Therapy and The Postpartum Woman: Notes on Healing Postpartum Depression for Clinicians and the Women Who Seek Their Help, the first of its kind, offers both clinicians and women with postpartum depression, an inside view of therapy and the psychodynamics that influence the healing process.  Clinicians will be armed with valuable insight and tools of intervention that have proven to be successful after years of implementation. Women with postpartum depression will be enlightened with information and awareness that can facilitate a smooth and expeditious recovery.

PREFACE

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 hyperventilate instantaneously when my son was 10 minutes late getting home 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.

One major premise of this book is based on the notion that a woman who gives birth to a baby and  who suffers from depression at the same time is generally not in the mood for therapy, and she does not 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 conglomeration of conflicting emotions; it can cause a woman to challenge everything she has ever thought about herself and 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, the client’s 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, 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 a woman’s first bout of depression or one of many, experiencing these 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 (Frank, Weihs, Minerva, & Lieberman, 1998). 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. While everyone else would be chatting about cribs and changing tables, I’d be 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? This is because 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 they will go away on their own.

Sometimes they do. Often, they do 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 new clinicians are now expanding their practices to incorporate this area of specialty.

Clinicians can read up on postpartum mood disorders and familiarize themselves with the associated symptoms and treatments, but they also need 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. For me, I never take that for granted and am forever honored to be an integral part of this journey toward recovery and renewal of self. I work hard to make sure that each client feels safe when she comes into my office seeking comfort and answers. I know she feels it the first time we meet. This is not simply because I understand postpartum depression; it’s because I do my best to understand how hard it is for her to be there. There are many excellent books on postpartum depression. Many are written with the voice of an authoritative expert offering solid information on the nature of the illness and treatment options. Other books on postpartum depression are written by courageous women who share their personal dramatic accounts through vivid stories of despair and determination, culminating in the success that enabled them to tell their stories. My own previous works on the subject were self-help books written as guides for the postpartum woman and her family to help them find their way through the fog of depression. To date, there are no postpartum books that take the reader inside the private world of the therapeutic experience to give both the clinician and the woman in therapy a clear sense of what to expect from this work together.

Long before I began writing this book, I was asked by a writer for a popular magazine to describe my theoretical ideologies. What did I believe was making a difference? How did I treat women with postpartum depression? Good question, I thought, and certainly one for which I should have an answer. After wavering a bit with procrastinating charm, I filled in the space with something like, “We use a combination of supportive psychotherapy and medication when indicated.” That worked for the time being. More recently, when trying to satisfy the demands of publishers and academic reviewers, I was again forced to contemplate the theoretical foundation of work that had always come naturally to me. A book about my good instincts was surely out of the question. I started reading the works of brilliant minds such as D. W. Winnicott and felt that light bulb go off in my head: Oh, so that’s what I do! Further exploration into earlier psychoanalytic teachings gave credence to the intuitive principle that mothering a new mother made perfect sense and helped postpartum women heal. It’s all about the connection. The therapy, the treatment, the healing, and whether she comes into our office in the first place all depend on whether she feels connected to the process and to the relationship. This concept is not a new one for practicing therapists. Still, our connection with the postpartum woman is unique in that it emulates the mother–child relationship. Specifically, it is based on a need-dependency schema set in motion by the symptoms of depression. The thrust of this book is to take a closer look at these unique needs, with apologies to Winnicott for my simplistic integration of his inspiring work.

During our postgraduate training classes, clinicians convene from across the country to gather around the conference table discussing how it feels to do this work. Rather than lecturing to an auditorium full of students hoping to gain knowledge of relevant theories and effective interventions, we discuss how painful it can be to sit with a woman who has lost her baby after carrying him in her belly for 9 months. We talk about how hard it must be to have ambivalent feelings about your new baby after 3 years of expensive, time-consuming, gut-wrenching infertility treatments. Most importantly, we talk about the connection between the therapist and the mother in therapy. A point I will make repeatedly is that the connection is the reason that what we do works.

Early in the book, it will be clear that my voice is speaking directly to therapists, addressing clinicians who work with postpartum women as “we.” In chapter 4, when I discuss the characteristics of a postpartum depression (PPD) therapist, I will shift to singular tense, speaking directly to “you,” the therapist, since my objective is to facilitate individual introspection. At times, I will specifically reference our practices at The Postpartum Stress Center. Please note that these reflect only our approach and not necessarily those that might best serve other clinicians. I will also refer to the client as the “postpartum woman” for brevity’s sake, rather than to imply that every postpartum woman is experiencing depression—but certainly the ones I refer to here are. I presume that postpartum women will also be reading these pages and because the notion of therapy can feel disquieting to many, my hope is to make the experience of therapy less intimidating for them. It may at times appear that I am glossing over certain aspects of the illness in favor of focusing on topics I believe have significant bearing on the personal and professional experience as a whole. Throughout these pages I provide a framework for thinking about the woman who suffers from PPD and offer concepts that help her treating clinician better understand the circumstances that have brought her into therapy. Understanding the illness and treatment options is one part of the healing process. Understanding the woman’s experience of this illness is something quite different.

For this reason, you might find that certain topics are missing from this book. For instance, if clinicians are looking for an explanation of the hormonal influence on postpartum depression or whether Wellbutrin is safe to take during pregnancy, they’ll need to find that information in another resource. To be sure, there are facts that exist in the literature regarding the treatment of postpartum depression that remain the foundation for much of the work we do. Clinicians are obliged to continually stay informed and revise practice guidelines in order to provide state-of-the-art treatment. Therefore, I am comfortable making the assumption that clinicians will find theories and evidenced-based research elsewhere to support their clinical decisions and address questions that may arise. In writing this book, my intention is to provide a new framework for thinking. It is not a comprehensive handbook on the treatment of postpartum depression. It is a compilation of my most meaningful experiences and personal reflections complemented by professional strategies and relevant research. Mostly, it is a book that probes the private world of therapy through dynamic exploration of what works and what doesn’t work on the path to healing postpartum depression. I stand firm in my conviction that none of the abstract theories can explain what it really feels like to sit in the room and share the same space with a woman who no longer knows who she is. It is another matter altogether. It is quite personal.

A few years ago, a great researcher and colleague, Kathy Wisner, M.D., honored me with the gift of her wisdom when I was attending one of her presentations on perinatal mood disorders. I recall approaching her just prior to the lecture, handing her a copy of my then new book, What Am I Thinking? Being ever so humbled by her awesome expertise, I said something unimpressive, like, “I love listening to you speak. I hope you’ll like a copy of my book.” I always feel somewhat irrelevant when I’m in her presence. Perhaps because she speaks of meta-analyses and supraphysiologic doses of various compounds about which I know very little. I continued to gush with praise like a star-struck adolescent and told her how much I’ve always learned from her lectures and how listening to her reminded me of how much I still do not know. She welcomed me with her unassuming grace and, though unmoved by my adulation, thanked me for the book. She told me how helpful my books have been to the postpartum community and that my work was just the right complement to her research. Then she said something I cannot remember exactly, but I felt it inside my heart and have carried it with me ever since. She reminded me how important my work was and that, though she studied and reported on the statistics and the implications for treatment, it was I who was in the trenches with the mothers who suffered and who had a front-row view of what was happening and what needed to be done. It was a gracious observation coming from someone who has so tirelessly dedicated her energy to this field of study. But most importantly, it is this very perspective to which she referred that set the stage for this book. After all, I’ve always said I’ve learned everything I know from the women who seek my help.

I believe that women with postpartum depression have never been in a better position to get excellent help. Clinicians are beginning to pay closer attention to the unique needs of this special population of women. The individuals I have had the pleasure of supervising are incredibly passionate about this work. They are eager to enhance their skills and willing to dig deep into their own personal life experiences to find the best paths for healing.

For these reasons, I have set a few parameters for this book:

To clinicians:

Whether you are a novice or seasoned therapist new to this field or an advanced clinician seeking to refine your work, the information in this book promises to enlighten you and enhance your clinical experience as well as increase the likelihood that your client will feel better sooner.

To postpartum women:

Whether you are currently in therapy, considering entering therapy, or wondering why in the world you would need therapy after having a baby, this book will facilitate a better understanding of the process. It will also help you determine whether therapy would be helpful for you or not and, if you already have a therapist, whether you are getting as much out of your work together as you can.

This book is not:

• An all inclusive comprehensive resource manual for postpartum mood disorders

• A reference book to answer all of your questions about postpartum depressio

• A substitute for clinical supervision

• A self-help book for the treatment of postpartum depression

This book will:

• Provide an inside view into the world of therapy with postpartum women

• Offer specific suggestions and clinical interventions that have proven successful in clinical practice

• Encourage you to look deep inside yourself regardless of which side of the therapy office you sit so that you can get the most out of the experience

• Provide clinical information illustrated by case vignettes for further elucidation

• Address specific challenges that clinicians and clients must confront throughout their journey together

• Help instill confidence and increase understanding of how therapy works and why it might not within the postpartum setting

• Augment the therapeutic process to increase the probability that both the treating clinician and the woman in therapy will benefit and learn from the mutually rewarding experience

A postpartum woman who seeks treatment needs to feel safe and understood. When she does, she can be free to tap into her own healing resources. The difference between a successful therapeutic experience and an unsuccessful one is solely determined by the connection between this woman and her therapist. Therapy and the Postpartum Woman is a companion tool for the clinician and client, one that I hope will enlighten and embrace the process of therapy for both of them.

– Karen Kleiman, MSW