Postpartum Women in Therapy: Are you up to the task?

Ever since I can remember, I wanted to be a mother. When I was a young girl, my favorite pastime was playing house and of course I was the perfect mother. I held my sweet doll tightly to my chest and promised her a lifetime of whatever she wanted.  I leaned against the giant Oak tree in the backyard and cradled her in my arms, rocking her back and forth. “I love you,” I whispered and told her that she didn’t have to be afraid of anything.  I would always take care of her. Forever and ever.

I was a very good mother when I was a child.

I knew all the right things to do and I said all the right words.  I was able to fix any problem and in return, I was loved unconditionally.  If anyone asked, I would stand up tall, head up, shoulders back and boast, “When I grow up, I’m going to be a mommy.”

Before I had children, I never gave much thought to what kind of mother I would truly be.  It was something I presumed would unfold naturally.  As my children grew, I watched myself morph from the always-nurturing, selflessly devoted idealized mother in my mind’s eye to one that would hyperventitlate instantaneously when my son was ten minutes late from school.  I experienced the chaos, the flood of unexpected emotions, the feelings of betrayal and disbelief when my children didn’t see me the way I saw myself.  I lived through anxiety from which I never thought I could recover.  I made mistakes, I overreacted and above all, I learned how to be a mother the way everyone learns, by doing it.  However I wasn’t depressed.  I’ve never known the agony of mothering a child without being able to breathe.  That is something I learned from the women who have trusted me with their private stories.

It’s fair to say that woman who gives birth to a baby and who suffers from depression at the same time is generally not in the mood for therapy.  Nor does she want to take medication, or make time for one more appointment, or take care of herself, for that matter.  She’s tired and restless; she’s overwhelmed, and can hardly find the time to do what she needs to do.  She’s sleep deprived, hormonally compromised, and trying desperately to come close to her idealized image of what a mother should look, sound, act and feel like.  She’s finding it hard to concentrate, she’s crying more than she usually does, her nerves are shot and every single thing that anyone says or does makes her angry, sad, irritable or scared to death.

Then, just when she begins to believe that having a baby was really not a good idea after all, someone tells her she needs to get help.  Someone is worried about her.  It may be her husband; it may be her doctor or her mother.  It may even be her own inner voice that knows something is terribly terribly wrong.

In the early stages of feeling bad, her typical response to someone suggesting she see a therapist for the treatment of depression is something like, “Are you kidding?!  I don’t have time.”  But if she feels bad long enough or if her symptoms are scary enough, she will make that call.  When she does, it’s the clinician’s job to know how difficult it is to make that call and know exactly what to say and do to help her feel better.  When depression sets in, the birth of a child becomes more than a rite of passage.  Postpartum depression can create a combustible combination of emotions; It can cause woman to challenge everything she has ever thought about herself, about her own childhood experience, as well as her identification with her own mother.  It robs her peace of mind and it makes her feel as if she’s lost touch with her very core.

It fractures her soul.

Thus, when we speak about treatment for postpartum depression, we refer to more than which therapeutic intervention is most effective or which medication is compatible with breastfeeding.  Clinicians who treat women with postpartum depression the same way they treat anyone else with depression may miss some critical differences that will affect the outcome and ultimately, her well-being.

Postpartum depression emerges at a time in a woman’s life when both the demands and stakes are high.  In addition to the disturbing feelings and symptoms such as weepiness, anxiety, sleeplessness, panic, and feelings of inadequacy, guilt, hopelessness and despair, there is one more complicating factor. There is a baby in the picture.  This makes everything more dramatic, more precarious and much more urgent.

Whether it’s her first bout of depression or one of many, experiencing theses symptoms while she transitions into her role of mother, can make her wonder if this is just what being a mother feels like.  Too often, a woman is unaware she is suffering from a treatable condition.  Rather, it is perceived as a character flaw, a defect in the vision of maternal perfection she held so close to her heart.

For this reason, it is insufficient to treat only the illness when treating postpartum depression. Handing out a prescription for antidepressants and telling her to come back in a few weeks for a follow up may, in the short run, relieve some symptoms.  But it fails to address her wounded self-esteem and belief that she will never be a good mother.  In doing so, we abandon the heart of a mother who has been injured beyond belief at a time when she expected what everyone else expected – that this would be the happiest time in her life.  It seems our society should stop insinuating that this is so.  As exciting as this time is for many women and their families, it is also a time in their lives when many are at risk for emotional illness.  It would be prudent for women to prepare for the possibility of depression rather than expect maternal bliss and then be blindsided by the illness.

I would definitely be a downer at any baby shower.  When everyone else is chatting about cribs and changing tables, I’m thinking to myself, does she have enough help at home, is her marriage solid, does she have a history of depression, did she really want to leave her job, will she get enough sleep?  I worry most about women who are not prepared, who are at risk for depression or who think it can’t happen to them.  It can and it does.  When it does emerge, the very last thing that woman feels like doing is telling anyone about it.

Despite increased attention to the illness, women with postpartum depression are still hesitant to reveal to their healthcare practitioners how bad they are feeling.  Fearing judgment or casual dismissal, they hold tight to their private worries and simply hope it will go away on its own.

Sometimes it does.  Often, it does not.

The good news is that there has been a huge shift in current thinking about postpartum depression brought on by increased public awareness.  Groundbreaking legislation for improved screening practices and treatment options has paved the way for women who are seeking treatment.  Yet, despite these recent advances there remains an enduring unknown.  Can we make the assumption, after we screen, assess and refer for treatment, that a given woman will get decidedly good treatment?  Therapists have rallied in response to this awareness campaign and are now in position to treat women with postpartum depression but they need more information.  A great number of experienced as well as novice clinicians are now expanding their practices to incorporate this area of specialty.  Clinicians can read up on postpartum mood and anxiety disorders and familiarize themselves with the associated symptoms but what they need is insight into the practical application and hands-on tools with which they can navigate the therapeutic territory.

Sharing the therapeutic space with a woman with postpartum depression is uniquely challenging for the clinician.  The client may be resistant to or eager for help.  She may be grateful or resentful. She may be bleary-eyed and bone-weary.  She may be motivated for treatment or suspicious of anyone’s ability to help her.  Nevertheless it’s a journey the two embark on together.

A journey that challenges the postpartum woman’s sensibilities, awakens her traumatized soul and ultimately transforms her.



Adapted from “Therapy and the Postpartum Woman” (Routledge, 2009)


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