A space where I chat to inspiring people about Womb stuff!
Today is the first conversation ever held in the chat Womb between my good friend Dr Debbie Hartwell and I. Debbie had the idea to record and share some of the conversations we have had about mental health / cycles over many hours. In this conversation Debbie asks me questions and then we swap. Grab yourself a cuppa and dive in!
Debbie is a experienced clinical psychologist who runs a private practice in South Wales. Find her at www.drdebbiehartwell.com @drdebbiehartwell
"I am passionate about helping people find ways to make sense of and manage complicated and distressing thoughts, feelings and behaviours. Throughout my career I have fought to de-stigmatise mental health problems by normalising the human experience through shared understanding, empathy and compassion."
Debbie to Hannah:
At times when I’ve suggested that my clients between 40-50 are likely to be in perimenopause, the most common response I have is that “the GP has done a blood test and said I am not”. This infuriates me as the medical view is held with such absolute certainty, when we know how undertrained GPs are in cyclical related issues. Do you think we should be moving away from a medicalisation of menstruality? If so, how do we begin to do it?
It infuriates me too, but it isn't surprising given how over-medicalised our society is. We rely so heavily on the medical system to ‘fix us’ and I find it so dogmatic and patriarchal. I have heard so many stories from women who have felt let down and unheard by the medical system yet we still revere it! It stokes the flames of fear and portrays menopause as something that only needs medical management, which I believe buys into the idea that women are broken and need fixing!
There is no specific blood test for perimenopause. Once periods have stopped for 12 months, menopause occurs, and a blood test can be used at that point to detect elevated levels of FSH (follicle stimulating hormones) that can confirm menopause but the way that perimenopause is confirmed is through a combination of symptoms such as hot flushes, irregular cycle, brain fog etc.
As a menstrual cycle coach, I think medical management of menopause absolutely has its place but I would welcome a move towards integrative medicine, where we treat the whole person holistically with an emphasis on a preventative approach.
To help shift this narrative, we have to start by getting menstrual education right in schools. We don't medicalise and treat puberty in the same way as menopause, despite it being a very similar biological transition. So for me it's about reclaiming the narrative and reframing menopause as a means of initiating women into their power, attitudes are starting to shift which is really wonderful but this is a marathon not a sprint!
What do you think about the diagnosis PMDD?
I think a diagnosis of PMDD can be very validating for some people who have had cycle related mental health challenges for a long time, especially if they have had other different diagnoses before that they have found unhelpful. But I also think the criteria for diagnosis is quite loose, if you look at the symptoms that you need to tick off to confirm PMDD, they are very similar to PMS and so I would imagine diagnosis is tricky, especially with the stigma women experience when seeking support with menstrual issues.
For me it comes down to what the diagnosis may give someone, if that is reassurance or confirmation and it means that they are going to get the holistic support they need, then wonderful. But if it means unnecessary medicalisation and further stigma, then that's really unhelpful. I have spoken with a number of women who thought they did have PMDD but found that the severity of their symptoms have reduced significantly through menstrual cycle awareness (the practice of tuning into how you feel on certain days of your cycle and working with that) and other holistic support. But I have also seen women try all the holistic options and found that an antidepressant was the only thing that helped. It is all so individual isn't it?
I still feel the need to be quite sensitive when I bring up the possibility that someone’s cycle may be heavily influencing their emotional state. It can easily be interpreted as invalidating (due to years of the patriarchy diminishing menstruality). Even women have become quick to dismiss their own cycles as being a valid reason for their changing emotional states. By the time someone finds you they have already worked out that their cycle is interesting and relevant. Any hints or tips on new ways I could approach this?
The people I have worked with as a cycle coach have either come to me because; they are interested and want to reconnect with their cycle (often before it changes as they move into perimenopause), they are coming off the pill and want to reclaim their cycle or because they have real challenges and don’t want to dread their period, but you are right, my people are already cycle aware.
I hear you on the sensitivity of not wanting to just blame hormones, as this can totally buy into the ‘women are hormonal and unpredictable’ rhetoric. I wonder if it's about encouraging people to start charting / tracking their cycles and getting curious? Once we track we start to learn what is usual for us, and are better able to work out what is unusual or less likely cycle related. I know you are great at being curious with clients and I think that co-investigative approach can be really helpful in reducing any blame and shame. Instead of the mansplaining that can happen.
In your work you explore the depth and breadth, not only of monthly cycles, but of life cycles and intergenerational stories. Given that statistics suggest most women will experience some kind of trauma in their lives, you must come across this in your work. What do you do when you come across such trauma in your work?
Yes, I think this is a very real issue, lots of cross over. I am still in awe of how open people are in sharing their experiences of trauma, and hope that I can offer a safe space to hold some of that with them. I am trauma aware and aim to invite people to explore events in their menstrual journeys that may have impacted on how they feel about their cycle today so it is grounded in the present. I am also clear in my agreement that I am not qualified to treat trauma and that I can refer on to someone who is, if needed. I know a very good clinical psychologist who I recommend often!
Where does cycle work cross over into trauma work? How do you navigate this crossover?
I meet all of my prospective clients to discuss the work so we can decide if we are a right fit before we start sessions. This allows me to get a feel for where they are at and whether I feel I could support them. If they disclose experiences of trauma that they have not received any other support for I would recommend they found this either before or alongside our work. Most of the women I have worked with have either had counselling / therapy or are continuing to have this so I am able to judge how trauma aware they are and perhaps suggest certain issues are taken back to their therapist, for example.
This can be muddy water to navigate in terms of the crossover between cycle work and trauma work and I rely on my professional judgement, instinct and also regular clinical supervision to reflect on working within my scope of practice but as a human I don’t get this right all the time.
I send you a lot of hormone/period related memes because I relate to them. Do you think these memes contribute to the stigma and invalidation of women’s hormones, or do you think it is good that it is getting airspace?
That is such a good question! I think both! Some of the ones you send me I am not into, as I think they perpetuate misogynistic attitudes and stigma, but some I like! It's all so personal. I think some of it is internalised patriarchy, where we have been taught to think that misogyny is funny, so we think we do! I do think that menstrual health is getting more airspace for sure, and this is wonderful, but we have to be careful not to reinforce the negative stereotyping.
Hannah to Debbie:
I have been banging on about periods and cycles for ages now and you graciously listen! You have also shared how you include menstrual cycle awareness into your work as a therapist, which I love! How has menstrual cycle awareness changed your practice as a psychologist?
Firstly, I love listening to you. Your passion and authenticity is boundless and infectious!
I think over the years I had unconsciously recognised a pattern in my clients that there were ebbs and flows in how well women felt they were doing (emotionally, practically, energetically, therapeutically etc). However, it wasn’t until you recommended Period Power by Maisie Hill that it clicked into place, initially for myself. I started charting my cycle and noticed patterns that resonated with the seasonal framework in the book (winter, spring, summer, autumn). Then I started seeing it in my clients and asking them about their cycles.
With permission I make a note of where my clients are in their cycles. My tracking is not sophisticated. I literally draw a small circle with a cross in it to give me 4 quarters at the top of my notes, then I mark which season they are in. I generally see people weekly (i.e. a day in each season) where we start the session with a brief overview of how their week has been. The patterns can be pretty clear in how emotionally regulated people feel at different points.
One of the strongest patterns I’ve seen is that for people who struggle with suicidality it is the strongest in Autumn, or in the ‘void’. I don’t know if there is any official research on this, but it is my observation. I remember reading that there is an increased risk of suicide in women around age 45-50 , and with hindsight it dawned on me how curious it always was that a women who may not have accessed mental health services before may have a first admission to hospital around that age.
In short, how it has changed my practice is that I ask about people’s cycle now as standard, whereas I’d not have done that before. I ask how much they know about the impact of their cycle on their mental health. I do a brief bit of psycho-education about the seasons. I try to highlight it as something very relevant rather than just something else that is happening in the background. Since I’ve been asking women about their cycles, which has only really been since I started private practice, I’ve been amazed by answers like “every time I’ve been admitted to hospital it’s been just before I bleed”, “nobody has ever asked about my cycle before”. It is really powerful.
And how has menstrual cycle awareness changed your relationship with yourself and your own cycle?
I remember initially being a bit resistant to reading Period Power when you kept talking about it. I thought I was so self aware because I could predict my 28 day cycle and ovulation. I arrogantly thought there wasn’t much more this book could teach me about my cycle. I was wrong! Charting and finding the patterns in each of the seasons blew my mind. It was possible to pinpoint so many things (e.g. feeling weepy, assertive, angry, horny) down to the same days each month. Knowing this has enabled me to cut myself some slack and quiet my internal critic when I’m being overly harsh on myself. I’ve been able to slow down and rest in winter without guilt. I’ve learnt to use my frenetic autumnal energy for good. I’ve learnt to pause and bite my tongue in autumn where I may have previously launched hurtful attacks or reacted to things rather than responded. Importantly I have been able to recognise my needs at different phases and ask for these to be met. I’m proud to have taught my little boy about all of this so he has an awareness of what happens for girls and women. I also have a baseline to check into which helps towards knowing what I’m taking to my work with my clients. As you know, I am more in tune with my autumn and winter than my summer and spring. And I'm still uncertain why I have resistance towards knowing those parts of my cycle as well.
In your work with many menstruating clients, how do you think stress and trauma impact the menstrual cycle?
Good question. It has taken me ages to think about whether stress and trauma impact on the cycle or whether the cycle impacts stress and trauma. I think both can be true. Stress and trauma can impact people in many different ways. If someone has experienced a sexual trauma, birth trauma or miscarriage then seeing blood and having to focus on that area of the body can be very difficult for people. It can be a reminder of what happened, it can bring flashbacks and traumatic memories. Imagine this happening once a month! For people who may be transitioning gender a period, or lack of one, may be a reminder of a body they do not feel in sync with. Some people who may not be menstruating due to anorexia may have a difficult relationship with their period. A period could be a sign of a mature body which they do not want, or a sign of being a ‘healthy weight’, which they may not feel comfortable with. Some people choose to take the contraceptive pill so they don’t have to deal with menstruation anymore. Cycle related symptoms can also have an impact on relationships and conflict if the person is unaware of their changes in the seasons and their needs. So, it’s not straightforward or clear cut.
How do you support clients with clear cycle related symptoms?
Once we have noticed the pattern we might change what we do in therapy at the more challenging times of the month. For instance we may choose not to do trauma reprocessing work (EMDR) if we know the person’s resilience and energy levels are very low at a certain time of the month; or if their self-harm and suicidality is heightened. Instead we focus more on soothing and self-care elements at that time.
I’m aware of my limits when it comes to cycle work. My knowledge around this is surface level and extends to awareness raising, psychoeducation and some strategies. However, when the cycle is clearly more of a problem than the issue they have come to therapy for, I recommend Period Power, mention cycle coaching and of course recommend they look you up on Instagram or your website. I tell people they can chat with you and find out more via a free virtual cuppa!
How well are psychologists prepared for / taught about cycle related mental health challenges?
I do not recall menstrual cycles being spoken about at all in my doctoral training. Given that we were 10 female trainees, predominantly taught by female psychologists, I find this absolutely shocking now. I am not sure if clinical training incorporates this into the programme now but it would be worth finding out. I can’t speak for all psychologists in how well prepared they feel for recognising and working with cycle related challenges, but I do not recall any conversations about it through my career. For instance I worked in the NHS for 15 years and we would have lots of meetings about different people’s special interests, or someone would bring a research paper to discuss a new topic. I do not recall any conversations about cycle awareness throughout my career.
What are your views about PMDD and other cycle related ‘disorders’?
I wish we didn’t have to view everything as a ‘disorder’ to start off with. I understand the value of diagnoses for many people but I think society overly pathologises human experiences. If the diagnosis helps someone access adequate help and support that leads to positive changes then that’s helpful. However, if it just becomes a coverall label that everything else is put down to (e.g. emotional dysregulation, mood, anxiety, pain), or the person themself uses it to dismiss their own behaviour and experiences then that is not so positive. I think the type of help and support offered to people should include more than medical solutions. It goes without saying that cycle coaching would be so much more helpful, and therapy too.
If you have any questions or comments please add them here, or please reach out to Debbie or myself as we love to chat about this.
If you would like to join me in the Womb room or if you have anyone you think I should talk to please let me know.
Love from your friendly Cycleologist,
Hannah CEO @ Womb Wisdom
