Therapy and the Postpartum Woman

Notes on Healing Postpartum Depression for Clinicians and the Women Who Seek their Help

Karen Kleiman

• Publisher: Routledge
• Year: 2008
• eBook ISBN: 9781135856328
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book provides a comprehensive look at effective therapy for postpartum depression. Using a blend of professional objectivity, evidence-based research, and personal, straight-forward suggestions gathered from years of experience, this book brings the reader into the private world of therapy with the postpartum woman. Based on Psychodynamic and Cognitive-Behavioral theories, and on D.W. Winnicott's "good-enough mother" and the "holding environment" in particular, the book is written by a therapist who has specialized in the treatment of postpartum depression for over 20 years. Therapy and the Postpartum Woman will serve as a companion tool for clinicians and the women they treat.

Part 1 The Framework: Women, Babies, and Therapy

Chapter 1 Masquerade

Clinical Profile

DOI: 10.4324/9780203893913-2

We will have to give up the hope that, if we try hard, we somehow will always do right by our children. The connection is imperfect. We will sometimes do wrong.

Judith Viorst

Necessary Losses

Postpartum depression is not always what it looks like. Women who are severely ill can present well and look good. Really good. At first glance, they can look good physically with every hair in place, and they can look good clinically, responding to our questions with deliberate precision. Unremitting symptoms of depression might be lurking behind the camouflage that things are fine. If clinicians aren’t carefully reading between the lines at all times, they might miss that. Other times, symptoms that shriek with alarming intensity might be a sign of a transient emotional state that has less clinical urgency. To reconcile this apparent discrepancy, I emphasize the most basic lesson that shapes the work of a postpartum therapist: Do not assume, if she looks good, that she is fine; do not underestimate the enormous power a postpartum woman achieves by maintaining the illusion of control.

Early in my career, I received a phone call that was not unlike those I was used to getting on any given day. “I need your help,” her voice said, shaky with a familiar desperation, begging for immediate attention. “I’ve never felt this bad. Something’s really wrong.”

Regardless of how many times I hear the impassioned pleas, hearing them never gets easier. I always feel the palpable terror. The words may vary with each voice, but the panic is the same. It’s the feeling that accompanies the sheer loss of control and the descent into obscurity. “What isthis? Who amI? What is happening to me?”

Megan was a 32-year-old mother of a 3-month-old daughter. Her frantic call reminded me of the ongoing challenge that clinicians face when treating the needs of postpartum women. It’s not as though women with young babies can be expected to plan their crises according to our schedules. Ideally, I’ve always known that we should be prepared to see women who need to be seen without delay, but logistics of the practice and constraints of scheduling do not always make that possible. Still, there are some phone calls that scream such urgency that accommodations need to be made. Even the best training and the most impressive of organizational skills cannot substitute for good instincts. In this business, having good instincts can mean the difference between life and death.

Initial phone calls are a crucial part of establishing the therapeutic alliance. The challenge is whether we can simultaneously(1) review the relevant historical information, (2) assess the severity of the mother’s needs, (3) ascertain whether there is a crisis situation, (4) determine the best course of intervention, (5) reassure and comfort her, (6) offer tools for preliminary symptom relief, (7) instill confidence that she will feel better so that we can reduce the secondary panic that sets in, (8) convey our expertise in this area so that she can trust the process and disclose the depth of her suffering, and (9) encourage her to follow up with the proposed action despite the fear, resistance, guilt, anxiety, confusion, despair, and overwhelming sense of hopelessness that misleadingly renders her unworthy of our professional attention and support.

And can we do all of this in 20 minutes or less, on the phone?

Megan told me she needed to come in that day. “My doctor gave me your number weeks ago; he knew I might feel this way. I was hoping I wouldn’t, and then, when I started feeling so bad, I guess I hoped it would just get better on its own. But it’s not.” Megan’s voice crumbled into tears. “I’m sorry,” she whispered through her labored breath, as if she were imposing in some way.

I’m not certain why women feel the need to apologize when they cry. Perhaps, on some level, they fear (or know) that raw emotions can make others uncomfortable, forcing women to feel responsible for this burden. I hope, however, that skilled psychotherapists are able to tolerate this level of emotion and to be comfortable, albeit sensitized to some extent, with the pain their clients reveal to them.

If they are not, I wish they would find another profession.

“That’s okay, Megan; it sounds like this is awful for you. Let me see what I can do to help.”

Would that be enough to provide a trace of relief? Will I be able to pick the perfect words with just the right intonation to get across everything I need to say? As hard as it might be for her to make that first phone call (she did admit she carried the card for months before she came to terms with the extent of her suffering), actually making the call can bring enormous relief. By calling, it’s as if a woman is saying, I can’t do this anymore. I need your help. Tell me what I need to do so I can feel better. I’m terrified. Tell me I will not always feel this way. Tell me I’m going to be okay.

This is the voice of depression. These are the words that reach out from beneath the surface, gasping for air. This is the language that serves to protect women from themselves, when they can no longer breathe, when they are too tired to move, too weak to eat, and too hopeless to care. If they are lucky, they find the words to cry out for help when someone is there to listen.

A response to this call should include the following message: I know what to do to help you feel better. No, you will not always feel this way. You don’t have to suffer by yourself. I can tolerate whatever you are feeling and whatever you need to tell me. We will make a plan and get you on track to feeling like yourself again. You will get better.

This is the beginning of the magic. It is how these women begin to get better. It is the initiation of therapeutic healing, a hint of relief, a splash of hope while they are drowning in despair. It is what connects them to the process.

The likely result is an initial reprieve, taking on any number of forms. It can be expressed: Thank you. I feel better already that I called. It can be implied: Okay, I’d love to come in and make an appointment. It can be tentative: I’m not sure anything can help; I don’t even know why I called. Or it can be misdirected: I’m not sure what to do for myself, can I call you in a couple of days?Whatever the outward appearance, one thing is certain: No one makes this kind of phone call in the first place unless they are scared, desperate, symptomatic, or in a state of unfamiliar and quiet panic (unless, of course, she is a terribly compliant patient who is dutifully following the instructions of her concerned healthcare provider). It is our obligation to know that each woman who calls is asking for something that is hard (if not impossible) to ask for and important to get. She is not likely to reveal what this is at first. She is, however, certain to need it.

It is our job to figure out what that is.

Megan and I talked for a few minutes on the phone, and I asked if she felt she could wait until the end of the day, at which time I could stay later and see her. Or, did she need to go to an emergency room? She reassured me that she could wait but was grateful that I could squeeze her in that same day. When her appointment time rolled around, I was finishing a last-minute phone call and heard someone in the waiting room that I presumed to be her. I remember the waiting room when it was not filled with mothers who were struggling with mothering. I remember thinking, how do I make this small space pleasant enough for women who are feeling so lost? After all, a woman who gives birth to a baby does not plan to go to a therapist. Typically, this is not something a postpartum woman is motivated to do on her own for personal growth or spiritual edification. Under other circumstances not related to childbirth, women seeking therapy may do so with purposeful anticipation, along with some trepidation and an incentive for change.

But let’s face it, when a woman has a baby (add sleep deprivation, mood swings, cracked nipples, 30 pounds she hopes belong to someone else, raging hormones, a screaming infant, and a husband who wonders where his wife went), making an appointment to see a therapist to talk about how guilty, anxious, nervous, remorseful, and inadequate she feels is not high on her priority list.

Thus, we conclude that few postpartum women are there by choice, which is not typically the case in the broader population of therapy clients. In the early years of my career, I pondered this notion of imposed therapy. I realized that many of the women calling were doing so only to comply with the request of their doctors or loved ones. This made me consider how important the superficial trimmings of a waiting room—the space that first greeted a reluctant postpartum woman in distress—might be.

The waiting area should be warm and inviting, but professional. It needs to suggest that we are experts while, at the same time, be unassuming and engaging. How do you do that in a room? The colors? Sage and beige—they work. The choice of furniture? Shabby chic is one good way to make sure nothing has to match. Magazine collection? I used to fill the rack with all kinds of intellectual materials so everyone would be impressed with my intellectual propensity. Now I only get Peoplemagazine because that’s all everyone, including me, wants to read, anyway. Guilty pleasure, they tell me—better than chocolate. Soft classical music, lots of creative writings, educational materials on postpartum depression, and a disclaimer framed on the wall, though admittedly insufficient, for women who have suffered a loss and must sit amid the pregnant and postpartum energy.

The walls of each office are covered with wallpaper rich in deep warm colors and framed images portraying women in varying emotional states. I love the way the office makes me feel each day I walk in. Every time I open the door, I feel how good it feels to be there.

I walked into my waiting area to greet Megan. Our first phone call was only hours ago that morning, so her disquieting sentiments remained fresh in my mind. As hard as we try to resist the temptation, most therapists probably make some assumptions about what someone “sounds like” on the phone, what they may “look like” in person, and what we might expect to see when we first set eyes on them. Will she be disorganized and symptomatic? Will she be demure and soft-spoken? Will she be resistant and hostile? Will she be dependent or demonstrative?

On this day 20 years ago when I was embarking on the profession that would shape the rest of my life, Megan demonstrated that everything I thought I knew up to that point would mean something completely different within the context of women and postpartum depression. It wasn’t that becoming a mother was a dramatically new concept for me, either personally or professionally. Rather, it was this notion of becoming a mother while weakened by depressive thinking. The two don’t mix well.

In its most simplistic connotations, motherhood is often synonymous with elation, joy, and anticipation shared by a couple on the sublime brink of parenthood. Take that dynamic force of life and love and overlap it with the hopelessness of depression and the heavy heart of a mother who is disconnected from her baby, and we are left with a raw, indescribable injury to a woman’s spirit and soul.

I wasn’t prepared for what I saw. Megan sat tall in the chair and stretched out her arm to firmly greet my welcoming hand. Her grip was strong and deliberate, something I regularly take notice of and often a fleeting sign of inner resourcefulness. Her auburn hair was cut short, very short, smoothed back with a peach colored band wrapped snuggly behind her ears. Her makeup was on, lipstick and all, button-down tailored shirt tucked neatly into her ironed jeans. Her fabric belt matched her headband, which I couldn’t help but notice matched her manicured nails. I daresay she had spent more time putting herself together than I did on my best day. Megan smiled a warm, I’m-so-happy-to-be-here-and-meet-you smile and followed me into my office.

In the moments that followed, I marveled at how she looked and, equally important, whyshe looked that way. This was no feeble effort on her part. It took time, thought, effort, and attention to detail that belied her state of mind. Surely this was not a coincidence.

I am forever a student of postpartum depression: observing the cues, studying the subtleties, trying to comprehend what sometimes makes no sense. Though it still strikes me as peculiar and something I would not have the strength to carry off, I am beginning to understand why it’s so important for women struggling with depression to look so good. There’s an undeniable loss of control that is so hard to bear that it forces women to make a choice between two options: give up completely or fake it. When giving up isn’t an option, creating an illusion of control becomes their sole driving force.

Megan was clearly being driven by such a force. As she spoke, I continued to be struck by how different she looked from what I expected after speaking to her briefly on the phone. She was so composed, almost rigid in her presentation. Her words, though spoken softly, were strong and poignant: “All I ever wanted was to have children. Ever since I can remember. I’m not so sure about that right now. I’m not so sure about anything. My sister wanted children, too. We used to talk about that, we used to play house together, both of us cradling our dolls against our breasts; she was mommy number one and I was mommy number two.” Tears hugged her blushed cheeks as she continued. “She never got to have children. She couldn’t stand the pain. She couldn’t save herself.” Megan lowered her head and sighed. Then held her breath and sat quietly.

“Megan, what happened?” I asked quietly.

“She couldn’t take the pain anymore.” She seemed to stop breathing,

becoming one with the still silence in the room.

“What happened?” I am certain I was holding my breath as well.

“She found my father’s gun. She knew exactly where it was. We all knew where it was. She was only 22 years old, sweet baby. It was 8 years ago. Seems like yesterday.”

Megan again sighed deeply and slowly through her nose, held her breath and let it out slowly and deliberately while she closed her eyes. Story after story, sh...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Table Of Contents
• Dedication
• The Author
• Foreword
• Acknowledgments
• Preface
• Part 1: The Framework: Women, Babies, and Therapy
• Part 2: The Tools: Doing What Works
• Part 3: The Work: Clinical Challenges
• Part 4 The Healing
• Appendices
• References
• Index