Post-Partum (now Peripartum) Depression: What you should know . . . and some resources to help you know it

Note: This post is provided for individuals interested in learning more about post-partum or peripartum depression. It’s also a supplement for the recent Practically Perfect Parenting Podcast on “Post-Partum Depression.” You can listen to the podcast on iTunes:


For the first time ever on planet Earth, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the diagnosis of Peripartum Depression. Although I’m not usually a fan of labeling or big psychiatry, this is generally good news.

So, why is Peripartum Depression good news?

The truth is that many pregnant women and new moms experience depressive symptoms related to pregnancy and childbirth. These symptoms are beyond the normal and transient “baby blues.” Depressive symptoms can be anywhere from mild to severe and, combined with the rigors of pregnancy, childbirth, and parenting a newborn, these symptoms become very difficult to shake.

But the most important point is that Peripartum Depression is a problem that has been flying under the RADAR for a very long time.

Approximately 20% of pregnant women struggle with depressive symptoms. The official 12-15% estimates of post-partum (after birth) depression in women are thought to be an underestimate. What makes these numbers even worse is the fact that society views childbirth as a dramatically positive life event. This makes it all-the-more difficult for most pregnant women and new moms to speak openly about their emotional pain and misery. And, as you probably know, when people feel they shouldn’t talk about their emotional pain, it makes getting the help they deserve and recovering from depression even more difficult.

Jane Honikman, a post-partum depression survivor and founder of Postpartum Support International has three universal messages for all couples and families. She says:

  • You’re not alone
  • It’s not your fault
  • You will be well

Keep in mind that although peripartum depression is thought to have strong biological roots, the first-line treatment of choice is psychotherapy. This is because many new moms are reluctant to take antidepressant medications, but also because psychotherapy is effective in directly addressing the social and contextual factors, as well as the physiological symptoms. Additionally, as Ms. Honikman emphasizes, support groups for post-partum depression can be transformative.

Below, I’m including links and resources related to peripartum or post-partum depression.


A very helpful informational post by Dr. Nicola Gray:

Books by Jane Honikman can be found at this Amazon link. Her books include: I’m Listening: A Guide to Supporting Postpartum Families.

Although it’s true that peripartum depression can be debilitating, it’s also true that it can be a source of personal growth. Dr. Walker Karraa shares optimistic stories of post-partum related trauma and growth in her book:


More Methods for Discussing Suicide with Mental Health Clients

nick-nacksNearly everyone agrees that asking clients directly about suicide is the right thing. However, because every client situation is unique, there are also many different strategies for asking about suicide. In this short excerpt from Clinical Interviewing, we discuss how to bring up suicide using information from outside of the counseling or assessment session.

Using Outside Information to initiate Risk and Protective Factor Assessment

Outside of the formal suicide assessment interview, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:

  1. Client Records
  2. Assessment Instruments
  3. Collateral Informants

Client Records

If available, your client’s previous medical or mental health (med-psych) records are a quick and efficient source for client risk and protective factor information. Many risk factors listed in this chapter won’t be in your client’s records, but you should look closely for factors, such as: (a) previous suicide ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interviewing opening and rapport building, you can use the records to broach these issues.

I saw in your records that you attempted suicide back in 2012. Could you tell me what was going on in your life back then to trigger that attempt? 

When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 10.2). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.

The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future. 

Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.

Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt.

It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:

I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked for you back then?

Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).

Traditionally, previous suicide attempts are considered one of the strongest predictors of future suicidal behaviors. However, as with all risk factors, previous attempts should be considered within the idiosyncratic context of each individual client. Case example 10.2 provides a glimpse of a case where a previous attempt ends up serving as a protective factor, rather than a risk factor.

Case Example 10.2

Exploring Previous Attempts as a Method for Understanding Client Stressors and Coping Strategies

Exploring previous suicide attempts is an assessment process. It can illuminate past stressors, but it’s equally useful for helping clients articulate past, present, and future coping responses.

Therapist: You wrote on your intake form that you attempted suicide about a year and a half ago. Can you tell me a bit about that?

Client: Right. I shot myself in the head. It’s obvious. You can see the scar right here.

Therapist: What was happening in your life that brought you to that point?

Client: I was getting bullied in school. I hated my step-father. Life was shit, so one day after school I took the pistol out of my mom’s room, aimed at my head and shot.

Therapist: What happened then?

Client: I woke up in the hospital with a bad fucking headache. And then there was rehab. It was a long road, but here I am.

Therapist: Right. Here you are. What do you make of that?

Client: I’m lucky. I’m bad at suicide. I don’t know. I suppose I took it to mean that I’m supposed to be alive.

Therapist: Have you had any thoughts about suicide recently?

Client: Nope. Nada. Not one.

Therapist: I guess from what you said that getting bullied or having family issues could still be hard for you. How do you cope with that now?

Client: I’ve got some friends. I’ve got my sister. I talk to them. You know, after you do what I did, you find out who really cares about you. Now I know.


Talking with Clients about Suicidal Thoughts and Feelings


Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.

Here’s a link to the text

And here’s the excerpt:

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can se0em rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

Three more examples of using a normalizing frame follow:

  • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
  • Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?
  • I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this  (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask:

When was the last time when you had thoughts about suicide?

Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)
  2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
  3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)
  4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)
  5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
  6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual for you to sometimes think about suicide. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.


The White Privilege Piece for the Montana Psychological Association

Reblogging this in response to Michael Smerconish’s feature on CNN today.

John Sommers-Flanagan


A White, Male Psychologist Reflects on White Privilege



On Invisibility

The challenge begins with the definition. White privilege…

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State Leadership in Education: A Missoulian Op-Ed Piece

Arntzen at opi meeting

Hi All.






The Missoula CASA Keynote








Author, Speaker, University of Montana Professor