She eyes me like a pisces when I am weak

I've been locked inside your heart-shaped box for weeks

I've been drawn to your magnet tar pit track

I wish I could eat your cancer when you turn black

Kurt Cobain

I was asked to speak at a conference about screening women for postpartum depression during pregnancy and the postpartum period. I oversee a prenatal clinic for low income women and universal screening is a key component of the services we provide. In a study conducted to measure the effectiveness of our screening activities, I noted that only a small percentage of the women who screened positive for depressive symptoms and were offered free counseling actually engaged in behavioral health services.

Conference participants engaged in a vigorous discussion about the challenges surrounding engaging women, especially low-income women, into behavioral health services. The many experts in the audience suggested a variety of interventions which might be effective solutions for the problem. Some suggested support groups, home visitation models and primary care management as options for treating maternal depression and helping women get the support they need. I listened attentively and understood the validity of the contributions they were making. Having worked with pregnant women and new mothers for many years, I have an inkling of the complexities of their lives, their perceptions of their own problems and their attitudes towards what we call treatment. My mind drifted for a moment as I thought of a patient I had seen the previous week. This is a snapshot of our encounter.

She sat in the chair across from me and was eager to talk. Juggling her body in her seat she shifted her weight from her right hip and then to her left and her foot shook rapidly back and forth. She was exhibiting a fair amoung of psycho-motor agitation and her speech pattern flowed just as fast as she thrust her words in rapid fire. She was particularly eager to tell me the unhappy experience she had around the birth of her first child. She shared her story about the labor, delivery and postpartum experience she suffered through. I knew it was important for her to tell me this story and listened intently. I was concerned, though, about the results of the depression screening test she took before entering my office. She scored very high.

I let her tell me about her birth story in detail. It was essential that I allow her to share any information which was important to her before I started the formal intake process. It was my sense that it would be vital for her to feel as if she were in control of our interview. She spoke for a long time but when she was done and believed I really heard and cared about what she had to say I resumed the intake and began the interview process following a prescribed sequential order of questions.

She was a bit hyper and anxious. As I observed and listened to her responses I keep thinking about the results of the depression screen. I decide not to confront her with the screening results until after I complete the mental health section of the intake form. At that juncture she answers yes to having a history of depression, to having panic attacks, to experiencing postpartum depression after the birth of her first child, to having an eating disorder, to a history of cutting herself as an adolescent and to a past suicide attempt. I ask if she was ever treated for any of these things. She reports she was hospitalized as a teen and received medication but that she was non-compliant with her treatment and medication regimen.

She tells me when she suffered from postpartum depression she was treated by her primary care doctor who prescribed an SSRI. She tells me that medication has been helpful in managing her depressive symptoms. Unfortunately, she stopped taking her medication when she found out she was pregnant. This is a common occurrence among women who are already on psychotropic medications when they discover they are pregnant. It is very common for pregnant women to take themselves off their medication without medical consultation.

In this instance she describes an exacerbation of symptoms since she discontinued her medication recently. Her anxiety and sadness have been increasing. She has again started to feel uncomfortable inside her own skin. I precede cautiously to the last part of the mental health assessment. At this point in the interview she is beginning to feel comfortable with me.

At last I query about a history of sexual abuse. With the history she has given me, in particular the cutting and psychiatric hospitalization as a child, I expect her answer to be yes. Instead her response is, "not that I recall." I take the chance of alienating her and gently push by saying "not that you recall or not that you want to tell me about." The look on her face changes when I ask this. I am unsure if it is surprise or relief. She admits to me the worst of all her possible secrets. She was repeatedly sexually abused as a child by her stepfather and this secret is something she doesn't tell anybody. Her speech pattern slows and her breathing becomes labored as she recounts the details of her past. Her story is complicated. It is an complicated as human beings and our interactions with one another. It is as complicated as the mysteries of life we don't understand. As she speaks her voice reflects a child who is unable to interpret what is happening to her little body. This is a most personal story and her unique human experience and I am respectful enough to know my role as witness to and receiver of the story which is at the core of her existence. I feel a sense of reverence for the quiet space in the room, for her courage and for her strength and ability to endure. I feel humbled by what she has chosen to share with me.

She stops talking and appears numb to the sound of her own words. There is silence in the room. I ask her if she would like to talk to one of our counselors and work through some of what she has told me. She does not. She describes all that she has disclosed as being inside a box. "Why open the box?" she asks me. "What would it accomplish?" This is more a statement than a query. She believes she knows how to live as long as her secrets remain inside a box. There is nothing i can do at this time to change her mind. She is deeply attached to her box of secrets.

People write songs about boxes. I think of the late Kurt Cobain. He makes the box a heart. That is a true sign of love … isn't it? The things we silo inside of our being are the things we do not integrate. We grow strange and powerful attachments to the things we set aside from the rest of our selves. Sometimes that deeply contained secret is the thing that prevents us from moving forward. It can be the thing that keeps us a victim of our own failed attempt to surgically remove a part of our memory. But our memory belongs to us and no one can control or take from us what is inside the box of our secrets.

What is the box in Cobain's song? I don't know. Is it cancer? Is it a psycho-analytic interpretation of the vagina as a diseased flower? Is it the womb and a desired place to crawl back into? I don't know. I am only a child of the question. I think of the song and its richness of imagery and symbolism and how it might relate to the young woman sitting across from me and her own tar pit trap. I am getting nowhere with her and decide to move on with the interview.

At the end of the interview I make one more attempt to get her into counseling. She assures me that she will follow up with her primary care doctor about continuing her antidepressant medication but that she will not consider going into counseling. She asks me a pointed question, "Why dig up a grave?" I ask if her partner knows about her past. She tells me he knows that her stepfather was physically and emotionally abusive but not about the sexual abuse. She says he is kind and does not press to learn the details of that relationship. They havea pact. She tells me he said, "As long as you don't ask me about Iraq, I will not ask you about your stepfather." They know each other as kindred souls. They are tied together in their shared history of trauma.

Amy Gagliardi has worked with low income women and their babies at afederally-qualified health center for many years. She is also a writer, researcher, COO of Lily's Kids Inc.,and is involved in policy which will improve the lives of the families she serves. She lives in Connecticut with herhusband and four children. The story "Heart Shaped Box" is an excerpt from a book Amy is writing about women's lives and and perinatal health.