PREFACE

The Art of Holding

My clients have gotten so much younger.

Not so long ago we were all the same age. We were comrades in parallel worlds, raising our babies together, in a manner of speaking, navigating the ebbs and flows of new motherhood. I would observe through a therapeutic lens, and later reflect on the relevance to my own naïve mothering experience. In the blink of an eye, my children turned into adults while my clients all seemed to stay the same age. One after the other, pregnant and postpartum women greeted me with tender tales of pain and loss. As years passed, young women continued to share stories of private anguish as I quietly aged in the background.

Today, clients tell me they worry that I will retire soon and abandon them. Or, not return from a vacation. Or, get sick and frail, or die. My clients never fail to remind me how old I am getting, how long I have been doing this work and the pièce de résistance – how much older I am than their own mothers. I take it all in stride, because, well, I am a resilient, thick-skinned professional.

Most of the time.

I am, at the very least, my best grown-up self when I sit with my clients.

Truth be told, I have been doing this a long time. I am reaching the age where my peers and colleagues are retiring. Often a client mentions that her mother-in-law is way too old to help with the baby, though she is younger than I am. Or, she says her boss doesn’t understand her because he’s old so doesn’t have any perspective. Turns out he is a decade younger than I.

The honored cliché is true, with age comes wisdom, and for many reasons, I feel more at ease with my work at this point in time than ever. I can sit with a postpartum woman in distress and know, for certain, that she will leave my office feeling better than she did when she came in. There is nothing mysterious about that. It comes with study, practice, the passage of time, and countless missteps.

The art of holding a postpartum woman in distress comes naturally to me. I suspect the same can be said by many therapists who specialize in the treatment of perinatal distress. As treatment for postpartum women has progressed, what originally felt like an instinctive and obvious response, holding has developed into something more substantial. Those who practice holding techniques understand this intervention as a fundamental therapeutic gesture, perhaps, a prerequisite for optimal healing. The act of holding a client in distress does not merely represent our intuitive supportive response, as it might with a friend who is suffering. We know what it means to hold a friend who is hurting, both figuratively and literally. When we hold a postpartum woman, however, it is an intervention with a purpose and expected outcome.

Over the course of many years, our team at The Postpartum Stress Center has witnessed tired postpartum women meander from one inadequate therapy experience to another, only to reinforce their feelings of helplessness and perhaps their greatest fear – that they will feel like this forever. The development of the holding points was a natural and necessary product of this widespread pursuit of a reasonable and reliable response to the frantic cry for help. The holding approach tells the postpartum woman that we are listening. We are taking her seriously. We are skilled, determined, and able to help her find relief.

That has always been my number one professional priority and my greatest passion. Now, there is more.

As my clinical practice, interests, and ambitions evolve in predictable ways, I find my focus shifting. While The Postpartum Stress Center continues to provide services and support for treatment and professional training, I find my personal attention turning toward the succeeding generation of therapists. Passing on what I have learned simply feels like the next best thing to do. It feels indispensable and essential. Particularly in light of the recent surge of public awareness and positive momentum in field of maternal mental health. Healthcare practitioners, mental health advocates and consumers are desperately looking for excellent clinical resources.

The outpouring of awareness points to the harsh reality that topnotch resources are scarce.

We must buckle down and make premium training a top priority. The community of perinatal therapists is a growing body of dedicated, exemplary clinicians. I have been honored to teach hundreds who present as a collective force of enthusiastic, warm, intelligent therapists with common goals and tons of heart. Training therapists who wish to focus their clinical practice in line with my decades of experience and commitment is infinitely gratifying and humbling. Offering guidance and inspiration to psychotherapists who seek clinical enrichment is nothing short of the peak of my career.

The transformation which has taken place is a parallel holding process, which will make more sense as you continue to read this book. While writing, it occurred to me that I am in the midst of a major professional pivot. As the development of holding practices and my desire to introduce this concept to other therapists gathered force, I realized that the tone of the book reflects my effort to hold you, the reader, the clinician determined to provide postpartum clients with the best possible options for relief and recovery.

We hold all the time. At work, at home, with loved ones, with people we meet for the first time. If you are a caring and sympathetic person, you probably hold someone or something, much of the time and may wonder how holding a postpartum woman in distress is decidedly different. You may wonder what gives it more therapeutic value than simply being kind and attentive. You will learn that holding in the context of postpartum women is a supportive psychotherapy technique which, based on anecdotal and subjective observation, has shown to augment the therapeutic connection. This connection, subsequently, becomes the entry point to treatment options and recovery. You will learn that while your good instincts are paramount and instrumental to this process, your skills and aptitude for specific techniques bring credibility to your response. Caring about her is not enough. Assessing her symptoms and identifying her pain is not enough. Knowing what to say, why you are saying it, how to say it, and when not to say something, can make the difference between her coming back and getting help or her leaving and surrendering to her suffering.

Holding is the gateway to healing.

This book is divided into three parts, a) The theory behind the holding approach, b) The practice of holding and c) On becoming a postpartum specialist. Each section presumes preliminary knowledge of postpartum mood and anxiety disorders as a prerequisite for holding.

Some of the concepts introduced in Therapy and the Postpartum Woman (Kleiman, 2009) have been reworked and expanded in this book. Readers who are familiar with that book will note recognizable topics which may appear, at first glance, to be redundant. This book was originally conceptualized as a complementary resource, offering in-depth inspection of constructs introduced in Therapy and the Postpartum Woman. While you may initially feel your level of expertise surpasses the review material in the early chapters, I urge you to dig in so you can grasp a fuller explanation of the subject matter.

Terminology within the postpartum community is a constant source of debate and confusion. Among experts and the general public, maternal mental health terms are forever interchanged and overlapped with varying degrees of clarity. Those that are germane to this book will be defined in Chapter 1. The decision to use the phrase postpartum women did not come without ample consideration. My initial preference was to use a term more inclusive to the entirety of maternally-related experiences. After all, women who are pregnant, or hope to get pregnancy, or experience a pregnancy or infant loss, or adoption, infertility, and termination issues, also seek our help. The term perinatal was considered first, because it is more all-encompassing. Ironically, it also felt too limiting. I realized that opening the discussion to the wide-range of perinatal experiences distracted from the objective to underscore the needs that are unique to postpartum women, when a baby is involved. This is not to say the needs of pregnant women or women who desire to get pregnant, or women who have lost a pregnancy are any less significant. It’s just that they are different, thus, rerouting the content ever so slightly.  It was decided that postpartum was most in sync with the message of this book, although its entirety is applicable to any perinatal woman.

Additionally, the word depression, like postpartum, doesn’t come close to saying it all. The term postpartum depression, as an umbrella term which covers the spectrum of disorders, is understood to include anxiety disorders such as excessive worry, PTSD, OCD, and panic. We must also be careful not to exclude postpartum bipolar illness and postpartum psychosis, as they are serious concerns that are very much a part of larger perinatal picture.

All holding principles in this book can and should be applied to any woman at any stage of any prenatal, postpartum or reproductively-related experience. Regardless of which diagnosis, symptom set, or psychological influences, if a woman in pain finds herself in a therapist’s office, she should expect and deserves to be held in the precise manner described throughout these pages. For brevity, terms in this book were pared down to the use of postpartum depression and anxiety, sometimes, postpartum depression, and sometimes, postpartum. Please do your best to generalize these references as applicable to the range of diagnoses or classifications. Thank you for understanding that these references should not be construed as exclusive to other perinatal experiences.

Postpartum depression is increasingly being recognized as a serious and treatable condition. There is every reason to be optimistic about the recent government recommendations and pending legislation. The tide is definitely turning.

Therapists wishing to specialize in the treatment of perinatal mood and anxiety disorders have never been in a better position to do so. Access to information along with the recent surge of public awareness makes this the perfect time for dedicated professionals to zero in on this passion. Holding is an intervention that bridges the passion you have for this work with treatment options that have been shown to reduce suffering and augment recovery.

Perhaps if we were to embody the words of poet Mia Hollow below, our message and meaning of holding would prevail. My hope is that you learn to use your goodness and your strength as you guide each postpartum woman through the shadows that obscure her path.

 

Bring me your suffering.

The rattle roar of broken bones.

Bring me the riot in your heart.

Angry, wild and raw.

Bring it all.

I am not afraid of the dark.                       

~Mia hollow, poet