A psychotherapeutic approach to an event in a person’s life focuses on acknowledging all that the person experiences within the context of the person’s life.
It is thus a field/phenomenological approach.
This means that as many factors regarding the mother’s experience and her social environment are taken into account in assessing the system including the mother and finding ways to ease the distress.
Some questions requiring an answer may be the following:
What is the mother’s physical health status?
Is the baby healthy?
How was the labour and birth?
Was there a previous history of depression?
Who are the significant others in the mother’s life and are they psychologically present?
Such information colouring the particular experience of childbirth must be seen in the light of the life-giving experience that is also a major and swift change in the life of the person for which no one is ever well-enough prepared.
The only thing a woman may be prepared for is to be surprised!
Naomi Stadlen (2004) states that the one common factor in the description of mother’s experiences is in fact, SHOCK.
There are many rites of transition inbuilt into culture such as: marriage, baptism, confirmation etc.
When we fall in love, for example, popular culture eases us into our role. There is much poetry, prose, films and songs. In our daily life we are presented continually with images of couples meeting dating and marrying. This is not so with the reality of having a new baby.
Stadlen describes a lullaby where a mother is finding great difficulty putting her baby to sleep. The lullaby involves passing the baby to her sister and then to her own mother and then to her grandmother and so on…it goes on and on and there is no end to it.
This lullaby gives very useful information. It sings of mothers who are muddling along, experimenting, exploring this new experience. It teaches that the mother does not instinctively know how to automatically settle her baby, nor have the other women got some superior wisdom that she has not.
Popular cultural messages on the other hand give the impression that mothers must know exactly what the baby wants and when and must know how to soothe him or her at all times. Mothers must also be joyful now that they have given birth to this wonderful little person.
In actuality the new mother is usually a person who has been through so much physically and emotionally in a short time and some of this has been far from pleasant.
She may have had surgical intervention such as a Caesarian Section; she may have had an episiotomy, not to mention the number of times she has had external and internal examinations. Many of these interventions are necessary and viewed as necessary by the mother but they are nonetheless invasive and distressing to the mother who may experience, rightly, a loss of control and loss of ownership of her body-self.
She also has been interacting with a number of different professionals within the health system who have been treating her in different ways and giving her lots of different messages. Some of these encounters may have been sensitive and others may not.
Different personalities respond in different ways to such events. The more robust women come through relatively unscathed. They tell the tales philosophically and are satisfied with their responses to the challenging event. Other more sensitive ones do not do so well and are more prone to developing depression.
Yet other normally robust women have faced very distressing situations such as pre-natal or birth complications, problems with their new-born such as disability and perhaps even stillbirth.
Together with the usual losses experienced such as loss of usual body parameters, shelving or loss of career together with collegial support, loss of free time, loss of time with partner, lack of sleep, loss of energy for personal pursuits, there may also be the loss of the baby or the loss of the baby she dreamt of. (in the case of disability)
In these cases it is not surprising that the woman is depressed.
But how is depression conceptualised in psychotherapy?
We can answer this by considering what is understood by psychological health.
healthy person is one who is aware of his or her needs and knows how to reach out to contact the environment to get them met. In doing this a person also takes into account her own limitations and those of others.
If the person blocks her own process of movement towards satisfaction, life becomes dull, confused and painful. (Perls, 1955, 1986)
Let us consider the case where the birth has been particularly difficult and the woman has had little encouragement and understanding from her partner. She is expected to put it all behind her and manage the family and new baby without addressing all her pent-up feelings of loss, pain, anger and maybe even shame and guilt at feeling these difficult feelings.
She may respond by disowning the body experience or parts of the experience. When she says “I” she refers only to her mind, the body becomes the disowned self. She is split in two, an “I” consisting of thinking and verbalizations and an “it” which consists of feeling and nonverbal expression.
What happens is that the woman cannot experience her feelings, she fears to feel them because she believes she may be overwhelmed or because there is no place for them in her life situation – she is just too busy to pause and experience her feelings. So she blocks them, she is dull, confused, apathetic, tired and looks and feels numb and lifeless.
She has given life and her own life seems to have no meaning.
Post-natal depression is in this sense a creative adjustment following a traumatic situation. The experience is overwhelming so there is a kind of systems shutdown with certain signs: sleep problems, eating problems, apathy, slowness, tiredness, weepiness, etc.
What has happened to this woman’s sense of herself?
In depression she has lost her sense of herself as an
‘active process, a deliberateness, experiencing wants, interests, and powers that have a definite but shifting boundary’.
A woman may not feel able to engage herself fully in asking:
‘What do I need?’
‘How do I feel about what’s happened to me?
‘Who am I in relation to my baby and my family?’
If she is not able to contact herself in order to recognize her needs she cannot reach out to get them met. If she does not know, for example, that she is lonely spending long hours on her own with her baby, she will not call her sister or her friend to ask them to come and spend some time with her.
Depression may thus be conceptualised as a breakdown in self-support and environmental support.
The psychotherapeutic relationship may help in several ways.
The main way is that it may provide the opportunity for nourishing contact, the support to bolster her self-support mechanisms which she may have ‘forgotten’ or is underusing in the new situation.
The psychotherapeutic space is one where the woman may be free from expectations to be joyous and grateful. She may tell her story of what exactly happened to her, what the doctors and midwives said, how her partner reacted….all the details of her experience to someone who will take her seriously and receive respectfully what comes from her.
If she recognises that what she says is important to the therapist since she is genuinely interested she may offer also some indication of how she felt so that some integration of her experience may start. Worries, fears both rational and irrational, anger for the husband, anger at hospital staff, anger with God, may be said out eventually as the person describes how she would have preferred things to have been.
A mother with post-natal depression may be quietly mulling over many distressing scenarios.
Some examples May be:
Now everyone’s happy at last – I have delivered!
What about me? Who cares about me?
Of the husband she might think: Now I gave him the baby, does he still want me?
In this state she may be sad and very lonely, feeling she has to carry all the burdens on her own.
In therapy, Introjects (messages as to how she should or should not be) may be examined. She may become clearer about what she believes and thinks about things especially pertaining to the baby. Wellwishers may have innumerable and varying bits of advice which may confuse the mother so that she doubts herself and her ability to cope.
In this way the therapist psychologically holds the client. The therapeutic relationship is the container for all the upcoming contents including difficult emotions.
The therapist’s task in depression – the breakdown in self-support – is to facilitate the woman’s experience of her contact functions, her main source of her self-support. Contact functions are the ways we experience the world around us. We do this through our breathing, seeing, hearing, touching.
A therapist trained in observing human phenomenology, may notice shallow breathing patterns for example.
This may be pointed out and the awareness may encourage the woman to breathe deeper into her lungs, receiving more oxygen and thus feeling better. She may be looking away from the therapist, at the floor for example and awareness of this may help her notice the therapist’s gaze as sympathetic and accepting. She may also refrain from hearing certain positive caring messages or noting differences in voice quality of the therapist and when this is pointed out by the therapist, she may choose to make some changes towards becoming more contactful with the therapist and thereby receive nourishment for herself. In this way she may get some insight into how she might get nourishment from other significant people in her life.
Other foci of observation may be facial expressions, body postures, and movements which when pointed out to the woman may bring her in touch with blocked emotions which may then be released, thus providing some relief.
Other aspects of therapy which may help are breathing activities, body work, identification activities, fantasy dialogues and of course group work.