salience on Female Body Objectification”, Psychology of Women Quarterly, Vol 29, 2005.

6. Harding, Anne Eating disorders: Not just for the young, CNNHealth.com, June 27, 2012. http://www.cnn.com/2012/06/26/health/mental-health/eating-disorders-not-just-for-young/

7. Barton, Adriana, “Are middle-aged women succumbing to ‘Desperate Housewives syndrome’?” The Globe and Mail, March 6, 2013.http://www.theglobeandmail.com/life/health-and-fitness/are-middle-aged-women-succumbing-to-desperate-housewives-syndrome/article578178/

8. Tiggemann M., “Body image across the adult life span: Stability and change,”Body Image 2004; 1:29-41. 9. Slevec JH, Tiggemann M., “Predictors of body dissatisfaction and disordered eating in middle-aged women,” Clinical Psychology Review 2011; 31: 515-524.

Aggressive Self-Care

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I just bought myself a book light. Yes, I still read actual books. Every night, while lying next to my child (resorted to this- see Confessions of a Failed Sleep Trainer) I read. I have been using a flashlight that is slowly wearing its batteries down and I have to shake it to get it back on. My eyes have begun to strain. Every night, before going to sleep, I have had the thought “I should get a book light.”

Why is it so difficult for Moms to take care of themselves? It is a given that I bring my child to all of his doctor visits, dentist visits, haircuts. I make sure he gets plenty of playtime, fresh air, exercise, organic food, sleep, baths. We have special time during which he gets to decide whatever he wants to do. We play games and make up stories for all of the themes that he is encountering in growth opportunities. The cars learn how to say goodbye and then come back together, share racetrack time, use their words to say when they feel MAD or SAD. The part of me that is just-trying-to-survive-as-a-Mom, however, has no time for being playful, kind, or patient with my own feelings and needs. This part wishes they would “just go away” because I don’t have time! And yet they don’t. We all know what happens when you try to rush a young child to get through feelings quickly because we don’t have time: they get bigger! Time doesn’t exist in the emotional world. Grown-ups need to care for their feelings, too. Or they get bigger. (Or turn into depression, resentment, eating disorders, alcoholism, etc)

I am in a moms-who-are-therapists group in which we spoke about aggressive self-care recently. We shared about our “ideal, but realistic” days as moms. What would we do? The answers weren’t huge changes. They were little shifts internally and externally that made a big difference: getting up ½ hour early in order to write, enjoying cooking instead of trying to just-get-everybody-fed, going OUT to dinner to have a night off from cooking, going for a family hike on the weekend instead of spending so much time on laundry, getting a haircut or a pedicure.

Why the term “aggressive”? I like this because it expresses how much it truly is an opposite action to take care of one’s self first (or at all) for many moms. As moms, we often defend and protect our child/dren’s well-being. How often do we turn this energy toward our own care? It requires attention, intention, and yes, some level of aggression. Because the cultural messages for moms are often about martyrdom and loss of self. And so turning toward, back to the self, honoring and tending to one’s self, requires fierceness. In case you didn’t notice the quote that my new book light is illuminating:

 …every day, the world will drag you by the hand, yelling, “This is important! And this is important! And this is important! You need to worry about this! And this! And this!

And each day, it’s up to you to yank your hand back, put it on your heart, and say, “No. This is what’s important.”

-Iain Thomas

PS By the way, just to name the obvious, you don’t have to be a Mom to practice aggressive self-care. It absolutely applies to eating disorder, codependency, and recovery general good self-care as well. Put on your own oxygen mask first.

 

Bellies

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     This is my son’s belly. He is very proud of it. He is also proud of his poo and pee. He lives in a shame free land (so far). I will protect him from shame for as long as I can. He is in Erikson’s “Shame vs Doubt” stage exploring the question “Is it ok to be me?” He happily runs around, showing off his belly, exploring this question. I will fiercely fight for him to hold onto the truth that lives in his belly that it is not only ok but ESSENTIAL that he be himself.

     I remember 15 years ago very early in my eating disorder recovery thinking in the midst of horrible body image distress “My belly is so fat- it looks like it is pregnant!” It wasn’t pregnant- it was full of shame, anger and unexpressed emotions. It was FAT: Feeling Are Thick. It was also nowhere near the size of a pregnant belly, having lived the reality, I now know. If I were to talk to my younger self now, I would say, with great compassion and fierceness, “Honey, you are nowhere near to having a pregnant belly. You want to see a pregnant belly? HERE. Now. What is in there that needs to be birthed and expressed? Get it out because it is not only ok but ESSENTIAL to your recovery and your life that you be yourself.” My older self has learned that. And my belly is now (mostly) free from shame and anger having receivied many apology letters for how I abused it and having been listened to much more frequently over the past decade and a half.

this belly

I’m not going to say it wasn’t difficult with body image postpartum (see “Dear New Mama” and “Does being a Mommy make me look fat?” previous posts). However, I AM proud of my Mama belly. I grew a child in there. Yes, my belly looks different in a bathing suit because I GREW A CHILD in there. Wow. That is pretty miraculous. Thank you belly.

A friend of mine sent me this video postpartum. It is well worth watching the celebration of a woman’s body and belly.

http://www.youtube.com/watch?v=kfOBGQpG9fA&feature=player_embedded#

Mommy Brain

Mommy brain

I distinctly remember 1 moment postpartum when my husband and I were in a bookstore, with baby in the carrier, browsing. I saw the book The Female Brain and picked it up, thumbing directly to the section on “Mommy brain,” and, more specifically, “Breast feeding and the Fuzzy brain.” I was still breast-feeding, fuzzy brained, and seeking some scientific proof that I wasn’t going crazy. I found it. Louann Brizendine, MD writes:

“…one down side of breast feeding can be a lack of mental focus. Although a fuzzy brained state is pretty common after giving birth, breast feeding can heighten and prolong this mellow… unfocused state…the parts of the brain responsible for focus and concentration are preoccupied with protecting and tracking the newborn.”

During this time, I would walk into the next room of the house to get something and forget what it was. Keys? Diaper bag? One of my husband’s friends, a Stanford scientist with two children, explained: “You’re breastfeeding. Your brain will come back after you stop.” This fuzzy breastfeeding brain also explained why I felt physically connected with my baby when I went back to work. Brizendine writes:

Many mothers suffer ‘withdrawal’ symptoms when they’re physically separated from their babies, feeling fear, anxiety, and even waves of panic. It is now recognized that this is more than a psychological state but is a neurochemical state.

The longer and more often a baby suckles, the more it triggers the prolactin-oxytocin response in the mommy brain…Oxytocin dilates blood vessels in the mother’s chest, warming her nursing child, who also gets doses of feel good compounds in the breast milk…

Ah, Oxytocin, the bonding hormone. By 3:00pm at work, I would be physically and emotionally longing for my baby. I’m sure it was no accident that this was the time that I would pump milk for him and he would be having his afternoon snack! I remember coming home from work, checking in with the nanny on how baby’s day went, and she would say “he’s probably not hungry- just had a bottle about an hour ago.” I would nod ok, and then, as soon as she left, baby would lunge for the breast like a long lost lover and Mama would feel relieved and reconnected.

According to Brizendine, This lovely, feel-good state of oxytocin is turned on at the time of birth.

 The mommy-brain transformation gets underway at conception and can take over even the most career oriented woman’s circuits…At the same time, her brain signals for eating, especially in the morning, become finicky as her brain is changing how it reacts to certain smells…she wouldn’t want to eat something that would harm her fragile fetus…That is why her brain is now overly sensitive to smell.…Progesterone spikes from ten to a hundred times its normal level … and the brain becomes marinated in this hormone, whose sedating effects are similar to Valium.

 IMG_3261Pregnancy brain

I wish I had had this book when pregnant. Sometimes there is no substitute for empirical, neurological data to combat shame and confusion. I remember sitting at my desk at work while pregnant feeling like I was in a mental fog and wondering where my focus had gone? Where was my motivation for work? I would sit there feeling like a hippo (I know, hippo is not a feeling- see previous blog), daydream about rocking chairs, and eat olives with hummus and crackers (My baby had a Greek craving theme). I could not tolerate perfume smells and threw up in the airport when walking through the fancy shopping section filled with expensive scents.

I was also studying psychological material for the EPPP (Examination for the Professional Practice of Psychology: the licensure test for Psychologists) at the time, and confused about why nothing I was studying seemed to be able to stick in my brain. I would study material and then the next day it would have flown out of my mind. This was not very pleasant or ego syntonic for someone who had earned 4.0’s all through her undergraduate, Master’s and Doctorate degrees.  At 7 months pregnant, I was scoring 50% on practice exams. Finally, with humility, resignation, some resistance, and a good dose of radical acceptance, I threw in the towel and postponed.

Why have 9,000 books have been written about

helping your baby sleep through the night

While oxytocin is a lovely feel-good chemical, drops in hormone levels mixed with lack of sleep do NOT feel good. I remember a mother in my brand New Mommy group telling me about how her baby slept through the night at 3 months. Bless her for her kindness (or perhaps it was discernment that the other mothers may have killed her) for not sharing this at the time.  Every baby, like every person, has their own temperament, their own capacities, and their own preferences from the time of birth.  I see this in my own child, a boy, who seems to be predisposed to fire trucks, dump trucks, dinosaurs, and things that go bang or boom. As a feminist, I would have ardently fought this Nature-Nurture debate prior to children. However, my little boy is naturally drawn to trucks, particularly those that dump things or make loud noises.  Anyway, that is a whole other post (See http://www.scarymommy.com/boys-vs-girls/)

My baby did not naturally sleep through the night at 3 months, 6 months, 9 months, or 12 months. That too, is a whole other post as well as bookshelves filled with thousand of experts offering their advice on how to get one’s baby to sleep. For the new Mom, though, lack of sleep can contribute to a fuzzy brain.

In a new mother, sleep is disrupted by repeated awakenings of the infant, but hormonal factors also seem to play a role.  Immediately after childbirth, levels of the reproductive hormones, estrogen and progesterone, drop precipitously.  It is believed that, because these hormones modulate neurotransmitter systems in the brain responsible for sleep quality, this dramatic hormonal shift may cause significant disruptions in sleep. (See MGH Center for Women’s Mental Health http://www.womensmentalhealth.org/posts/postpartum-depression-and-poor-sleep-quality-occur-together/ )

I remember going into work and hearing my (childless) co-workers say, “Gosh, I’m tired today.” Then they would sheepishly look over at me a moment later and say “Oops sorry” as I gave them the death stare. However, sleep-deprived states aside, there are other brain changes that can occur postpartum that are both beneficial and astounding.

Does the brain grow BIGGER postpartum?

Research from the American Psychological Association suggests this is the case.

Exploratory research…found that the brains of new mothers bulked up in areas linked to motivation and behavior…A comparison of images taken two to four weeks and three to four months after [new mothers] gave birth showed that gray matter volume increased by a small but significant amount in various parts of the brain. In adults, gray matter volume doesn’t ordinarily change over a few months without significant learning, brain injury or illness, or major environmental change. (Craig Kinsley, PhD and Elizabeth Meyer, PhD, Behavioral Neuroscience, October 2010)

I was sharing with a friend recently about the hidden gift of humility in needing to slow down on my desired accomplishments due to being a Mommy. She replied, “You are doing and growing more than most people I know, with or without children.”

“Oh,” I thought, “it certainly doesn’t feel like that.” I often tell my clients, who are recovering from eating disorders, that they are growing much faster than they realize. As they say in twelve-step recovery “You can’t kiss your own ear.” In other words, others will see your growth before you do. I certainly see that in my son. Sometimes it seems as if he has literally grown overnight. One day he is standing by the couch scooching, and then BAM! He is walking. One day he is babbling incoherently and then Bam! He is saying “Bump!” for Mr. Bump, and banging his chest for the gorilla. Where did my newborn go? And so, as I begin to let go of my Mommy brain fuzz (Hooray!!!), I am also letting go of my little breastfeeding baby (sweet sadness), toddling about, developing his own cerebral cortex and synaptic formations. (http://main.zerotothree.org/site/PageServer?pagename=ter_key_brainFAQ#changes) May the growth continue.

 

Linda Shanti McCabe, PsyD, works at the Association of Professionals Treating eating Disorders in San Francisco. You can learn more about her at http://WWW.DrLindaShanti.com

 

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