Guilt and Shame

As an avid reader of the work of Brene Brown, I am especially interested of her explanation and exploration of the differences between guilt and shame. Most of us use guilt and shame interchangeably, but there is a big difference between the two feelings. Brene Brown explains it as guilt is: I did a bad thing; shame is: I am a bad person. Guilt is about a action and helps us realize that we want to do things differently the next time we are presented with a similar situation – for example, I feel so guilty I left the diaper on for so long; next time I’ll check it more frequently. Guilt helps us continue to change and adapt to our environment and continually work on becoming a better person. Shame is a different story all together; shame is about who we are as an individual. Shame destroys our identity, our sense of self-worth, our ability to love and be loved. Shame makes us isolate, hide, and stop interacting with others – for example, I should have known my baby was going to use all the diapers in the diaper bag. How could I be so stupid to not plan ahead – I’m such a bad mother because I ran out of diapers.

Mommy-guilt is a much talked about concept but many of the stories of mommy-guilt I hear are really moms shaming themselves. As cliche as it sounds, mothering is one of the hardest jobs in the world. We could spend hours second-guessing ourselves and hating our choices, but that doesn’t help mothers and it doesn’t help their children. We need to practice recognizing our mistakes, learn from them, and actively choose to be better and act differently next time. One of my favorite quotes from Brene Brown is: Our job is not to teach our children that they are perfect. Our job is to teach that children that they are imperfect, that they are wired for struggle but they are worthy of love and belonging.

You are worthy of love and belonging. You. Are. Worthy. If you are struggling, ask someone you trust to listen to you, to help you.

How do I find a therapist I like?

As with many aspects of life, there is no easy way to find a therapist when you need help. I wish there was an easy way to be guaranteed to find a good therapist but it often takes time and energy, two things in short supply when you’re struggling and particularly in the perinatal period.

The easiest way is often to enlist your support system – talk to friends and family members you trust and see if anyone has a recommendation. Word of mouth can be a great way to find someone that people you trust think highly of and who are skilled. Friends and family can often do some of the “weeding out” but recommending professionals they think would be a good fit for you.

Another option is to go through your insurance provider. Most insurance companies provide a list of professionals who are contracted or paneled with their company. Different insurance companies have different requirements and application processes for professionals but you will find people who are credentialed and saavy in navigating managed healthcare. If you use an insurance website to find someone, keep in mind that insurance companies do not always update their listing of providers; you should always confirm with the provider that your insurance is covered for the services they provide.

If you are using your insurance benefits, it is also worthwhile to call the insurance company and ask specifically about your Outpatient Mental Health benefits (following parity regulations, this sometimes will be under your general medical benefits). You want to ask several questions including:

  • What are my outpatient mental health benefits?
  • Is _________ a covered provider for my insurance (and if the representative tells you to talk to the provider, ask if they can confirm network status, which they are required to do to the best of their ability)? Some insurance plans offer out-of-network benefits or lower coverage for non-contracted providers.
  • Whether the provider is in your network or outside your network, ask if there is a copay or coinsurance that I am responsible (copay is a flat fee for every appointment; coinsurance means splitting the cost of the appointment with your insurance company)?
  • Are my outpatient mental health benefits subject to a deductible (if you have a deductible, often you will have to pay that amount out of pocket before switching to a copay or coinsurance)?
  • Is there a visit limit on my plan (again, with new parity laws, the answer is typically no, visit coverage is determined by “medical necessity” but it can be an important question to ask)?

Based on the answers to these questions, you can find out about your financial responsibilities and in choosing a provider that fits your needs.

If you are choosing not to go through insurance or cannot afford the coverage your insurance provides, there are still options! Many private practice clinicians are not covered by insurance or offer reduced rate/sliding scale options for those who need help covering treatment. Some of the clinicians will want to verify qualifications but others may not require any documentation. If you are concerned about costs, it is always reasonable to ask about sliding scale options. Other people elect not to go through insurance coverage because of concerns about confidentiality and record keeping; while licensed clinicians take every step to protect your confidentiality and often limit dictated notes for exactly that reason, it is a personal decision for everyone. If you choose a provider who is not covered by your insurance company or elect not to use your insurance plan, you will be responsible for paying the clinician personally. Clinicians should be able to offer you a receipt or “superbill” with all the required codes and numbers if you would like to submit the information to your insurance plan for partial reimbursement.

When do I need help?

How do I know when to start therapy?

Mental health, particularly in pregnancy or after having a baby, is hard to define. There is no blood test or written test to confirm a diagnosis. And in our world and culture, mental health has a negative stigma – struggling with mental health has the connotation that someone is “less than;” that they are flawed and broken, and there is no future or hope for them. I believe that asking for help, reaching out for help, is a sign of strength, not weakness. It takes an enormous about of courage, energy, and intuition to realize that something is not right and want to make a change. I am always in awe of women who can take the first step towards change.

And because there is no test for perinatal mood and anxiety disorders (PMAD), we measure the need for help in an elusive way. If the symptoms or struggles happen more often than not, more days than not in a two-week period AND if the symptoms and struggles interfere with her ability to take care of herself and her family. When both of those are true, I encourage new parents to reach out for help. Women are at risk of  PMAD for the first two years after giving birth; in the first year, the most common spikes in symptoms are at 1 month postpartum, 3-4 months postpartum, and 8-9 months postpartum. PMAD can show up almost immediately after birth, or months down the road – the faster you reach for help and work with a professional, the shorter the symptoms last. Partners are also at risk for PMAD – studies show that fathers are most at risk 3-6 months postpartum. Often just as mothers are starting to improve and feel better, their husbands begin to struggle and decompensate. We all have bad days and we can all have a bad couple of days but if you’re having trouble breaking out of the pattern, it’s time to consider asking for help.

Reach out to a friend or family member you trust. Ask for help. Call for a free consultation.