You & Me and Our Therapist Makes Three
It is difficult to convince a postpartum woman to go to therapy. Whether or not she is depressed, a new mom is exhausted, overwhelmed and preoccupied with her new baby. Understandably, early motherhood is not the best time to introduce a therapeutic-relationship or impose a healing process that is time-intensive and costly. However, if her symptoms become worse after the baby is born, if she is experiencing intrusive or distorted thoughts, or if she is suffering enough, then she needs help and there may be no choice, but to get help right away. But how do you encourage her to engage in therapy?
Many postpartum women begin therapy at the urging of partners and loved ones or are dutifully following a referral made by their obstetricians or pediatricians. Most of these women enter therapy with a desire to be better for their babies and their families. Very few enter therapy willingly or for themselves. Therapists who are trained in Perinatal Mood and Anxiety Disorders (PMADs) and who are familiar with this population, can address a mother’s resistance and convince her that the road back to herself is worth the exhausting effort of therapy, whether she believes this or not.
If you or someone you know is suffering from postpartum depression or postpartum anxiety, you face two initial challenges: 1) deciding that you need therapy and 2) finding the right therapist. For clarity, I am going to describe some evidence-based therapies used to treat postpartum mood and anxiety disorders. This will help you make the right decision for your family.
Cognitive Behavioral Therapy (CBT):
CBT is one of the most widely used therapies for treating depression and anxiety. It has proven to be effective in treating postpartum depression and anxiety. CBT theorizes that the way you think affects the way you feel. CBT treatment with a postpartum woman is focused on helping the mom have control over her thoughts so that she can change them. This is especially effective with intrusive, distorted and obsessive thoughts.
When I am working with a mom, I help her identify and acknowledge her automatic thoughts, (“Something bad will happen to the baby, if I take her out of the house”) evaluate the evidence supporting and opposing these thoughts, (“Nothing bad happened when I took her to the pediatrician last week”) exploring and challenging unhelpful thoughts and underlying beliefs, (“I feel like I am not capable of keeping her safe when we are out of the house”), and developing a new and more helpful perspective, (“While I have a distorted fear about leaving the house with my baby, I actually am capable of keeping her safe and it important for both her and me to leave the house.”) Using CBT, I help a mom to develop effective coping skills so that she feels better equipped to manage her distress and anxieties.
Interpersonal Psychotherapy (ITP):
ITP is thought to be one of the most effective therapy models for treating maternal distress, such as postpartum depression, as it is directive, time-limited. The primary goal of ITP is to provide symptoms relief. ITP can be used with couples to help improve communication and build a stronger and more supportive relationship. I like to use this type of model with individuals and couples. When I use this form of treatment with my clients, I address four main areas:
- Grief: Grief acknowledges losses; these can be the losses that occur to your sense of self, losses or changes in relationships or more specific losses. We don’t always talk about the grief that comes with being a new mother, but it is important to acknowledge that adding a new baby to your family also brings a sense of loss.
- Role Transitions: Role transitions refer to life stage transitions and social transitions. This is a big one for new moms (and dads) who are transitioning to parenthood. All new moms are required to reconstruct themselves in some way in order to meet the demands of a new baby.
- Interpersonal Disputes: Interpersonal disputes occur frequently after the birth of a new child and can include unmet expectations and intimacy struggles within partnerships. When partners are involved in treatment, they can address and explore conflicts that occur around the challenge of having a new baby. See Part I.
- Interpersonal Deficits: Interpersonal deficits look for struggles with attachment in other relationships, which may be causing distress. The birth of a new baby can complicate a mother’s attachment to her own mother. In therapy, she can explore how these attachment issues may or may not be causing her distress.
Solution-Focused Therapy is a goal-directed collaborative approach that focuses on solutions rather than problems or past failures. Therapy focuses on the mom’s strengths and skills. She sets goals and focuses on solutions. When my client’s main complaint is that she is exhausted and overwhelmed, I help the mother look for opportunities where she can increase sleep by having a partner take on a night-feeding, asking for help from family or friends or finding times during the day where she can rest. We focus on increasing the mom’s overall wellness to address and decrease maternal distress.
A postpartum depression support group combines psychoeducation, which can range from teaching about maternal mental illness to life strategies to typical new mom distress, with validation from other group members who may be experiencing something similar. The goal of PPD support groups is to build a community and give a mother the space to be heard by others who are experiencing similar struggles. The mother is helped and feels less alone.
Couples therapy brings both partners into therapy and focuses on the couple’s relationship, not only the individual issues. This helps the person suffering from postpartum depression to feel like it is not just her problem. The partner has a supportive and active role in the treatment process. There is also the opportunity for the partner to accept and receive help. In my work with postpartum couples, we address issues related to PMADs, as well as addressing changing dynamics in a relationship, discussing the decrease in romance and intimacy, improve communication and restore the couple’s connection to one another. We do this by providing a space for the couple to hold and validate one another’s thoughts and feelings without rushing to “fix” it right away, which can often feel dismissive.
There are many benefits to individual and couples’ counseling. Starting therapy as a couple may feel less threatening or blaming for the individual who is suffering. A marriage counselor can help the couple explore thoughts and feelings about their new family in a non-judgmental environment that is safe. After the birth of a baby, couples can have difficulty working together and can lose the connection with one another. All of this can be addressed in therapy and explored in a way that protects the sanctity of the couple’s relationship.
Four reasons to see a marriage counselor:
1. Partner support is associated with better outcomes
There is a well-known link between a supportive partner and postpartum depression; however, perceived support within the context of postpartum depression can mean different things to different people. Some women feel supported by their partners and are open about how they are feeling. Other women withdraw from their relationships and reject any emotional connection their partner attempts to provide. Sometimes the depressed partner is so good at hiding how she is feeling that her partner is in the dark. And other times, women are reluctant to ask for help from their partner out of guilt and fear.
A therapist understands that depression places an unintended strain on any marriage. The therapist makes sure both partners get the support that they need provides coping tools for them to use outside of session.
2. Help the non-depressed partner understand the changes that mom is going through and learn what is most helpful in supporting her.
Most people don’t expect a new mom to become depressed after the birth of her new baby. It can be disarming and confusing for partners, who anticipated a joyful experience. Many partners find themselves unprepared to cope with the feelings of their wife’s depression.
Therapy can help this partner understand what is happening to their family. Therapists can provide psychoeducation as a way to normalize, strategize and provide hope in this situation. Therapists can also help the partner learn the words and behaviors to best support mom as she finds her way out of depression.
3. Improve communication
The way that couples communicate and the way that they listen to one another is essential to a healthy relationship. Sometimes fears, ambivalence, guilt, and shame come up. Partners can learn to communicate their feelings effectively and respectively. One of the most effective things that a therapist can offer in couples treatment is to acknowledge the couple’s shared struggle and help them find the words and space to talk about it.
4. Restore romantic and sexual connection
Restoring a couple’s connection to romance, to sex and most importantly to each other is the foundation of couple’s work. A therapist can help the couple restore the connection that they had prior to the birth of their baby. That is to say, not the current relationship as it exists now, but rather the couple’s connection that has carried them throughout their relationship and supported them through difficult times previously.
A woman, who is suffering from postpartum depression or anxiety, knows that something is not right. She knows that this doesn’t feel like her. But usually, she doesn’t say anything. She might think that there is something inherently wrong with her; she might feel worthless or guilty for wanting a child and now feeling ambivalent about her new role as a mother, or worse, she may believe that this is just what motherhood feels like.
As partners, friends and family members, it is up to you to get her to go to therapy if she is unwilling to go herself. She may hope that the symptoms will go away on their own. She may feel embarrassed that this is happening to her. PMADs is a serious mental illness. No one asks to be depressed or anxious after a baby is born. What she needs to understand, and what the people around her need to convey, is that this is not her fault, she is not to blame and that help is available.
Gagnon, C. (n.d.). And baby make 3: A marriage counselor can help you adjust to your new life and keep your marriage strong. [Blog post]. The Couples Expert. Retrieved from https://www.thecouplesexpertscottsdale.com/2014/05/5-reasons-see-marriage-counselor-postpartum-adjustment/
Grigoriadis, S. (2007). An approach to interpersonal psychotherapy for postpartum depression: Focusing on interpersonal changes. The College of Family Physicians of Canada, 53(9): 1469-1475. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234626/
Hibbert. C (n.d). Postpartum Depression Treatment: 10 things you should know & 10 things you can do. [Blog post]. Retrieved from http://www.drchristinahibbert.com/postpartum-depression-treatment/postpartum-depression-treatment-for-couples/
Kleinman, K. (2015, November 7). Are you treating a postpartum woman in distress? [Blog post]. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/isnt-what-i-expected/201511/are-you-treating-postpartum-woman-in-distress
Kleinman, K. (2016, January 3). Postpartum women and therapy? Replace pathology with purpose. [Blog post]. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/isnt-what-i-expected/201601/postpartum-women-and-therapy
Kleinman, Karen (2014). Therapy and the Postpartum Woman. New York, NY: Taylor & Francis Group, LLC.
Kleinman, Karen (2013). This isn’t what I expected: Overcoming postpartum depression. Boston, MA: De Capo Press.
Kripke, K. (n.d.) 8 types of psychotherapy for postpartum depression treatment. [Blog post]. Retrieved from http://www.postpartumprogress.com/8-types-of-psychotherapy-for-postpartum-depression-treatment
O’Hara, M.W., (2018). ITP for perinatal depression. Interpersonal Psychotherapy Institute. Retrieved from https://iptinstitute.com/ipt-for-perinatal-depression/
O’Hara, M.W, Stuart, S., Gorman, L. L. et al. (2000). Efficacy of interpersonal psychotherapy for postpartum depression. Jama Psychiatry, 57 (11). Retrieved from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/481669
Weissman, M.M., Markowitz, J.C., Klerman, G.L. (2007). Clinicians Quick Guide to Interpersonal Psychotherapy. Oxford, NY: Oxford University Press.