Why Screening of Postpartum Moms is Important and Who Can and Should Do the Screening

Today’s post was inspired by a March 19, 2018 NPR article by April Dembosky titled “Lawmakers Weigh Pros and Cons of Mandatory Screening for Postpartum Depression,” as well as a June 2018 Romper article by Karen Fratti titled “Moms Should be Screened for Postpartum Depression in the ER, New Study Suggests, & It Makes Perfect Sense,” a June 30, 2018 News Medical article titled “Screening mothers for PPD in emergency setting,” and a June 29, 2018 Austin360 article by Nicole Villalpando titled “Who should be screening moms for postpartum depression? More doctors now can.

Screening moms for postpartum depression (PPD) serves multiple purposes.  Screening will help ensure moms get the help they need and avoid suffering unnecessarily.  In case you weren’t aware, screening educates women on what PPD is, why it happens and just how common it is (1 in 7 new moms experience it), and helps them avoid what I and so many other mothers have gone through (PPD makes you feel alone, like you’re losing your mind and will never return to your previous self).  It will ensure fewer moms will ultimately fall through the cracks.  It will ensure fewer tragedies involving mothers and their babies.  And I’ve said this many times before, but a mother who is not well cannot care for her baby the way a healthy mother can.  This is pure logic.  Unfortunately, logic takes a back seat because our capitalist society places more priority on what benefits the pocket over what benefits the people’s well-being.

So…..question is WHO should screen new moms for PPD?

Her OB/GYN?  This should be a given, period, hands down, no questions asked!  In May 2018 the American College of Obstetricians and Gynecologists recommended that, in addition to the standard 6-week postpartum visit, OB/GYNs perform a follow-up visit within the first three weeks postpartum.  This new recommendation is due to the fact that symptoms of PPD often begin before the 6-week appointment.   See second half of my blog post on the issues many OB/GYNs are faced with in terms of screening.

Her baby’s pediatrician (but here the patient is the baby, not the mother)?  The American Academy of Pediatrics (click here and here) recommends doctors screen mothers for PPD when they bring their newborns in for wellness visits, since they occur numerous times in the baby’s first year; whereas, the mother only gets the one wellness check at postpartum week six.  Pediatricians who realize that the baby’s development can be negatively impacted when the mother is ill with PPD will try to screen the mom for PPD.  Problem is, most pediatricians as far as I’m aware are not prepared to screen and refer mothers since the mother is not a patient.

An ER physician?  While you will no doubt raise your eyebrows, doctors like Dr. Lenore Jarvis, an emergency medicine specialist with the Children’s National Emergency Department at United Medical Center in Washington, DC, have been seeing moms bring their babies to the ER, and it turns out the baby is fine but it’s the mother who is highly anxious and feeling overwhelmed.  In these cases, it’s logical to try to determine if it’s the mother who needs help.  In fact, Dr. Jarvis and several colleagues conducted a research study with several colleagues on screening moms for PPD in an ER setting.  A Eureka Alert release dated June 29, 2018 explains the results of the research study. Moms who participated were screened using the Edinburgh Postnatal Depression Scale supplemented by other questions.  The great thing about the research study is that, when moms scored positive for PPD, they received information about PPD and were offered–or if they had a strong positive score from screening, they were required to have–a consultation with a social worker.  Additionally, the researchers followed up with mothers who screened positive one month later to see how they were doing.  This is akin to case management programs we have in place when patients check out of hospitals (I explain all this in my post below). Now THIS is the way it SHOULD be!

Dr. Jarvis refers to the ER as a “safety net  for people who are not routinely accessing regular checkups for themselves and their children. If a mother is having an acute crisis in the middle of the night and feeling anxious and depressed, they often come to the emergency department for help.”  Because American policymakers have been so resistant to instituting policies that would require insurance companies to work with doctors to ensure PPD is caught early through screening and subsequent referrals–researchers/subject matter experts on PPD are left to make recommendations for what Dr. Jarvis referred to as a “safety net” approach of having emergency rooms screen for PPD when moms come in either for their babies (for colic, fevers, etc.) or even for themselves (symptoms of a postpartum mood disorder).

While I agree we need to cover all bases and try to screen a new mother wherever and whenever possible, why do we even need to resort to waiting until a mom comes into the ER to screen them?  Why do we have to have such a safety-net, fall-back, beats-nothing-at-all, better-late-than-never approach in the first place?  Answer:  our society continues to place too much priority on conception and childbirth but once the baby is born, everyone forgets the mother.  Once the baby is born, the mother’s health falls by the wayside.  I’ve blogged about this before, but the attention from that point on will be on the baby from visitors who coo at the baby and treat the mother as invisible.  Same thing with doctor visits; the mother only gets one postpartum wellness check at 6 weeks.  That’s it.  It’s like the mother ceases to exist.  Whereas, other cultures have customs to honor and mother the mother (click here and here for past posts).  The birth of the baby is synonymous in these cultures with the birth of the new mother and they are honored for bringing new life into the world.  This, my friends, is why maternal mental health advocacy is so important.  Until American policymakers institute policies to demonstrate the importance of mothers and their health, we advocates must continue to act as “squeaky wheels to get the grease.”

The following section is an excerpt from my book.

New mothers, especially the ones at high risk for PPD, should be screened during their six-week postpartum visit, provided she doesn’t complain about symptoms up to that point. If she is symptomatic before the six-week visit, she should be screened right then. If the six-week screen doesn’t indicate PPD, she should be assessed once more at the twelve-week point—or when she weans or when her period returns, whichever comes first, since these events can trigger PPD in some women.

The following—in addition to screening tools like the Edinburgh Postnatal Depression Scale or Cheryl Beck’s Postpartum Depression Screening Scale—should be asked at the six-week follow-up visit with the OB/GYN, which can help diagnose PPD:

  1. Have you been feeling any of the following for the past two weeks?
  • Persistent and mostly inexplicable sadness/tearfulness and feeling empty inside
  • Loss of interest/pleasure in hobbies/activities you once enjoyed; inability to laugh
  • Overall impaired functioning
  • Sleep difficulties (either insomnia or sleeping too much)
  • Weight loss (usually fairly quick) associated with a decrease in appetite
  • Weight gain associated with an increase in appetite
  • Excessive anxiety about the baby
  • Restlessness/irritability
  • Detachment from and inability to bond with the baby
  • Difficulty thinking, concentrating or making decisions
  • Feelings of guilt, inadequacy, failure and/or worthlessness
  • Urge to run away
  • Onset of panic attacks
  • Sense of despair and/or hopelessness leading to thoughts of death/suicide
  1. How have you been feeling physically and emotionally?
  2. Are you feeling particularly stressed, and, if so, is it due to a major change you are experiencing, such as marital problems, death of a loved one, financial problems, a recent move, or a job change?
  3. How do you feel about the baby? Are your feelings in line with your expectations of how you’d feel about the baby?
  4. Do you feel you have adequate emotional and practical support from your partner? Do you have any relatives or any other help, like a doula, to help you with the baby during the day?
  5. Are you breast-feeding and, if so, how is it going?
  6. How do you feel the labor and delivery went? Do you feel you experienced any sort of trauma during the delivery?
  7. Do you feel your childbirth and motherhood experience are meeting your expectations?
  8. Do you feel particularly anxious about your baby’s health (colic, SIDS)?
  9. How is your appetite?
  10. How are you sleeping? Have you been able to get at least four, if not five, hours of sleep a night?
  11. Have you had any recurring thoughts/images that are disturbing?
  12. How have you been adapting to motherhood, in general?
  13. Have you returned, or will you return, to work?

I believe these types of questions should be incorporated by all OB/GYNs throughout the country. This all theoretically sounds good and fine, but in most cases, OB/GYNs are not prepared to implement. Why not? At the very least, it would require training on perinatal mood disorders (recognition of symptoms and treatment), as well as ability to provide the right referrals as needed.

This last paragraph from my book excerpt remains true to this day.  Sad because I published my book in 2011.  Seven years later, things have not really changed.

California’s screening bill, AB 2193, has yet to pass the Senate and get signed into law.  Once passed, it would be an exciting development for mothers, as it doesn’t just require screening for PPD.  It requires health insurance companies to set up case management programs (same way my mother was assigned a case manager each time she had to stay overnight at a hospital to ensure she had a plan in place to address the issues that landed her in the hospital–i.e., physical therapy in a rehab center, visiting nurse to change her bandaging, etc.) to help connect moms who screen positive for PPD with a mental health practitioner.

Case management is set up to ensure there is a treatment/referral plan in place.  I sincerely hope that this means health insurance companies are prepared and able to carry out the new requirements.   And I sincerely hope that California will lead the way for other states to follow suit in setting up similar screening bills that will actually require health insurance companies to set up case management programs.

It goes without saying that screening moms for PPD serves no purpose if you can’t help those who test positive for PPD.  So far, as the first state that put mandatory screening in place, New Jersey has not had any reason to be excited ever since its initial groundbreaking “first-state-to-mandate-screening” announcement.  New Jersey, as well as 3 other states— Illinois, Massachusetts, and West Virginia — have tried mandated screening, and it did not result in more women getting treatment, according to a study published in Psychiatric Services in 2015.

A whopping 78% of those who screen positive don’t end up getting mental health treatment per a 2015 research review published in the journal Obstetrics & Gynecology.  Why have women in these states with mandatory screening not been getting treatment?  Well, for starters:

  1. Some obstetricians and pediatricians are afraid to screen for PPD because they are not equipped to refer.  But why is that?   Why is it hard for them to all rely on the resources available via Postpartum Support International?  Its website lists resources in every state.  And many states have already formed, or are in the process of forming, chapters to focus on state-specific efforts at advocacy, training, and other improvements.
  2. The resources to whom doctors (obstetricians, pediatricians, general practitioners, etc.) can refer mothers are limited, especially in more rural areas.  And in more rural areas, it’s harder to find mental health practitioners trained in prescribing meds to pregnant/breastfeeding women, let alone trained in treating moms with PPD.
  3. All too many mental health practitioners don’t take the woman’s insurance or there are significant limitations from an insurance coverage perspective.
  4. There’s a very long wait (several months) to see most mental health practitioners, especially for the first time….a woman in the throes of PPD can’t afford to–both literally (from a cost perspective) and figuratively (from a life & death perspective).
  5. There’s little incentive financially, thanks to insurance companies’ lack of adequate coverage for doctors who do such screening…..in my opinion, screening should be done at the standard 6-week postpartum checkup and therefore covered as part of that checkup.

Attention, American policymakers….our mothers are worth it.  I mean, we make such a big stink about fetuses and unborn babies in this country, let’s start thinking bigger picture, shall we?  Without mothers, there would be no babies to conceive and bring into this world.  Let’s start treating mothers less like second-class citizens and more like human beings who deserve to be able to give birth to and care for their babies without getting sick with PPD and possibly dying in the process!

 

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A Must for All New Jersey Medical/Mental Maternal Healthcare Practitioners, Doulas, Midwives, etc.

After a two-month dry spell in posting on my blog due to lots going on at home and at work, here I am briefly to help spread the word for the Postpartum Support International 2-day training on November 15-16, 2018 in Fort Lee, New Jersey:  Perinatal Mood Disorders: Components of Care. 

Led by PSI’s very own Birdie Gunyon Meyer, RN, MA (whom I’ve known since I became a member in 2006), Lisa Tremayne, RN, CPPD, CBC, and Joanna Cole, PHD, it is a critical training intended not just for mental health care practitioners but anyone and everyone who would ever need to care for an expectant or new mother.  That includes obstetricians/gynecologists, general practitioners, pediatricians, doulas, midwives, nurses, ER doctors and their staff, etc.

You can visit the site that goes over the training objectives, location, and cost via the above link, but the training will cover the basics in identifying/treating perinatal mood and anxiety disorders (PMADs)–which include antepartum depression, postpartum depression, postpartum anxiety, postpartum panic disorder, postpartum OCD, postpartum PTSD, and postpartum psychosis–as well as understanding risk factors, treatment options, breastfeeding, consequences of untreated conditions, impact on loved ones, importance of social support, cultural differences, spirituality, etc.

Please attend and/or help spread the word about this training.  It is so, so critical that we ensure as many people as possible are trained so that fewer mothers suffer unnecessarily (like I did) and even worse, fall through the cracks and become another tragic outcome of a perinatal mood disorder.

 

World Maternal Mental Health Day: May 2, 2018

With just a few minutes left to World Maternal Mental Health Day, I wanted to do check one more thing off my TO DO list: Taking a picture with The Blue Dot Project sign with a very important message on it to do my part in spreading awareness about the statistics (1 in 7 new moms), common symptoms, who to call for support/where to find resources & info (Postpartum Support International or PSI), a positive message (the PSI mantra: You’re not alone, this is not your fault, you will get better with the right treatment), and the hashtag #RocktheBlueDot.

 

 

 

 

 

 

 

Earlier in the week, I did the whole Twibbon thing with the #WorldMMHDay on social media, I have been sharing the daily Facebook posts of The Blue Dot Project on both my personal and my author page, and I figured I would wrap up today with this blog post.

With May as Maternal Mental Health Month, keep your eyes open for all sorts of social media campaigns, fundraisers, news articles, and blog posts.  The wealth of information is satisfying to see, as it is 100 times–to say the very least–more than what I had when I found myself stuck all alone and scared on the very difficult postpartum depression (PPD) path I found myself forced to take over 13 years ago!   We need to keep the public awareness going to continue to chip away at the stigma and ignorance that still prevent moms suffering from PPD (and their loved ones) from knowing what to look out for, knowing how to get help, having all medical/mental healthcare professionals that work with moms knowing how to detect/diagnose/refer moms who need help.

Please, please, please do your part to spread awareness.

Click here to find out how you can take your very own #RocktheBlueDot picture with your own message, and share it with the ladies over at The Blue Dot Project so they can share it on their end as well.

Share Postpartum Support International, The Blue Dot Project, and posts by other maternal mental health organizations across the globe.

Join the movement!

 

Recent PPD Successes and Failures in the Media

I went from blogging once in two months to 8 times so far this month!  With Maternal Mental Health Month a little less than a week away, a lot of fundraising, training and public awareness events are being prepped to happen throughout May.  Another reason to love this time of year….hello spring!

Okay, so the title of my post is “Recent PPD Successes and Failures in the Media.”  There were 2 things in the media that caught my attention on my Facebook feed today that motivated me to blog once again. One is a success and one is a failure.  If you’ve been following my blog for some time, you would know that one of my favorite things to blog about are successful and failed attempts at depicting new mothers suffering from a mood disorder in the media, like my recent post about “Black-ish.”

Let’s start with the SUCCESS……
On this morning’s Megyn Kelly TODAY a postpartum mood and anxiety disorder (PMAD) survivor, Ashley Abeles, shared her experience.  The segment also included brief appearances by Dr. Catherine Birndorf and Paige Bellembaum who are the Medical Director and Program Director, respectively, of The Motherhood Center of New York. The Motherhood Center provides support services for new/expectant moms and treatment for PMADs. I met these ladies from the Motherhood Center at previous Postpartum Support International conferences.  If you missed the show, you can watch it here.  We need more moms sharing their PMAD experiences on shows like this!  Experiences kind of like my own that, as her husband explains, isn’t “headline-grabbing” material involving the tragic death of the mother and/or baby.  Because guess what, the vast majority of PMADs experienced by new mothers are NOT headline-grabbing material.  They’re mothers suffering from anxiety, panic attacks, insomnia, weight loss and/or intrusive/obsessive thoughts who need medication and/or therapy to recover.  Yes, severe postpartum depression (PPD) can cause a mother to feel so depressed that she just wants to disappear or her baby would be better off without her since she can’t feel joyous like a new mother should, but postpartum psychosis is too-often confused with and lumped under PPD (as a catch-all term) by both the general public and doctors alike.  Yes, doctors!  Also, PPD is not the same as the baby blues and even today, doctors still mix up the two!  We’ve come a long way since I had PPD when it comes to information in the news, in publications, on the Internet and in social media.  But we still have a LONG way to go.

And here’s the FAILURE……
The movie “Tully” starring Charlize Theron.  A Motherly post by Diana Spalding titled “We’ve seen Tully– and we’ve got some real concerns” it seems yet another movie director/producer has failed to do their homework about PPD before coming up with the screenplay and releasing it.  What every movie director/producer or TV show director/producer needs to do before even contemplating a movie or TV show about PPD is consult with Postpartum Support International.  This organization is the leading authority on maternal mental health matters and should ALWAYS be consulted to ensure the right information is incorporated into the movie/show plot.  “Tully” attributes the bizarre experiences of Tully (i.e., hallucinations she has of Marlo, frantic baking and cleaning late into the night, impulsive behavior that leads to her car crash, suicidal ideation) to PPD.  However, her behavior is actually attributable to postpartum psychosis, hence this movie spreads misinformation about what PPD really is.  Her talk of suicide is brushed off by her husband, which I can see happening in the real world when loved ones fail to “get it” and ignore the mother’s serious need for help.  While this is a movie and movies don’t necessarily have to educate–after all, this is not a documentary–it should at least get terms right (postpartum psychosis, NOT PPD!)  and it should try to mention at some point that yes, the new mother who’s obviously not well and diagnosed, albeit incorrectly, with PPD needs help!  Maybe put some kind of disclaimer at the beginning or end of the movie like you sometimes see at the beginning or end of a TV show.  Something along the lines of:

“Approximately one out of seven new mothers suffers from a postpartum mood disorder.  If you are a new mother that is experiencing any of the following symptoms: insomnia, crying/sadness for more than 2 weeks, lack of appetite, sudden weight loss, rage, hopelessness, lack of interest in the baby, loss of interest in things you used to enjoy, thoughts of harming the baby or yourself, please know that you are not alone, what you are experiencing is not your fault, and you will recover if you get the right treatment.  Contact Postpartum Support International at 800-944-4773 or visit http://www.postpartum.net

Free Webinar: Bringing Light to Postpartum Depression and PMAD

ATTENTION:
OB/GYNs and their staff, general/family practitioners, therapists, social workers – basically, everyone who would ever treat a new mother. Also, new/expectant mothers and their loved ones!

Once again, I’m piggybacking off of my last 2 posts about the Postpartum Resource Center of New York by sharing this great opportunity I learned from this post I just spotted on my Facebook feed for all who care for / about new mothers and their postpartum well being to learn about PMADs, treatments, resources, and how loved ones can help.

PMADs are experienced by 1 in 5 mothers.  What better way to spread awareness than this FREE webinar!  We need more of these opportunities to combat stigma and ensure as many people are educated as possible, as there are still way too many people whose job it is to care for mothers that don’t accurately identify PMADs and get them the help they need.  With more awareness, we will chip away at stigma.  We will ensure fewer mothers suffer alone and in silence.  We will ensure fewer mothers and children suffer the consequences of undiagnosed/untreated PMADs.

When:  Wednesday, May 2, 2018 from 8:00pm – 9:00 pm
Who:  Sonia Murdock (Exec. Director of the Postpartum Resource Center of New York) and Bridget Croteau (St. Joseph’s College NY alumna; Mrs. Suffolk County America 2017-18)
Cost:  It’s absolutely free, and open to the public!
Registration:  Click here to sign up. If you can’t make it to the live session, no problem!  You can access a recording, provided you register.
For more info:  Contact Taryn Kutujian at tkutujian@sjcny.edu

Please spread the word about this!  Share WIDELY on social media!

 

Traumatic Childbirth: The Ever-Widening Ripple Effect

Piggybacking off of my last blog post “Mother May I?” – An Important Documentary About Childbirth Trauma 2 days ago, I wanted to make folks aware about a childbirth-trauma-related event that I spotted on my Facebook feed today.

LMR Visioning Educational Series 2017

Sonia Murdoch, Jane Honikman, and me

The Lisa Mary Reilly Visioning Educational Series hosts an annual event in collaboration with the Postpartum Resource Center of New York.  Last year, I attended the event that took place in Manhattan and featured Jane Honikman, founder of Postpartum Support International.

This year’s event will be co-hosted by The Rochester Postpartum Wellness Coalition and will take place on Thursday, May 3, 2018, from 11:00 am-2:00 pm, at the Rochester Academy of Medicine, Rochester, NY.  The guest speaker of this event will be Cheryl Tatano Beck, DNSc, CNM, FAAN. She a Distinguished Professor at the University of Connecticut School of Nursing.  Dr. Beck serves on the editorial boards of 4 journals and has published over 150 scientific articles as well as 4 books.  The title of her presentation is Traumatic Childbirth: The Ever Widening Ripple Effect.   Click here to find out more about the event and to buy tickets, which are $50 each and includes lunch.

My wish is for every medical professional that treats mothers–from OB/GYN doctors and their staff to maternity ward staff, emergency room staff, midwives, doulas, and family doctors/general practitioners, as well as mental healthcare practitioners–were required to take this kind of training regardless of where they are located. This means this kind of training should be replicated and hosted in every major city in every state.  Until then, we are going to continue to have medical/mental healthcare professionals fail to realize the connection between traumatic childbirth and postpartum mood disorders.

We need to emphasize the importance of care for mothers just as much as people emphasize the importance of care for babies.  As I’ve said before, it just seems so obvious that, once a mother gives birth to a baby, all the attention goes to the baby and its care and the mother falls by the wayside.  Hello, she just carried a child for 9 months and had to give birth! Her body goes through extreme physical changes, including hormonal upheaval.   Any complications that occur during childbirth can increase the chance of a postpartum mood disorder to occur.  The ONLY view that matters on how a childbirth went should be is the new mother’s view on her childbirth experience.  If she feels like it was a God-awful experience, we need to respect, acknowledge and try to understand her feelings.  We should never pooh pooh her experience.  We should never assume her feelings are what you think they ought to be.  A new mother’s experience is her experience, period.

Let’s care more about how a mother views her childbirth experiences.
Let’s care about the kind of care she receives during childbirth.
Let’s care about how she envisions her childbirth to go.
Let’s care about how she feels about breastfeeding.
Let’s care about how anxious she feels about taking care of the baby.
Let’s care about her enough that when she seems to not be herself, we get her the help she needs.
Let’s care enough to realize that about 20% of new mothers experience a postpartum mood disorder that usually starts within the first 4-6 weeks postpartum but can happen up to a year and may be triggered by weaning.
Let’s care about her feelings, bottom line.

 

 

 

Playing Monopoly with God – New York City Performances!

I am super excited to share the news that “Playing Monopoly With God” is coming to New York City! (Unfortunately, I won’t be able to make it due to prior commitments).

“Playing Monopoly With God” is an amazing, one-woman play.  Melissa Bangs is the talented and passionate actress behind this play.

Her mission is to share her experience and in so doing, spread awareness on what it’s like to be one of the 20% of new mothers who suffer from postpartum mood disorders and encourage mothers to share their experiences.

Melissa has been touring for 4 years putting on 37 shows—including sold-out shows in Seattle and Los Angeles– reaching nearly 5000 people

♦♦♦♦♦♦♦♦♦♦♦♦♦

Postpartum Support International presents:

Playing Monopoly with God & Other True Stories
Hilarious. Heart-wrenching. Human. 
A true tale of childbirth, madness and the journey home.
LIVE. NONFICTION. STORYTELLING. PERFORMANCE.
 
TICKETS ON SALE NOW!!! MAY 17th – 20th

Evening
 Performances – 6PM Doors – 7PM Performance
THE RATTLESTICK THEATRE @ 224 Waverly Place, New York, New York
Thursday, May 17th – Live Performance followed by a PSI Gala Event at Bobo NYC ($175)
Friday, May 18th – Live Performance w Wine, Cheese and Panel Discussion ($75)
Saturday, May 19th – Live Performance (also to be webcast) ($45 in-person)
and a Mimosa Matinee…
Sunday, May 20th – 1PM Doors/2PM Show ($45)
 
In September 2012, at 40 years old, Melissa Bangs gave birth to her beautiful daughter Adelaide.  A month later, dramatically hormone depleted and sleep deprived, Melissa is admitted to the Providence Psychiatric Facilities in a complete manic state.  After nearly a month, she is sent home with a bipolar diagnosis and on lithium.  What comes next is an extraordinary journey.
 
On her path back to wholeness, one of the things Bangs did was read her entire 100 plus page hospital record.  Somewhere, around page 87, there is a nurse’s note that looks as if it were scribbled late at night after a long shift.  It reads, “Patient says she will do comedy on this experience.”  Upon reading this, Bangs laughed out loud.  
 
The psych team couldn’t have possibly known that Bangs has been a storyteller her entire life and did comedy for a stint, as a student, at the Upright Citizens’ Brigade in New York City.  They couldn’t have known that transforming details from the most painful experience of her life into a room full of laughter would prove healing for so many.
 

Join Postpartum Support International for an evening of storytelling full of bewilderment, chaos and hilarity.  Bangs has a knack for telling true stories that cut to the bone of our shared, vulnerable human condition. Her true gift, however, comes in the moments in which she’s able to strip away the shame or agony of an experience and transform the room into an uproar of laughter.