Holding: The Essence of Postpartum Therapy

“Many people who have never experienced intense anxiety presume it is an acute state of nervousness or exaggerated worry. This may be true for some. But for a majority of postpartum women, for whom anxiety is predominant, it is an emotional state that is as close to the edge of insanity as imaginable. In comparison, for infants deprived of security, Rodman refers to Winnicott’s description of this unthinkable anxiety as a feeling of “falling for ever” (Rodman, 2003). Falling forever is a poignant expression that characterizes a great deal of what postpartum women in despair describe to us: I will never get better. I will go crazy. I will die. I am alone.

When we highlight a new mother’s indefinable need to be cared for, we discern a deeper purpose to this [therapeutic] holding environment at the core of our work. One study attributing psychoanalytic concepts to postpartum depression pointed out that women with postpartum depression exhibit regression along dimensions of affect tolerance and expression, as compared to the non-depressed control group. They concluded that a high level of postpartum distress was associated with regressive tendencies, with particular respect to affective development and emotional expression (Menos & Wilson, 1998).

This regression can magnify right before our eyes in early sessions. If we think about this regression in Winnicott’s terms who claimed, “There is no such thing as an infant” (Winnicott, 1960), implying that without a mother, an infant cannot exist, and stretch our analogy to extreme dimensions, we begin to realize the role of the therapist with the postpartum woman. As our client sits awkwardly, in this state of imposed dependency, she finds herself reluctantly clinging to the desire for comfort (symptom relief) and nurturance (compassionate expertise). This is not to suggest that she has reverted to an infantile level of functioning. It does suggest, however, that in order for her to successfully reenter her mommy-baby world, which is often contaminated with negative thoughts and feelings that repel her, the postpartum woman must first sit with her ambivalence, anxiety, and symptoms of depression, forcing her to confront her simultaneous need for caretaking. When she acknowledges, on some level, this state of vulnerability, she enters the holding environment and allows us to care for her in manner that is compatible with an optimal therapeutic outcome.

When therapists assume the role of the “good-enough mother,” we pave the way for “primary maternal preoccupation” (Winnicott, 1956), which enables us to be available to our client physically, emotionally, and exclusively throughout our work together. Not unlike Winnicott’s constructs, our role is to teach and demonstrate that any imperfection along the way (and there will be many) and her rebound from perceived failure, is a necessary component for developmental progress. This holds true whether it refers to her progress in therapy, in recovery, or, as a mother. Learning that there will be disappointments along the way is a message that may sound patronizing or over simplistic, but it is one we should reinforce nonetheless. Just as a child learns to pick himself up from a fall and push ahead, our client might need to be reminded that it’s okay to lose ground while she is cautiously moving forward in all aspects of her present state.

In this way, we become the good mother, certainly “good-enough” in Winnicott’s (1953) words, flaws and all, but we strive to be even better than that. Since we are not her mother, we are in a unique position of integrating our theoretical training, our good instincts, our own life experiences, and our objectivity. In combination, these components create the good mother poised to nurture, support, and heal the postpartum woman in crisis.

Therapy and the Postpartum Woman (Routledge, 2009) Ch 5 “The Holding Environment”, p 39)

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