Tuesday, April 7, 2009

The Thin Path

I read this post, MOTHERS Act To Drug America's Moms For Fake Postpartum Depression, over at blogHer this morning, and I've been thinking about it all day. I've got several things to say about it, but I'm a bit wary about saying them. This is a super-sensitive topic for many people, and I'm not out to step on any toes. BUT...there are some things that need to be said. So here goes.

It seems to me like there's a simple binary presented here. On the one hand, you could wholeheartedly support the Melanie Blocker Stokes MOTHERS Act and refuse to question the financial interests of the pharmaceutical companies that back it or the cultural views and social contruction of women and motherhood that are entailed by it. This is the view that the author of the blog post supports. On the other hand, you could oppose the legislation on the basis of the claim that every diagnosis of postpartum depression or anxiety, postpartum OCD, postpartum psychosis, or depression and anxiety during pregnancy is fraudulant and that this bill is just an elaborate hoax on the part of big pharma to make more money.

So these are your two choices. Either collude with the pathologizing of women's experiences or tell them "it's all in your head." The thing is I sympathize with both perspectives here. But I reject them both. It's true that there's a long and rich history of pathologizing women's experiences, attributing their behavior to those mysterious hormones, and drugging them when they display "unwomanly" behavior. Oh yes, believe me, it's a long and rich history. It's also true that the pharmaceutical industry has it's dirty little hands in all kinds of legislative pies, and anytime you see that a bill is backed by or written by big pharma you should be very, very suspicious. Very.

On the other hand, there's also a long and rich history of dismissing women's health concerns and telling them that their experiences are "all in their heads." When women have tried to describe their real lived experiences, medical professionals have often dismissed whichever portions didn't fit into their carefully delimited categories and instead imposed their own understanding of the situation in their diagnosis and treatment, even if that was deeply inconsistent with the actual experience of the patient. So the author's fear that opposition to this bill amounts to dismissing the experiences of women as "fraudulant" is not unfounded.

But in reality, we're not forced to make a choice between these two options. We could reject them both in favor of some other view. And, if I had my say, that view would require a lot more detail and nuance than either part of our original binary possess. For instance, what is actually entailed by this bill? A quick skim through the bill itself seems to back the claims of those who fear that big pharma is using pregnancy as a platform for screening women for a wide range of mood and anxiety disorders that would result in millions of new lifelong customers for the industry. Many of the disorders screened for don't seem to relate to pregnancy or childbirth at all. Then there's the additional fact that congressional support for the bill comes from politicians from "pharma-rich" districts. Seems a bit shady.

Other concerns center around the screening process. I personally feel a bit resistant to any kind of mandatory mental health screening I would be exposed to simply because I was pregnant. But I have some fairly strong anti-paternalist tendencies. While I was pregnant I actually was asked on several occasions whether I was feeling anxiety or if I was depressed or "tearful." On each occasion I truthfully answered "no" and the subject was dropped. However, one concern is that in the new mandatory screening, many experiences that will become "symptoms" are merely a normal part of the experience of being a new mother. Being tired and a little worried about your ability to handle your new responsibilities is a perfectly normal part of the postpartum period, and I would hope that this doesn't become pathologized and medicated. On the other hand, feeling completely overwhelmed and unable to cope is often an indication of postpartum depression, and those who are concerned about mothers whose depression goes undetected have a very valid concern.

Similarly, one concern is about the suggestability factor, since patients in this case would be undergoing screening not because they have complained of any symptoms, but merely because they're pregnant. During a time in your life when you're experiencing a whole range of new emotions and your identity is undergoing some fundamental changes, you may be more open to suggestion and inclined to innaccurately characterize your experiences using the vocabulary made available to you in the screening process. Further, the nature of interactions between patient and care provider tends to be characterized by a huge power and knowledge imbalance, where the patient is contructed as the ignorant supplicant who ought to be docile and cooperative if she cares one ounce about the health of her baby, and the care provider is contructed as the all-knowing, superior being whose words cannot be questioned. This power differential is likely to contribute to the suggestability factor. Once again, this would not only serve to benefit big pharma, but it would be a further step in pathologizing behavior and experiences of women that are well within normal parameters.

Of course, much of this is speculation. And it's certainly true that women need access to assistance and resources to help them deal with serious issues they may experience postpartum. And there shouldn't be any stigma surrounding their use of this help or any economic barriers in place to prevent their access to this assistance. But I think the economic barriers to seeking assistance is actually the issue we should be focusing on.

So a part of me can't help but question the motives involved in this legislation and the wisdom of imposing mandatory screening, beyond the basic inquiries and mention of available assistance that I experienced during and after my pregnancy. I don't want to be forced to answer a bunch of questions and expose myself to a lot of scrutiny if I feel that my mental health is fine. And I don't want to have some culturally informed norm held up to which I'm supposed to aspire. I came to terms with the fact that I often don't emote or express myself in a stereotypically feminine way long ago, and I suspect that many women don't naturally experience the world this way, although most of us are very good at covering that fact up and acting out the script. To me, imposing mandatory mental health screening is one more way to institutionalize these norms and expectations while pathologizing any experiences that fall outside of them. Further, it infringes upon women's autonomy by assuming that they're not self-aware enough to understand their own inner life and seek help when necessary. At the same time I realize that my experience is not that of everyone's, that a person who is experienceing depression may well be the last to recognize it, and that economic barriers are often the true culprit here.

So what I'm saying is, topics like this are very complicated and rarely fit neatly into a binary of two extremes, as they are often portrayed. In most cases, we'd be better served by rejecting the binary altogether and searching for a third way. But that third way often involves negotiationg a thin path between the two extremes, and much care is needed to avoid stepping on toes and unintentionally othering people or their experiences. Walk carefully!


  1. Anonymous4/07/2009


    Thank you for your insightful and well thought out article.

    For me it's simple, I trust my judgement and ability to do what's right for me and my baby. When Big Brother feels they have to step in and tell me what's right for me - it raises a red flag.

    The amount of vested interests in all this screening is unbelievable!

    Melanie Stokes - who the bill before Congress is named after - was not a woman who "fell through the cracks". She had been identified by the psychiatrists, she had been on numerous psychiatric drugs, she had received ECT and despite all this treatment, drugging and shocking she killed herself after less then 7 weeks of treatment.

    Perhaps it was the treatment - the same treatment that has black box warnings from the FDA on suicidality, the same treatment that all those vested interests subscribe to.

    It's frightening to me that any American would give up so many of their freedom's under the guise of help and the Big Brother mentality that says "We know what's best for you!"

    Big Government can just back out of my personal life! and take their pharma connections with them!

  2. Given that this Act does not MANDATE screening or "drugging" or any specific form of treatment, why is there such opposition?

    1. There is opposition based upon the mandating that doctors OFFER screening. This is based upon the claim that postpartum women are too vulnerable to make that decision.
    As a feminist and teacher of Women's Studies I bristle at portraying women in that manner.

    2. The claim that the supporters are a "front" for "Big Pharma."
    The argument based on the pharmaceutical support of this bill is intended to discredit it by making it appear to be based on greed, not on concern for women. However, the bill was NOT crafted by the industry, as opponents claim. The primary supporters, such as Postpartum Support International, are NOT a front for Big Pharma - but rather is made up primarily of people - many of them new moms - who volunteer significant portions of their time to HELP other MOMs - largely by providing peer support. I've rarely met such a selfless group of women. Most get NOTHING out of this except the knowledge that they have helped another mom. In fact, many spend hundreds or even thousands of dollars of their own money (and forgo even more than that by working on a volunteer instead of paid basis) simply to help others! And to be painted as a front for "Big Pharma" is such an insult to their dedication and sacrifice.

    I share many of the concerns and beliefs you express. In fact, I have written about my unease with the influences of big business on our government. I am cynical enough to think that if big pharma were behind this, we would not be having this debate. It would be a foregone conclusion - buried in legislation that barely hits the radar. It would likely not be reliant on grassroots support at all.

    The two primary (and prolific) people who are stirring up opposition are Amy Philo and Evelyn Pringle.
    A web search on Evelyn led me to a website claiming that mental disorders have never been proven to actually exist. Therefore all pharmacuetical treatment on them is wrong.
    A search on Amy revealed that she, unfortunately, experienced hallucinations postpartum and was given an antidepressant. That is the WRONG treatment - and is just the sort of thing we would like to change through better EDUCATION, which the MOTHERS Act would assist. But instead Amy would have us stick with the status quo that caused her such grief! Instead it seems she has decided to oppose ALL medication for everyone on the basis of her mis-treatment. Notably, she proposes no alternative for those who suffer.

    This bill does not FORCE anything upon postpartum women. Those who oppose it oppose even giving women the OPTION to be screened and treated for a postpartum mood disorder. I think we should be free to choose for ourselves.

  3. First, I want to thank you for your reasoned and balanced approach. You actually cared about thinking about this and looking into it, and I respect you greatly.
    Here are a couple of things I would say in response just to further the discussion, and I hope you don't think that I'm trying to negate your feelings in any way:
    1)My understanding is that the "mandatory" in mandatory screening is for the doctors, not the women. The purpose was to get doctors to start paying attention to these illnesses, because they don't. So they would be required to screen, but NO WOMAN is EVER required to respond. She can decline to take it.
    2) It was also my understanding that the mandatory screening portion of the bill was actually taken out before it was passed by the House. The focus now is funding more research and education and to look into whether requiring doctors to screen would be helpful.
    3) I'm not a fan of big pharma at all, contrary to what the conspiracy theorists would say. Unfortunately I just can't figure out how to separate them from this equation. The only thing I care about is the suffering of moms, having been through it myself, and the suffering of their children should they continue to go untreated. Some women are in fact treated with meds, and it works. Other women use other methods of treatment. I actually hope there is a day when we come up with some PROVEN natural way to handle all of this. But in the meantime I don't know how we can elect not to support looking into these illnesses further and how to better help women just because the damn pharmaceutical companies are going to stick their noses into the fray.
    4) You said: "Further, it infringes upon women's autonomy by assuming that they're not self-aware enough to understand their own inner life and seek help when necessary." I know exactly what you're saying but interestingly enough one of the things about these illnesses is that you aren't self-aware. I'm an EXTREMELY self-aware woman, but something about depression (regardless of whether you are a man or a woman) takes that out of the equation. It's like you just can't see what's going on in front of you. You know that something is wrong but you can put your finger on it, and you're afraid of it so you'd rather withdraw that reach out. It's easy to assign the logic of healthy people to sick people, but it often just doesn't work that way.
    5) I couldn't agree more with you on the issue of economic barriers to help. There are women who don't have insurance, can't get to a doctor's office, don't have someone to care for their children while they get treatment, can't afford meds or therapy or acupuncture or whatever it is they choose as a method of treatment. It's absolutely awful and I would give anything to have an endowment of some sort set aside for them. I'm not sure if this bill or something else would bring about the attention necessary to get that done.
    6) You mention that many of the disorders to be screened for don't have anything to do with childbirth at all. Could you let me know which ones those are? I'd like to look into that. Because as far as I understand it, we are only talking about the spectrum of perinatal mood and anxiety disorders, ALL of which have to do with the period during pregnancy and the first year postpartum (postpartum depression, postpartum anxiety/OCD, antepartum depression, postpartum psychosis, etc.) If something else was added in there that doesn't belong, I'd like to know about it.

    You are right that the best answer would be a thin path between all of this. It would be great if the pharmaceutical companies were not involved. It annoys me greatly to be libelously tied to them as though I somehow profit from them simply because I took medication and believe it helped me and I know many other women who were helped as well by it. I'm just not sure what else to do.

  4. earthMomma4/08/2009

    Hmmm. I guess any involvement by the pharmas makes me pretty skeptical. They've never been known to back any legislation out of purely charitable or benevolant motives. So I would bet they do stand to gain a load of cash from this bill.

    I wonder how different the screening would be than what's done now? As with Rachel, during my pregnancies I was asked on each visit if I was experiencing certain symptoms like tearfulness or anxiety. Then also at my 6-week checkup and at each of the visits with the pediatrician for the first 6 months. And the pediatrician gave me an info sheet about local resources for mental health for new moms. That might not happen everywhere, but to me, that seems sufficient.

    And I agree with all of you that the economic barriers are the big concern that needs to be dealt with.

  5. Your thoughts on this are right on, I think. If indeed it is only the "doctors" who are mandated to ask, that is a better option, however the imbalance of power still comes into play. For instance, I have refused many "standard" tests during my pregnancy that are "offered" by doctors and got more than a little pressure to do them anyway. The paternalistic attitude that can be present in some settings makes the "option" more like a requirement, depending on who is doing the offering. It seems that many of these issues discussed would be solved if we moved back to a midwifery model of care for pregnant and postpartum women. My midwife will be coming to visit me post-birth "as many times as I need" as she has said to me, to help with breastfeeding, feelings of being overwhelmed and just to be a support. She is also well-loved for her "notes" to house guests that she posts around for anyone else coming to visit, that they make visits short, meaningful and helpful!! I really feel that if women were loved, supported and part of communities that took care of them there would be far fewer "diagnoses" of mental illness.

  6. Angela4/08/2009

    And to add to earthMomma's comment, I would inquire into the research and education that will be funded by it. In many cases this is a front that the pharmaceutical companies use to get more funding. In this case, you can almost guaruntee that the research will show that there are millions and millions of women who need to be medicated.

    That doesn't mean I don't think there are a lot of women who need postpartum help. But in this model the product (drug) is created first and then the market for it is created, by labeling previously non-problematic behavior as pathological. The creation of
    PMDD as a way to extend the patent of Prozac is a great example of this.

    I'm also wary because once you get the drug companies involved they tend to block research on prevention, environmental and othercausal factors, alternative treatments, etc. This is clearly seen in the case of breast cancer, where the pharmas (which are almost indistinguishable for the Komen foundation) have been actively blocking research into the many environmental toxins that cause breast cancer for years.

    So I guess I would ask who would be implementing this research and education. If it's big phrama, then that's a deal-breaker for me.

  7. @ Carmen

    It seems that many of these issues discussed would be solved if we moved back to a midwifery model of care for pregnant and postpartum women.

    Amen. *observes solemn moment of silence*

  8. I think many of the comments here really illustrate how complicated this is and how often women have been exploited and/or not taken seriously by the medical industry/big pharma in the past. So I think being wary in this case is a good thing.

    Beyond that
    1) I too would be interested to know what form this screening is going to take. If it's similar to what earthMomma and I experienced, then I don't see a problem with it. I was asked often by nurses, my midwife, and our pediatrician how I was holding up and if I had experienced any of a short list of specific symptoms. But I can see how somebody without medical insurance or a stable relationship with their pediatrician could fall through the cracks. The inquiries into my well-being continued through my daughter's 9-month checkup, and I was also given info on local resources, free support groups and play groups, and free mommy-and-me style yoga and other exercise classes. I thought all of that was fine and not at all invasive. Beyond that I would probably get irritated.

    2) I do realize that the very people who often need help are least likely to recognize it or be motivated to get it. But I think the best remedy for this is well-educated friends and family members who know what to look for. Also, bringing in pediatricians on this is helpful because they often have more contact with the mom in the first few months than any other health care provider.

    3) Like Carmen, I still feel skeptical about how "voluntary" this type of screening would be if doctors were required to "offer" it, because I spent most of my pregnancy and a good portion of my delivery(!) fighting off unwanted tests and interventions. And I had a midwife, but she was working in the context of a larger medical clinic that had strict guidelines and then she was out of town when I went into labor. I can realistically say that the only stressful thing I experienced during my pregnancy was the constant power struggle with medical professionals. But I don't stress out that easily, either. The many "voluntary" screenings they already "offer" are very difficult to turn down. When I turned down the Downs syndrome screening, for example, a doctor came in after I had spoken to my midwife to browbeat me about it. I said that I wasn't interested because of the high rate of false positives, the risks involved with amniocentesis, which always follows a positive test, and because we were planning on keeping the baby, downs or not. This still wasn't accepted without a long discussion and me explaining all the research I had done on the topic and on and on and on. And this happened everytime I turned down a screening. Not to mention the fact that I practically had to physically intervene on my own behalf to prevent an unwanted episiotomy after pushing for only 15 minutes. my birth plan had already been thrown on the floor and kicked under the bed by that point. So... yeah I have my doubts about how "optional" these kinds of things really feel like to expectant and new moms. Especially if you're not armed with lots of info and research you've had access to prior to the consultation in the way I did.

    4) Unlike the one opponent to the bill that teresa mentions, I do believe mental disorders exist. But I think the trend to pathologize women's experiences, especially when the huge body of cultural mythology surrounding hormones is in play, is something that feminists should be really cautious about. Women are already diagnosed with and treated for a number of mental disorders at twice the rate of men. This seems really problematic to me. Especially given the fact that so many "feminine" behaviors are socially constructed as problematic, and the cultural framework surrounding women's behavior is already so deeply normative and informed by profoundly essentialist ideas. Of course things have imporved drastically, but the history of the use of mental health treatment as a tool for managing the behavior of women is another factor that ought to make us uber-cautious. And yet, I agree that you can err on the side of caution here and end up with many women not receiving the help they need. So... once again I just conclude that this topic is very complicated and hard to navigate.

    I'm loving the discussion, though!

  9. Anonymous4/09/2009

    I loved the comment that if there were more love and support (such as the midwife mentioned) offered, we could reduce these pressures on women and possibly the severity of their symptoms. Social support, psychological support (if needed) and SERVICES would be funded by this bill. It would be overseen (as proposed) by the Department of Health and Senior Services.

  10. @ Anonymous

    But I think that community support and clinical or institutionalized support are very, very different things. The way that our nuclear family setup isolates women seems deeply problematic to me, and I would bet it contributes to the problems many women experience. Feeling less isolated and less like you're carrying this big burden alone while constantly being socially judged regarding how good of a mom you are would most likely help to alleviate a lot of the stress and depression many women feel. But how can a doctor's office help with that?

    I think the idea is that there are social changes we could make that would help prevent problems rather than always reverting to a medical model of treatment. And I think this is what Angela was getting at. Once we bring in the medical model, prevention is out the window and treatment is the only way. This can be seen in the way breast cancer has been handled (as Angela noted) and also with Alzheimer's a many other diseases which have identifiable contributing environmental causes.

    That being said, I don't think it has to be either/or. We could work to bring about social changes and to promote preventative measures while also increasing access to the treatment available. But I tend to think that if big pharma is involved in implementing this, the preventative aspects will be either ignored or suppressed. It would be nice to see some specific language in the bill to prevent this treatment-only tracking.

  11. Stacey4/30/2009

    I realize I've come to this discussion a little late, but I just wanted to say I'm impressed by the discussion going on in the comment thread here. This is an example of thoughtful and constructive dialogue. It's refreshing!