Cheryl Tatano Beck, DNSc, CNM, FAAN, and Board of Trustees Distinguished Professor, University of Connecticut School of Nursing has published the majority of qualitative research regarding postpartum depression, PTSD following childbirth offering unparalleled data regarding the lived experience of these phenomena (Beck, 1993; 1995; 1996a; 1996b; 1996c; 1998; 2001; 2002; 2004a; 2004b). She continues today to pioneer the application of qualitative methodology to this crucial issue (Beck, 2011). The foundation of Beck’s work in phenomenological inquiry demonstrates the efficacy and power of qualitative research in the following ways.
Phenomenological Themes
Beck (1993) published a landmark phenomenological inquiry “Teetering on the edge: A substantive theory of postpartum depression” from which she theorized a four-stage process for the consequences of PPD: (1) encountering terror, (2) dying of the self, (3) struggling to survive, and (4) regaining control.
Encountering Terror.
According to Beck (1993), women were initially “hit suddenly and unexpectedly by the postpartum depression” (p. 44); and when it did happen, they were blindsided. One of Beck’s (1993) participants described:
I was on cloud nine through my whole pregnancy…then it hit me when my baby was 14 days old. One night I had my first severe panic attack. I felt like everything was closing in on me. Something just snapped in me and there was no going back. (p. 44)
The conditions of the experience of terror manifested in (a) panic attacks as one participant recounted: “It came out of the blue. I just felt numb all over and I started to hyperventilate. I felt this pain in my chest so I started to think, Oh my God, I’m having a heart attack. I’m dying!” (Beck, 1993, p. 45); (b) obsessive thinking: “My thoughts were extremely obsessive. They would never stop. I thought, Oh my God, am I going crazy? What if I have to be admitted to the hospital? and so on. It was just nonstop” (Beck, 1993, p. 45); and (c) enveloping fogginess described by one participant as: “Oh, I tried to do something—go out for a run, visit a friend, or take the baby to the mall—but it didn’t work. The fogginess would set in” (Beck, 1993, p. 45).
Dying of the Self.
Due to the conditions of the encountering terror stage, the dying of mothers’ normal selves in the second stage occurred (Beck, 1993). As a result of the sense of pronounced sense of incongruity between past definition of self, and present reality of life as a new mother, mothers feared others perceptions that they were bad mothers and withdrew into increased sense of isolation, loneliness and desperation. Within the dying-of-the-self stage, there occurred an “alarming unrealness” where mothers experienced the normal self as gone: “It’s very scary.You feel as though you are not the same person” (p. 45), and resorted to extreme isolation from family, social support, and even the baby, “I couldn’t be around him” (p. 45).Ultimately, the stage resulted in contemplating, if not attempting self-destruction “I just wanted to get out of this world. It was like everything was black” (Beck, 1993, p. 46).
Struggling to Survive.
Beck (1993) theorized the conditions created for stage three where women engaged in three strategies to cope: (a) battling the system, (b) praying for relief, and (c) seeking solace in support groups. Once women had decided to reach out for help, Beck (1993) related that their experience of navigating the health care system as a “torturous” (p.46) process of primary provider patronizing, minimizing their symptoms, frequent referral to other physicians, lack of knowledgeable providers, limited treatment options, and financial hardship. Interestingly, Beck (1993) found that along with battling the system, women frequently used prayer to strategize surviving PPD. One participant offered, “I used to go to church and pray for hours. My God, how much ore can I endure?”, and another, “The Lord was what really got me through a lot. It was just a lot of prayer and crying to the Lord that helped me get through it” (p. 46). In addition to prayer, women struggled to survive by seeking solace in postpartum depression support groups (Beck, 1993).
Regaining Control.
As a consequence of struggling to survive Beck (1993) theorized the final stage, regaining control, as a “slow process consisting of three consequences: unpredictable transitioning, mourning lost time, and guarded recovering” (p. 47). Recovery was not overnight, and the nature of recovery, unpredictable. As the recovery was experienced, Beck (1993) found that mothers experienced mourning for the time with their babies that they perceived as lost due to PPD. Finally, the experience of recovery was experienced with high levels of concern that PPD would return, as a participant offered:
Postpartum depression makes you very, very vulnerable. You still feel like you’re on a fine line between sanity and insanity because when it first happened it came out of nowhere. You’re normal and then the next thing you know you’re crazy. (Beck, 1993, p. 47)
Conclusion
Clearly the Beck (1993) exploration of the thematic content sheds invaluable qualitative light on the understanding of the complexities of the phenomenon of postpartum depression. Qualitative research methods provide essential evidence of maternal experience. In coming weeks, I am honored to bring an exclusive interview with Cheryl Beck to Lamaze and Science and Sensibility.
References
Beck, A., & Alford, B. (2009). Depression: Causes and treatment (2nd ed.). Philadelphia, PA: University of Pennsylvania Press.Beck, C., & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones and Bartlett.
Beck, C. T. (1992). The lived experience of postpartum depression: A phenomenological study. Nursing Research 41, 166-170.
Beck, C. T. (1993). Teetering on the edge: A substantive theory of postpartum depression. Nursing Research 42, 42-48.
Beck, C. T. (1995). The effects of postpartum depression on maternal-infant interaction: A meta-analysis. Nursing Research 44, 298-304.
Beck, C. T. (1996a). A meta-analysis of predictors of postpartum depression. Nursing Research 45, 297-303.
Beck, C. T. (1996b). A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing Research 45, 225-230.
Beck, C. T. (1996c). Postpartum depressed mothers’ experiences interacting with their children. Nursing Research,45, 98-104.
Beck, C. T. (1998). The effects of postpartum depression on child development: A meta-analysis. Archives of Psychiatric Nursing, 45, 12-20.
Beck, C. T. (1999). Maternal depression and child behaviour problems: a meta-analysis. Journal of Advanced Nursing, 29(3), 623-629.
Beck, C. T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50, 275-285.
Beck, C. T. (2002). Postpartum depression: A meta synthesis. Qualitative Health Research, 12, 453-472.
Beck, C. T. (2003). Recognizing and screening for postpartum depression in mothers of NICU infants. Advances in Neonatal Care, 31, 37-46.
Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.
Beck, C. T. (2004b). Posttraumatic stress disorder due to childbirth: The aftermath. Nursing Research, 53, 216-224.
Beck, C. T. (2011). Meta-ethnography of traumatic childbirth and its aftermath: Amplifying causal looping. Qualitative Health Research, 21(3), 301-311.
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I am a mother of 2 and have had two c-sections. The first in 2002 was an emergency section due to a placental abruption. Everything was fine after this then I had another c-section in 2007. I had a drain fitted after for a few days then after release from hospital I got an infection in my scar so had to go back in. After the section I was told there was a lot of scar tissue and if I had another section it would have to be done at 37 weeks to avoid any complications. After this there was a small hole left in the scar which bled with every cycle. After 10 months of this I finally had an operation in which they said they had found quite a lot of endometriotic tissue which they removed. Everything was fine for a couple of years then started to get pain in my scar. I went to the doctor and she referred me to a gynaecologist. I had a tissue scan which showed where the blood was apparently leaking from and where it was pooling. I was told that I could have surgery but advised against it because it would most probably come back, so at the moment I am running my Microgynon packs through and having a period every 3 months so I don’t get the pain as often and was told to take some Ibuprofen to ease the pain. Also, when I do get my period I only bleed for about a day and then nothing, but have the pain for about a week. I’m not sure if I should just carry on like this or try having keyhole surgery as I read this is the best way to get rid of the tissue. I haven’t had this done before because my scar was cut open in the last surgery.
Its great to read other stories and know that I’m not the only one suffering since a c-section! Any advice would be great thank you.
I am not a doctor or midwife, so I cannot give you specific advice, but I can tell you that the authors of all the medical journal articles I have read on cesarean scar endometriosis (also called “endometrioma”) agree that the only curative treatment is wide excision of the endometriotic tissue. Whether that can be done as a “keyhole” surgery is a question for your ob/gyn.
I always speak about baby blues and PPD in my prenatal classes where we discuss the need for good supports. Thanks for the websites…this is tremendous. We are hoping to start a PPD support group here and this will be a great resource.
In my discussions, we always discuss supports and attachment. We talk about birth as a continuum, not an event. And I am trauma informed, so my work reflects that–which I think cannot be over estimated!
There is PLENTY of room for improvement in my curriculum since I hardly acknowlege the possibility of postpartum depression prenatally except when discussing placenta encapsulation (which I do not personally offer). Talking about placentophagy with couples these past few years has been a way to discuss the hormonal changes and energy needs of new mothers and to reflect with them about the needs of some mamas for additional “nourishment” (emotionally, physically and spiritually) in the postpartum period. I think this has been my indirect way to approaching the subject and I’ll look forward to reading contributions from those of you who do this more directly! One aspect I do treat with more diligence (and may contribute overall to less problems for mamas)is what I call “who does what”. We review with detail who walks the dog, services the car, makes the appointments, takes out the trash, picks up the drycleaning, shops for food/housewares/gifts, and all the other gotta do’s of life NOW and then we anticipate that with the new baby there is going to be a redistribution of getting them done! A nice practical conversation begun during class with me then becomes their homework. Obviously this isn’t a panacea for the myriad reasons a women may feel overwhelmed or sad but it definitely reflects my reality as a mother whose husband traveled over half the time. I suppose we teach what we have lived no?
Also, like most experienced educators I have my “go to” list of local professionals if a family asks for help. I suppose my strength lies in “being there” for families in the days and weeks after the birth via visits, phone calls and emails. Mothers-to-be whose births I will be attending, come to my home in the final two months of pregnancy to form community with the other women who have already birthed. These mother baby gatherings occur every month and there is always time before and after the multi hour visit for a mama to approach me privately with a concern.If someone doesn’t attend then I call to find out why! I may not have the training of a psychologist but she has the confidence of knowing a very loving, experienced and interested person is listening. Finally, I can’t help but wonder if having experienced safe and respectful birth hasn’t gone a loooonng way in reducing the incidence of PPD in the women I have worked with over the years. Certainly I have never in 800 births had anyone who suffered post traumatic stress syndrome! That alone has to have reduced the number of PPD. Even as I write this short contribution I am reminded of the woman with whom I have nearly daily contact (since late November) whose baby died at 2 months. I was the doula for her first baby but was not available to accompany her for the recent birth. When her daughter died though, she wrote me immediately and called. Perhaps “mental health” wasn’t listed on the curriculum guide but the discussions, anectodal stories, and underlying belief system…you are important, you’re baby needs you whole, you may need additional support to meet this new lifestyle….contribute to forming a safety net what mother’s will seek when they need it. Certainly a baby’s death put her at risk of becoming seriously depressed and despondent and so far she is coping in healthy ways.
Joni,
I really value your input, with your lengthy experience attending births, as a mother, and a birth professional working in a different setting (Mexico) than many readers of this blog site. The personal contact you describe both before and after a woman’s birth is HUGE in supporting her emotionally–and creates a bridge that is easier to walk across if/when she needs extra support.
Your discussion in class of the “who does what” is an excellent suggestion, and likely one that many first time expectant couples don’t recognize the need for. It is hard to explain to expectant parents all the ways life will change following baby’s arrival–implementing these types of conversations is so fruitful and hopefully just a starting point for couples to springboard off of.
Thank you for sharing!
@Snorkel
Um… no, it is NOT “clutching at straws” … it is factual to identify flaws in any study and consider them for what they are. Henci simply states that there IS the possibility of perinatal deaths due to congenital anomalies, which were NOT excluded in any setting.
Furthermore, we actually can not conclude (from the home birth transfer data) that poor perinatal outcomes after a home birth transport are a direct result of PLANNING a birth at home or beginning labor there. Risking women OUT of labor & birth and home is the entire point! We move to a higher level of care to safeguard the mother and baby. That doesn’t remove the risk as it then exists for that mother and her baby.
A midwife, for example, might identify fetal stress/distress during the course of labor and transport the mother appropriately, risking her out from further laboring/birth at home. That stress/distress event is not necessarily the CAUSAL factor in the actual outcome however. As we all know… some depressed babies will still do well, needing only close monitoring but require few other interventions and result in a healthy birth and baby; while others, despite closer monitoring and necessary interventions will continue to spiral precariously downward, requiring cesarean delivery to potentially safeguard their health (although C-sec does not guarantee a live, healthy baby is ANY circumstance)…
My point is… just because a home birth TRANSPORT OUTCOME ends in a perinatal morbidity or mortality does not MEAN that the DECISION to plan a home birth and begin labor at home is CAUSAL in the OUTCOME. If that were the case, then we could suggest we transport healthy, low risk, planned hospital birthing women to a birth center or home to birth and still use the same rationale “the decision and plan to birth in hospital” as CAUSAL in those hypothetical outcomes.
I believe that it is a serious FLAW in the study to base the OUTCOME of transports on the PLAN and ONSET of labor LOCATION as CAUSAL. You really can’t prove that.
Hello Henci, could you clarify the grammar in one of the sentences of this article? It is: “Confidence intervals overlapped, which means that differences were not statistically significant, i.e. unlikely to be due to chance.”
Does that mean differences WERE or WERE NOT “unlikely to be due to chance”? I was confused and this seemed important. Thanks!
Here’s a few more on this website http://mana.org/conf.html:
MANA Region 5: Feb 17-19 in Phoenix, AZ
MANA 2012: Sept 27-30 in Asilomar, CA
Int’l Breech Conference: Nov 9-11 in Wash DC
Thanks for the summary of Beck’s study and profound description of this alarming experience for women and families.
Dear Madam
I am a father form India. my wife underwent c section yesterday. i want mext birth vaginally naturaly. what precautions should my wife take for the same. how can we strngthen the uterus scar. also what information should i take from my doc right now hich shall be useful for future VBAC. thanking u in anticipation
Thank you, Annie. Your comment truly speaks to the value of qualitative research to give a woman’s experience voice in research. This is what Cheryl Beck has masterfully offered to the quantitative data on all perinatal mood and anxiety disorders.
Take care, Walker
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Thanks for sharing this research, Walker. I’m looking forward to reading the interview. It is encouraging to see qualitative studies on PPD. It’s kind of like counting the grains of sand that buried us, but it’s heartening, just the same. There’s solace (not just strength) in numbers.
Yes. Women know those grains of sand buried within. And we have knowing of the essence of the experience of them in others–this is where qualitative research feels like a gasp of air, an urgent inhale of reality while we all swim around in this ocean of quantitative science telling us about us! Measuring, counting, tabulating experiences… Empirical, quantitative science is the host for the majority of conversations about women’s bodies, and I often feel we assimilate just to survive, be heard, or earn a living.
I am so happy that women like Cheryl Beck have reached across the numbers and included, pragmatically, the voices of women in the research about the women.
Sorry about the double negative. “Statistically significant” means that a probability calculation shows that the difference between groups was unlikely to be due to chance. The difference in mortality rates was *not* statistically significant, which means it may have been due to chance. The thing with calculations of statistical significance, though, is that they never rule in or rule out chance absolutely. They just quantify how likely or unlikely it is that chance caused the difference.
wow, awesome blog article.Thanks Again. Will read on…
Hi Walker – Lovely review of Cheryl Beck’s qualitative research (I love qualitative research!). And looking way forward to your interveiw with Ms. Beck! thanks for keeping us posted!
Thank you, Walker, for this fine synopsis of Cheryl Beck’s first groundbreaking study of Postpartum Depression. Women’s words are extremely powerful in conveying the true meaning of their lived experiences. It’s interesting that when one woman’s words reach others who are going through something similar, they can be comforted to realize they are not alone and to begin healing by reaching out to others. And care providers who read their words with an open heart and mind will bring wisdom and empathy into their practices.
Here’s to the Queen of Qualitative Research, Cheryl Beck!
Thanks for your interviews Walker, introducing Cheryl to LI community is so appreciated. I hope I get to meet her in person someday! Looking forward to #3.
Hi Annie,
I was so struck by her insight that prevalence rates for PTSD could be as high as 18%. And the universal presentation and incidence globally while not shocking, is a good reminder of how desperately we need to prevent, screen, and treat PTSD following childbirth.
Walker and Cheryl, thank you for this fascinating and informative interview series.
With regard to PTSD: why are we not regarding transvaginal ultrasound as an aggravator? Word on the street is that women hate this; the device is like – excuse me – a dildo on a gun. Yet nobody’s taking feedback from patients. They’re told, ‘It’s best for your baby’ (despite lack of evidence. We should be adapting the technology to the patients, not forcing the patients to accept the technology. This is a form of institutional rape & has got to go. http://vaginal-ultrasound.com/
Such a great piece,Darlene.
History is an invaluable component to deeper understanding. The treatments of Silas Weir Mitchell dominated mental health as well. Confinement became the core theme in Foucault’s post positivist work on madness. Clearly there are so many links…thanks for a great article.
Thank you for this interview and clarification of the screening roles. I was quite concerned about the blurring of roles in this matter. I use EMDR for release of birth trauma, it is an evidence based psychotherapeutic method for PSTD and other trauma used by the Department of Defense for veterans and also endorsed by the Israeli and Irish governments.
Great article with many links and implications. Yes, why are women confined? A rhetorical question on my part and one with many levels.
Great feedback from all. Thank you. While I can’t speak for Cheryl, from my own experience, I agree completely with you Dr. Hikel regarding the intrusive nature of the transvag US. Particularly for women with hx of CSA–the mixed messages are so confusing and the emotional outcome deleterious.
Kathy, thank you for your input. I am hoping to bring an article/interview with Phyllis Klaus regarding her work with EMDR and birth trauma as well. Thank you for sharing your use as well. And I hear your concern regarding the blurring of roles and screening. I really appreciate Cheryl’s clarity, and hope we all engage in ongoing conversations about screening and prevention.
Tomorrow Cheryl shares about doing research (my favorite part) and it is so interesting. Hope you enjoy it.
we really do not have much to offer in terms of treatment for preterm labor, preeclampsia, vaginal bleeding, etc and so providers can feel that at least they are doing something, right!?
In researching this topic, it was amazing to see that there really is little to no scientific backing for bed rest. Pretty darn amazing given that 3/4 of a million are prescribed a baseless prescription annually! But like Judith has said, it may be that providers need to feel like they are doing something. But the NEED to feel like you are doing something and actually DOING something (i.e. effecting change and creating a positive outcome) are two very different things. Although the road is slow, there is research being done and hopefully more evidence based treatments for high risk pregnancy complications will be implemented in the near future.
This is a very interesting topic and I think the discussion will only increase as more women choose to delay parenting to concentrate on careers. As women rightfully gain more equal rights in the workplace, although this is a slow process, childbirth will be delayed. It’s positive to see that studies are being undertaken, so we can analyse the risks involved and avoid heartbreaking situations like miscarriage. However, we should take into account the circumstances of each study and analyse the merits of their findings. Some researchers may have predetermined ideas that they wish to portray through their data and that is something we should be wary of.
FYI: recent article. Women with preterm premature rupture of the membranes do not benefit from weekly progesterone
http://www.sciencedirect.com/science/article/pii/S0002937810010252
“data included in the study suggests a higher neonatal death rate (for both home and hospital births) compared to perinatal death rates. This, of course, is not possible as neonatal deaths ought to be included in the perinatal death numbers—therefore the data here are paradoxical in nature.”
Isn’t the definition of “neonatal death” a death occurring in the first month whereas “perinatal death” is death in the first week? If so, the neonatal numbers would be higher than or equal to the perinatal numbers and this isn’t paradoxical at all.
Another excellent prenatal yoga teacher program is Karen Prior’s Mamaste Yoga!
@Carla Harless Yes, she does have a good program. It was one of the ones I looked into when I was looking to take my prenatal teacher training.
Useful to know. Thanks for posting.
Not really interested in Yoga…but exercise is nice.
[...] Part 1 we talked about how to help your client choose a prenatal yoga class; in Part 2, we will look at [...]
I have taken yoga classes and weight training classes when pregnant, and I really think that the weight training helped me more than the yoga. Maybe it’s just because I’m not as into yoga. I think that learning to relax while lifting weights and working all of those muscles really helped me have a fast and relaxed first birth experience. I’m sure the yoga didn’t hurt, though!
Thank you for talking about Yoga and Lamaze together. They are so complementary. I have only been practicing faithfully for a year myself but have had almost a complete relief from two years of joint pain so I am personally convinced about the benefits of Yoga. These articles gave me some resources and some ideas for incorporating yoga principles with Lamaze principles. I hope as my childbirth business expands I am able to offer my clients prenatal yoga as well. I will guide some of my wonderful yoga instructors to your recommendations for prenatal certification.
Yoga classes should include asana (physical postures) that are weight bearing. Warrior (standing lunges) are weight bearing, Downward Dog, bears weight on your hands, etc. So, a good prenatal yoga class should include all – physical, breathing and meditation/relaxation.
Strength training is very helpful as well, pregnant or not.
Ah, I didn’t recommend the programs above. I apologize if my intentions were unclear. I gave them as examples of the variety of duration and quality of programs that are out there. An online at home program is, in my opinion, totally inappropriate and vastly insufficient. There’s no hands on training, with a hands on practice.
A 12 hour weekend program vs. an 85 hr Yoga Alliance program? What’s missing in the 12 hour program? Hours aren’t the only factor, though. Look at the course content too.
To your other points, yes, Yoga and Lamaze are very complimentary. I’m most of the way through a philosphical discourse on the subject on my own blog http://www.shininglightprenatal.com/2011/07/04/integrating-yoga-and-lamaze-how-the-ethical-practice-of-the-yamas-and-niyamas-relate-to-pregnancy-and-childbirth-%E2%80%93-a-bit-of-background/
I kept up my regular yoga practice throughout my last pregnancy and I know it made a difference for me. I strongly recommend yoga practice to my clients and I recommend a few yoga-based breathing exercises to do at home, too.
There is so evidence to support the use of mindbody therapies! If mindbody therapies were a drug, we would be inundated with TV ads about them! Thanks for sharing this info abt yoga and perinatal health.
Of course, the HuffPo quoted me out of context. I am the LAST person on earth that believes breastfeeding breasts = OK whereas sexual breasts = not OK.
I think ALL breasts are delightful! Please know this. I would ALSO love for us to get to a place of acceptance in society where breastfeeding could be looked at, just like sex, as something that simply feels good. ♥
Did you mean “A hefty dose” in the Editor’s Note?
Thank you for finding the typo.
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Hey Star, I’m a childbirth educator, and we talk about sex in my classes. Well, mostly I talk about this, with some laughter from the moms and birth partners.
Not so much about sex and breastfeeding but generally about how the sex will come back, then I pull out a little bottle of astroglide and share how this might help when the parents are ready later!
With breastfeeding I try to listen for any concerns they might have and address them. We only do about 45 minutes in my classes, though, probably much better for the mom are conversations one on one with a counselor.
Obviously partners are in my classes, and I share that it’s their support that will really make a difference to the mom — keeping the mom fed, drinks a lot of water, and trying to make sure the mom sleeps as often as possible in the first few days and weeks. (Sleep when the baby sleeps, right? Mom staying in pajamas throughout the day so people don’t feel comfy overstaying their welcome.)
And it’s interesting, perhaps like breastfeeding, childbirth ed classes really look at birth from a physiological and/or medical process (depending on the parent’s approach), not from a sexual process. We focus on the reproduction part of it, not the sexual/intimate so much. Of course, the moms and partners are paying for the class to help them through the reproduction part of it; the sexual part they already have down pat! But letting people know about future sex things is also important in classes, as it is with breastfeeding help.
Neat topic for Valentine’s Day — thanks!
There is an interesting future discussion in here about how we women define ourselves pre and post delivery. Motherhood should not come at the exclusion of who and what we were before. Because so many people/sources depict the two as exclusively different many rebel against the traditional depiction of motherhood. A healthy motherhood does not come at the expense of our own health, our relationships/marriage, it is a balancing act where our whole self is the anchor on which the other pieces are placed. Women can be both “hot” and dowdy when they are mothers, most of it comes from their interior sense of self and their integration of their many selves. How they carry themselves not whether they have a baby on the hip or breast or not.
Sarah ~ You are absolutely right. Taking a holistic view of the self both before we become mothers and after is one of the keys to making it work for ourselves. If we only define ourselves by our job, or by “Owen’s mother”, then we neglect our core being. Our true self lies within and she is all, and one, and none at the same time.
I give my yoga students the mantra “I am” and I tell them to add no qualifiers to that. “I am” is the whole and it is enough. When we define ourselves, we limit ourselves.
Sat Nam (Truth is my identity)