Middle Phase

During the middle phase (Sessions 4-9) we worked on resolving Ellen’s interpersonal problem areas. I continued to provide psychoeducation about PPD and to explore how it affected her social functioning, and I repeatedly linked her symptoms to her role transitions and role dispute.

During the initial phase, I identified Ellen’s old roles and acknowledged her sense of loss. Thus, I had already begun to encourage Ellen to mourn the loss of her old roles—an important task in helping patients with role transitions. We continued this discussion in the middle phase of treatment. I encouraged Ellen to explore how she could regain some of what she missed about her life before Sara’s birth. We explored how she could find time to exercise, go on dates with her husband, and spend time with other adults.

In one of the first sessions, Ellen asked me if I had children. I told her that I was happy to answer her question, but that her question was more important than the answer. She explained that she thought that if I did, then I “looked like I had figured out how to manage both a job and children.” She had wondered about how other women can “have children and a life” As IPT does not focus on the therapeutic relationship, I gently redirected the patient. I used this as an opportunity for exploring options and to encourage Ellen to reconnect with old friends and to form new relationships.

therapist: I do have children. It’s great that you are interested in learning about how other women meet the demands of motherhood. How can you learn more about what other new moms are doing?

ellen: I guess I could ask my friends who have children, but their children are older.

therapist: Great idea! Since your friends made it through this difficult time in the past, could it still be helpful to ask them?

ELLEN: I suppose so.

therapist: What could you ask them?

ellen: I guess I’d want to know how they managed to do everything when their kids were babies.

therapist: Great! What would it be like for you to ask that? ellen: I guess it would be okay. therapist: You sound hesitant.

ellen: I just don’t want to burden them and make them think I’m stupid. therapist: When people are depressed they feel down on themselves and, therefore, fear they will burden others when they reach out for help. In fact, getting social support from others is so important for improving your mood. You’re allowed to have needs too. Does this make sense? ellen: Yes.

therapist: I appreciate that we’re talking about your trying something new and different, but I bet you will be pleasantly surprised.

Role-playing asking her friends for help allowed Ellen to practice her communication skills, rehearsing the content and tone of what she might say, and to begin to feel more comfortable reaching out for support. I encouraged Ellen to explore options for meeting new mothers: “You mentioned that your friends have children who are older. What options do you have for meeting other new mothers?” Ellen said that she had heard of groups for new mothers getting together with their babies. She was concerned that the mothers in these groups would be much younger than she. We explored options for finding out about existing groups with women her age and possibly forming a group herself.

Ellen reported in the next session that she had spoken with a couple of her old friends. They were happy to hear from her and to share their experiences. When she admitted her embarrassment about her own and her apartment’s appearance, they reminded her that their homes were still messy and that they too had often not been able to shower when their children were infants. They agreed that carrying the remaining baby weight was frustrating, but assured her she would lose it within the year. They also reminded Ellen how helpful and supportive she had been to them when they had newborns and said that they would love to see her and help her out with her daughter. Ellen accepted her friends’ offers and scheduled dates for them to visit with her.

Ellen’s success in reaching out to her friends improved her mood. It gave her a greater sense of control over her situation and inspired her to reach out to others. She reported that after speaking with her friends, she began initiating conversations with women who appeared to be around her age and were mothers of a young baby. For example, she met a woman in her pediatrician’s office who invited her to a playgroup she was forming with a couple of other women.

I began each session by asking: “How have you been feeling since we last met?” This opening question elicits affect and an interval history of events between sessions. In one session Ellen responded, “‘I am so frustrated with Joe.”

therapist: Tell me more about that. What are you frustrated about? ellen: He still doesn’t help out enough with the baby. I wish he had more of a relationship with her.

therapist: Have you told Joe how you feel? ellen: Sort of.

I conducted a communication analysis, asking Ellen to recount exactly what she said to Joe, how she said it, his response, how that made her feel, and how she then responded. Ellen had called her husband at work to complain that she needed more help with the baby, but did not specify that she wanted more help from him. In response, Joe asked Ellen if she would like to hire a babysitter. Ellen explained that she wanted more help from him at night and on the weekends when he was not working, but felt guilty asking him because he worked so hard at his job. I pointed out it was great that she appreciated how hard he worked, but that she was working hard too. Her guilt was a symptom of depression. Furthermore, her husband would not be able to understand what she wanted unless she were specific about what she wanted. I empathized that it was difficult for her to assert her needs given her depression, and I suggested that we explore ways to communicate her feelings so that Joe might better understand her needs.

We role-played asking Joe to help her more with the baby when he was home. Ellen acknowledged that he worked hard, but avowed that she did too, and that she wanted him to take care of the baby so that she could have a break. She also wanted to share more of the experience of parenting with him. To Ellen’s surprise, Joe revealed that he would like to do more, but felt unsure of himself with Sara and needed more direction from her. He said that she was the “expert” in taking care of their child. Ellen said that her husband’s compliment made her feel good.

He also admitted that he missed spending time alone with her. Before Sara was born they would frequently attend work functions together and enjoyed trying new restaurants and going to art museums. Joe went out with colleagues a few times since the baby was born, but missed sharing the experience with Ellen. She realized that becoming a father was a big transition for Joe, too.

Ellen and Joe agreed that a babysitter would be helpful for her when he was work to give her a break. They also agreed that they needed a babysitter to take care of Sara so that they could go out alone. We explored options for babysitters. Ellen’s parents had offered to babysit more, but she had been reluctant. When I asked her why she replied:

ellen: I don’t want to bother my parents. Also, my mom is constantly telling me what to do with Sara. therapist: What do you mean?

ellen: My mom has spent a lot of time with my brother and his kids and she is always telling me how they do things. therapist: Can you give me an example?

ellen: The other day I was telling her that I am starting to try solid foods with Sara, and she told me that my brother has this little food processor that is really great for making baby food. therapist: How did that make you feel?

ellen: Annoyed. It makes me feel like she thinks I don’t know what I am doing and that my brother and sister-in-law are perfect parents. [1]

therapist: How did you respond to your mother? ellen: I told her Id think about it.

therapist: Have you let your mom know how you feel when she tells you about things your brother and sister-in-law have done? ellen: No, because she will just get defensive. therapist: What do you mean? ellen: She’ll say she was just trying to help.

I asked her if it was possible that, in fact, her mother was just trying to help, and she agreed that it was possible, but still annoying. I told Ellen that people often give unsolicited advice to new parents, but that when you are depressed it can be hard not to perceive the advice as criticism. Patients with depression are down on themselves and assume that others are down on them too. We explored options for responding to her mother’s advice and role-played. Ellen decided to tell her mother how she felt. Her mother admitted that she was eager to help her, particularly since she had been struggling with depression. In addition, Ellen’s mom had received very little guidance from her own mother or any of her peers when she became a mother and wanted to offer her daughter the support she wished she had been given. She assured Ellen that she thought she was a great mother to Sara. Ellen reported feeling better about clearing the air and gradually started asking for more help from her parents.

In addition to discussing what Ellen had lost, we discussed what she had gained by becoming a mother. She did enjoy her time with Sara and said that playing allowed her to be silly. She felt good that she was usually able to intuit what Sara needed when she cried and comfort her in a way that others could not. She also gained a new appreciation of her own parents and the challenges they faced raising her brother and her. They were younger and had fewer financial resources and supports than she did when they first became parents. Her parents were playful with Sara and able to take good care of Sara when she and her husband were out. Once she felt better able to communicate, she appreciated being able to spend more time with her parents than she could when she was working long hours at her law firm.

Ellen was increasingly excited by her new skills in speaking up with her husband, family, and friends. By Session 9, her score on the Ham-D had fallen to 12, consistent with mild depression, and her EPDS score to 12.

  • [1] wondered if, in fact, Ellen’s mother was being critical or if Ellen was being hypersensitive, which patients with depression can be.
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