Ellen’s case includes some of the issues that often arise in treating women with PPD. Other important issues frequently affect the postpartum transition. While Ellen struggled with her new role as “just a mom,” women who return to work after having a baby often struggle with incorporating their new role as mother with their old role as employee. They describe feeling unable to do a good job at work or at home, feel guilty about not spending enough time with their children, and feel they are failing at their jobs. The return to work is yet another role transition. I help these women evaluate and readjust their expectations of themselves as mother and as employee. When appropriate, I encourage patients to mourn the loss of being able to give their job “110 percent” and help them learn to set boundaries with their work in a way that they felt unable to before having a child. Ultimately, these patients often find themselves being more efficient at work because their time is more limited, and feel empowered being able to set a boundary between their career and family.
I have worked with a number of mothers whose babies were born prematurely and with medical complications, and were treated for weeks in a neonatal intensive care unit (NICU). I have conceptualized these cases as role transitions but identified the role transition as the transition to being a mother of a sick baby. I help these women mourn the loss of their wish for and fantasy of having a healthy newborn. Some new mothers struggle with babies who are difficult to soothe or have difficulty sleeping or feeding. Some women develop major depression in the setting of having their second or third child, struggling with taking care of more than one child and the changes this causes in their relationships with older children.
Ellen’s husband was very supportive of her. Other women report more marital discord or even abandonment by the baby’s father. Some report ambivalence towards their new baby because he or she is related to a father who is absent or abusive, especially if the baby resembles the father. New mothers who report that their pregnancies were unwanted or unplanned also struggle with ambivalence about their baby and regret about not terminating their pregnancy.
Having children often activates feelings and thoughts about one’s own parents. Women who are adoptees may experience increased anger at their birth parents and a greater appreciation for their adoptive parents. Experiencing the bond with their own biological child makes them wonder how their parent could have given them up. On the other hand, others who now appreciate the challenges of parenthood may better understand the decision to give a child up for adoption.
Single mothers by choice report struggling with isolation and not being able to share the experience and child care responsibilities with a partner. They often fear being criticized for their decision to have a child on their own and have difficulty reaching out for help.
Similar issues arise when working with women who are depressed during pregnancy. However, working with women antepartum is an opportunity to anticipate and address these issues, prepare a woman for the transition to motherhood, and treat depression before giving birth.
Working with women with perinatal bereavement presents additional challenges. These women often describe traumatic pregnancy losses that can be difficult for the therapist to hear about. Telling the story of the loss is generally cathartic for the patient, who may not have shared the story with others for fear of upsetting them. Addressing the social isolation among women with perinatal bereavement can be particularly challenging for the IPT therapist. These women often have peers who have children or are pregnant, and they report feeling very uncomfortable being around them. Nevertheless, the IPT therapist can help them reconnect with peers and form new relationships. In some cases, augmenting IPT with a pregnancy loss support group can be helpful. The IPT therapist instills hope that the patient will recover from her depression, but cannot promise that a woman will get pregnant again; in some cases, pregnancy loss leads to the diagnosis of a fertility problem. While this provides some women with hope that they will be able to carry a pregnancy to term, they may also mourn the loss of conceiving or carrying a child without medical intervention.
Like Ellen, depressed pregnant and postpartum patients often want to know if the therapist has children. They explain that a therapist with children is more likely to relate to the challenges of pregnancy and motherhood. I explain to patients that while there are common experiences among new mothers, each woman’s experience is unique and our goal in therapy is to help each woman identify her feelings and thoughts about motherhood and the options that will work best for her to manage the transition. Conversely, in my experience, the majority of patients who have experienced a pregnancy loss do not want to know if I have children. They report that if I do have children, I can’t appreciate their emotional pain. Furthermore, they feel that they cannot feel comfortable expressing jealousy and anger towards other people who have children. A therapist’s pregnancy affects patients in different ways. Among patients who have experienced loss, the therapist’s announcement of her pregnancy can result in a therapeutic rupture or even termination of the treatment. For those who are pregnant or postpartum, a pregnancy can evoke competitive feelings with a therapist. The IPT therapist does not focus on the transference, but she does encourage the patient and compliment her efforts to express her feelings.
It should be noted that pregnancy, pregnancy loss, and the transition to parenthood affect men too, and they are also vulnerable to depression during these times. In fact, they struggle with many of the same issues that women experience. However, the literature on peripartum mood disorders and the mental health community have historically focused on women, and men are generally less likely to seek treatment. In recent years, PPD in new fathers has started to be acknowledged in the media and by mental health professionals. IPT would be a great option for these men too.
Many factors can influence a woman’s experience of having a baby and make her vulnerable to depression during the peripartum period. While there are common themes among women with peripartum depression, each woman’s experience with pregnancy, motherhood, and pregnancy loss is unique and can be addressed
Bennett S, Indman P: Beyond the Blues: A Guide to Understanding and Treating Prenatal and Postpartum Depression. California: Moodswings Press, 2003 Jaffe J, Diamond MO, Diamond DJ: Unsung Lullabies. New York: St. Martins Press, 2005
Kohn I, Moffit PL: A Silent Sorrow. New York: Routledge, 2000 Leon IG: When A Baby Dies. New York: Ballou Press, 1990
Shields B: Down Came the Rain: My Journey Through Postpartum Depression. New York : Hyperion , 2005
Stone SD, Menkin AE: Perinatal and Postpartum Mood Disorders: Perspectives and a Treatment Guide for Mental Health Professionals New York : Springer Publishing , 2008