Have you ever wondered what CBT is? It stands for Cognitive Behavioral Therapy, right? Ok, but have you wondered what that actually means?!? Instead of lecturing you about core beliefs, the cognitive triad, automatic thoughts, cognitive distortions and citing hundreds of research articles about how effective this therapy can be, I thought that a few images will help you understand how it works, especially for a new mom.
This first image, thanks to the Parent Connection (UK), shows how our thoughts (also known as cognitions), feelings and behaviors are linked - and these arrows should be bi-directional, because in this example, feeling unsupported or lonely might also cause one to turn away from a partner or a friend.
But thoughts are not facts.
Let that sink in for a minute and then take a look at all of these cognitive distortions we make, many on a daily basis:
So what now?? I have visually shown you how your thoughts influence your feelings and cause you to act in ways that may not help - which is probably not news to you.
The slideshow of images below, thanks to a former patient (all identifying information removed), is a step-by-step example of a thought record that a new mom completed in session to begin to challenge these thoughts and change the resulting feelings and behaviors.
Cognitive behavioral therapy is a process that takes 10-12 fifty minute sessions and thought records are only one piece. I am asked about how this therapy works, on a regular basis (even from the physicians I work with at Cedars), and thought this post might help.
If you have questions, please comment below and/or contact me.
This weekend I went away with girlfriends to celebrate a close friend’s milestone birthday. I am so privileged and grateful to be able to afford to go on a trip like this every few years. We decided to go to Miraval, a beautiful resort outside of Tucson, Arizona. This place is the epitome of self-care and I enjoyed my weekend which included many activities like a rose renewal massage (pictured above), mindfulness meditation, yoga and hiking. This may be what many imagine is self care = too expensive and time-consuming. But that isn’t really an accurate definition.
What is self-care?
Self-care is about identifying your own needs and taking steps to meet them. It is taking the time to do some of the activities that nurture you as a living breathing human being who cannot (and should not) always be on autopilot. And it is particularly important for new and expecting moms. Why?
The only way I can answer that question is to tell a story. I used to fly a lot during my college and grad school years. The flight attendants always described the safety features of the plane and I got very used to ignoring this spiel. Then I had a baby. This time when the flight attendant said, “in case of a change in cabin pressure an oxygen mask will drop in front of you and you should put on your own oxygen mask before you assist anyone else,” I thought - Wait, what? I take care of myself first?!?! I decided on that very flight that I was learning something very important: Only when we first help ourselves can we effectively help others. Caring for yourself is one of the most important things you can do for yourself. It is also one of the easiest things to forget. But you benefit greatly from self care and so do others in your life.
Why is Self Care Important specifically for Women?
Women spend most of their lives nurturing others. This can be fulfilling and still have significant ramifications:
"When we find ourselves focusing more on others than ourselves, we become worn out, stressed out and run down. For those of us who spend time helping and caring for others, it is too easy to neglect our own needs. It’s like “running on empty” when we don’t take the time to re-fuel. We spend so much time and effort caring for our partners, children, pets, friends, family members, employers and employees. Add to that the numerous volunteer activities, errands, housework, family functions, meetings, etc.—and there isn’t much time left for caring for ourselves. Women need to balance the stress and activity of daily life with activities that bring a sense of peace and well being to their minds and bodies. Women who neglect their own needs and forget to nurture themselves often become unhappy, have low self-esteem and feel resentment. Self care can help you avoid this outcome by treating yourself as a worthwhile person who is valuable, competent and deserving."
*Fort Garry Women's Resource Centre
What are Some Examples of Self Care Activities?
Practicing self care does not have to cost a lot of money. In fact there are many things that you can do that are free or inexpensive:
My personal goal is to do one of these things for myself every single day. Sometimes I only get 10 minutes for myself. Other times I can spend an hour. But I make the time, because I am worth it and because it allows me to be the best mother, wife, psychologist, scientist, daughter, sister, friend etc. that I can be.
For registration information please click HERE
My program of research at Cedars-Sinai focuses on mood and anxiety disorders during the female reproductive life course and in response to chronic illness. I study the physiological processes that are associated with higher risk for depression and anxiety in pregnancy, postpartum, perimenopause, and following diagnosis and treatment of breast cancer and heart disease. I am also interested in the association between maternal mental health and adverse pregnancy and birth outcomes. My results are published in peer-reviewed journals and I strive to produce work that informs my own and others' clinical practice.
I am the primary or co-investigator on three ongoing institutional review board (IRB)-approved research studies: (1) The Postpartum Heart Health Registry and Biorepository which is designed to understand how early cardiovascular screening and evaluation can help child bearing women reduce their risk of developing heart disease later in life. This database of women with complications during pregnancy will allow us to longitudinally study possible links between complications during pregnancy, mental health, and heart health; (2) The PROVIDE study: Preeclampsia Research on Vitamin D, Inflammation, & Depression which explores whether systemic inflammation and vitamin D deficiency place women at higher risk for developing preeclampsia and postpartum depression; and (3) The Postpartum Depression Quality Improvement Study which will determine accurate prevalence rates of postpartum depression at Cedars-Sinai, test the acceptability and effectiveness of the new Depression Screening, Education and Referral program and will provide valuable patient centered qualitative and quantitative data that can be used in future services planning.
In addition to the three ongoing IRB-approved research studies, I work on analyzing and writing up data collected on Vitamin D levels (not nutritional intake, blood levels) and perinatal depression and other important birth outcomes like preeclampsia and preterm birth. Some of this data will be discussed in an upcoming FREE webinar on Thursday February 1st, 2018.
African American women have the highest rates of prenatal and postpartum depression as well as adverse perinatal outcomes (e.g. preterm delivery & low birth weight babies) compared to other racial groups in the U.S. They are at increased risk for vitamin D deficiency because darker skin limits synthesis of vitamin D and due to lower intake of supplemental vitamin D. An exciting and novel area of research focuses on vitamin D’s anti-inflammatory properties and possible anti-depressant effects.
1. Identify symptoms, prevalence and consequences of depression and anxiety in pregnancy and postpartum, with a focus on racial disparities.
2. Learn about the links between perinatal depression and vitamin D and inflammation.
3. Become familiar with research on adverse perinatal outcomes, including depression, and postpartum multi-systemic dysregulation, as measured by high allostatic load.
For registration information please click HERE.
My husband and I went shopping for a new mattress last weekend and it got me thinking about menopause. Why? Well, the sales woman kept talking about the Brisk mattress and winking at me. Ok, I’ll bite. I finally asked her, “What is a Brisk mattress?” She looked cautiously from me to my husband, and back again, and whispered: “You know, for the CHANGE. It’s for when you get hot at night.” Ohhhhh. Well, damn. Do I look old enough for that?!?!? Trying not to get offended, I thanked her and we moved on. Since I currently use 3 blankets to my husbands one, we laughed it off and did not buy a Brisk mattress. The interaction, however, got me thinking...
Comedienne Sandra Tsing Loh jokingly says that, "Menopause isn't the "CHANGE" it's the “RETURN” to who you were before the fertility cloud came down!" Her funny TEDx talk made me think about menopause, and the psychological symptoms related to reproductive change, in a completely different way. Check it out:
When I was in graduate school I reviewed the research literature on perimenopause and depression. Researchers had discovered that the risk of new-onset depression increased during the perimenopause and that sex hormones (like estrogen and progesterone) were associated with this risk. Whether depressive symptoms are directly related to changes in reproductive hormone levels is a controversial issue in women’s health. Specifically, some researchers insisted that depression in women occurs more often during times of intense hormonal fluctuation (during menstruation, postpartum, and menopause) and it is exposure to changes in hormone levels that are important - rather than absolutely low levels. In support of their theory, they note that there is a relatively low incidence of depression at times of stable hormone levels, as in the postmenopausal years. More recent research found that the earlier a woman goes through menopause, the higher her risk for depression, especially if the early menopause is due to medical reasons, i.e. cancer treatment etc.
Ten years and 2 kids later, the science hasn’t changed too much. Thanks to Loh, however, my perspective on this topic has. She exaggerates to say that fertility is a relatively short period of our lives. Depending on how long you live, it could be half of your life! But the wisdom in her joke is that we can choose to perceive it as the most important half, or not. If not, then we don’t have to grieve the “CHANGE.” We may struggle at first, with the physical and emotional changes, and we may need support through those changes. But we don’t have to despair nor do we have to go through it alone.
1. Accortt EE, Bower JE, Stanton AL, Ganz PA. Depression and vasomotor symptoms in young breast cancer survivors: the mediating role of sleep disturbance. Archives of women's mental health. 2015; 1; 18(3):565-8.
2. Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow, BL. Risk for new onset of depression during the menopausal transition. The Harvard Study of Moods and Cycles. Arch Gen Psychiatry. 2006; 63:385–390.
3. Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry, 2006; 63:375–382–382.
4. Georgakis MK, Thomopoulos TP, Diamantaras AA, Kalogirou EI, Skalkidou A, Daskalopoulou SS, Petridou ET. Association of age at menopause and duration of reproductive period with depression after menopause: a systematic review and meta-analysis. JAMA psychiatry. 2016; 1; 73 (2):139-49.
5. Richardson T, Robinson R. Menopause and depression: A review of psychologic function and sex steroid neurobiology during the menopause. Primary care update. Obst Gynecol. 2000; 7: 215–223.
Social support is critical at any stage in life, especially for a new mom learning the ropes. Virtual or online support is even more important and useful if that mom recently moved to a new area and hasn't yet built a support system. I was interviewed back in March about the importance of social support in mothers. The CBS reporter spent almost 30 minutes asking me many questions, yet they only ended up using about 12 seconds of my answers. That is ok, except that they left out a very important conclusion which is that IF depression or anxiety is interfering with a mother's functioning (she cannot take care of herself or her baby), then it’s time to seek professional help.
Are you a Supermom? Wonder Woman? Goddess?
I know I am not! A few years ago, however, another mom called me a Supermom when I volunteered at my then 7 year old's classroom. I had really mixed feelings about her comment. I had taken half a day off from my full time job to be there. So I guess that’s commendable? She meant well and I felt proud of myself for juggling things at work to be there and happy that my son was happy. But I also felt a shadow of doubt creep in that day. I don’t want to be held to that impossible standard, put on a pedestal of parental perfection, and have only one way to go...down…FAILURE.
Isn’t that the fear from the beginning?
...that our birth plan will go horribly wrong.
...that our baby will not latch and we will have to give up breastfeeding.
...that we will have so much anxiety about being a good mother.
...that we will feel guilty for going back to work.
...and feel guilty for not going back to work.
We are damned if we do and don’t, aren’t we?
It doesn't have to be this way. The expectation to be a Supermom goes hand-in-hand with Mom shaming and guilt. Let’s stop this madness. We aren’t super, wonderful, or god-like most of the time. We are just doing our best. Let’s start supporting each other, not setting ourselves and others up for failure. Let’s remember that we do have powers - they just may not be super. We have the power to (1) pick our priorities, (2) pick our battles and (3) pardon ourselves and our loved ones.
(1) PRIORITIES: I might have seemed super to that mom that one day because I seemed to be doing it all: Working fulltime and still helping in my son’s classroom. But that was just one priority that I set that particular day. I think she is super for keeping her house so clean and for being such a marvelous baker. She is, because she makes that her priority, and that’s great. I am the mom that buys the cake from the store, even if my kids beg to bake. Pick the priorities that work for you, let go of the rest, and compliment others for their choices!
(2) Picking our battles is certainly a super power. My kids get upset if they can’t bake that cake, or miss one birthday party because we have other plans. We can’t do it all, all the time - it’s simply not possible. We have to be firm and pick our battles. Explain to your kids, your spouse, (even your boss), what you can and simply cannot do. Your kids will forget about that cake or that birthday party in a day. They will love you for being there and for being their loving mom, even if the cake is store-bought.
(3) The last super power, pardoning ourselves, is the hardest of all. Our kids will forgive us if we miss that one birthday party or one school play because of work. Why can’t we forgive ourselves? Pardoning ourselves and our loved ones is challenging. Forgiving mistakes, however, is one of the keys to staying calm and avoiding guilt. When I see my kids baking with my mother or my husband I don’t get down on myself for not being a baker, I am very thankful that they get their needs/wants met! And that is super!
When I am not seeing clients in private practice I am an assistant professor and research psychologist in Cedars-Sinai's OBGYN department. I am proud to have been recently interviewed about the PPD Screening, Education and Referral Program that I helped initiate this April - see local story HERE. The first step in getting help is identifying the problem! #Postpartum #Conejovalley
One thing I love about my career is that I get to wear many "hats." At times I don a "research hat", other times a "teacher hat" and sometimes a "therapist hat", and I find immense satisfaction and pride in all of these roles.
For three years I was a professor of psychology at Miami University (in Ohio) teaching undergraduates Abnormal Psychology and Health Psychology and more recently I taught an upper level Women's Mental Health course at UCLA. For several years I was primarily a therapist and worked at the Veterans Affairs Administration working with newly returning veterans from Iraq and Afghanistan. All the while, I was conducting some level of research, basic or applied (clinical), and I always kept writing. My most recent manuscript was just published in the September issue of OBGYN Survey. Feel free to flip through the paper HERE - the focus is on the importance of screening for perinatal mood and anxiety disorders (PMADs) in Obstetrics and Gynecology settings. I am very passionate about educating OBGYN physicians about PMADs and how to treat/heal the whole woman, not just her uterus! Feel free to print and share it with your OBGYN!
On Nov. 30, 2016, Rep. Katherine M. Clark (D-Mass.) announced that her maternal mental health legislation, the Bringing Postpartum Depression Out of the Shadows Act, passed in the House of Representatives. On the following Wednesday, it passed in the Senate. The bill authorizes the Secretary of Health and Human Services to provide federal grants to states for the purpose of screening, assessing and treating PPD. The grants would allow states to create, improve or maintain programs around maternal mental health and help women who are pregnant or recently gave birth.
"For too long, stigma and outdated attitudes about mental health have kept moms from getting the help they need," said Clark. "It’s past time that we turn the corner from stigma to the sound medical science that tells us postpartum depressions is common, it’s diagnosable, and that treatment benefits the entire family. This is a victory for families, and we’re looking forward to strengthening this program in years to come."
Read more HERE!
Thank you very much for visiting this website. Perinatal depression and anxiety have long been under-recognized and under-treated. Some national recommendations have come out recently to help change all of that!
Read more HERE!
Dr. Accortt in the News
May 2020: Hawaii News Now, Sunrise, How to Prevent Anxiety & Depression Before and After Giving Birth
April 2020: The Bump, How to Spot Postpartum Depression in Your Partner or Friend
12/3/19: Quartz, Ten questions about mothers’ mental health could promote resilient pregnancies
5/10/19: CGTN America, US comedian uses her act to turn the spotlight on postpartum depression
5/1/19: KTLA News, How One Comedian’s Battle With Postpartum Depression Turned Laughs Into Legislation
3/20/19: KFI News Radio, FDA Approves First Drug for PPD, Brexanolone (Zulresso) - Correction: Rix states that Dr. Accortt "treats thousands of women at CS" - Thousands of women delivery babies at CS every year. Dr. Accortt does not treat them.
Winter 2019: Cedars-Sinai Discoveries Magazine, Stop The Stigma
9/11/18: USC Center for Health Journalism, Cedars-Sinai PPD Screening Program May be Model for State
Summer 2018: Cedars-Sinai Catalyst Magazine, The Helping Hand of Los Angeles Funds Postpartum Depression Screening Program, scroll down to page 40 of magazine
5/18/18: TODAY.com, Alyssa Milano on Postpartum Anxiety
5/3/18: Cedars-Sinai Maternal Mental Health Research
10/19/17: Cedars-Sinai Postpartum Depression Screening Program
3/24/17: MomCo. App for Social Support
Dr. Accortt is a California licensed clinical psychologist. When she isn't seeing patients in private practice she conducts research in the OBGYN department at Cedars-Sinai. She will update this page with important maternal mental health news and research.