Participants in our post-graduate training program will hear me utter those words at the beginning of each training, and again, throughout the training, probably at least 30-50 times! There just isn’t enough time to cover everything we need to cover. There isn’t enough time to address all of your questions. There isn’t enough time to do what we all want and need and hope to do. I also request, somewhat tongue in cheek, that they not put this down on their evaluations at the close of the training. Please, I implore, do not tell me there wasn’t enough time. I know this, and by the way, there ISN’T enough time. This is not an opinion, it is a fact. How could there possibly be? After all, we promote the training as a specialized crash course promising to inspire clinicians and help them become “experts” in the treatment of postpartum depression.
But alas, after each training, typically ¾ of the group will note on their evaluations, that there wasn’t enough time. A few hours more would help. Another half a day. Another whole day. Since each training group is comprised of 8-10 highly motivated, passionate and accomplished clinicians, we spend far too much time, off course, so-to-speak, addressing the unique concerns of each group. This, of course, leads to both stimulating discourse and, much less time to adhere to our agenda. Still, even if we stuck rigorously to our path, we would, ultimately, disappoint someone because, well, there just isn’t enough time.
And so, depending on the particular group, I will hear variations of the following:
But we didn’t adequately cover…
1) Support groups or
2) Hormonal influences or
3) Neurobiological factors or
4) Male postpartum depression or
5) EMDR, CBT, DBT or
6) Biopsychosocial determinants or
7) Consequences of fetal exposure to SSRIs or
8) Cultural differences and socioeconomic factors or
9) Implications of advanced maternal age or teenage pregnancy or
10) Domestic violence and PPD or
11) The impact of abrupt weaning on postpartum depression or
12) The relationship between fear of childbirth and PTSD or
13) How to better identify women at high risk for PPD or
14) How various medical conditions can present as postpartum depression with psychotic features or
15) Exploring the value of telephone, Skype, email or in-home visits/sessions or
16) Sleep disturbances: are they the cause or result of postpartum mood and anxiety disorders? Or
And so forth. You get the idea.
There just isn’t enough time.
But here’s the point. Clinicians who are eager to do this awesome work come to our training in the hopes of receiving state-of-the-art information and learning how they can best proceed with their clinical practice. So I remind each of them, from the outset, that the information is out there. There are numerous books, articles, and tons of research with information that can enhance their understanding and practice. But what is NOT out there in the vast land of academic study and lit searches can, in fact, be found here – in the intimate environment that unfolds as clinicians with a common purpose begin to explore possibilities.
However, some clinicians may leave the training feeling like they missed something. Perhaps some question unanswered, some vital bit of essential knowledge that wasn’t addressed. After all, one certainly should expect a solid foundation of information after investing so much time, money and personal sacrifice on behalf of one’s professional development. Still, remember that sometimes, the information may not be enough. Therapists eager to launch into this special area of expertise, who earnestly seek the right answers to the anxiety-triggered questions from their clients, may leave feeling less than totally prepared.
In this context of therapy with postpartum women, wisdom is the balance between the knowledge we have and who we are.
There are so many unknowns regarding postpartum depression. Many more questions than definite answers, to be sure. As this ambivalence cascades into the therapeutic environment, it can feel daunting to not have all of the answers to our clients’ questions. Why did this happen? What did I do? What did I not do? Will that make me feel normal again? Can’t I just take hormones?
This question about hormones is a common one so let’s use this as an example.
Postpartum women seek immediate information for immediate relief. After all, they have an urgent agenda. Seeking a hormonal explanation feels less “pathological” less stigmatizing, more medical and treatable. We, too, as dedicated clinicians, would like to offer some variation of the quick fix that they so desire.
Although much of the research has focused on the dramatic changes in estrogen and progesterone levels that rise during pregnancy and drop after delivery there are also changes in metabolic, gluco-corticoid (stress hormones) and endocrine systems, which may be linked with mental illness.
A few years ago, there was some excitement about the estrogen patch, which has been shown to decrease some symptoms in some women with PPD. But the research shows that the results of using the patch do not correspond with predictability to mood. In one older trial (Gregoire, et al, 1996, Lancet), it’s notable that the study included women who were also taking antidepressants, which limits the ability to determine an estradiol-specific treatment effect as opposed to an augmentation association between the estrogen and the antidepressant. So it’s difficult to isolate the variables and know what was making the difference.
More research is needed to determine the specific link between the rapid drop in hormones after delivery and depression. Evidence does not support a correlation between levels of estrogen or progesterone and the development of postpartum depression. But there does seem to be a subset of genetically predisposed women, who are sensitive to the abrupt hormonal changes, which may contribute to the onset of postpartum depression. In many cases, these women have been previously sensitive to other hormonal changes, such as PMS.
We know that in addition to these biochemical and hormonal changes, there are often significant social, psychological, relational, genetic and environmental influences that are associated with an increased risk for postpartum depression. Additionally, issues related to trauma and sleep deprivation may play a role in perinatal depression.
All if this may sound like too much information for an anxious new mother to integrate.
A note to all clinicians seeking to become experts in the treatment of postpartum depression –
Do not look for a sound bite. There are none. Do not look for the one correct answer to the complex questions that will challenge you on a regular basis. That doesn’t mean you shouldn’t continue to read, explore, study and learn. Of course you should. You should do it for your personal and professional growth and the development of your knowledge base.
But you will miss the essence of our training if you think that specific answers or lack of answers will compromise the integrity of your client’s recovery.
Instead, we all need to remember why we do this work and how we can best help our clients. We need to resist responding to their anxious questions with our own anxious desire to help them. Rather, we need to help them tolerate the discomfort while we search for tools, interventions, and relational skills to help them feel safe, cared for and listened to (holding). The medicine, the hormones, the biological context, the diagnoses, and the science behind all of this are undeniably, crucially relevant.
But they are not, I assure you, the mainstay of your work.
Continue to study. Work well.