Podcast Transcript

Episode 50: Postpartum and Eating Disorder Recovery, Part 2

[Bouncy theme music plays.]

Sam: Hey, I’m Sam.

Ashley: Hi, I’m Ashley. And you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.

Sam: We believe that all bodies and all foods are welcome. We would love for you to join us on this journey. Let’s learn together.

Ashley: Welcome back to Part two of our conversation with Angela Kaloudis, LMHC, PMHC, and clinical training specialist at the Renfrew Center. Last episode, Angela discussed both the perinatal and postpartum timeframes for the birthing parents and broke down the various postpartum diagnosis we may see such as postpartum anxiety or postpartum depression to name a few. We discussed the implications this had for folks experiencing eating disorders at any point. during these timeframes and realized that we had so many more questions and areas to unpack that we asked Angela to come back for part two. Angela, thank you for joining us again.

Angela:  Thank you. I’m so excited to be here for part two. Yeah. A topic that I love.

Ashley: I just want to like jump right in. And I think one of the areas that we left off, we were talking about the signs and symptoms to be on the lookout for in perinatal and postpartum timeframe, as far as what could come up for somebody with an eating disorder. And I’m curious, adding onto that, how does body image play a role? And what are the signs and symptoms, if you will, of that kind of coming up and affecting somebody?

Angela: Yeah, it’s such a good question, I like to view that in any major life transition, whether it be when there’s like a rapid change and whether someone moves, or there’s a change in relationship or menopause, or puberty, we see a lot of focus overly on the body. I think in pregnancy, there’s just a lot of anxiety and uncertainty and, early pregnancy, you’re waiting for 10 weeks to even get into a doctor’s appointment. And within those 10 weeks, you have a lot of symptoms. For some people, it’s nausea, for some people, just discomfort. Some people don’t even know that they are pregnant and like they’re checking for that, but then it happens pretty rapidly. So you’re going from your first to the second trimester and you might be body checking more. There’s a lot of comments, unsolicited, from strangers, partners. There was actually an article that came out last year. I think maybe, Ashley or Sam, you may have heard me talk about this, but it’s about weight stigma and not just partner relationships, but who is a source of it in both pregnancy and postpartum. And they say that the unsolicited advice comes from family members and strangers in that pregnancy period. And in the postpartum period, the same people that were surveyed while pregnant said the biggest source of their weight stigma was partners.

Sam: Wow.

Angela: Yeah, yeah. So it was like really fascinating and thinking about, not just our own perceptions, like if and when we get pregnant, or if a person conceives and becomes pregnant and sustains their pregnancy but thinking about not just our own viewpoint on our bodies, but how other people perceive the pregnant body and then the postpartum body. It’s like “oh are there twins in there? Oh wow, you must be carrying insert sex here, because you’re carrying glow or a boy.” I mean, there’s all of these theories around that get endlessly shared. That body image becomes a source of like, “should I be looking a certain way? Should I be acting a certain way? What clothes should I be wearing?” And we when we think about other things that bring us anxiety, the focus on the body sometimes. And so I’ve talked to my clients about that too. You can’t control X, Y, and Z symptom, right? But trying to change your body in pregnancy and postpartum can feel like the most accessible to you in this moment, even if it’s through unhealthy practices.

Ashley: That makes sense.

Sam: Well, I was shocked to hear that it was partners. I remember you said this in your talk, you gave a talk on this in Orlando at a conference and I was shocked. Maybe I shouldn’t have been, but I guess you just expect, well, you have expectations for your partner that they’re going to be a support to you. And it’s just awful to think that it could be just another source of judgment and weight stigma that you experience. And they might not even realize it.

Angela: Yep.

Sam: Angela, do you work with partners? Do you coach them around this?

Angela: Yeah, I do. I mean, I’ve always been a proponent that we can’t heal in isolation and we need to bring in supports. And so I feel really passionately about that, especially in that postpartum period where it really can impact because we’re talking a lot about the birthing individual, but all of these perinatal mental health disorders can actually also impact partners. And it’s lesser known. So like I’ll bring them in early and kind of saying, “hey, we’re talking about symptoms for the birthing individual because they’re at higher risk and it’s also going to impact you. And so how do we work together so that way it doesn’t feel like you’re making things worse, but you’re also not dismissing your own symptoms.” Similarly, irritability or anxiety can be inward, but it could also be outward. And maybe they don’t realize how their anxiety is coming out and impacting the birthing individual in that moment.

Sam: Yeah, helping partners be more aware of how their own inner experiences are impacting the relationship.

Angela: Right.

Sam: Angela, I thought maybe we could talk a little bit about this concept of “bouncing back.” We see this on social media. Yeah. Like it’s some major accomplishment if somehow your body looks the same or close to the same, immediately after you give birth. And I see a lot of influencers online, trying to maybe even give advice, you know, how to bounce back. And I was hoping, could you say more about how this concept in our culture impacts people, maybe with a history of an eating disorder or anyone vulnerable to developing an eating disorder?

Angela: Yeah, I’d love to. It’s a source of a lot of anxiety too and a lot of concern. But when there is, especially on social media, I see it mostly when there’s someone that someone feels connected to on social media, even if they don’t know them. Someone they’ve been following for a long time, and there a sense of community, even if they don’t know them personally.

Sam: Right, like some people can feel like your friend and they don’t even know who you are.

Angela: Absolutely!

Sam: But yeah, you’ve been following their life and you feel like you know them.

Angela: Yeah, like Brene Brown for me! You know, but these people have no idea who you are, and then you feel so connected. And I see this being more of an issue than with a celebrity. Whereas people have more of this idea of, “oh, they have resources or they have money to do this.” When there’s a person who isn’t a celebrity, but has a big following or feels like they’re an expert in that field, they come to me and they’re very much like, “how can they do it and I can’t do it.” Or like our perception of the body was the same, or I had a child and they had a child and now it’s six weeks or two years postpartum and I should have the same body. There’s just so much shame. And it’s really interesting, anecdotally, I do notice that sometimes people give themselves more grace within that first year post birth. But then when the child becomes like two or three, there’s this notion that your body should be back. “It’s been a couple years now, and, why is it so hard for me?” And then, so people go to social media, because there isn’t really much of, I mean, I’m talking about Instagram specifically, but people go to these like Facebook groups or like listservs, right? And they’re talking about the impact of being two to three years postpartum, unable to get their body back. And now they’re asking for advice from a group of thousands of individuals. And I wish I could tell you that sometimes the advice is “Oh you just had a baby only a few years ago.”  Not that we’re seeking reassurance, but that was a major life transition that your body had. But people are so quick to give advice as to the weight loss plan that they should get on. And then when people try that and then it fails, that’s when I also see, “what’s wrong with me?” They question, “can I get pregnant” if they want to get pregnant again? “I can’t get pregnant again because I’m at this higher weight body now. And what does that mean for me in the future?”  There’s a lot of anxiety around it. And so much impact around this back and forth and “ well, this person said I should do this and then this person said I should do this.” And we’re moving away from our own inner wisdom. I often say, “you’re outsourcing all of these questions to people you don’t even know before even asking yourself, ‘what’s what do I need right now?’

Sam: Right. Or forgetting that you can get the support of registered dietitians and therapists with eating disorder specialties. And you know, you don’t have to do it alone either. Like how important it is to be in touch with your own needs, and also know where you can get support that’s actually going to be helpful.

Angela: Right, right. I mean, it’s also important to remember though, people go into remission and pregnancy from their eating disorder. And then those who go into remission and pregnancy, most of the time, relapse. It’s like majority go into remission and pregnancy and then that majority relapses postpartum. And so, it’s a really vulnerable time mentally, physically, and so the messages that get sent, there’s less literacy around “this does not apply to me,” or “this person might be giving me advice from a very like sick place themselves” or “they’re also a product of die culture.” There’s less the ability to kind of like decipher, “Oh, is this like really advice that I should be taking that doesn’t compromise my recovery?”

Sam: Well, when you’re feeling so vulnerable, it can be very hard to think critically in those moments. And you bring up such an important point. I bring up this point also when I do my presentations on social media literacy, that we are way more likely to compare ourselves to peers than we are to celebrities and models and influencers. And it’s sort of like, we need to be aware of that, that it’s actually, maybe your biggest trigger might be this person you know from high school, who is talking about how quickly they lost weight after having a kid. And, I just think it’s so important to be mindful of the fact that our triggers aren’t always coming from Hollywood and they aren’t always coming from the places we think they’re coming from. And then maybe we need to unfollow and hide and mute, you know, people who we just, we find ourselves comparing ourselves to in an unhealthy way.

Ashley: And if we do unfollow or mute those people, that means that we can always re-follow them and unmute them when we’re in a better space, you know, like if we do want to stay connected with them.

Sam: Right. Or maybe connect with them in a different way. Right. Who knows, you know? But I think mindfulness is so important, just being aware of what your triggers are and how they’re impacting you.

Angela: Right. Which you’re not going to get from social media. You’re going to get from a licensed professional if you have access to that. Right? It’s like having these conversations around, “what is it that I’m looking for? What am I craving? What are my needs?” And the whole bounce back culture. When we’re yearning for a body that we used to have, we forget about what our body has been through, and, it’s been through a lot. I always ask the question, “are you yearning for your pre-baby body or your pre-baby life?” Like the ability to like travel. I miss that. I have a two-year-old, I’m pregnant now and, I know I miss being able to kind of just go to the grocery store without having to call a two and a half year old who has her own needs and gets over simulated so quickly. And not have to plan around nap time. All of that is a big life change that people don’t realize that impacts.

Ashley: Angela, I want to tell you a funny story on that real quick. We went to the beach recently. And I also have a two-year-old. And I found myself on the beach. It was beautiful. My feet were burning. It was so hot. I wanted to walk into the water. The waves were just crashing. The walk into the water was really kind of steep, actually. It wasn’t just a gentle walk. And I came out of that experience just really frustrated and a little bit overwhelmed? And I was like, “why do I feel this way? I’m at the beach, it’s beautiful. And I looked down and I realized that I’m holding the hand of my sweet little two-year-old who’s kicking and screaming wanting to go back into the water. And I thought, “oh, this is why this isn’t good for you.” It changes everything., I guess I hadn’t been to the beach since I had a kid, you know, and certainly hadn’t taken her. And that experience was a completely different experience than I’ve had before at the beach, which is a calming place.

Angela: Right, you can read on your beach chair and close your eyes.

Ashley: I couldn’t do that.

Angela: Yeah, yearning, I mean, that’s what it is, a yearning for some of that peacefulness that may not be in the season right now.

Sam: See, this is so important in therapy to be able to go deeper, beyond that, “oh, I’m grieving the loss of my body.” Because yes, that could be part of it and often is part of it. And what else are you grieving? What losses? Because I think a lot of people in society don’t feel safe talking about the fact that there can be grief when you’re a new parent.

Ashley: I could not agree with you more, Sam.

Angela: Yes, even if you go through IVF, even if you go through all these fertility treatments, I think there’s a lot of guilt there too. It’s like, “I’ve always wanted to be a parent. I’ve always wanted this. I just went through years of treatments for fertility and I’m feeling guilty. I’m making me a bad parent.” You’re allowed to feel guilty. You’re allowed to feel these things and feel conflicted no matter what your journey was like.

Ashley: And that doesn’t make you bad if you feel that way.

Angela: Exactly. That doesn’t make you a bad parent, right?

Sam: And so many things can be true at once. We talk about this in other episodes, where it can be true that you really, really wanted more than anything to be a parent. And it could also be true that you’re grieving the loss of certain experiences or an identity or changes in your relationship, changes in your body. That’s all normal. We need to normalize that and hopefully create a space where our clients can talk openly in therapy about these losses, because it’s okay and it’s normal.

Ashley: I think it’s so important. I wish it would be more normalized, even as someone who is a therapist, who is also the mom of a toddler. There is a level of grief there. You can’t just pick up and go sit at the beach. Lay out, get your sun.

Sam: Right, right.

Angela: There’s a level of “oh, I thought I worked out my stuff.” Right? Like “I thought that I worked through my short fuse” or you know, some people have been in therapy for years and then they have filed and they think, “I am losing like my brain here.” You know, like “I cannot, I’m losing it, and I don’t know why. I thought I worked through this” and then all of a sudden they have a child and their fuse is short. They can’t take care of themselves the way that they did. Self-care looks much different. Right? Like, self-compassion, is just you’re doing it sometimes with your child and you’re self-regulating learning, trying to do that. And of course, people have different resources. Some people don’t have childcare resources. People don’t have the ability to just go for two hours somewhere. For those that do, that’s a luxury and that’s a privilege and we should use it. But for those who don’t, they have to figure out another way. And I noticed that’s also the barrier, right? It’s like, “well, if I can’t do this, I can control my body.”

Ashley: That’s what I’m thinking, like just this, like this compounding stress. you know, taking it, okay, well, then what is the one thing that I do have access to manage? I know I can manage this, right? Or control this or, you know, whatever that is. Can I ask a question, in talking about triggers or activators? What about folks that have had a medical issue with birthing, like a prolapse or a C-section or even just a natural birth? I mean, that changes everything, your body goes through so much. What do you see come up for them?

Angela: Yeah, I mean, we have to think about clinically from like a therapist perspective or provider perspective, more so around a postpartum PTSD or PTSD that starts in the peripartum onset. What I’ve noticed and what the research says is that there’s an estimated, I think, 9% or 10% of people who have a traumatic birth go on to develop postpartum PTSD. So that’s a pretty big amount. And there’s a higher likelihood for LGBTQ, trans-parents, black individuals, right, because of discrimination, things like that. But it’s also the sense of choice. and the sense of being informed. A lot of birthing individuals who had a medical emergency during birth say that it is the lack of autonomy and choice around what happened that I can’t stop thinking about. Less about what happened, but like what happened because that happened. Were they informed by the nurse or the doctor, OB, midwife, whomever was in the room? Did they have a support person that kind of walked them through? Because people come in with a birthing plan. And oftentimes, birthing plans don’t go the way that we want them to go, whether it be getting an epidural if you didn’t want one or whatever that might look like for that person. But it was mostly like the, “I was in labor for 48 hours and no one told me that saying yes to x, y, and z would increase or decrease my chance of an emergency c-section.” That lack of being informed around it. Because planned c-sections don’t end up with, not for everyone, trauma, PTSD or flashbacks or intrusions. Even if they don’t meet full criteria for the diagnosis, but unplanned and emergency c-sections or a prolapse cord or pre-eclampsia or eclampsia, right? All of those things that they were not informed of their choice. That’s what led to those intrusions. So just important to kind of think about, what we can do as providers in talking to gynecologists or midwives saying for instance, “hey, like, can we just walk in a trauma-informed way, walk through the support person, and have a conversation around, if this were to happen, what are the wishes of the birthing individual.”

Sam: It’s so important. Trauma-informed care is so important, whether it’s in a medical hospital setting or in the therapy room. And I keep thinking over and over of the phrases, voice and choice, right? And trust and transparency. I mean, some of the pillars of trauma-informed care. And this is especially true for our clients who have a history of intergenerational trauma, where they have ancestors who experienced no voice, no choice, no trust, no transparency. And I imagine it impacts them even more to come into, I mean, here you are so vulnerable. And being in the care of others and they’re not giving you voice, choice, trust and transparency.

Angela: Absolutely. I mean, it is a stark difference. And if a person has trauma in their history, right, it’s even more important to communicate, I think it should happen regardless because we don’t know again, like generational trauma, but we also have to think about expanding our scope around what trauma might be. Because I have a lot of clients that come to me and they have had hyper-MSS Gravidarum, which is throwing up throughout their entire pregnancy, who are afraid of getting pregnant again, because of it happening all over again. And the same thing goes for traumatic births, afraid of it occurring again. And even if they have desire for another pregnancy, they may not go through with it due to that fear. I think all providers and healthcare professionals need to be knowledgeable around how to have these conversations in a trauma-informed way and how to increase the prevention of it. You can’t just take it away because emergency sections are there for a reason, to keep mother and baby alive, right? But that’s not what I hear as the crux of the trauma.

Sam: Yes. I have a quick question. What are the differences between PTSD and postpartum PTSD? Is it just the timing of it, or I’m just curious about signs and symptoms, like how might someone know that maybe they’ve developed postpartum PTSD?

Angela: It’s mostly that the intrusions are around the birth, or what happened after the birth. If it’s with a peripartum onset, it would be about happening in the pregnancy. So thinking about, what are the flashbacks about? What are the nightmares about? And it could be like that they had PTSD prior, and it was about a different trauma in their life, a traumatic situation. And it has shifted to that birth or delivery process that was traumatic. But it could also be brand new. That’s also important to kind of remember.

Sam: So intrusive thoughts, flashbacks, nightmares and avoidance I imagine is part of it as well.

Angela: That’s a huge one, avoidance of getting pregnant again. Sometimes it’s even picking up the baby, too. Thinking about or talking about the birth story. You know, avoidance of coming to baby showers, hypervigilance around hospitals, healthcare settings. If it’s not avoidance of the doctor’s appointments postpartum, there will be hypervigilance about that.

Sam: Yeah. Avoidance of any reminder of the traumatic experience. Important for our audience to know in case someone out there might be suffering.

Angela: Yeah, absolutely.

Ashley: So Angela, let’s talk a little bit about support systems. I know we talked a little bit about partners, but just in general, like, what can our partners do? What can our loved ones do? our support systems?

Angela: I think: one, getting educated on signs and symptoms. If you’re a partner or a loved one listening to this, I think this is step one. And, you know, if your loved one, or the birthing person does have providers, ask about joining one of those sessions. There’s also a Postpartum Support International offers a group for loved ones support that I highly recommend. All their groups are run by professionals. They go through a training process. It is peer support, but it is also facilitated. I often recommend that, and that partners know like screening questions, like knowing what to look for. Because I get a lot of ranting calls from partners or loved ones asking, “my loved ones in the laundry room hysterically crying, is this normal? Is this not normal?”  You know, timeframe matters. Are they looking out for for themselves, but also for their partner? Knowing that, I also recommended a postpartum support plan, which includes, what do meals look like? Who’s taking care some of those meals? They should know that sometimes postpartum depression looks like rage and anger. I get a lot of questions related to that. And my education is often focused in on it may not look sad. It may not look like someone might be crying. But sometimes it’s like this increased irritability. It’s resentment. And you’re like, I didn’t I didn’t have the choice to carry, or it was discussed that you would carry this time, and I would carry next time, you know, if it’s a queer relationship, but that resentment and that anger can be very ever present and people don’t know about it, people don’t talk about it. So it just looks like they’re having a moment whereas it could be postpartum depression just not in its typical fashion. I often try to educate on that. I try to educate on the differences between, if someone is at risk for postpartum OCD and postpartum anxiety, how it might differ from postpartum psychosis, because I get a lot of calls around like, “is this a medical emergency” type of questions? And oftentimes it is not, whereas postpartum psychosis is a medical emergency, but postpartum OCD is not. And so doing some education around the differences.

Ashley: Because postpartum OCD includes the compulsive thought or sorry, the intrusive thought?

Angela: It’s actually both postpartum psychosis and postpartum OCD are categorized by intrusive thoughts. But with postpartum psychosis, the person believes the thought is inadubible, and it doesn’t bring them distress. The reality is that, this thought is true, and I have to act on it because it is here. Whereas with OCD, whether it’s postpartum or not, most people know, if not all people know that the thought is not a good thought to have, and it kind of freaks them out. Actually, they’re like, “Why do I have this thought? I know this is not actually what I want to do. I know that I love my baby so much and I want the best for them. But why do I keep thinking that I’m going to stab them when I love them.”  It is what we call ego dystonic. So you’re having that thought, but you don’t actually want to act on it. And most of the time do not act on it.

Ashley: Thank you for that example. I think we may have defined that in last week’s episode, but I appreciate you.

Angela: Of course! But I usually just educate on that for partners, using, just regular terms around, “hey, if you are worried, of course, reach out. But here are some signs and symptoms to look out for your partner, but also for yourself. I just like to remind them that they’re not absolved from that because it’s not, it’s hormonal. Yes, there’s a drop in hormones, but it’s also very much like environmental, right? What’s happening in the moment that contributes to a perinatal mood and anxiety disorder?

Sam: Angela, in the postpartum period, what does a treatment team look like?

Angela: Yeah, you know, it’s interesting. I love this question because it has expanded. I just recently did a talk in New Jersey and I had a lactation consultant in the room and she asked, “Oh, have you ever thought about adding X on the care team?” And I said “yeah, absolutely actually.” So, we’ll talk about if you have access to resources, and the basics could be a therapist, a dietitian, a psychiatrist or nurse practitioner. This is with an asterisk because they do need to have perinatal theory and understanding. And the reason for that asterisk, is that if the person has a psychiatrist or prescriber that they are really attached to, that prescriber can call a hotline through PSI and get consultation. And I can give that to you both so that listeners can get that. But it’s actually a really cool resource. So a psychiatrist with, of course, like perinatal focus, but if that is not available to you, they could call hotline and get kind of that information accessible to them. So those are the three. And then I also recommend a meal support specialist. Someone to kind of help them carry through the postpartum support plan that hopefully you’re doing with said therapist, if you are lucky to see them during your pregnancy. And then, a doula. A doula actually increases success in labor and delivery in having your voice heard. Doulas are really well trained in listening and asking the hard questions around, “hey, if this happens, so what would you like? How can I help carry through?” And a great doula would actually defer to the midwife or the OB and say “I’m going to note this is your preference, the birthing preference, and here are the categories in which, you would want this, what’s the next plan B if that doesn’t work and what’s plan C if that is unavailable to you”. So that’s a great doula, is being able to kind of note all of your wishes on your birthing plan that could be executed. And doulas just, especially for black women, increase survival rate for both baby and mother. So highly recommend. And there are some doulas who are free or low cost. So usually in the state, the state will hopefully fund some free doula support. And then there’s also lactation consultants. Some people who do desire to breastfeed or chest feed, they can reach out to La Legge League. And then, so there’s lactation consultant on that care team. And of course, a midwife for an OB as part of that.

Sam: It takes a village.

Ashley: It does. And I have a follow-up question, just thinking about that community, maybe afterwards, what would be helpful? You mentioned a PSI group for partners. How can birthing individuals build community and why would that be helpful? And also if blood-borne family doesn’t live near them, why and how would community be helpful? Does that make sense?

Angela: Totally. Actually part of that care team postpartum should be peer support. But the quality of the peer support also needs to be examined because not all peer supports are created equal. So you want to make sure that you’re vetting out the types of communities you’re looking for, or that you are a part of, and that they are all value driven. And that if you’re confused about that, then that’s a really great place to kind of talk about with your therapist around, “hey, what should I be looking out for in a peer community?” But oftentimes in that postpartum period, you feel so alone. Friendships can change. You no longer get invites to things because you’re occupied and people are trying to be nice maybe. And they’re like, “oh, you’re busy, so I’m not going to extend the invite.”  Life just changes, and you might feel like, “I don’t have anyone to talk to about this, in this period.” So PSI also offers virtual groups, which some people they like because it’s accessible and they are free, but could also look for perinatal therapists who can hold groups, and they try to make them at convenient times for new parents. There’s sometimes a lot of Facebook groups, this is where that literacy that we were talking about before, it can be really helpful because these groups can be super accessible and a lot of people in that area can meet up. You know “we’re doing a meetup on the playground on Sunday at two, and this is for age ranges of zero to one.” Or a lot of people might say,  “hey, I’m Angela, and I have a two and a half year old, and I just moved to this area. Would love to make new friends with people around the same ages.” And you get so many messages or an opportunity to connect with people who are in that same kind of range and life circumstance. There’s a lot of resources out there. And the community is so, so important because there’s a divided loyalty that sometimes happens in that postpartum period, right? It’s like, I’m heeding to my child. And if you are recovering from an eating disorder, that desire to heed to your eating disorder, right? And so if you feel really alone, that loyalty to your eating disorder might make more of a presence, it’s important that we connect because eating disorders thrive in that disconnection.

Sam: Angela, thank you so much for coming back for a sequel. This was so informative. Thank you so much for sharing your expertise and all of the wonderful resources. I think this is an episode that we’ve had more resources than ever before. We will link all of them. There are so many. Yes. But this is wonderful for our audience because they will know where to go to get the support that they need, and it’s all thanks to you.

Angela: Thank you for having me on for part two. I’m really grateful.

Ashley: Thank you for listening with us today on All Bodies. All Foods. presented by the Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

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