Do you ever wonder if change is possible for you? If you’re just going to have to be stuck in despair, your eating disorder, depression, alcoholism, or feeling not-good-enough forever?
I have this posted on my office door:
Butterflies have long been a metaphor for recovery for me. Butterflies (the eggs they start as, the caterpillars they become, the cocoons they build, and the butterflies they emerge into) embody the miracle of transformation that happens in recovery.
In recovery, one model for change, called the Stages of Change,* divides the gap between thinking-about-change and implementing it into 5 Stages. This model was developed from addiction recovery, but can be used for eating disorder or postpartum depression recovery, or another vision you thought was not possible for your life. As an example (because it clearly embodies tangible hope, which can be hard to do in eating disorder or postpartum depression recovery), I’ll take you through my butterfly garden stages of change. As you are reading, you can fill in whatever vision of yours that you think is not-yet-possible.
- Stage 1: Precontemplation or The Hopeless-Caterpillar Stage (Not thinking about changing, Do not want to change, or Feel change is hopeless/not possible. This is the stage in which disordered eating, drinking, or depression feels “normal” and/or there is a feeling of resigned this-is-the-way-it-is-and-will-always-be.)
So with my butterfly garden vision, there were years of thinking about this. (“Oh! I should do this! Oooh what a great way to practice ecological conservation in my own backyard! I love butterflies! I used to study butterflies! What a great idea! Butterflies are deeply symbolic of the transformation that happens in recovery and motherhood!!”etc, etc.)
Clearly, as evidenced by the exclamation points, they were excited, visionary thoughts. They were so excited that they tired me out even thinking them. I went back to changing diapers, trying to survive early motherhood, engaging with my professional work, and maintaining my own recovery self-care.
- Stage 2: Contemplation or The Asking-Friends-About-Their-Cocoon-Experience Stage (Considering there is a problem, Still ambivalent about changing but willing to become educated about alcoholism/eating disorders)
When I was in the contemplation stage, I would pay attention when my little one and I visited butterfly exhibits in museums or the insect house at the zoo. I would talk to the butterfly curators. I would get inspired by people planting gardens. I read one blog about a guy who re-introduced an endangered butterfly species just by creating a native garden for their caterpillars. I read educational signs at the museum and zoo and thought “Oh! They’re endangered! I could plant a butterfly garden to help! I could do that thing I’ve been thinking about!” Then I went back to my life and didn’t take any action about it.
- Stage 3: Determination or The I’m-Not-Always-Going-To-Stay-A-Caterpillar-Because-I-Know-There’s-Something-More Stage (Deciding to stop the behavior such as drinking or disordered eating, deciding to seek postpartum depression support. Beginning to make a plan.)
So in this stage, I was thinking “Well, even though I’m not much of a gardener, I could do this. I could get a book. I could go to the local garden store and talk to the people there. I could start a list of native plants that attract and feed larva, caterpillars and butterflies…” I was deciding that I was going to take action. I was envisioning how I was going to take action. I was less tired about the ideas, more determined, and getting ready to take action. I saved money to buy plants for my future butterfly garden.
- Stage 4: Action or The Building-Your-Cocoon-Of-TransFormation Stage (Beginning to take actions such as announcing to loved ones they are going to change, seeking support of a therapist or treatment program, beginning to attend eating disorder or postpartum depression recovery support groups or 12 step program)
So at this point, I told my family I would like a butterfly garden book for Christmas. I started actually writing (instead of thinking about) a list of plants. I bought a guide to local butterflies. I made a place on a shelf for my butterfly-garden materials. I posed on a neighborhood list serve about local butterfly plants. I made a special pile of materials that was designated butterfly-garden research. I looked into local gardening stores.
- Stage 5: Maintenance or The I-Now-Know-It-Is-Possible Stage (An alcohol, disordered-eating, or depression-free life is becoming “normal,” and the threat of old patterns becomes less intense/frequent. Relapse prevention skills and support systems are established.)
This is the stage that my garden is in now. Though this may sound like an end-point, (Ta Da! We’re Done! Now everyone lives Happily-Ever-After, The End), it’s actually a beginning. Now I have to water the plants. My husband (who is more of a seasoned gardener) helped to replant some of the plants in wire baskets under the soil so they would be protected from gophers, and in full sun (important for butterflies).
People in this stage of recovery CAN have the luxury of resting somewhat, having done some tough work digging in the soil (therapy, treatment, etc) of planting their garden of transformation. However, the work of continued action is crucial in maintenance. If I don’t water my plants, they might not survive. If you don’t go to your recovery support meetings, or practice the self-care skills you cultivated in your recovery from PPD or an ED, you are at risk of relapse. One of the best ways to prevent relapse/stay in the butterfly stage is to connect with a caterpillar. That is why I work in recovery. So I can remember the darkness of the cocoon AND stay in the sunlight of the spirit.
Here’s to your garden, your butterfly-ness, your recovery. Whatever stage it (You) are in.
*Researchers, Carlo C. DiClemente and J. O. Prochaska, introduced a five-stage model of change to help professionals understand their clients with addiction problems and motivate them to change. Here is one summary article that I referenced in this blog: “Stages of Change” by Mark S, Gold, MD
I remember when I was a brand new first-time mom, like four days brand new, and went to a new mom group. I was in the no-sleep, hormones still rollercoaster-ing daze. I was trying to look like I knew what I was doing, even though it felt like the bottom had dropped out of my body, my breasts were bowling balls, and I was wondering why no one ever tells you about urinary incontinence…
(This is Guest blog- to read full article, go to psychedinsanfrancisco.com )
The short answer? “It’s complicated.”
The longer answer: Genetics and temperament both play a strong role in the possibility of Depression or an Eating Disorder developing, but do not determine it.
The hopeful answer: Even if your child develops an Eating Disorder or Depression, it is possible to recover.
In this post, I will look at some of the risk factors that can lead to an Eating Disorder or Depression.
Eating Disorders: Are they inherited?
Eating Disorders develop as a combination of genetic vulnerability combined with temperamental traits and a facilitating environment. Some (but not all) risk factors named in Carolyn Costin and Gwen Schubert Grabb’s book 8 Keys to recovery from an Eating Disorder (W.W. Norton, 2012) that can contribute to developing an eating disorder include:
- being overweight or dieting as a child
- having a mother who diets or has an eating disorder
- early menstruation
- being bullied or teased
- engaging in sports or activities with a focus on appearance or weight (for example ballet, cheerleading, ice skating, wrestling, gymnastics, modeling)
- a history of childhood abuse
In a 2000 study in the American Journal of Psychiatry, results showed that anorexia nervosa has a heritability of 58%, but the authors were unable to rule out the contribution of environment. However, they did conclude that genetic factors influence anorexia and contribute to comorbidity of anorexia and depression.
Along with genetic links being discovered with both anorexia and binge eating, certain temperamental traits tend to foster the birth of an Eating Disorder. Ovidio Bermudez, in presenting at Eating Disorder Recovery Services conference* this past year discussed the following temperament traits as those at risk of developing an Eating Disorder:
- Anxiety, Depression, or OCD
- Low stress tolerance
- Low distress tolerance
- Sensitivity to real or perceived injury
So in other words, if you have a sensitive child who struggles with tolerating “distressing” feelings such as sadness, anger, or shame and you (or a family member) struggle with Depression, Anxiety or OCD, the ground is fertile for the seed of an Eating Disorder to sprout.
What about Depression?
At least 10% of people in the U.S. will experience Major Depressive Disorder at some point in their lives. According to statistics, two times as many women as men experience major depression. (There is a lot to be said there in terms of mis-diagnosis of symptoms, gender bias, and who reaches out for support to mental health professionals, that can affect these statistics, but that is for another blog.)
According to two Stanford doctors writing about genetics and brain function, genetics play a strong role in causing Major Depression (Levinson, Douglas F. M.D. and Nichols, Walter E. M.D., Professor in the School of Medicine Department of Psychiatry and Behavioral Sciences, Stanford, 2015). They write:
- The heritability (or percentage of the cause due to genes) is probably 40-50%, and might be higher for severe depression.
- The situation is a little different if the parent or sibling has had depression more than once (“recurrent depression”), and if the depression started relatively early in life… the siblings and children of people with this form of depression probably develop it at a rate that is 4 or 5 times greater than the average person.
What else contributes to Depression? And what about Postpartum Depression?
Stressful life events (trauma, loss of a loved one, moving/loss of support, having a baby) can lead to depression in and of themselves. When combined with a genetic risk, there is a stronger possibility of developing depression. And having one (or more) episode of depression increases the risk of having future episodes. (Kendler, Thornton, and Gardner, 2001)
While many women experience some mild mood change or “the blues” during or after the birth of a child, 1 in 7 women (and some recent research says 1 in 5) experience more significant symptoms of depression or anxiety. 1 in 10 Dads become depressed during the first year. (Postpartum Support International)
Risk factors for Postpartum Depression
Some women are more likely than others to develop Postpartum depression. The following factors put you at an increased risk:
- Previous history of depression
- History of severe PMS or premenstrual dysphoric disorder
- Medical complications for you or your baby
- Lack of support from family or friends
- A family history of depression or another mental illness
- Anxiety or negative feelings about the pregnancy
- Problems with a previous pregnancy or birth
- Marriage, Relationship, or money problems
- Stressful life events
- Substance abuse
How does Postpartum Depression impact children?
Postpartum Depression and other Perinatal Disorders (Anxiety, OCD, Psychosis) can affect children in the following ways:
- Behavioral Problems
- Delays in Cognitive Development
- Emotional Problems and/or Depression
According to Zero To Three, a research-based resource for federal and state policymakers and advocates on the unique developmental needs of infants and toddlers, untreated Depression can have detrimental effects on children’s functioning and future outcomes (2009).
The mental health of parents can affect young children… infants of clinically depressed mothers often withdraw from caregivers, which ultimately affects their language skills, as well as their physical and cognitive development. Older children of depressed mothers show poor self-control, aggression, poor peer relationships, and difficulty in school.
Unlike adults, babies and toddlers have a fairly limited repertoire of responses to stress and trauma. Mental health disorders in infants and toddlers might be reflected in physical symptoms (poor weight gain, slow growth, and constipation), overall delayed development, inconsolable crying, sleep problems, or aggressive or impulsive behavior and paralyzing fears. Early attachment disorders predict subsequent aggressive behavior. Some early mental health disorders have lasting effects and may appear to be precursors of mental health problems in later life, including withdrawal, sleeplessness, or lack of appetite due to depression, anxiety, and traumatic stress reactions.
So, if you have had or are currently suffering with and through (because it is possible to recover and get through it) an Eating Disorder or Depression, your child does have risk. But that does not mean they are doomed. It means, even more important than ever, that you get treatment and recovery yourself! When I attended Postpartum Support International’s training on Perinatal Mood Disorders, the message that they gave was: There is Hope and You are not alone. It is possible to recover and in recovering yourself, you help build a more protected base from which your child can thrive and grow.
Wade, Tracey D, Ph.D., Cynthia M. Bulik, Ph.D., Michael Neale, Ph.D., and Kenneth S. Kendler, M.D., “Genetic and Environmental Risk Factors Anorexia Nervosa and Major Depression: Shared Risk Factors,” Am J Psychiatry 2000; 157:469–471.
Eating Disorder Recovery Services The mission of EDRS (Eating Disorder Recovery Support), Inc. is to promote recovery and wellness for those impacted by eating disorders by providing support, information, and education to individuals, families, professionals, and the community at large regarding eating disorders and recovery resources. EDRS.net
Ovidio Bermudez, MD Dr. Bermudez has lectured nationally and internationally on eating pathology across the lifespan, obesity and other topics related to pediatric and adult healthcare, and has been repeatedly recognized for his dedication and advocacy in the field of eating disorders. eatingrecoverycenter.com
“Major Depression and Genetics” Douglas F. Levinson, M.D. and Walter E. Nichols, M.D., Professor in the School of Medicine
Department of Psychiatry and Behavioral Sciences (2015) Depression and Genetics
Zero To Three The Zero To Three policy Center is a nonpartisan, research-based resource for federal and state policymakers and advocates on the unique developmental needs of infants and toddlers. zerotothree.org
Link to Depression during and after Pregnancy Fact Sheet
Link to study on teaching sleep with infants to prevent Postpartum Depression:
Link to study on effects of Lexipro on treatment of Postpartum Depression:
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.
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
* 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.