Therapy and the Postpartum Woman: INTRODUCTION TO THE ITALIAN EDITION

Guarire dalla depressione postpartum. Indicazioni cliniche e psicoterapia


With my deepest gratitude, I post the translation of the introduction to the Italian edition of: Therapy and the Postpartum Woman by Pietro Grussu and eRosa Maria Quatraro:

Fourteen years have passed since the Editorial Collection “Psicologia della Maternità” (Psychology of Motherhood) debuted with the publication of its first text entitled “Treating Postnatal Depression” written by Jeannette Milgrom with several of her colleagues.  In Italy, this manual became, and remains, among the principal clinical-practical references for those who treat postpartum depression.  When we discovered that work at the book exhibit of the First World Congress on Women’s Mental Health held in Berlin – Germany – in 2001, it seemed important to us to make it known and to promote it to the public in our country for its clinical value, but also because at that point in time, there were few publications in Italy that proposed such an exhaustive and systematic approach specifically for the treatment of postpartum depression.

Today the situation is decidedly different:  for example there are numerous conferences and cultural initiatives offered in the Italian context. Additionally, the dedicated health services are in full expansion mode, despite limited economic resources available to regional health and hospital services. Furthermore, many professionals who specialize in perinatal psychological health document read up on the topic and are constantly updating their knowledge. Additionally, women who suffer from emotional disorders are more willing to ask for help and to admit to being in difficulty at a time of life which most people think should be a time of joy and happiness. There are still many cultural barriers and prejudices surrounding motherhood which is often viewed in a manner that either idealizes or belittles (the mother who harms), both by the women themselves as well as by the surrounding social context.

Usually, when something doesn’t work the way we would like, we have difficulty coping with it and admitting that we have limits, and we process the sorrow of our own vulnerability.  Everything must work well; there is little room for error, or for the feeling of incompetence and solitude, especially when one becomes a mother.  There are dangers and pitfalls hidden behind the ideal of perfection, the organization and efficiency that our own society requires and to which women are often convinced to adhere if they want to move forward in their careers and in their family life. Becoming a mother inevitably compels a woman to come to terms with her own limits and weaknesses.

It is from this key point that Karen Kleiman starts, taking us on a journey of 38 chapters, packed with clinical psychology, kindness and a deep understanding of the lives of women with postpartum depression.  The text, written by an American psychotherapist for professionals and for American mothers, has a down-to-earth style without, however, ignoring the quest for a direction of treatment and the theoretical roots that support the therapeutic model that the author follows at the Centre which she founded and directs in the United States.  The important references to the teachings of Donald W. Winnicott, together with the attention given to several concepts of cognitive-behavioural and interpersonal theories make the book a tool of the trade rich with original tidbits that make up a solid theoretical-clinical framework for the working model described by Karen Kleiman.

What stands out is the importance of offering women suffering from depression an all-embracing context where the concept of holding is in the foreground, as is the capacity to hold-contain, and to make the mother feel supported and included. All of these elements thus become the therapeutic-experiential premise from which the author begins the assistance offered to patients.  To mother a mother, in that scenario which the French call “maternage” and which depicts a way of being cared for in order to be able to care for others, is the principle which, according to the author, must guide the clinician who practises perinatal psychotherapy.

The author, who in her writing style shows a distinct ability to render plain and apparently simple that which in reality is not, succeeds in freeing herself from theoretical dogmatism, applying theory by putting it at the core of the treatment.  In developing the text, the author seems to be guided by the need to find all that the different theories and techniques have to offer, in order to achieve the greatest possible well-being of each patient.  Karen Kleiman graciously reveals herself, describing in detail what happens between her and her patients.  Each chapter and each passage are explained with clear clinical examples which demonstrate a remarkable relational ability and a deep intellectual honesty. Additionally the author shows unceasing attention to clinical reflection, insisting continuously on the importance of providing ongoing supervision (supervision to which she herself claims to be subject at all times, despite her considerable experience) as an instrument of growth, reflection and awareness of one’s own clinical performance.

Even the parameters introduced in the therapeutic technique are described bearing in mind that not all professionals will be in agreement, but also, in this case, explaining in detail the clinical thinking behind the potential deviations in technique. The result is a text that is eagerly read, and that engages even those who are not psychotherapists.  We believe that with this work, diverse professionals who concern themselves with the perinatal period, as well as the women who experience it, can feel that they have a guide in the exploration of all those aspects that characterize the life and classic adversities of the depression that follows the birth of a child.

Postpartum depression, which in chapter six the author herself considers to be like a syndrome made up of a set of symptoms and clinical manifestations which can vary in intensity, duration, time of onset, and severity, but which always must be taken into consideration with the utmost attention, even with the involvement of a long-time professional in the perinatal field.

The concept of postpartum depression is more fully explored in its clinical aspects and its numerous symptomatological manifestations, recognizing the relevant importance of a potential psychiatric diagnosis, sometimes necessary for a good therapeutic intervention.  Beyond that, Karen Kleiman emphasizes the importance of making differential diagnoses so as not to err by underestimating or overestimating some clinical manifestations present in the affected women.  These skills can be honed only by daily clinical experience with this typology of patient.

With a simple, fluid and understandable explanatory style, Karen Kleiman describes the diverse transitions and labyrinths that the therapist and patient must deal with on the path to healing. In the first part of the book (chapters seven and eight), the author illustrates with clarity the model of “the voice of depression” which she has structured during the course of many years of work at her Centre.  The book is intriguing because it proposes an eclectic work model which integrates several techniques of cognitive behavioural therapy, interpersonal therapy and support therapy with the ability to move to a deeper level tied to the world of interpersonal relationships past and present.

The urgency of making the mother feel better in the shortest time possible, relieving her, first and foremost, of the most debilitating symptoms, is the departure point for Karen Kleiman, given the important repercussions that postnatal emotional suffering, even of brief duration, can have on the mother-child relationship, the marital relationship, and the well-being of the entire family.

“The Tools: Doing What Works” is the title that opens the second part of this book. How can one not concur with the author who, step by step, leads us through the pitfalls and difficulties that accompany the clinical evaluation, the diagnosis and the management of treatment of this particular form of perinatal emotional suffering?

It is not easy to help women who are in profound difficulty and are suffering psychologically during the phase of transition to parenthood, nor to motivate them to seek and accept qualified help.  It is precisely for this reason that Karen Kleiman dedicates great attention to the initial phase of taking charge of a patient’s care, looking at it from the point of view of the healthcare professional, but also taking into consideration the woman’s past experiences.  Together they affront the “thorny knots” such as the rationale to undertake psychotherapy or the potential use of psychopharmacological drugs.

In the third part of the book it comes to light that psychoanalytic therapy with these patients is a significant challenge, given the multitude of clinical aspects associated with the anxious-depressive past experiences typical in this transitional phase of a woman’s life.  Alarming thoughts, hostility, the idealization of oneself as a mother, suicidal thoughts, breast feeding, insomnia, problems with one’s partner and with the mother-child relationship, and the therapist’s countertransference are all aspects which are dealt with chapter after chapter, investigated in great detail in their diverse clinical aspects and debated in a descriptive style which makes reading enjoyable.

Following occurrences such as pre and postpartum depression, the women no longer recognize themselves, and they struggle to find themselves.  This is why they are often unable to find the words to express how they feel so that they might be helped to find clarity within a tangle of sensations, emotions and thoughts that make them feel like outsiders.

Another aspect of great clinical honesty lies in the author’s ability to leave the woman free to decide the point she herself wishes to reach on her own therapeutic pathway—to choose how far to deepen her understanding of herself and of her own cognitive, affective and relational conduct.

There are, in fact, women for whom it is enough to be relieved of the most debilitating symptoms, while others want to understand why they became ill and seek to make deeper sense of their own experience of the illness.  But this, when it does happen, cannot help but occur gradually, in the course of the work that Karen Kleiman describes and proposes to move forward.  Of course, therapy has a financial cost and demands the additional non-monetary outlay of revealing personal matters, which is why it may not be possible or important or urgent to explore how ties with their own caregivers can possibly be connected to the malaise that the woman is experiencing when, at the same time, she must care for a being who is totally dependent on her.

In the last part of the book, it becomes clear how helping women come out of their postpartum depression is possible not only thanks to the theoretical-technical competence of the psychotherapist, but especially thanks to the transformative power that an empathetic and supportive therapeutic relationship can have on the patient.  This premise is the point of departure for the author, but also for the writers:  that all clinicians, if they want to work with women suffering from postpartum depression, must closely monitor their own work in order to continually grow and improve.

All that remains is for us to wish you a good read, with the hope that the offerings of Karen Kleiman in this work may be beneficial and fruitful, especially for the professionals who are involved in the perinatal field every day, but also for the women who have experienced or are experiencing emotional difficulties at a time of their lives that is rich with excitement and change which, although sometimes frightening, has great potential for development and for personal growth.

Rosa Maria Quatraro e Pietro Grussu

Padua, ITALY, March 2017

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