What day of the week is it?” “Why can’t I get my baby to stop crying?” “Did I take a shower this morning, or was that yesterday … or the day before?” These are the types of questions that parents — and especially mothers — often find themselves asking in the foggy, exhausting and often-overwhelming months that follow the birth of a new baby.
“The first three months [of motherhood] are a twilight zone,” says Susannah Baldwin, a licensed professional counselor (LPC) who is the founder and director of a Greenville, South Carolina, counseling practice that specializes in maternal mental health. “Some people call it the fourth trimester, but I call it the twilight zone phase. … They go from working to, boom, they have a baby and don’t leave the house for two weeks.”
Regardless of whether the child is the woman’s first or fifth, the postpartum period can be characterized by the presence of unique mental health needs and challenges. In addition to learning (or reacclimating to) the ropes of parenting and bonding with a new baby, mothers must adjust to changes in their identity and to different pressures on their relationship with a partner and the family system as a whole. Navigating this major life change is made more difficult by sleep deprivation and by bodies that are undergoing the biological and hormonal shifts associated with not being pregnant anymore.
Counselors can play a vital role in preparing clients for this “twilight zone” and normalizing the often anxiety-provoking challenges that accompany the postpartum period. One of the most important things counselors can do for postpartum clients, Baldwin says, is to create a welcoming space and foster a therapeutic bond so that these mothers are comfortable talking through the good, the bad and the ugly of their experience. This includes bringing to light the irrational, fearful and sometimes shame-inducing thoughts that can be part of new motherhood.
These challenges are amplified for mothers who have a pre-existing mental illness, who don’t have a stable partner or strong family supports, or who are part of various at-risk populations, including those living in poverty. Clients who already struggle with self-doubt, negative thought patterns, unprocessed trauma or other issues related to mental illness may find it overwhelming to assume the role of caregiver for themselves and for an infant, says Baldwin, whose practice serves clients going through issues related to infertility, pregnancy, traumatic childbirth or postpartum distress.
Postpartum “is such a critical time,” says Baldwin, a practitioner certified in perinatal mental health. “If existing issues are left untreated, it will affect their attachment and entire [parenting] experience. Do not underestimate that this is a time of gravity in a new parent’s life. Really attend to that and keep it in mind.”
It is normal for new mothers to experience periods of worry or sadness in the days and weeks following the birth of a baby. If these feelings intensify or last longer than a few weeks, however, it may be a sign of postpartum depression.
The Centers for Disease Control and Prevention reports that 1 in 9 mothers nationwide experience depression either in postpartum or peripartum, which includes the period of pregnancy through and after the birth of a baby. Peripartum depression is the more accurate term to use because symptoms can begin during pregnancy itself, not just after the birth, notes Isabel A. Thompson, a licensed mental health counselor in Florida who is writing a book for mental health practitioners on strength-based approaches for working with clients with peripartum depression.
Counselors working with clients who are pregnant or are new mothers should listen carefully for potential indicators of peripartum depression. According to the organization Postpartum Support International, these red flags can include:
- Crying and having persistent feelings of sadness
- Feeling ambivalent toward the baby
- Feeling numb, angry, irritable, guilty, restless or hopeless
- Worrying about or having thoughts of harming the baby or oneself
Thompson, a member of the American Counseling Association, recommends that counselors conduct periodic wellness check-ins with all peripartum clients. This action helps screen for peripartum depression and mood disorders but can also identify other areas in which these clients are struggling. Check-in questions can include:
- How is the client feeling in her relationship with a partner (if applicable)?
- How much is the client socializing?
- How is the client’s physical health? Is she eating regularly and sleeping when she is able?
- Is the client feeling connected to her religion or spirituality (if applicable)?
“Also ask about her sense of meaning and purpose,” suggests Thompson, an assistant professor in the counseling department at Nova Southeastern University. “Sometimes in the day-to-day slog of caring for an infant, it’s easy to lose your sense of meaning. Bring her back to why she wanted to be a parent in the first place.”
Isolation can also come into play for new mothers. “Before,” Thompson says, “they were working and having social contact, and now they’re home alone. Help her find ways she can reintegrate with previous friendships and find support with other parents.”
Tools for the journey
The estimated prevalence of peripartum depression in the United States ranges from 8.9 percent of women during pregnancy to as much as 37 percent of mothers during the first year after birth of a baby. These statistics were included in a February 2019 JAMA article that recommended counseling — specifically cognitive behavior therapy (CBT) and interpersonal therapy — as an effective means of preventing perinatal depression.
The journal study, conducted by a government task force, compared the effectiveness of CBT and interpersonal therapy versus the effectiveness of physical activity, the use of antidepressants, omega-3 fatty acids, and other supportive and behavioral interventions such as infant sleep training and expressive writing. Researchers found the two therapy methods to be most effective in preventing perinatal depression, especially for mothers with a history of depression or “certain socioeconomic risk factors” such as poverty or single parenthood. Women who received either CBT or interpersonal therapy during the study were 39 percent less likely to develop perinatal depression than those who did not receive counseling.
The anxious and fearful thoughts that often come in pregnancy and postpartum can generate a barrage of new cognitive distortions, says Quinn K. Smelser, an ACA member and LPC in Washington, D.C., who is working on a doctoral dissertation about parent-child attachment and the Marschak Interaction Method. Teaching clients to challenge these distortions — such as through the help of CBT — can greatly enhance their ability to cope and persevere through the challenges of peripartum.
Smelser, who presented a session on attachment and maternal mental illness at the ACA 2018 Conference & Expo in Atlanta, says that person-centered approaches, mind-body interventions, breathing techniques and mindfulness can also be helpful with this population. Likewise, grounding techniques can be beneficial, but Smelser cautions counselors to remember that a woman’s body will process sensations differently as she progresses through pregnancy and postpartum. For example, Smelser had a client who found that pressing her feet into her shoes helped her to center herself — until she was about six months pregnant and the exercise just became painful.
Thompson notes that narrative therapy can also be helpful for new mothers. Each woman’s experience of conception, pregnancy, birth and postpartum will be different — and can range from easy to miserable. Having the client tell her story, whether it involved an unplanned cesarean section or was a long-awaited miracle after struggling with infertility, can help her process the experience, Thompson says.
Remember also that the childbirth experience itself can be traumatic and might require processing with a counselor. Thompson suggests having clients talk through or write (if they prefer) how the entire pregnancy, birth and postpartum period went for them and what they wished had been different.
A population at risk
When it comes to clients who are pregnant or new mothers, counselors’ first instinct may be to screen for signs of peripartum depression. That’s wise, given how common it is. But this population is also at risk for a number of other issues, from social isolation and burnout connected to exhaustion, to guilt and other emotions related to wanting — or not wanting — to return to work after maternity leave.
Baldwin, a co-author of the ACA Practice Brief on peripartum and postpartum anxiety, separates the issues that these clients are at risk for into three categories: perinatal distress, interpersonal distress and relationship distress.
Perinatal distress includes the classic symptoms associated with peripartum depression or anxiety, such as crying and sadness, but it extends to anything that is interfering with aspects of everyday life such as eating, sleeping, relationships or home life, Baldwin explains. For example, a mother with perinatal distress may be so worried that her baby is going to stop breathing that she stays up all night watching the child sleep. Or she stops checking the mail because there is a steep hill leading to her mailbox, and she’s afraid the baby might somehow fall out of the stroller.
Risk of isolation also falls under this category. An example is a mother who fears taking her baby out in public because it’s flu season, Baldwin says. “In American culture, we are driven to be independent and individualistic, and that drives parents to feel like they have to do everything alone. If they ask for help, it’s seen as a shortcoming,” Baldwin says. “The biggest threat [that can lead to isolation] is the cultural belief that you’re supposed to do this without anyone’s help.”
Interpersonal distress involves issues related to a woman’s changing identity and her transition to motherhood. Similar to what people experience during a midlife crisis, new mothers may feel generally unsettled in life. They may wrestle with difficult thoughts such as “I love my kid, but I don’t love this role” or “This isn’t what I thought it would be,” Baldwin says. This sense of unease can arrive with a first baby or a later birth.
“These crises come from subconscious places. [Mothers] don’t realize why they’re upset or unsettled,” Baldwin says. “They may find themselves making rash decisions. All the sudden, they have an awareness of a gap or hole that must be filled, and they don’t know what to do but try and fill it in.”
Relationship distress involves the new pressures that come when baby makes three (or four or five). Couples often assume that having a baby will make them stronger and create the family that they always wanted, Baldwin says. “But it can be the opposite if we’re not attentive to it. It’s so often underestimated, the huge impact that adding a child or dependent to a family will have,” she says.
Babies often provide lots of joy, but the simple reality is that they also exert a substantial drain on a couple’s finances, time and personal energy — all of which can affect the relationship dynamic. Clients may report feeling distant from their partner or struggling with a lack of intimacy after having a baby, Baldwin says. She adds that those struggles don’t revolve just around sex but also around finding time alone or experiencing a loving connection.
“Couples often put themselves on the back burner” when a new baby arrives, Baldwin says. “They haven’t been on a date in six months. Or perhaps they’re not fighting but only talk about bottles and play dates and not about other things. … Resentment and bickering over tasks — that’s what often brings people to therapy.”
Smelser, a trauma and play therapist at the Gil Institute for Trauma Recovery and Education in Fairfax, Virginia, notes that peripartum clients and their partners are at risk for developing unhealthy patterns in their relationships. Examples include not making time for each other, having vastly different parenting styles, not dividing up responsibilities in an equitable manner, and getting so ingrained in certain roles and patterns that all flexibility is lost. If not addressed, these issues can create tension and grow into larger problems later in the relationship, Smelser says.
Counselors can broach the subject by asking questions about a client’s dynamic with her partner, Smelser says. Prior to having a baby, the client may never have seen her partner with a child or in a caregiving role. How she perceives her partner now may need some therapeutic attention, Smelser says. In cases of a pre-existing mental illness, counselors should stress the importance of these clients getting the support they need so that they can focus on themselves and engage in self-care.
“There’s so much opportunity to psychoeducate a pregnant client or new mom,” Smelser says. “They just need help adjusting. Really deep dive into that rather than glossing over how stressful new motherhood is. Don’t dismiss it [as a clinician]. Really talk about it and validate those feelings.”
How counselors can help
Do you know the difference between a doula and a midwife? How about what organizations offer postpartum support groups in your community? Are you comfortable conferring with a client’s OB-GYN if she has questions about taking antidepressants while breastfeeding?
Counselors don’t have to be parents themselves to offer empathy and a listening ear to peripartum clients. Becoming familiar with and sensitive to the unique needs of this population can make a major difference to mothers who are struggling.
> Make a plan: During pregnancy, help these clients create a safety plan to ensure that both they and their babies get the support they need in the months ahead. This is important for any mother, but it is vital for those with pre-existing mental illnesses, Smelser says. Counselors should discuss what steps the client would take to keep herself and her child safe were she to find herself in crisis and unable to manage. Identify the supports that she can rely on ahead of time. Also talk through what her therapy plan will look like with an infant at home. What might her needs be, and what should she focus on in counseling?
“Stopping therapy for a few months because of the demands of motherhood is the absolute last thing we want to happen,” Smelser says. “Plan on how and when she will give herself breathers. Will it be a neighbor taking the baby for 30 minutes while she goes for a walk? What does she do now to regulate [her mental health], and how can we ensure that it still happens? Make sure the mother has lots of support so she can take a break if she needs to, to help her better regulate to return to caring for the child. Even an hour a day for self-care, that can be vitally important.”
> Identify supports: Counselors should familiarize themselves with the parenting and maternal support groups — especially those geared for participants with a particular mental health diagnosis such as depression — in their local areas. If one doesn’t exist, Smelser suggests counselors consider starting a group themselves.
Thompson advises counselors to also be aware of lactation consultants, breastfeeding support groups, and pelvic floor and other women’s/maternal health specialists in their communities. In addition to birth doulas, there are also postpartum doulas who can support mothers in the weeks after a birth, she notes. Also, counselors can help connect clients who are struggling financially with programs that provide food and other assistance to new mothers, including the federal Special Supplemental Nutrition Program for Women, Infants and Children (WIC).
Some mothers may not feel comfortable sharing their struggles in a support group format, Baldwin notes. She suggests that play groups and other child-focused activities can offer an alternative that helps these mothers find social support and meet parents who are facing similar stressors. Counselors should also be aware of parenting classes, moms groups and exercise classes for mothers at local houses of worship, community centers or medical centers.
Baldwin also encourages counselors to become familiar with Postpartum Support International (postpartum.net), an organization that provides various resources and maintains local networks across the country.
> Focus on strengths: A new mother may experience feelings of inadequacy when a new baby arrives and she struggles with seemingly simple tasks such as figuring out her baby’s sleep schedule. First-time mothers especially may have thoughts such as “Why can’t I do this?” or “I have a Ph.D., but I don’t know how to help my baby stop crying,” Thompson says. These assumed inadequacies can spur feelings of guilt, shame or anxiety.
Counselors can help by normalizing clients’ experiences, Thompson says. Explain that it’s routine to struggle, and there are nuances to learning a baby’s needs and preferences. In addition, counselors can highlight clients’ strengths and focus on what they are doing well, she says.
“Help her identify her strengths, even if she’s not feeling them currently. How did she feel strong before she had the baby? How can she reconnect with that?” Thompson says. “Ask questions in a way that can help [her] identify the differences between caring for an infant and succeeding at work. Explain that it’s a totally new role, and validate that it will be hard: ‘You are used to being able to accomplish things easily, but now even taking a shower requires you to wait for your husband to get home from work.’ Normalize those challenges.”
Smelser tells clients that it’s normal for all parents — including those without pre-existing mental health issues — to feel like they’ve reached their wits’ end at times. “Recognize those moments as just thoughts. It’s just a moment and will pass,” Smelser says. “There are so many shoulds, such as ‘I should be able to handle this.’ Identify that as a cognitive distortion and equip the client with tools to handle it.”
> Ask the right questions: Baldwin suggests that counselors start by asking peripartum clients general, broad questions and then “follow the trail” to identify areas where they are struggling and need more therapeutic work or support outside of counseling. Have them discuss life “before” and “after” the baby: How are they sleeping? How often do they get time to themselves? How is their relationship with their partner?
“Depending on how open they are,” Baldwin says, “ask more specific questions, such as ‘When was the last time you talked [with your partner] about something other than the baby, chores or errands? Do you have a ritual in place for spending time together and connecting?’ Depending on their answer, go down the trail and ask more: ‘How often do you bicker? How often do you feel you’re parenting solo?’ One of the biggest challenges is that prioritization. The baby and the bills and the stuff gets prioritized.”
Follow up with more leading questions, Baldwin suggests, such as “Tell me how much of your energy goes into worry. Who in your life helps you out emotionally, practically and socially? Do you have people who can help you in all three areas?”
One of the most important questions counselors can ask, Baldwin adds, is whether a client has a family history of postpartum depression.
> Explore expectations versus reality: Exploratory questions can also help clients work through expectations they might be harboring (either consciously or unconsciously) about parenthood, Baldwin says. She suggests asking, “Where did you imagine you’d be at this point, and how does it compare to where you are?”
“Perhaps they always imagined loving staying home [with a baby], and it turns out they hate it. … Expectations can get people in trouble,” Baldwin says.
Control issues can stem from creating an expectation — such as planning to breastfeed or have a natural birth — that goes unmet due to factors outside of a client’s control, Baldwin says. Clients who have perfectionist or Type A tendencies may struggle in this area. Counselors may need to help these clients understand that having a baby is simply not a controllable experience, she says. It’s not as simple as making a plan and sticking to it.
> Discuss returning to work: Counselors can play a key supportive role as clients navigate emotions surrounding the decision of whether to return to work. Remind clients that there is no right or wrong decision and that nothing is permanent: If they return to work and find themselves overwhelmed, they have the power to make changes, Baldwin says.
“The whole point of questions on this subject is to empower them to realize that they choose their job, their lifestyle,” Baldwin says. “Ask them, ‘What are your plans for returning to a job?’ I don’t even say your job. If they express hesitation or distress, then I’ll focus on it and ask more questions: ‘How did you imagine it would be? How did you imagine it would feel to drop your child off at day care?’”
Counselors can help clients who have made the decision to return to work prepare both mentally and practically. Baldwin suggests that clients do a “dry run” long before their first day back. This includes waking up early and getting themselves and their child ready as if they needed to leave by a certain time to make the drop-off at child care. “Going back to work doesn’t have to be this big ominous day,” Baldwin notes.
> Work on your vocabulary: Do you know what a nipple shield is? When was the last time you walked down the baby aisle at Target? Unless a counselor is familiar with a new mother’s world, that mother isn’t going to feel comfortable disclosing feelings that are intense, personal and sometimes scary in therapy sessions, Baldwin says. Counselors who don’t specialize in maternal mental health should bring themselves up to speed on current birth and parenting practices to connect with peripartum clients. Postpartum Support International has a page of resources for practitioners on its website and offers a certification in perinatal mental health.
Counselors should also be aware of the different options for childbirth, adds Thompson, who presented a session on breastfeeding and peripartum depression at the ACA 2017 Conference in San Francisco. Babies are born today in hospitals, at home or at birth centers with a range of support professionals, from midwives to nurses, all of which have different philosophies.
> Focus on attachment: Counselors who are working with postpartum clients should be mindful of the importance of the mother-infant bond and provide support for mothers who are struggling in this area. Research suggests that the bond formed through breastfeeding can be protective for mothers and reduce symptoms of peripartum depression, Thompson notes. However, many mothers are unable to breastfeed for various reasons, so counselors should frame questions on this topic carefully to avoid inducing guilty feelings. In addition to breastfeeding, mothers and infants can bond through skin-to-skin contact, by making eye contact while bottle feeding and in other ways, Thompson says.
Maternal mental illness — and untreated mental illness in particular — has the potential to affect the attachment bond, which can have negative implications for a child’s cognitive development and relationship patterns later in life, Smelser says. Counselors can ask questions to get indications of how well mothers are connecting with their babies. “How does she react when her child cries? Are there moments in the day when it’s harder?” Smelser says. “If she has a baby with colic, she may need a space where she can simply be honest and say, ‘It’s awful.’ Can she soothe her baby? What’s working and not working? Is she figuring [her child] out?”
Counselors can also normalize these struggles and stress to these clients that it is OK to ask for help whenever they need it, Smelser adds.
> Talk about medication: Many psychiatric medications have different risks and side effects when taken during pregnancy, breastfeeding and postpartum. Counselors must make sure that their clients are communicating with their prescribers, Smelser emphasizes. Counselors should also check in regularly during counseling sessions about clients’ medication management and how medications are affecting their mood. If granted permission by the client, counselors can also check in with the client’s OB-GYN and other medical professionals.
“Make sure everyone is talking to one another and that the mother is getting all the information she needs from her prescriber. Help and empower her to advocate and ask questions,” Smelser says. “Connections between practitioners — a client’s OB-GYN, prescriber and counselor — are not always that great. Medical professionals don’t always ask [patients] about mood or mental wellness. In an ideal world, all these people would be housed in the same space, but we are not there.”
Thompson also stresses the need for regular check-ins with clients about medication usage. Clients should discuss any changes in dosage with their prescribers, weighing the possible risks of taking the medication during pregnancy or breastfeeding against the risks to their own wellness if medication is reduced or not taken, she adds.
> Be baby friendly: Allowing and even inviting mothers to bring their newborns into counseling sessions can go a long way toward helping them feel supported and understood, Thompson notes. Finding child care can often be a barrier to treatment. When it comes to referrals, counselors should look for inpatient programs that allow new mothers to attend with their child, she adds.
> View mother and baby as one unit: In the United States, medical professionals often place greater focus on an infant’s health in the first few months of life. In reality, Thompson asserts, the mother’s and baby’s health are intertwined, and counselors should keep this in mind.
“During pregnancy, they were literally one unit, and only recently have become two. Emotionally, they’re still so bonded. That connection needs to be honored,” she says. “Addressing any mental health needs the mother has will automatically help her connect with her baby. If she is struggling with mental health, she will be less responsive to her baby’s facial cues and expressions. Healthier moms mean healthier babies.”
Contact the counselors interviewed in this article:
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
ACA Practice Briefs (counseling.org/knowledge-center/practice-briefs)
Use your ACA member login to access practice briefs on postpartum posttraumatic stress disorder, peripartum and postpartum anxiety, and peripartum and postpartum depression.
Counseling Today (ct.counseling.org)
ACA Interest Networks (counseling.org/aca-community/aca-groups/interest-networks)
Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at email@example.com.
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