What Does Effective Psychotherapy for Postpartum Depression and Anxiety Entail?

by Aga Grabowski, LCSW, Co-founder of Wildflower Center for Emotional Health            

Coming home with a new baby is like entering a familiar space you have lived in for years only to find that all your furniture and possessions got glued to the ceiling. Especially in the initial months, nothing seems to make sense or follow some semblance of a rhythm. While adjusting to the massive shifts that a new baby brings to everyday life, up to 20% of women are beset by painful symptoms of depression or anxiety. It is imperative that women who are experiencing perinatal mood and anxiety disorders (PMADs) seek specialized assessment and treatment. Easier said than done when you are overwhelmed, confused and trying to get to know and take care of your newborn baby at the same time!

Research has demonstrated time and again that psychotherapy is an effective first-line treatment for PMADs. That is hopeful news, but how can a woman know that she is in good hands and on the path to feeling better? Here we discuss four components of effective psychotherapy with postpartum clients to help women and their providers make informed decisions about initiating and continuing in treatment.

1: INFORMATION IS POWER

Well-trained therapists will provide extensive education about PMADs; they will do so both early on and throughout treatment. It is important that they have specialized expertise in perinatal mental health. They should be able to explain current biopsychosocial understandings of causes of perinatal illness, clarify risk factors, demystify symptoms, as well as offer a clear sense of what psychotherapy will entail. Postpartum clients we work with at Wildflower consistently report to us that the information they have gained in their early sessions was a powerful engine of recovery; it legitimized their experience, reduced sense of isolation, and gave them language to describe pain that so often feels bewildering and indescribable. Additionally, the process of learning helps the client build trust in knowing that despite feeling lost and scared, she has the therapist in her corner who will navigate the treatment space with skill and competence and will be there to support her. The client is no longer alone – she has a team. The ensuing hope adds energy to the therapeutic work and propels it forward.

2: EVIDENCE-BASED INTERVENTIONS

Experienced therapists base their clinical interventions in treatment approaches that have been demonstrated in research and clinical literature to be effective in alleviating symptoms of PMADs. Treatments that have received the most empirical attention and support to date are interpersonal psychotherapy for postpartum depression (IPT) and cognitive behavioral therapy (CBT) for depression and anxiety. At the minimum, the therapist needs to be skilled in both.

It is important to note that IPT and CBT are not the only approaches in the perinatal therapist’s toolkit. Research is increasingly demonstrating the value of mindfulness-based treatments for PMADs. Couples counseling may be an important adjunct to individual therapy. When bonding with the baby is adversely affected by depressive or anxiety symptoms, treatment needs to also focus on the mother-infant dyad. The therapist should have the clinical skillset to continually assess whether psychotherapy alone is going to be sufficient in alleviating symptoms or if referral to a reproductive psychiatrist to consult about the need for psychotropic medication should be considered. The bottom line is that the therapist should be able to flexibly select and apply a variety of empirically-driven treatment techniques and approaches that fit her particular client’s presenting problems, preferences and needs. There is nothing “cookie-cutter” about psychotherapy with postpartum women!

Furthermore, effective perinatal psychotherapists are active in sessions and strongly engaged in a collaborative, direct effort with their clients to pursue mental wellbeing. Postpartum women make very unique psychotherapy clients. While every person entering mental health treatment hopes that she/he will not have to wait forever to feel better, for new moms the need for efficiency and clear pathway to recovery takes on added urgency and meaning. Time has become a luxurious commodity and it cannot be wasted. She has an infant at home and life that demands her attention and strength with heightened intensity. She not only wants to but needs to feel better quickly, ideally not tomorrow or in a month, but as one of the prospective clients who recently called our practice said, “Yesterday!”

This is not the sort of psychotherapy where women in crisis are exploring their distant pasts or otherwise reflecting on deep-seated sources of their struggles. While for some this may become an important focus in a later phase of treatment, initially therapy needs to be about strengthening capacity to cope, which means, among others: learning new ways of approaching painful thoughts and feelings, increasing self-care, improving interpersonal relationships, and bolstering sense of community and belonging.

3: THE IMPORTANCE OF THE THERAPEUTIC RELATIONSHIP

None of the above can take place in the absence of a nurturing therapeutic relationship, the kind that makes the new mom feel heard, genuinely understood and validated. Struggling postpartum women often feel an overwhelming sense of guilt and shame that cause them to withdraw from relationships and become increasingly alone. An essential part of recovery from PMADs has to do with restoring a positive sense of self and belonging. This kind of healing cannot take place in isolation, outside of caring relationships with others. Feeling accepted and genuinely respected by the therapist thus enables the client to begin the process of recovery. Research had shown time and again that the strength of the therapeutic alliance is most associated with positive psychotherapy outcomes.

4: FOCUS ON SOCIAL SUPPORT AND SELF-CARE

As already mentioned, the quality of a postpartum woman’s relationships and of her overall social support network has major implications for her wellbeing. Interpersonal conflict and isolation are well-recognized risk factors for the development of PMADs. Effective psychotherapy seeks to resolve any interpersonal distress that may be present and help women skillfully navigate the challenges of changing roles and relational dynamics that accompany the arrival of a new baby. Psychotherapists can also be vital in connecting women to larger support networks – mom and baby groups, educational workshops and classes, lactation and infant sleep experts, and others. The therapist’s knowledge of these resources is a helpful sign that she is actively involved in the local professional community that provides support to new parents and an expert in this area.

Additionally, experienced perinatal psychotherapists emphasize the importance of self-care practices, help women address barriers to self-care as well as develop creative methods of ensuring that both the mom and her baby are cared for. The mantra in psychotherapy with postpartum women is that where mom thrives, the baby will too. So often the emotional and pragmatic needs of new mothers are neglected; psychotherapy provides an opportunity to develop more sustainable family patterns in which the client’s needs for adequate rest, nutrition, and sleep are central. Involving her partner or other close family members in the pursuit of this goal is frequently an effective strategy.

Psychotherapy plays an essential role in the treatment of perinatal mood and anxiety disorders. We hope this article helps women and their medical providers understand key determinants of its effectiveness, and in doing so, makes the process feel less confusing and daunting. Every new mother deserves to have access to the highest quality postpartum mental health care.