Let’s take a look at what we are really doing when we treat a postpartum woman in therapy. Most therapists who are interested in pursuing private practice work have been trained with a clinical emphasis during their academic preparation. We were exposed to the conceptual psychodynamic framework and time-honored therapeutic traditions that have proven to make a significant different in the lives of clients to seek our assistance. We have learned about transference, countertransference, resistance, therapeutic alliances and boundaries. Most of us (I am hopeful it is all of us) pay careful attention to these concepts throughout the course of our daily work with each individual client. Much has been written about the therapeutic relationship and how it potentially guides an individual into new realms of healthy functioning.
However, this is time-consuming, costly and quite possibly the last thing a woman caring for an infant feels like doing. So again, as we highlight the notion that a postpartum woman is not interested in therapy, we shift our focus to what she does want. Symptom relief. Pure and simple. That’s it. She does not want to talk about how feelings of abandonment might be contributing to her sense of inadequacy. Nor does she want to explore how her impaired relationship with her mother has impacted her self-esteem. She wants to sleep, think clearly, feel less anxious and stop crying all day. She wants to return to her previous high level of functioning so she can get on with the business in her life.
Not far below the surface we discover a longing to reclaim her lost self or who she was before she had their baby. Alison was three months postpartum when she asked, “Will I ever feel like myself again? Will I ever feel normal?” This quest becomes a fundamental objective for the postpartum woman starting therapy. It will evolve throughout the process, without a doubt, but it remains her goal, all the same. She is not yet able to see the larger picture, that her attachment to the baby will develop as she continues to heal and her “old self” will be successfully absorbed into her new emergent self. Can and should this be interpreted and shared with her at this early stage? Would she even believe us if we assured her it would happen in due time?
After several weeks of treatment, Alison created her own expression for this time in her life. She called it a “new normal.” Life indeed has been changed forever, a concept that is hard to grasp while being bombarded with symptoms that make getting through the day feel impossible. While we may need to hold that secret that things will never be the way they were, to ourselves for a short while, in time, our journey takes her right there with us. Never the same, but usually, better. A new normal, indeed.
For the time being, however, at this earliest stage of our alliance, it’s back to basics: to achieve symptom relief, to encourage coping strategies and to facilitate healing.
I prefer to think of this initial phase of treatment as a sanctuary with structure. Women must hear, feel and know that they are:
Not being judged
Free to speak candidly
Not the only ones who have said these things
Not always going to feel this way
In a place that is familiar with what they are saying and what they are feeling
Protected from ridicule, criticism, and disapproval
Beginning the process of recovery and can expect relief from their symptoms
Being guided by an expert who knows exactly what to do to help them feel better
If you tell a postpartum woman she needs therapy, she may not come.
If you suggest she may have issues to work out before she feels better, she will find someone else to talk to.
If you tell her she will be agreeing to a once a week commitment for an unknown period of time she will tell you she has more important things to take care of right now.
For some postpartum women, there is even a slight revulsion from anything that may foster more dependence. This notion is complicated by the ambivalent feelings of mutual dependence with the baby as well as an overwhelming sense of responsibility. It can all feel like too much.
If, on the other hand, you tell her that your sole objective is to get her feeling better as quickly as possible she’ll feel cared for and enticed by the prospect.
There is a certain specialness that surrounds a woman who has just given birth. There is often so much excitement it practically entitles a woman to expected considerations and attentiveness. As a culture, we shower her with adoring praise and honor her achievement. And yet, if she struggles or admits discontent, she is cast aside, disregarded or patronized in some way, evidence of our inability to reconcile this seemingly contradictory aspect of childbirth.
Family, friends, doctors and nurses are often quick to minimize, “postpartum depression is very rare. You just need more sleep. You’ll be fine.” They may be right. But if they are not, the stakes are high and I, for one, am not willing to risk the life and emotional wellbeing of the mother by presuming she is fine until I know for certain.
So with all the obstacles, denial and distractions, why are women willing to seek out specialized therapists to help them during this demanding time?
Because they are exhausted and tired of doing it all themselves.
Because they are terrified and need to know they’ll get better and be okay.
Because they truly want to feel better, more than anything else.
Because they’ve tried to feel better on their own and it’s not working.
Because no one else is listening or understands how bad they really feel.
Because they are afraid if they don’t, they will feel worse and never feel better again.
So are we really doing therapy?
Not at the beginning we’re probably not. We are containing her symptoms and building a foundation on which she can begin to feel secure and cared for. We are establishing ourselves as specialists who can expertly lead her through the fog. This is the pitch we use to hook her into the process that will help her and it’s the commitment we make to her and to ourselves to ensure that it happens.
copyright 2013 Karen Kleiman
Adapted from Therapy and the Postpartum Woman (Routledge, 2009)