Blog: Postpartum Matters

Tokens of Affection: Are You Ready?

Most of us married folk think we are right, much of the time, and we believe we know what is best for us and our marriage. This is especially true for women, who generally take the plunge when it comes to initiating marital repair tactics. However, what is true all of the time, without fail, is that each and every interaction between two people is just that, an interaction between two people. While it might feel like one event (we went to the park) and may be perceived by both as the sharing of one experience (we had a wonderful time), it is actually the convergence of two people and two experiences. Neither of which, is more right than the other. Still, we each think we are right.

I learned this early in my marriage. Back when my husband and I were just discovering the fine points of how to arbitrate terms of a young marriage, something caused me to storm out the front door with a harrumph and a half. Off I went, with self-righteous fury, and plunked myself on the street curb.  Like a four-year-old tantruming in protest while simultaneously checking back to make sure Mommy is there, I repeatedly glanced behind me, expecting to see my husband, dutifully chasing after me. Surely, he knows how upset I am, I know he will come get me and apologize or at least make sure I’m okay! But the trail from the house to the curb was silent with only the exasperated sigh of my unmet needs. I can’t believe I have to sit here and feel bad by myself. This is not okay. I sat and sulked a bit more, all the while peering back at the doorway in disbelief. He was not coming out to look for me. Unbelievable. Who had I married? Was he really this selfish? Was he heartless? Did he not care? Did he not even know?

Grudgingly, I sucked back the tears, took a deep breath and went back to the house. There, I found my husband sitting on the couch watching TV, as if nothing had happened. “Hi Babe,” he quipped, “Where were you?”

Really? Wow. Is this A.D.D.? Is this Men-Are-from-Mars stuff? Is he kidding?

“I was outside. Crying. By myself. Waiting for you.”

“You were? Why were you crying? Why were you waiting for me?” He looked at me as if he had no idea what I was talking about – his eyes and mouth wide open like a toddler being punished for doing something he didn’t know was wrong.  Almost immediately it was obvious that he, really, honestly, and most assuredly, had no idea what I was talking about.

“Did you know I was upset?” I asked incredulously.

“Yes.” He replied proudly, positive that he had the right answer for me.


“Well if you knew I was upset, why didn’t you come out after me? I mean, helllloooooo?? I went out, upset. WHY DIDN”T YOU COME AFTER ME??!!”

“Because… I… I thought you went out because… you wanted to be alone?”

Now, it was my turn to look at him as if I had no idea what he was saying.

“Why would you think I wanted to be alone?”

“Because you went outside, and I was inside?”

 Omg, I thought, do I have to teach him, coach him, tell him every single thing I need? I would find out later that yes, of course I would.

“Okay, so let’s be clear about this,” I began slowly, “When I’m upset, and you know I’m upset, and I bail out, leaving a dust trail behind me, I”

“Okay.” He responded gently. Probably thinking something like, that doesn’t make sense to me at all, but I’ll buy it.

“So,” he calculated, “when you crash out the front door in disgust and say something like, I can’t stand this, and you slam the door behind you, that means you want me to come after you, is that what you’re saying?”

“Yeah, something like that.”

“Well, for the record,” he continued, “I thought that meant you wanted to be alone. Because when I’m upset and I walk out to be alone, I actually want to be alone. I assumed that what you wanted, too.”


“Okay, so when you’re upset,” I tried to make sense out of this, “You do NOT want me to follow you and talk to you about how you are feeling?”

Um. Right.

“Really? I thought the best thing for me to do, if you are upset, is to help you express it so we can talk about it together.”

“Nope. The best thing for you to do is let me be alone. At least for a while. Then we can talk about it later.”


I concluded, “So when I walk out by myself, I want you to come be with me. But since you want to be alone, you presume (mistakenly) that that is what I want. Therefore, by leaving me alone, you think you were doing what I want, but I feel abandoned and unloved. On the other hand, if you walk out and want to be alone, I presume (mistakenly) that you need to me to come help you express yourself (major misperception) so by following you, chasing you, stalking you, I am making things worse, instead of better?

Oh, yeah. Definitely.

This is an example of the good sense that two people can actually make, when they are not quite making sense to each other.  Couples often take two divergent paths to reach a common goal.  This is true for couples in conflict and couples in harmony. Thus, while the common goal may be marital satisfaction, each partner may maneuver the pathway with opposing tactics and without understanding of what is happening, feelings can get hurt and resentments can mount. The revelation that opened my eyes that day was as simple as this:

I will feel better if I better understand what he needs.

Overshadowed by our tender marriage of cluelessness, prior to that instant of divine enlightenment, we had strolled along with naïve confidence. Until that moment, I wasn’t ready to think in terms of how he was thinking. I really believed much of that would just take care of itself when two people love each other. Isn’t that how it works in the movies? Truthfully, as an insanely sensitive person who is empathetic by nature, it didn’t always dawn on me that I would have to do more than that sometimes! I just presumed my husband would have the same instincts I did. Rule number one that I learned early on: Never presume.

That’s the moment I realized I was ready. Ready to dig in and figure out what I needed to know to help him help me and by doing so, enable me to be a better partner to him. When we think about that seemingly simple statement, I will feel better if I better understand what he needs, we elucidate the underlying motivation for the use of Tokens and the paradox it presents.

Do you feel ready to give?

You will know when you are ready to use the Tokens because it won’t feel like work. It will just feel like the right thing to do.



Excerpted from “Tokens of Affection” by Karen Kleiman

image credit: Kuznetsov


Worldwide Attention to Perinatal Mental Healthcare.

The following post is directly from the WPA position statement as presented in pdf format on their website.



WPA calls for greater global focus on improving quality of mental health care for women in the perinatal phase

Geneva, 8th March 2017.

To coincide with International Women’s Day, the World Psychiatric Association (WPA) has issued a statement which calls for an improved worldwide focus on perinatal mental healthcare. In today’s statement, the WPA outlines 12 recommendations for healthcare professionals and policy makers around perinatal mental healthcare which are designed to improve pregnancy outcomes, reduce maternal and infant morbidity and mortality, improve care of the infant and enhance the mother infant relationship.

Mental disorders are among the most common health problems of pregnancy and the year after birth (the perinatal period), with more than 10% of women in high income settings experiencing a disorder, and more than 25% in many low and middle income countries (LMICs).1,2

The perinatal period is a time when there is an increased risk of psychiatric episodes.3 Mental health disorders can impact on pregnancy outcomes (e.g. low birthweight, prematurity); mother-baby interactions which are associated with an increased risk of child behavioural, cognitive and emotional problems internationally; impaired growth in children from LMICs; infant mortality; and maternal mortality resulting from suicide, substance misuse, domestic violence homicides and comorbid physical health problems (including HIV).3,4,5

The ‘WPA Perinatal mental health position statement’ was developed by 12 experts from 8 countries and calls for:

1. mental health data to include information on whether women are pregnant, have recently experienced any obstetric issues or have recently given birth.

2. all care providers in contact with women in the perinatal period to be trained to be equipped with knowledge and skills to identify and treat, or refer for treatment, women with perinatal mental disorders.

3. integration of psychosocial assessments and core packages of mental health services into routine antenatal and postnatal care and establishing of effective referral mechanisms.

4. all health professionals and other care providers to look beyond depression and focus on other symptoms of anxiety, PTSD, somatic symptoms

5. all care providers to provide, or refer appropriately for, pre-pregnancy consultation including contraceptive services for childbearing aged women with a past, current or new mental illness.

6. maternity and primary care services to provide universal accurate and accessible information about emotional and physical health, to de-stigmatise mental illnesses, in addition to providing a range of specific information related to the perinatal period.

7. all health professionals caring for women with, or at risk of, perinatal mental illnesses to develop an integrated care plan in collaboration with women, their partners and their families.

8. policy makers to develop evidence-based policy for prevention, early intervention and treatment for women in the perinatal period

9. policy makers to work with National associations to ensure that there are relevant and affordable medication options available on the essential drug list suitable for women of reproductive age in LMICs.

10. research funders to provide support for research on the effectiveness and cost-effectiveness of pharmacological and psychosocial interventions.

11. all relevant stakeholders to address stigma related to mental illness and to recognize the ‘embedding opportunities’ in the maternal mental health field

12. the development, evaluation and implementation of interventions for health promotion and enhancement of maternal well-being

Dinesh Bhugra, President of the World Psychiatric Association said: “It is important that the prevalence of mental disorders in women in the perinatal phase be recognised. There is an opportunity to integrate mental health into maternity and child programmes within local cultural contexts. Healthcare providers, policy makers, national associations and research funders alike must come together to acknowledge the need to improve the care and support provided to mothers and infants and implement interventions to diminish mental health stigmatization.”

The full position statement can be read at %20FINAL.pdf.

For further information or to arrange an interview with Dinesh Bhugra or another member of the WPA Executive Committee, please contact:


Direct: +44 20 7089 6104

Mobile: +44 7817 864 815

NOTES TO EDITORS: About the World Psychiatric Association (WPA)

The WPA is the world’s leading psychiatry organization. It is an association of national psychiatric societies, which aims to enhance the knowledge and skills necessary to work effectively in the field of mental health and in the care of people with mental illness. It has 139 member societies from 117 countries representing over 225,000 psychiatrists.

The WPA has more than 72 individual scientific sections that cover almost every aspect of psychiatry. The purpose of the sections is to collect, analyse and disseminate information on research, training and services in the specific areas of psychiatry and mental health that they represent.

The WPA works to achieve the objectives through meetings, research, education, publications and collaboration with other health/ mental health and government organizations.

Visit for further information.


1 Fisher J et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lowermiddle-income countries: a systematic review. Bull World Health Organ. 2012;90:139-149

2 Howard LM et al. Non-psychotic mental disorders in the perinatal period. Lancet. 2014;384:1775-788

3 Stein A et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384:1800-19

4 Weobong B et al. Association between probable postnatal depression and increased infant mortality and morbidity: findings from the DON population-based cohort study in rural Ghana. BMJ Open. 2015 Aug 27; 5(8):e006509. doi: 10.1136/bmjopen-2014-006509.

5 Langer A et al. Women and Health: the key for sustainable development. Lancet. 2015. doi: 10.1016/S01406736(15)60497-4.


For more information World Psychiatric Association

This is What You Should Do if You Think You Might Have Postpartum Depression

You’ve recently had a baby.

You are more than 3 weeks postpartum.

You do not like the way you are feeling. You wonder if you are too anxious or too depressed.

Your family, friends and healthcare provider have tried to reassure you, but you wonder if they really understand how bad you feel.

You worry that this is what being a mother feels like and you might never feel better.

Here’s what you should do.

1. Ask for help. Any feelings of depression and anxiety that interfere with your abilty to function are not okay right now. Tell those closest to you that you are worried about the way you are feeling. If you know what they can do to help, ask them. If you are not sure, tell them you are not sure, but you need their help, regardless. Then, let them help you. No one is asking that you diagnose yourself. If you are not sure what is going on, you should err on the side of be cautious and healthy by letting someone you trust know how you feel.

2. Contact your doctor/healthcare provider. Be specific and clear about how you are feeling so you can discuss options. If you feel dismissed or misunderstood, make the effort to clarify and reiterate.

3. Do your best to locate a therapist who specializes in the treatment of postpartum depression and anxiety. You can find one here. Or, here. Or, here. Call one or two or three therapists and talk to them directly. See how that feels. Do not let feelings of guilt or anxiety get in the way of reaching out for the support that you need right now. Therapists who are trained to treat postpartum depression and anxiety understand how difficult this first phone contact can be. Take the risk and let someone help you. You do not have to go through this alone. If you cannot find specialist in your area, call one of the perinatal specialists listed and talk to them about finding someone closer to you. They will help you do this.

4. When you make your first appointment, ask your partner to accompany if that feels better for you. Most therapists will welcome that and it is highly probable that you can bring your baby to that session, also. Your family is an vital part of your healing process.

5. Stay off of the Internet until you get some relief from your symptoms. While there may be numerous outlets for support available online, you will inadvertently be exposing yourself to random and unpredictable anxiety-provoking, shame-inducing triggers. It is best for you to protect yourself from that for a while.

6. Accept the fact that you are not feeling good right now and that it will not always feel this way.

7. Avoid all triggers that make you feel worse. That includes people who are unsupportive, events or obligations that increase your anxiety. Self-compassion is essential. Pay attention to what you need and do your best to express this to your partner and helping professionals.

8. Do not stop until you find the right help. This means you should feel comfortable with the support you are getting. This means your healthcare provider, your therapist, your support group, your medication, your adjunctive recovery team, must all be appropriately responsive to your needs and it is important that you continue to communicate with those caring for you. If the level of caring you receive feels insufficient or inauthentic, you can decide to either let someone know how this feels, or find another/additional professional/treatment alternative.

9. You do not need to suffer. Not even a little bit. There are more and more healthcare professionals who understand that new mothers are at risk for serious depression and anxiety disorders. Help is out there. Do what you need to do to help yourself get the help you need and deserve.

You will feel like yourself again.




Pic Source: Lukonina 59952060

Therapy and the Postpartum Woman: A REVIEW

Cognitive Behavioral Therapy Book Reviews 1 2010, Vol. 6, No. 1
Copyright 2010 by the International Association for Cognitive Psychotherapy

Therapy and the Postpartum Woman: Notes on Healing Postpartum Depression for Clinicians and the Women Who Seek Their Help

While there are many books available for mothers and families on postpartum depression, this book is the first comprehensive work for the clinician. Postpartum depression is the most common issue facing new mothers. One out of every seven mothers will experience postpartum depression. Given this high prevalence rate, clinicians must become familiar with how to treat this potentially devastating illness.

In Part One, Kleiman describes the clinical picture of postpartum women citing many case examples as well as models of postpartum depression. She aptly describes why there is so much resistance to getting treatment in this population and how to help women overcome their resistance. She gives the reader concrete suggestions on how clinicians can respond to women struggling with postpartum depression drawing on the Winnicottian ideas of “the holding environment” and “the good mother”.

In Part Two, Kleiman devotes several chapters to intake, screening, assessment, collaboration, medication issues and alternative therapies. Initially, it was surprising that she spends so much time on the initial phone call. However, she makes a good case for the need to be thoughtful when initiating contact with postpartum women, given their tenuous emotional and physical state. She makes explicit the questions and responses that are effective in engaging this population in treatment. The many and very helpful assessment tools, symptom lists, and some other interventions mentioned in this part and the next are contained in the Appendix. Finally, the chapters on medication and alternative therapies for postpartum depression are thorough, highly informative, and condense a large body of research which will be useful to clinicians.

In Part Three, Kleiman tackles different aspects of postpartum depression ranging from obsessive thoughts, distorted beliefs, breastfeeding, sleep deprivation, marital issues, suicidality, mother-infant attachment and psychosis. She interweaves clinical observations with vignettes, research and theory to illustrate how these issues play out in the postpartum woman. She makes an excellent case for the importance of careful screening for suicidality and psychosis by urging clinicians to ask the difficult questions, and by specifically spelling out what these questions are and how to ask them.

Part Four addresses other theoretical and conceptual aspects of treatment for postpartum depression. Kleiman muses over the roles of meaning, recovery, resilience and parent-child attachment in the treatment of postpartum depression, showing her more psychodynamically oriented side. While providing case examples, this section is the least filled with research citations and practical tools. However, it is undoubtedly interesting from an intellectual standpoint and in terms of case conceptualization with this population.

Therapy and The Postpartum Woman provides tremendous breadth and depth of information, resources, theory, and interventions for treating this population. The book’s strengths are its infusion with research findings, its practical and explicit suggestions for how to treat postpartum women, and the interweaving of interventions from cognitive-behavioral therapy, Interpersonal Therapy and psychodynamic therapy. As a cognitive-behavioral therapist who works with women with postpartum issues, I find her illustration of the types of distorted thoughts and beliefs of depressed mothers to be extensive and her focus on workable solutions right in line with my own experience with this population. The book is not, however, a treatment manual or a comprehensive guide, and would not be appropriate for use by a novice clinician. Kleiman assumes that the reader already has knowledge of how to conduct therapy for depression and anxiety and, therefore, does not provide basic information on treatment of these conditions. It is up to the clinician to use her book as an adjunct to her own particular treatment protocol rather than as a guide. Given the high incidence of depression and anxiety in postpartum women, and the potentially lethal consequences of these illnesses, this book is a must-read for any clinician working with mothers and mothers-to-be.

Antonia M. Pieracci, Ph.D.
Senior Instructor University of Colorado Depression Center

The Art of Holding: FOREWORD by Joy Burkhard



Perinatal mental illness is a significant complication of pregnancy and the postpartum period. Depression and anxiety are common manifestations, with prevalence rates for major and minor depression up to almost 20% during pregnancy and the first 3 months postpartum. As research and public awareness gains momentum, more attention is being placed on medical protocols, interventions and better access to treatment.

For many years now, Karen Kleiman has changed the face of maternal mental health (MMH) for both clinicians and families.  As a speaker reaching many through outlets such as The Oprah Winfrey Show and as an author, through her many books for families and clinicians, Karen was a pioneer in this field providing the mainstream community with an understanding of this devastating illness, validating the women who suffered and helping clinicians gain insight into the experience postpartum depression.

Karen and I first spoke several years ago when I called her out of the blue to brainstorm solutions.  I, as an advocate in maternal metal health policy and systems change was combing the landscape to learn why women weren’t being screened, diagnosed and treated routinely by their physicians. I knew that Karen had developed one of the only training programs for clinicians in the U.S. at the time.

After speaking, Karen and I knew that more providers needed to be expertly trained so we could reach more women, augment recovery and improve outcomes. Since then my organization, 2020 Mom along with Postpartum Support International has launched web-based training to easily reach clinicians all over the U.S. and meet a growing demand to learn about this field. Though we have a long way to go, training is now available to more people than ever and Karen’s intensive postgraduate training program at The Postpartum Stress Center continues to produce expert clinicians and is recognized as a best-in-class training.

Recently the United States Preventive Services Task Force, the American College of Obstetrics and Gynecology, and the Council on Patient Safety in Women’s Health Care, joined in this mission and have highlighted the importance of screening and proper treatment of maternal depression. It is now more important than ever that we train providers.

Therapists in this highly specialized field have often turned to Karen’s books for guidance when working with the perinatal population. The Art of Holding in Therapy: An Essential Intervention for Postpartum Depression and Anxiety introduces a novel strategy for treating women with postpartum depression and anxiety. At a time when we are finally paying attention to this widespread crisis in maternal mental health, this book provides a hands-on resource for therapists who are dedicated to making a difference in the lives of women seeking their help.

Clinicians, we need you now more than ever; moms and families are counting on you. Karen Kleiman, thank you for your extraordinary contributions to the field – without your work we’d be several steps behind.


Joy Burkhard, MBA
Founder and Director;2020 Mom
Chair;The National Coalition for Maternal Mental Health


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


Empowerment in the Face of Despair

“I know what I’m ‘supposed to do’ to feel better. Everyone keeps telling me the same thing. I should exercise. I should sleep more. I should eat well.   I should take the medicine. I know, I know, I KNOW. But something inside my head keeps telling me to push through this. I can get better. I don’t want to take the medicine while I’m breastfeeding. I can’t possibly keep feeling this bad, so I’ll just wait. But then I start feeling desperate, like I’ll never feel better again….This isn’t working. Nothing I’m doing is helping. It doesn’t matter if I exercise or not, everything is dark and heavy around me. Inside and out. Nothing looks the same. I wish someone would just tell me what to do. Or do it for me. My head keeps spinning with all the reasons I shouldn’t take the medicine. I know I’m getting in my own way, like my therapist keeps telling me. I know that. But I can’t help it.”

Women with postpartum depression know only too well how the symptoms of depression interfere with help-seeking and solution-oriented behaviors. Therapists, doctors, partners, friends and family members can tell them over and over and over again, how they should be taking care of themselves, but many women find themselves swirling around the vortex of distorted thoughts and misperceptions. Anxiety driven ambivalence becomes a fierce enemy, what if…? Why can’t I just…? How do I…? Maybe I could just…

Postpartum depression and anxiety do not discriminate. Symptoms impede the functioning of devoted stay-at-home moms and Harvard-educated attorneys. Intrusive thoughts can puncture the most perfect plan. When this occurs, rational thought seems to evaporate. Any previous accomplishment or personal triumph takes a back seat to the all-consuming and interminable anxiety.  Soon, that is all that is felt.  Women describe this by proclaiming “this isn’t me” or “I just don’t feel like myself” or “I’m usually so easy-going, I don’t know who I am now.”

As thoughts and feelings alternate between despair and rapid-fire obsessiveness, women with PPD begin to lose focus, along with the ability to successfully advocate for themselves.

If your baby were sick right now, would you know what to do to get him help? The answer is usually yes.

If your husband needed to get to the emergency room right now, while you’re feeling this bad, would you know what to do? The answer is usually yes.

But women have difficulty fighting for themselves when they are entrenched in this battle of their lives. Their energy, motivation, inspiration and zest for life has been eclipsed by the cruel paralysis imposed upon them.  They also have difficulty responding appropriately to the loving guidance from those around them. They simply cannot see through the shame, the guilt, the incredible disbelief that they feel so ineffective in their own life. And so they sit, rocking back and forth between their opposing thoughts.


If symptoms are bad enough, if hopelessness sets in, functioning is severely impaired, and clarity has vanished – others must make some decisions for her. When it reaches the point when her wellbeing is at stake, we become less concerned about hurting her feelings or saying things to protect her. At this point of personal crisis, we no longer defer to her sadness or her longing to do this “her way.”  If doing it her way means postponing treatment or prolonging suffering, it is not okay.  This is when it becomes necessary to intervene on her behalf, tell her exactly what she needs to do next and how we will help her do that.

This commanding posture is not always a comfortable one for therapists who are working hard to empower their clients. But remember: Our objective is to lead her to symptom relief, before any other work can be done.  One of the ways we do this is by demonstrating a sense of expertise, confidence and composure. After all, it is our composure, our self-control, our trust in the process, that will convey our expectations of a positive outcome. And that, indeed, is empowering for her.

And so, we say:

1.      You will not always feel this way.

2.      You must take care of yourself and you need to follow through, whether you feel like it or not.

3.      If medication is part of your treatment plan, you need to take the medication – whether you are breastfeeding or not. Discuss any concerns you have with your doctor and then decide whether you will continue breastfeeding or whether you will wean. Either way, take your medicine if it has been prescribed for you.

4.      Do not let the noise in your head sway you from doing what you need to do. It may feel like you have no energy but you do. It may feel as if you have no power left, but you do. It may feel like no one knows how bad you feel, but some do.

5.      Pick a person you trust and listen to them. Do not question the veracity of their words. Let yourself believe that this person can help guide you through the darkness and then, stop fighting against them. 

6.      You need to keep moving forward through this, even if you don’t feel like it. Get up when you don’t feel like getting out of bed. Go outside even if the sunshine is too bright for your weary eyes. Eat even though you may not be hungry. Rest even when you are not tired. Try to turn off the chatter in your brain. Distract yourself. Count backwards from 300. Take a walk. Call a friend. Avoid caffeine. Avoid alcohol. Avoid people and things that make you feel bad. Come to therapy. Talk to your partner.

7.      Your depression is not your friend. It is an illness that confuses you and distorts your thinking. Do not forget this. Challenge the illness, not those who are there to help you.  Take your pills, no matter how you feel about having to take them. Remember that your fight is against the illness, not against yourself or those who support you.

8.      Believe that you will feel better again.


Originally appeared on  Posted Jul 11, 2012  Karen Kleiman, MSW, LCSW

image credit:

Announcing the Expansion of our Advanced Clinical Training Program!

for-professionals-mobileWe are excited to announce modifications to the PPSC training program for clincians who specialize in the treatment of perinatal mood and anxiety disorders.

Effective 2017, our premier 10hr training program will be 12 hours, adding two (2) hours of advanced clinical practice, focusing on Karen Kleiman’s Holding techniques. We have incorporated additional time for intensive clinical study by infusing role-play and break-out sessions for the clinical and practical application of assessment and therapeutic skill-building.

Special attention will be placed on the clinical challenges inherent in this work, based on the upcoming publication of The Art of Holding in Therapy: An Essential Intervention for the Treatment of Postpartum Depression and Anxiety (Jan, 2017).

Note: Clinicians who have already registered for the March 2017 class at the 2016 fee rate will have no changes made regarding the course fee.  New applicants will be subject to the increase in fees. We are aware that this training is costly and appreciate the sacrifices that participants make in order to attend this course. We are extremely confident that the small-group experience will enhance each participant’s clinical practice on both a personal and professional level.

Because classes are small, space is limited, and the demand for participation in this course is high, we recommend clinicians sign up as soon as possible to secure a spot. There are extensive waiting lists for this course with only limited opportunities for cancellations or last minute openings.

For questions, please email

For more information or to register click here.


Pregnancy Loss and Depression Kostareva Kostareva

It’s hard for most women to imagine anything worse than experiencing an unsuccessful pregnancy. But 15-20% of pregnancies end in miscarriage and the loss associated with this crisis can be devastating.

Pregnancy, even at its best, can be a time of uneasiness and worry. Research tells us that a woman is most at risk for emotional illness during and after pregnancy than at any other time in her life.

It follows, then, that when a woman experiences a miscarriage, the risk for depression is great. This risk is increased if: a) she has experienced a previous clinical depression b) there is depression in her family c) her support system is weakened or threatened by current circumstances d) external factors add additional stress.

Women who suffer through the loss of a pregnancy know better than anyone how well-meaning friends and family can unintentionally say all the wrong things: “It was meant to be.” “It was God’s will.” “It’s better that it happened early.” “You can always get pregnant again.” “Thank goodness you have your health.” And so on. Needless to say, this doesn’t help.

Unfortunately, women are often left to suffer alone, because although we expect there to be some stage of “normal grief”, most friends and family are eager for her rapid return to a previous level of functioning, perhaps dismissing the depth of her pain. This, in turn, can leave her feeling misunderstood and drive her further into isolation. Understandably, this set of circumstances can create the opportunity for depression to emerge.

A study from the Journal of the American Medical Association (JAMA, 1997) concluded that major depressive disorders are more common in women who suffer a miscarriage than in those who have not been pregnant. Furthermore, they suggest that women who suffer miscarriages should be monitored in the first weeks after reproductive loss, particularly those who are childless or who have history of major depressive disorder. Among miscarrying women with a history of prior major depression, half experience a recurrence. It is also interesting to note that this risk did not vary significantly by maternal age, by time of gestation, or attitude toward pregnancy.

Another study determined that during the first year after loss a) supportive counseling was effective in reducing overall emotional disturbance, anger, and depression; and b) time passing led to increased self-esteem and decreased anxiety, depression, anger, confusion, and personal significance of loss. The conclusion was that the caring attention from counselors as well as the passage of time had positive and significant effects on the integration of loss and improvement of self-esteem in the first year subsequent to miscarrying. This is important because many women feel they need to suffer in silence and may not feel it’s appropriate to ask for help or may resist reaching out.

So how do you know if what you are feeling is “normal” grief or depression?

Although no one can put forth rigid parameters, most would agree that there is an “expected” period of normal grief after any loss. This grief reaction would certainly include feelings of depression. If, however, the feelings of depression persist beyond several weeks and being to interfere with your ability to function at home and or at work (sleep disturbance, appetite changes, lingering irritability/anger, chronic hopelessness, persistent anxiety/panic), it would be time for some professional support.

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After a miscarriage, some professionals would call the emergence of depressive symptoms PPD (postpartum depression), loosely fitting in to the understanding that PPD is recognized as the presence of clinical depression following childbirth. Others would call it, Depression. It doesn’t really matter what we call it. What we need to understand is that the childbearing years are a time of increased risk for onset of depression in women.

After a pregnancy loss, depression is not only understandable, it is also treatable. Women who experience symptoms of depression that do not remit after a couple of weeks, should seek the help of a healthcare professional, either their doctor or a good therapist who specializes in the treatment of women and depression. Depending on the symptoms, depression responds well to psychotherapy and medication, if indicated. In addition to whatever professional or medical support they might need or want, some families find a great deal of support through social media, where they can connect with other families with similar losses. Some women may choose to plant a flower garden, or create a personal memorial or engage in some ritual or service to mark the passing of their child.

Pregnancy, miscarriage or pregnancy loss, infertility, and the postpartum period can tremendously challenge a woman’s mental health. We need to be alert to it, attentive to it, and responsive to it when whether we are healthcare practitioners treating these women or whether we are their family and friends who are embracing them during this difficult time.

A woman who has endured the unbearable loss of a pregnancy is suddenly cast into a world of unknowns. This isn’t what she expected. Everything has turned upside down. If a clinical depression descends upon her weary soul, her loss and her pain become deeper and darker. Family members, friends, and the medical community should be aware of this potential impact and respond appropriately.

Giving a woman permission to grieve sufficiently can ease the pain of her loss and promote healing.

Pay Attention to Your Marriage


Fathers are at risk for depression and anxiety after the birth of their baby.  If their wife has PPD, husbands are most at risk as she begins to recover. As noted in THIS ISN’T WHAT I EXPECTED:

“As you continue to recover and resume normal activities, an interest­ing phenomenon may occur. You may find that your husband begins to decompensate. As you get stronger, the equilibrium of the relationship often shifts, and your husband may relax his hold on whatever psycho­logical resources helped get him through this crisis. Though he, too, was overwhelmed, he may have suppressed these feelings. It’s as if when you needed oxygen, he held his breath, but now he needs extra air. As you get stronger, he may begin to let some of these feel­ings surface and may become disillusioned, exhausted, irritable, or depressed. When this occurs, women often respond with confusion and anger: ‘I’m finally feeling better, and now you fall apart?'”

Postpartum depression is hard on both of you. Pay attention to your marriage.

pic credit: photodune

♥ Coloring Book Giveaway! ♥

picThis Friday August 5 we are starting our coloring book GIVEAWAY!

Enter to win an autographed copy so you can begin to color your moods and find some relief from your symptoms! Honestly, studies show that the behavior you engage in when you color in adult coloring books (repetitive motions, attention to detail, distracted creativity) can create changes in the brain that are similar to those that occur during medidation and other mindful activities.

When you finish coloring a page, send it to our Moods in Motion facebook page so we can post it and share your creation!

Winners will be chosen at random and notified via email, and will also be posted on our facebook page.
Come join the fun on your way to recovery. Enter to win a book!

Goodreads Book Giveaway

Moods in Motion by Karen Kleiman

Moods in Motion

by Karen Kleiman

Giveaway ends September 05, 2016.

See the giveaway details
at Goodreads.

Enter Giveaway

A Note to Dads: Could You Be Depressed?


It’s possible that you too may be experiencing symptoms of depression. A study by Paulson in 2006 reported that 10% of all new dads experience symptoms of a clinical depression after the birth of a baby. That’s one out of every ten dads! Not only is it more common than we ever knew but if you think about it, it makes sense that some of the same factors that are contributing to a woman’s depression may impact you, too. If you don’t like the way you are feeling or think that something’s just not right, think about this:

Some factors in your life that may contribute to feelings of depression:

  • Personal history of depression/anxiety
  • Family history of depression/anxiety
  • History of alcohol or drug dependence
  • History of obsessive-compulsive tendencies
  • Change or dissatisfaction with job
  • Financial pressures
  • Sleep disturbances
  • Marital discord
  • Insufficient support network
  • Ambivalence about your role as father
  • Impaired relationship with your own father or mother

Depression doesn’t always feel like you think it would. Some people do experience deep sadness and feelings of hopelessness and worthlessness.

But you might also (or instead) be feeling:

  • Irritable
  • Unable to sleep
  • Anxious
  • Disinterested in pleasurable activities
  • Distractible
  • Frustrated or short-tempered
  • Reckless or impulsive
  • Alone or cut off from others
  • Tempted to spend time away from home
  • Disillusioned
  • Excessively worried about finances
  • Displeased with your job
  • Dissatisfied with your marriage
  • Rejected by your wife
  • Critical of yourself or others
  • Angry or overly reactive
  • Restless and/or exhausted

If your wife is depressed:

If you wife is currently being treated for postpartum depression, you may be feeling additional pressure to “keep it together” while she is recovering. That’s understandable. Depending on your relationship with your wife, how she is currently doing and how bad you are feeling, it makes sense that you would need to balance what you need to do for yourself and what you need to do for your wife. But remember, you will be more helpful to her if you are strong and healthy so don’t sacrifice your well-being. The last thing she needs to worry about is how YOU are doing. So do what YOU need to do to take care of YOURSELF.

What you might do that will NOT help:

  • Deny that you are feeling bad
  • Try to ignore your feelings
  • Hope that this will take care of itself in time
  • Spend more time away from the house
  • Hide what you are feeling
  • Withdraw from friends/family

Think faulty thoughts such as:

  • strong men don’t get sick, OR, depression is a weakness
  • Work longer hours
  • Spend more time acting-out, ex:staying out late, going out after work, drinking more
  • Snap at others around you who are trying to support you
  • Reject help

What you can (and should!) do:

  • Let others know how you are feeling.
  • Confide in someone you trust.
  • Contact a healthcare provider that you feel comfortable with.
  • If you are interested in therapy, ask someone for a referral.
  • Do not let your financial concerns get in the way of you seeking help.
  • Do not expect to feel better right away.
  • Participate in sports or mild exercise.
  • Put off making major decisions at this time.

Why it’s hard to get help:

  • You’d rather not tell anyone how you are feeling.
  • You’d rather believe this is just normal crankiness that will go away with a good night’s sleep
  • You’d rather acknowledge that all new dads are exhausted and feel this way.
  • It feels easier not to deal with it.
  • Men tend to be less willing to acknowledge their emotional symptoms.
  • Men are more likely to suppress their depression through the use of alcohol or other substances.

Why it’s important that you DO get help:

Depression is a serious medical condition that affects your whole body, your mood, and your thoughts.
Everyone in your family needs you to be healthy. When you take care of yourself, your wife will feel better, your baby will feel better, and YOU will feel better. If you are worried about the way you are feeling, ask for help so you can receive the treatment you need to get back on track.

Are You Working with Postpartum Women?

Women have been telling me, for almost 30 years, what they need, what they want, to help them recover. Most of what has been written in my books, came directly from their voices and their experiences. Postpartum women are very tuned in to what works, what doesn’t work, their sensibilities are often on hyper alert and most of the time, not always, but most of the time, they are very right about what they need and what they want, in order to heal. So, we listen.

But when it comes to scary thoughts, they are wrong.

They are very wrong.

Because most postpartum women find it impossible to talk about the scary thoughts they are having. The paradox is, that unless they take the risk of sharing these thoughts, or images or impulses, they can get bigger, more powerful and way more scary for her.

Life is messy. Life with a baby is really mess.  Life with a baby and symptoms of depression and anxiety is out of control messy.

When life feels out of control, what does a postpartum woman (and perhaps many of us?) try to do? Of course, we try to maintain control, things and thinking become very black and white. Good or bad. Healthy or sick. Part of our job is to help her understand that we are not there to help her clean up her mess, but instead, we are there to help her embrace it. This is a notion that is often met with resistance or anger, but the truth is, until she can learn to embrace some of what feels so out of control right now, she will continue to resist and symptoms will remain.

But she feels like she must hold tightly. She doesn’t want to let go of this shield she has set up to protect her. The last thing she wants right now is to feel vulnerable. And letting go, feels vulnerable.

So she pretends.

She hides.

She denies.

She disallows.

This leads to the biggest problem: What is left to take center stage, when she retreats into silence, is shame.

Shame is correlated with depression. We can treat scary thoughts with medication or good therapy. But if we do not address the shame, we are only scratching the surface.

Shame is not the same as guilt, which is also huge during the postpartum period. While guilt is focused on behavior, what I did or did not do, shame is focused on the self. I am a terrible mother. I should never have had this baby. I am a terrible person for having these thoughts. A good mother would never think these things.Mothers in our culture have been socialized to do it all, do it perfectly and never let anyone see them sweat, or complain, or whine, or god forbid, ask for help. This leaves them with massive unobtainable and conflicting expectations. Of course it would.

Secrecy, most often due to fear of judgment, makes shame bigger.

Think about this.  Vulnerability is not new for postpartum women. She has most likely opened her heart, opened her mind, she has opened her legs to various levels of invasive inspection. She has learned how to bleed, discharge, poop and lactate in front of strangers with little regard to judgment or consequences. I’m not saying that is easy to do, but she does it. It just goes with the territory of giving birth. However, the vulnerability that comes with admitting you have thoughts of harm coming to your baby, well, that is a state of nakedness that is simply too hard to bear.

Exposure takes courage. It’s hard to find strength when you are bone-tired and weakened by symptoms. Our job is to help postpartum women with scary thoughts find the courage to acknowledge this and talk about them.

Empathy is the key to reducing shame.

If you do not feel knowledgeable about the nature of scary thoughts, find reputable resources and educate yourself so you can sit comfortably with the high level of distress these thoughts can create in the heart of a new mother. Learn that her distress is a marker of acute anxiety which informs us, diagnostically, that these thoughts are anxiety driven and not symptoms of psychosis, which she fears. Make sure you know how to differentiate the frightening intrusion of OCD thoughts that can make her feel as though she is going mad, when she is not.

The job of each and every clinician who sits with a pregnant or postpartum woman is to take a good hard look inside yourself and make sure you are able to tolerate the details and know what to do and what not to do, if your client trusts you enough to tell you what she is thinking. She needs to know she is safe with you. Do your homework. Be informed.

Help her.


For more information see “Dropping the Baby and Other Scary Thoughts” by Kleiman and Wenzel

SSRIs and Pregnancy. New Research. New Worries?


Cropped view of pregnant woman taking pill with glass of water, possibly a prenatal vitamin.


There is new reserach on the use of SSRIs during pregnancy that is unsettling. This study reports that the use of antidepressants during pregnancy may increase the risk of having a child with autism.

Tons of folks are understandably reaching out to us for clarification and reassurance. I am writing this only to say that the jury is still out and I am doing my best to gather information so we can all rest easier. There is a buzz around this now and experts are trying hard to understand the implications so no one over reacts and so we proceed with knowledge and caution.

In response to this research, there is a good article that begins to break it down a bit. Their main point is:

“And while that sure sounds scary, it’s important to remember that this figure is relative to the risk that already exists for autism even before medications are involved, and there are multiple studies that have turned up no such link.”

They also say:

“Of particular concern is that headline-ready “87 percent” figure. On its own, it sounds alarming, but when you consider that the risk of a child developing autism is already 1 percent, that makes the risk associated with SSRI’s in this study 1.87 percent – small enough that it could have been an error in analysis.”

That point is worth repeating. If the risk of a child developing autism is 1 percent, the risk raised in this study increases that risk by 87%, which makes the overall risk now 1.87%.

Another point:

“This study looked only at one developmental outcome and there is no control group that would enable us to capture all of the potential harm that might have been prevented with the choice to treat depression”

Furthermore, they point out that depression is a serious illness and the risk of untreated depression is associated with behavior changes (e.g. nutritional, sleeping impairment, high stress) that could cause developmental problems for the infant.

This is an excellent rebuttal published by Science Magazine. Please read it.

Most important, each woman needs to discuss her risks and specific concerns with her health care provider.

The take-home point is that there is much conflicting research on this and while initially startling, we need to be cautious about jumping to conclusions or abruptly changing our practices.

I will follow up when I have more information to share. In the meantime, take a deep breath and remember that this is not the first time research has reported on a a negative outcome associated with the use of SSRIs and pregnancy. We will continue to study this so we can offer the best recommendations.


12 Things Your Therapist* Wants You to Know About Negative, Intrusive, Scary Thoughts

DISCLAIMER: These points refer to therapists who have been trained to treat perinatal depression and anxiety. If you do not feel like you are in the presence of a therapist you can trust or if you find yourself questioning his or her level of expertise in this area, please find yourself another therapist. We can help you do that.

35221820 - young woman suffering from a severe depression/anxiety (color toned image; double exposure technique is used to convey the mood of unease, progression of the anxiety/depression)

  1.  I know it is hard to talk about the anxiety racing through your mind right now. I know it is difficult to distinguish between what is problematic and what is normal. I can help you figure that out.
  2.  If your thoughts are about suicide, you need to tell me that so I can help keep you safe. If your thoughts are about harm coming to your baby, this is more common than you might know and if you feel too anxious to talk about it now, you might feel better talking about it at a later time.
  3.  Did you know that approximate 75-91 percent* of new mothers report having negative, intrusive, unwanted thoughts about harm coming to their babies? 
  4.  You might be surprised to discover that you feel better after you tell me what is worrying you.
  5.  Negative thoughts and images that worry you will not worry me.
  6.  No matter how scary, how intrusive, how overwhelming your thoughts are, I have probably heard worse and nothing you say will alarm me.
  7. Scary thoughts that are really scary are not diagnostically more serious than any other scary thought. The only thing bad about scary thoughts that are anxiety-driven is that they feel so bad to you.
  8. I know it can feel like you are going mad. Your high level of distress is an important indicator that what you are experiencing is anxiety, not psychosis.
  9. Do not let feelings of shame, embarrassment or guilt interfere with what you want to tell me. It will be okay.
  10.  Scary thoughts do not lead to actions.
  11.  Nothing bad will happen if you tell me what you are thinking.
  12.   You will not be judged here.

Take a deep breath. Decide what is best for you.

Try to put words to your resistance and fear. Believe that I can help you with this so you can start to get some relief.

*Abramowitz, J. (2006), 2003)

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