by Patricia Allen-Garrett
It’s amazing the perspective time gives. I forget this sometimes as a therapist; however, being a client again reminds me. I never thought I would be able to look at the most difficult time in my life with any perspective; it is this remembered truth that keeps me on track with my clients.
Some years ago, I wrote in Inside Out (Allen-Garrett, 2009) of the death of my best friend by suicide. I struggled to come to terms with that article because I usually write academically/theoretically, but in it I allowed myself to combine personal grief with a study of grief and its application in therapy. There has been no conflict in my heart this time – I make no apologies for the personal aspect of this article. This is my journey, just as it is the journey of far too many women.
This article has three aspects, firstly, facts about post-natal depression (PND); secondly my own journey including therapy, the good, the bad and the useful, and thirdly, how we as humanistic therapists can help mothers with and without PND. It is also an imploration of all person-centred therapists to be aware of the signs of serious distress and to remember that non-directive does not equal non-action-taking.
Post-natal depression – what is it?
PND describes feelings of depression and/or anxiety after having a baby. Clearly having babies brings huge change to parents’ lives with many feeling unsure of their new circumstances. Generally, for approximately 50-85% of women, this changes after a couple of days to a couple of weeks (MGH Centre for Women’s Mental Health, n.d.) and is about adjusting to having a new baby. But for mothers with PND things do not get better within a short period of time and life can become extremely difficult. The timescale for PND to develop is generally within the first few months up to a year after birth but it may start at any point before or after delivery.
What are the possible causes of post-natal depression?
It seems that there is no one cause but rather influencing factors. These include:
- Birth experience: traumatic/difficult birth and/or birth that wasn’t as good or was different from what was expected.
- Having premature baby/babies.
- Hormonal factors post-delivery.
- Recent stressful events in a mother’s life, for example, bereavement or a serious illness. In addition, women who are isolated from their families or without a supportive partner can be more likely to suffer depression after birth.
- A previous history of depression.
- Images and expectations of motherhood: popular images of motherhood suggest mothers should be radiant, energetic, and living in perfect homes with supportive partners. Mothering is perceived as instinctive, not something to be learned. Therefore, women who find the weeks and months after childbirth difficult often imagine that they are the only ones not coping. This can lead to overwhelming feelings of inadequacy, a sense of failure and isolation that can contribute to deep emotional stress.
- Sleep deprivation (Postnatal Depression Ireland, n.d.).
The statistics tell us that 10-15 women in every 100 are affected by PND (Association for the Improvement of Maternity Services, Ireland, n.d.). In the case of mothers of multiples “approximately one in five mothers of twins and triplets are diagnosed by their health professional as suffering from postnatal depression” (Fraser, 2010: 4). Importantly, however, PND responds quickly once it is addressed in good time.
So how do we feel with post-natal depression?
Persistently very low mood and/or mixture of moods changing from low to high and even elation can be present. Many women feel irritable, angry and/ or exhausted all the time (beyond the usual fatigue new mothers experience). Many experience difficulty falling and/or staying asleep, even when there is the opportunity, because of worry. Many report losing interest in themselves and/or not feeling close to the baby/babies. Anxiety is very common as is the feeling of no longer wanting ‘this’ life. Women may not want to engage with others as well as experiencing changes in or loss of appetite and sex drive. Women very often report feeling utterly overwhelmed and unable to cope.
Post-natal anxiety (PNA)
Much debate exists as to whether PNA is a different disorder to PND. Regardless, PNA affects women both in pregnancy and after delivery. It has many of the same factors as PND and additional factors, such as having had IVF and babies in a Neonatal Intensive Care Unit (NICU), are thought to influence it. According to Nurture the symptoms span from:
Constant worrying about the baby, parenting skills, partners’ parenting skills, the future, to feeling dread and having racing thoughts. Physical symptoms like dizziness, hot flashes, sweating, rapid heartbeat, rapid breathing, nausea, stomach and digestion problems, tight chest or throat and/or tension headache, feeling you need to be holding or with your baby all the time, feeling afraid to be alone with your baby, feeling like you have to be in control of every situation.
My meeting with post-natal depression
In 2014, following one miscarriage and three unsuccessful IVF treatments, I became pregnant with twins. As I started to bleed early I was scanned frequently. At seven weeks, following a bad bleed, the nurse told me one of the babies had died – which, although sad, she said was probably a good thing as twin pregnancies were ‘complicated’. Maybe so, but I grieved the little life that had been lost. Less than a week later the next scan re-found that little heart beat! I was thrilled and confused all at once. I began to worry what would happen at the next scan, the next blood test, the next appointment? I know now this anxiety was a huge factor in what happened after the birth.
Constant nausea until two weeks before delivery, worry about bleeds, and from week 21 concern about the disparity in sizes between my pair made this pregnancy difficult. During this time many female clients told me of their pregnancies, of losses they had never brought up before in our work, of abortion, of traumatic deliveries. It was as if my pregnancy opened up a whole new connection with women I worked with. Even then I had a nagging question around why this wasn’t talked about, but I had so much to be concerned with myself that I let it remain as just that.
At 26 weeks my consultant was getting concerned about one of my ‘littleys’. He estimated her size as ‘tiny’ and every two days I would hold my breath while he re-calculated measurements, looked at their head and belly circumferences, tried to get my blood pressure regulated. At 30 weeks I was admitted and due to reverse blood flow to my smallest twin had an emergency C-section.
Ten doctors, nurses and paediatricians, my husband and I awaited these two little ones. I was told to prepare myself as ‘the outcome might not be good’. At 3.54 p.m. my son was born at 3lbs 4oz and at 3.56 p.m. his little sister entered the world weighing just 1lb 9oz. For the next seven weeks, the NICU and Special Care wards were our home. We lived in a maze of monitors, alarms, respirators and incubators. Once again I found myself holding my breath as I rounded the corner each time to go through the alarmed doors.
I look back on photos of two little people, and yet my tiny daughter was the one who only needed 15 minutes of help breathing as opposed to a day for my little boy. She contracted jaundice only once while her poor brother was repeatedly sunbathing under the lights! As determined as she had been to live, she seemed determined to show the world she was okay and feisty.
After seven weeks we were all home. That should have been an amazing time, but for me it wasn’t. It was the start of a hell that I now know began during pregnancy and with all I had in me I forced that anxiety down. Sleep deprivation was huge, I was expressing eight times a day with no more than an hour-and-a-half sleep in any one stretch. Reflux entered the fray. But more than this, my obsession to ensure everything was ‘right’ took on epic proportions. Life became a military operation with time as its Sergeant Major dictating what happened. It was my only way to protect these two little lives that I was now responsible for. Very soon, every cry became something to worry over, every feed recorded. I knew I needed to cut down on expressing because I was so exhausted but all the medics told me they wouldn’t tolerate formula so I became panic-striken at the thought of it. The GP came up to me, she recommended anti-depressants. I fought her, eventually took them and felt like a failure.
My twin sister saw me going through this emotional and physical decline and, along with three amazing friends, came over to help with feeds. By this time I couldn’t sleep even when I didn’t have to feed because I was so scared. Within those 11 weeks I lost four stone in weight, panicked when my husband (who was at home fulltime) left me even to have a shower. I started to dread waking up from the very limited sleep I was getting. Within 11 weeks I became suicidal. The shame I felt was huge. I work as a group facilitator with people who are actively suicidal or contemplating suicide. I couldn’t put in place any of the things that have been proven to help, I could only sit and cry in terror and despair.
I found a humanistic therapist who specialised in PND. My experience was dreadful. I was told to breathe, walk, sleep and spend time as a family. I know now these suggestions are useful for mild-to-moderate PND but not when PND is severe which mine was. The therapist failed to understand I was terrified my babies would die. There was no understanding of the terror, just blanket suggestions. I know I was a difficult client – so agitated I couldn’t even sit. I paced and it was a relief when the hour was up. Our only agreement was both acknowledging I wasn’t going to take on her suggestions. I couldn’t. I wasn’t capable of taking in information at that point. I left far worse than when I had gone in because whatever hope I had slipped away as the therapist told me there wasn’t much point in scheduling another session. My shame was compounded even further. The fear I was going mad and nothing could help was now a reality.
A week later I saw a psychiatrist. Two weeks later, on Easter Saturday, I was hospitalised in St Edmondsbury’s with a dual diagnosis of severe PND and PTSD. More crying, more shame. My sister likened this to my own Calvary.
I will never forget my experience within the hospital and what I learned from some patients. There is something surreal about sitting in a dining room knowing no-one and yet feeling a connection with the pain that existed there. I met many women who, although hospitalised for other issues now, had previously struggled with PND. I was humbled and amazed at the strength of some of the patients I came to know. I discovered the battles so many fight silently and secretly. I came to utterly understand the importance of a kind word and saw incredible humour and fortitude.
With the help of the correct medication, therapy (that I fought for) and much needed rest I began to recover. In our first session, the family therapist said she didn’t know when but she knew I would get better. Even though I was doubtful I clung to that hope and on really bad days I reminded myself of it and then slowly I began to feel it. During that time, I developed a grudging respect for my psychiatrist. I initially deplored his authoritarian way, his refusal of therapy. In time he shared his reasoning for this; his belief my depth of shame, combined with my physical depletion, not to mention my ‘over-achieving’ personality, would be a recipe for disaster with therapy and I needed to rest first and foremost. After three weeks therapy began. It was painful, it was practical and it was profoundly empathic. Over a number of weeks we explored some of my anxiety, my personality and in all of that I was held with great competence and care.
Ten weeks later I returned to my family, still struggling, but stronger. On World Suicide Prevention Day, September 10th 2014, I returned to work from my maternity leave aware of how fortunate I was.
Our interventions as therapists
An important parallel exists between the birth of a baby and rebirth of a woman into a mother. In this I see an opportunity for rich therapeutic work without ever the shadow of post-natal depression being present. The learning, at this beginning stage, that mother and baby go through is huge. A baby must learn to live outside the womb in both a different environment and relationship with his/her mother. The baby moves from a one-to-one relationship to a multiplicity of relationships. The mother must learn to attend to this tiny new human being who depends on her for absolutely everything.
When we consider the significance a new life brings with all the deep love and corresponding responsibility, it is no wonder this can be a time of growth for a woman. It can be an opportunity to connect with a part she has never before experienced, linking to ancestral and generational archtypes of ‘Mother’ to which she never before belonged. What an opportunity this provides! And what an amazing privilege it is for therapists to walk beside a woman as she experiences this.
We also have a role with women who are suffering from PND. Catterall (2005) looks at central issues of new motherhood and the changes it brings at the intra-personal level where a woman’s identity undergoes a fundamental shift. I believe we can work with a woman to integrate these shifts into her sense of who she is and work with the difficulties that this may entail for some women.
At the societal level we can also explore the impact on a woman of what I call the ‘myths of motherhood’ where everything ‘should’ be wonderful, a time of bonding and quiet time at night feeding your child/children, etc. This ignores another reality which is sleep deprivation, isolation and feeding issues, a consistently crying baby, amongst others, which may be present in this new dyad. When a woman experiences this time in her life as difficult or isn’t enjoying what society has declared to be ‘the most special time in a woman’s life’, she can feel alone, ashamed and terrified. Here is the great strength of the humanistic approach. Here is where our commitment to be truly non-judgemental comes into its own. Here, by allowing ourselves to truly meet this woman we can show by our very presence that we hear her and convey she is not alone. This is priceless and in time I hope would allow our client to be able to face these painful feelings in herself.
Another area where we can help is in exploring when a woman’s locus of evaluation is so externalised that people in her life and society itself dictate what is a ‘good mother’ and, importantly, exploring how she may feel that she is not reaching these often unobtainable heights. Whilst she may have struggled with feelings of not being enough previously, it’s possible that being a new mother may have exacerbated these feelings enormously. Previously I often managed to overcome difficulties as a result of willpower and hard work; however, when someone’s belief system, as in my case that I could cope with anything, crashes down, it can be more than shocking, it can be overwhelming. When I could no longer rely on myself as being able to cope I didn’t know who I was anymore and that brought huge anxiety because if I didn’t know who I was how could I possibly care for two tiny babies who could do nothing for themselves?
However, I also believe that we as therapists (here I make the distinction between the practice of person-centred therapy and its practitioners) may be limiting how we help women who are severely distressed in this case by PND. Mearns and Cooper in their book: Working in relational depth, say of clients: “The secret is to meet them on their terms” (2005). This for me is the heart of humanistic therapy. However, sometimes I believe because we (correctly) try not to interfere with the autonomy of the client that a central core message of non-direction has become one of rarely taking action in any circumstances. So then how do we deal with the paradox that meeting the client ‘on their terms’ may in fact mean taking action, with the client’s involvement and agreement, if that is what is required if a person is in severe distress?
I fully uphold the core tenets of the client-centred approach that the client has all the answers inside and we can disempower should we interfere/guide decision-making and that giving direction to clients on how to live their lives does nothing to help them find/reinstate their own locus of evaluation. However, as a result of my own experience, I am really questioning the validity of non-direction when a client is in extreme distress.
As therapists we accept the concept of ‘normalising’ a client’s experience, helping him/her to realise that they are not going out of their minds when they are experiencing pain. With this in mind I believe that psycho-education does not run contrary to the person-centred approach when someone is in distress and neither does it disempower. I believe severe PND may require additional support from a therapist, e.g., the containment aspect of the relationship may need to be stronger than in relationships with other clients who are not in as much distress, where the therapist can become an attachment figure in reverse if you like. This is not about forging a dependence but offering a space where women can come to know that they are not “going mad, not alone in their experience and that they will get better” (Catterall, 2005: 219).
Where I differ from Catterall is that I don’t believe this falls “outside the scope of one-to-one Person-Centred Counselling” (Catterall, 2005: 219) once we are not rushing in to rescue or looking to be an expert on her life and importantly we are not filling any need of our own. For a period of time we are offering a space where, yes, there is an element of re-assurance. I believe in time we will be able to work with the deeper dynamics behind the despair and anxiety but this can come later. First anxiety must be reduced before defences against it can be relinquished and can be used as Rollo May suggests “as stimulation to increase one’s awareness” (1950: 371). Because as Lake says, although anxiety can be constructive: “nothing is more destructive in those whose power of being cannot contain it” (1991: 90).
I am not suggesting we look to fill every “possible gap in the woman’s experience” (Catterall, 2005). I am suggesting we allow ourselves become part of her support system, exploring the possibility of our client joining PND support groups, working with professionals such as public health nurses, GPs and accepting that we form part of her support. One-to-one therapy was not enough for me and from speaking with others I realise other women feel this way too. This is not a fault of our form of therapy. PND (and other forms of deep distress) may need more than any one support and for me that’s okay. This is particularly relevant if suicidal feelings are present and we must remember we have a duty of care to both mother and baby.
I fully accept that the above may be difficult for us as therapists, I find myself constantly questioning could an unhealthy dependence be forged, could I disempower a woman by working in this way? It is this commitment to my own potentially unconscious processes that leads me to keep therapy healthy and my client’s needs to the forefront.
I am now working with a wonderful person-centred therapist who has allowed me to do the things I have suggested above that can exist within a therapeutic relationship. She has allowed me talk about my fears on two levels – a practical level which, anecdotally, I call the-learning-how-to-be- a-mother level and, at a deeper existential level, to talk of what these fears mean to me and how they have been present in other ways in my life. The birth of my twins brought these fears to me in a way that was impossible to ignore. In none of these sessions have I been disempowered. I have felt a healthy nurturing of my new role as well as a thorough commitment to understanding what may lie deeper.
A friend of mine calls the time I was in hospital ‘my interruption’. Perhaps that is also applicable to the process of therapy; perhaps we can ‘interrupt’ how we might normally do therapy and extend it a little more to mothers in distress without feeling we are betraying our humanistic roots, perhaps it is merely an ‘interruption’ after which normal service will be resumed.
In time, parents must learn to allow their children to take steps on their own. We as therapists can mirror that for women in distress too – our help will become less needed as the new mum gains strength as well as insight. I believe, as therapists, we can offer so much to women as mothers and to mothers who are suffering and in distress from PND. Barbara Kingsolver (2013) sums up a wonderful parallel between children and clients: “Kids don’t stay with you if you do it right. It’s the one job where, the better you are, the more surely you won’t be needed in the long run” (255).
Two years on my son and daughter are big, blonde, bold, happy and healthy. They are an absolute joy and at times an absolute nightmare with their antics times two! There are days I still struggle with anxiety particularly if they aren’t eating or sleeping well but now I have ways to help myself. All of the things I couldn’t do when I was really ill ‒ practising mindfulness, taking a breath, walking, eating well and seeing friends ‒ I can do now. I know now it’s okay to ask for help and I urge all mothers struggling to do the same. Similarly, I urge all therapists to offer that help even if it feels like we are stepping outside of ‘how we do therapy’ because it will be short term.
Patricia Allen-Garrett works as a psychotherapist in private practice and in Hesed House, as well as working with Suicide or Survive as a group facilitator and with the Dublin Counselling and Therapy Centre as a core tutor on their professional diploma in counselling and psychotherapy.
Allen-Garrett, P. (2009). Reflections on the loss of a friend. Inside Out, 57, 29-33.
Association for Improvement in the Maternity Services – Ireland website. Retrieved 20 October 2015 from http://aimsireland.ie/postnatal-period/.
Catterall, E. (2005). Working with maternal depression: Person-centred therapy as part of a multidisciplinary approach. In Joseph, S., & Worsley. R. Person-Centred Psychopathology: A Positive Psychology of Mental Health, (pp.202-225). Monmouth: PCCS Books.
Fraser, E. (2010). Postnatal Depression: A Guide for Mothers of Multiples. Retrieved 10 October 2015 from http://www.tamba.org.uk/document.doc?id=279.
Kingsolver, B. (2013). Pigs in Heaven, New York: Harper Perennial.
Lake, F. (1991). In the Spirit of Truth, London: Darton Longman & Todd.
May, R. (1950). The Meaning of Anxiety (revised ed.). New York: Ronald Press Company.
Mearns, D., & Cooper, M. (2005). Working at Relational Depth in Counselling and Psychotherapy, London: Sage Publications.
Nurture website. Retrieved 14 October 2015 from http://www.nurturecharity.org/get-info/anxiety/.
Postnatal Depression Ireland website. Retrieved 13 September 2015 from http://www.pnd.ie/main/causes.php.
MGH Centre for Women’s Mental Health website. Retrieved 10 October 2014 from https://womensmentalhealth.org/specialty-clinics/postpartum-psychiatric-disorders/.