NOTE: Due to ethical and legal considerations, confidentiality is strictly upheld in social work practice; therefore this column articles depicting a therapy sessions is fiction. The characters and dialogue are solely imagined and not based on any clients so any similarities to anybody you know is purely coincidental. Although the information regarding post-partum is accurate, treatment in therapy may differ as it is individualized according the specific needs of each client, a therapist's orientation, and the unique relationship created in each therapeutic experience.
“But I don't understand how talking to you is going to help,” she says after she catches her breath.
As a therapist, my overarching goal is to help my client reach the functioning she wants to attain. When she asks this kind of question, I need to assess how much information my client needs. Is she just asking me to reassure her that I will be able to help her, or is she sincerely asking how therapy will work?
If she is actually asking how therapy works, and how specifically it will help her, how much information does she really need?
More importantly, I am an object relations therapist, and as such believe strongly that the success of therapy is strongly dependent on the therapeutic alliance that allows the therapeutic interventions to be applied effectively. If I flood her with information, it may at this time interfere with the therapeutic alliance that I have yet to establish with her.
In addition, I need to assess more carefully her symptoms in order to ascertain if indeed she is suffering from post partum depression, if she has a co-morbid diagnosis of post partum anxiety, and if the anxiety has any obsessive compulsive components.
I also need to know if she has any past history of anxiety or depression, if there is a family history of post partum depression or anxiety; and what supports she has or needs in her life to help her through this.
And so I decide to respond to her question with hope, some information, and a request for further assessment before giving exact details as to how therapy will help her.
“Therapy can definitely help you,” I say, “and it sounds like you are suffering from sadness that is commonly brought on by the birth of a baby. Before we make a plan of action to help you, I would need to know more about you and your background. Would that be okay?”
By asking her permission, I am empowering her to take charge of her own therapy, and not feel that the therapist, me, is doing anything without her consent. For someone who has never been in therapy, making that first step into therapy is pretty scary, considering the misinformation and misconceptions people have about therapy, and I want her to feel comfortable enough with me that she comes back for a second session. When people drop out of therapy, the greatest number drops out after their first appointment.
“I remember you had told me over the phone that you love your baby, but now you mentioned that you have little interest,” I say.
Chaya flushes, as if I had just accused her of a crime. “I do love her,” she protested. “Of course I love her! What kind of mother doesn’t love her baby? I just don’t have any energy for her.”
“You know,” I say conversationally, “There’s this big hype that the minute a baby is born, a mother bonds with her child. A mother is in labor for many hours, experiencing pain, exhausted, hungry, and then a second after birth, the nurse will wrap this little thing in a blanket, thrust it at the mother and expect the mother to delightfully start nursing her.”
I gauge Chaya’s reaction. She is silent, waiting.
“But not every mother bonds right away with a baby,” I say. “Sometimes it takes some time, and nobody ever tells you that. It can take a few days. Even a week or so until that newborn baby becomes a real person and a mother realizes how much she loves him. The weirdest thing is nobody talks about the father and his bonding to his baby. So there’s no pressure on the father to bond right away, or to announce how he loves his baby. It’s kind of expected that it will take the father some time.”
“I didn’t bond right away,” Chaya says, her relief at being so validated evident in her body language. “I felt so guilty that there was something wrong with me. And I don’t know if I ever bonded with her. It’s already six months and I just feel numb. I feel so guilty. She deserves a better mother than me. I should be doing a much better job and I just don’t think I can ever do this mothering thing. I don’t even know if I love her.”
By now Chaya was crying.
“So why don’t you just give her to your mother and let her raise your daughter?” I say, casually.
Chaya looks at me in horror. “Are you crazy?” she asks in disbelief. “She’s my baby! I would never want to give her away!”
“But it would be so much easier for you,” I point out rationally. “And you said you can’t take care of her, anyway. I’m sure your mother loves her.”
Chaya responds pretty much as I would expect. “Nobody can love her as much as I can,” she says indignantly. “Only I can nurse her. I’m her mother and nobody can change that!”
“Chaya,” I say. “Listen to yourself. Did you hear what you just said? When I challenged your ability to be your baby’s mother, you came back fighting. Of course nobody can love your baby as much as you can. It’s possible you feel numb, it’s possible that you need to get better for your child, but right now you are doing the best you can, especially as you have come to get help in therapy. It will take time, but you can do it.”
It’s true I had taken a risk here, in challenging Chaya that it would be better if she left her baby with her mother to raise, but if Chaya would have been that numb and depressed as to agree with me, I would know the situation was more serious that she had been presenting until now, and the baby may have been in danger remaining with Chaya. I would have had to assess that danger and make a decision to break confidentiality to reach out to her husband and/or her mother to keep the baby safe.
My challenge served to make Chaya aware of her love for her baby, and awaken a determination to get well to be the mother her baby needed.
Somewhere in this exchange, I am conscious that I have made a connection with Chaya and know she will come back to therapy. I have given her a very important gift. She had been secreting doubting herself that she loved her baby, especially since she may have bought into the myth of the instant mother-infant bond, and felt inadequate when it did not occur immediately in the labor room. Now she knew she loved her baby and could expend her energies finding out why, if she loved her baby, did she have so little interest in taking care of her.
“I can’t stop crying,” Chaya says. “I cry all the time and I don’t even know why.”
I allow Chaya to talk, listening for more symptoms of post partum depression.
“I have no appetite and I can barely eat. I have a hard time sleeping, and when I finally fall asleep, I wake up a few hours later and I can’t go back to sleep again. Then during the day I am so tired but again I can’t relax enough to sleep. I’m all wired up. My mother keeps making me food to eat but I am not hungry and everything tastes like cardboard. Or sand,” Chaya says. She talks through her tears, desperate to make me understand.
I want to assess her ability to do tasks, so I ask, “What do you do in you in your free time, when your mother is taking care of your baby?”
“I can’t concentrate on anything anymore,” Chaya confesses. “I used to be able to read, or play Scrabble with my husband. I can’t use my brains anymore. It’s as if it turned to mush.”
“Do you work outside of your home?” I ask.
“Yes,” Chaya answers. “I work as a school secretary.”
Her answer surprises me, but I do not allow my surprise to show.
“You are not going to believe me,” she says, “but nobody in school knows I’m going through this. They think I am a great secretary. I have an easier time concentrating away from the house, but even in school, I feel like I am walking in a fog. It’s just that it’s my third year working there, so I’m a lot on autopilot.”
“So that’s amazing,” I say, with respect. “You are suffering from post partum depression and yet you manage to function in a work setting. Not everybody can do that.”
I see I have given Chaya another gift.
It’s easy for her to criticize herself, but she has not paid attention to her strengths, how she has kept her job despite her suffering.
It’s a good place to stop the session and I tell her so.
“Our time is up,” I say. “Would you like to come back for another session?”
“Do you really think I can get back to the way I was before the baby?” she asks as she removes her money from her pocketbook to pay me.
I owe my clients the truth, and so I do not lie when I answer her question.
To be continued….
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