Tag Archives: women

Uncovering the root cause of mother-daughter conflict

By Rosjke Hasseldine January 8, 2020

An experienced counselor recently admitted to me that she felt out of her depth when a mother and adult daughter both came to see her for help with their incessant arguing. She said that she struggled to identify the core reasons for their arguments, and she knew that the communication skills and boundaries she tried to instill in them did not address the core reasons for their relationship difficulties.

Sadly, this counselor is not alone. Colleagues frequently tell me that they feel unprepared when it comes to working with mothers and daughters. They blame the absence of specialized training. This lack of focus on the mother-daughter relationship creates unnecessary anxiety among counselors and psychotherapists, and frustration for female clients. For example, only in 2016 was the Adult Daughter-Mother Relationship Questionnaire developed (for more, see Julie Cwikel’s article in The Family Journal). And in my office, all too often I hear mothers and daughters voice their frustrations about the lack of specialized help.

In this article, I share two insights that will help counselors understand the dynamics between a mother and daughter of any age. These insights come from the mother-daughter attachment model I have developed through my 20-plus years of listening to thousands of mothers and daughters of all ages from different countries and cultures. The model makes the complicated dynamics between mothers and daughters easy to understand, explains why mothers and daughters fight, and teaches how mothers and daughters can build strong, emotionally connected relationships.

I chose to specialize in the mother-daughter relationship back in the 1990s because that relationship is central to women understanding themselves. My relationship with my mother had shaped who I was, and when my daughter was born 30 years ago, I knew I had to change the harmful themes that were being passed down the generations. What began as a personal quest became my professional mission.

Mothers and daughters frequently tell me that they feel ashamed about their relationship difficulties. They feel that they “should” be able to get along because popular wisdom tells them that mothers and daughters are supposed to be close. This societal expectation makes mothers and daughters blame themselves for causing their relationship difficulties. The truth is, if my years of experience providing therapy are any indication, many women currently experience mother-daughter relationship conflict.

Based on the inquiries I receive from mothers and adult daughters from different countries, I believe that a larger, societywide dynamic is contributing to their relationship conflict. Often, I hear “hormones” being blamed as the cause for relationship problems, whether it is the teenage daughter’s or pregnant daughter’s hormones, or the menopausal mother’s hormones. Another common reason mothers and daughters give to explain why they are not getting along is their differing or similar personality traits. I have never found hormones or personality traits to be the core reasons for mother-daughter relationship conflict, however. Rather, I have concluded that society sets mothers and daughters up for conflict.

In the first insight, I show that the mother-daughter relationship is not difficult to understand once we realize that mothers and daughters do not relate in a cultural vacuum. In recognizing that mothers and daughters relate within a sociocultural and multigenerational environment, the dynamics between them become easier to grasp. We see how life events, restrictive gender roles, unrealized career goals, and the expectation that women should sacrifice their needs in their caregiving role all shape how mothers and daughters view themselves and each other and how they communicate. To illustrate this dynamic, I share the story of my work with Sandeep, a young college student from England (name and identifying details have been changed).

In the second insight, I explain how patriarchy’s way of silencing and denying what women need is the root cause of most mother-daughter relationship conflict in different cultures around the world. To illustrate, I share my work with Miriam, a doctor from Sweden who comes from a feminist family (name and identifying details have been changed).

Miriam and Sandeep come from different countries and cultural backgrounds, and their families are on opposite ends of the women’s rights continuum, yet their core relationship problem is the same. Both Miriam and Sandeep come from families in which women have not learned how to ask for what they need.

Insight No. 1: Mothers and daughters relate in a sociocultural environment

As is the case with any couple, mothers and daughters rarely fight over what they say they are arguing over. Sandeep and her mother were no exception to this rule. Sandeep was a young college student who lived at home. Her parents immigrated to England from India before Sandeep was born. Sandeep had three brothers, but she was the family’s only daughter.

Sandeep came to see me because she was feeling depressed about how critical her mother was. She was struggling to juggle her college work with the housework her mother and family expected her to do. She said her mother would accuse her of not being a good enough “housekeeper” and not caring enough for her mother when she was ill, which was often.

Sandeep had consulted a counselor before me who had suggested that her mother might be suffering from a personality disorder. I never got to meet Sandeep’s mother and work with her clinically, so I was unable to validate whether this might be the case. Regardless, even if Sandeep’s mother did have this diagnosis, it did not provide Sandeep with the answers
she needed.

Instead, Sandeep needed to understand the multigenerational sociocultural environment in which she and her mother lived. She also needed to understand what was going on in this environment that apparently caused her mother to be so angry and critical, and what caused Sandeep and her mother to believe that it was Sandeep’s responsibility to do all the housekeeping.

When I start working with new clients, I map their mother-daughter history. This is the primary exercise in the mother-daughter attachment model. It is an adaptation of the genogram exercise that family therapists use. The maps focus on the three main women in the multigenerational family, which in Sandeep’s case was Sandeep as the daughter, her mother and her grandmother. I map the experiences the three women have had in their lives, including the gender roles that have defined their lives and limited their choices and power. I also map how the men in the family treat their wives and daughters. Mother-daughter history maps provide an in-depth analysis of the multigenerational sociocultural environment in which the women in the family live and what is happening within that environment to cause mothers and daughters to argue, misunderstand each other, and disconnect emotionally. (Detailed instructions on using this exercise with clients are available in my book The Mother-Daughter Puzzle.)

Sandeep talked about her grandmother’s and mother’s lives and arranged marriages and shared how verbally abusive and controlling her father and grandfather were. She said the males in the family were encouraged to go to college and build their careers, while the females were expected to stay at home to help their mothers. As Sandeep provided these details, her family’s patriarchal structure came into sharp focus. Sandeep represented the first woman in her generational family to finish school and go to college.

Sandeep’s family believed in what I term the “culture of female service,” a global patriarchal belief system that views women as caregivers, not care receivers. Families that subscribe to the culture of female service expect mothers and daughters to be selfless, sacrificial, self-neglecting caregivers. This belief system does not recognize women as people with needs of their own.

Although I never met Sandeep’s mother, it was apparent to me (based on Sandeep’s descriptions) that she had internalized this family belief and did not know any other way of being. This meant that she did not understand Sandeep’s desire to go to college or her fight for her independence. I suspected that Sandeep’s independence felt threatening to her mother. Several reasons explain why Sandeep’s mother was so critical of her daughter and why she behaved in an emotionally manipulative manner — for example, by becoming ill just when Sandeep was busy with an assignment or exam.

First, Sandeep wanted to live a different life than her mother and grandmother had lived, and this likely made Sandeep’s mother feel alone and abandoned. Her only understanding of being female was that of women as caregivers and of “good daughters” stepping into their mothers’ shoes and walking repeats of their mothers’ lives. Sandeep’s mother had done that, her mother had done that, and she expected Sandeep to follow in that role. I suspect Sandeep’s wish for a different life and different relationships felt like a rejection to her mother. It made her feel that her daughter was criticizing the life and values she believed in as a mother.

Second, Sandeep’s mother could have been jealous of her daughter’s freedom and opportunities, even though she probably was unaware that her criticism and anger were rooted in jealousy. Sandeep’s freedom and opportunities might have been an uncomfortable mirror for Sandeep’s mother, reminding her of the freedom she never had and the dreams she had to relinquish.

Third, the mother’s attempts to keep Sandeep from graduating and leaving home could have been linked to her own fight for emotional survival. Sandeep reported to me that she was the only person who gave her mother love and care, so the thought of Sandeep leaving home must have been terrifying to her mother.

For mothers and daughters to build a strong, emotionally connected relationship, it is optimal for both parties to engage in couples therapy. However, if one person is not able, or willing, to participate, healing is still possible. In Sandeep’s case, her mother did not want to participate in therapy. This did not prevent Sandeep from working on understanding and improving her relationship with her mother, however. When one person changes their behavior, the relationship changes to incorporate the new behavior. Of course, Sandeep and I had little control over how her mother would respond to the changes Sandeep needed in their relationship.

My work with Sandeep involved teaching her how to listen to her own voice. Sandeep had become an expert on responding to what her mother needed and being a “dutiful daughter,” but she had little idea about what she wanted for herself, beyond finishing her degree. Sandeep did not know how to ask herself what she thought, felt, or needed emotionally because that conversation was not spoken in her family. My role as a mother-daughter therapist was to help Sandeep uncover the sexism she had inherited from her mother and grandmother that had silenced her voice. I helped her understand the gender inequality her family and culture normalized, and I taught her how to claim her own ideas of who she wanted to be and what she needed in her relationship with her mother — and in all her relationships.

I also helped Sandeep navigate the pushback she got from her mother and father when she stopped complying with their demands to be the family’s unpaid housekeeper. I helped her to understand her mother’s and father’s perspectives so that she had empathy for them and encouraged her to recognize that their anger and criticism weren’t as personal as they felt, originating instead from their cultural beliefs. Alongside Sandeep’s increased understanding of her family’s sociocultural environment, I helped her increase her entitlement to speak her mind, reject unreasonable demands, and carve out her own life path.

Sadly, Sandeep’s parents did not react well to her behaving differently from what they expected of a “dutiful daughter.” After Sandeep left home, her family’s anger and accusations that she had dishonored the family became alarming, leading her to obtain a restraining order against her parents and siblings. Through her therapy, Sandeep learned the degree to which her family members did not tolerate women challenging their long-held beliefs about what women could and could not do and could and could not wear. I had to help Sandeep stay safe and grieve the loss of her family even as she gained her own voice and life.

Insight No. 2: Mothers and daughters fight over their denied needs

My clients have taught me that the denial of what women need, especially when it comes to women’s emotional needs, ripples below most mother-daughter relationship conflict. As I write in The Mother-Daughter Puzzle, when a family does not speak the language that inquires after what women feel and need, mothers and daughters are set up for conflict. It creates an either-or dynamic in which the mother and daughter fight over who gets to be heard and emotionally supported in their relationship because they do not know how to create a normal in which both are heard and supported.

In every mother-daughter history map I draw, I see how the silencing of women’s needs harms women’s emotional well-being, limits their ability to advocate for themselves in their relationships and workplaces, and perpetuates gender inequality. I see how this dynamic makes women invisible, and how being invisible makes women hungry for attention. The inability to openly and honestly ask about what they need creates emotionally manipulative behavior between mothers and daughters and sets daughters up to have to mind read their mothers’ unspoken and unacknowledged needs.

Miriam, a client from Sweden, contacted me for help with her adolescent daughter. Miriam and her mother had benefited from the women’s movement fight for women’s rights. Miriam and her mother were doctors, and Miriam’s husband and father were extremely supportive of their careers. But just like Sandeep and her mother, Miriam and her mother had internalized and normalized the culture of female service, and Miriam’s daughter was angry about her mother’s selflessness.

Miriam’s daughter felt that she had to mind read what her mother really felt and wanted, and she was tired of it. She desired an emotionally honest relationship with her mom. She wanted to feel free to say what she felt and needed and for her mother to speak her mind and stop the guessing games. Miriam’s daughter did not want to feel responsible for meeting her mother’s unvoiced and unacknowledged needs.

The silencing of women’s needs is an intergenerational dynamic that gets passed on from mother to daughter because the mother is not able to teach her daughter how to voice her needs openly and honestly. When the daughter is expected, often unconsciously, to listen for and meet her mother’s unvoiced and unacknowledged needs, the daughter is learning to become an expert on understanding what her mother needs, not on what she needs herself. This means that the daughter will grow up to be as emotionally mute as her mother, thus setting up her future daughter to try to learn to interpret and meet her unvoiced needs.

Women’s generational experience of being emotionally silenced and emotionally neglected is a common theme between mothers and daughters. Happily, I am seeing a huge shift from adult daughters in their 20s, 30s and 40s who are waking up to this patriarchal theme and wanting change. These daughters recognize that they have learned — from their mothers and from society in general — to be far too tolerant of being silent and practicing self-neglect. More daughters are asking their mothers to join them in therapy so that together they can change these inherited behavioral patterns. Mothers and daughters are teaming up and pioneering a new normal in their families — a normal where women are speaking up and demanding to be heard. And they are passing on this new normal to the next generation of sons and daughters.

Mothers and daughters have always led the call for women’s rights. When we understand that mother-daughter attachment disruption or conflict tells the story of how sexist beliefs and gender role stereotypes harm women’s voices and rights, the mother-daughter relationship becomes an unstoppable force for change at the worldwide and family levels.

Sadly, Sandeep’s mother was not able to join Sandeep in her fight to challenge her family’s sexist cultural beliefs. I inferred that too much neglect made Sandeep’s mother emotionally unable to think her way out of her powerlessness. Miriam, having had a far more supportive and empowering upbringing, was able to join her daughter to find a new normal for women within their family. This mother and daughter team coached each other as they decontaminated themselves from their internalized sexism and self-silencing habits.

The mother-daughter relationship has tremendous power to change women’s lives around the world. When mothers and daughters band together, they create an impenetrable wall of resistance against family members who are threatened by women claiming their rights. I have had the honor of working with many pioneering mothers and daughters who dared to dream of a reality in which mothers and daughters are no longer starving for attention and fighting for crumbs of affection. These brave mothers and daughters recognize the harm that patriarchy, sexism, and gender inequality inflict on women, and they have decided that enough is enough. In essence, they are saying, “With us, it must end.”

 

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Rosjke Hasseldine is a mother-daughter relationship therapist, author of The Silent Female Scream and The Mother-Daughter Puzzle, and founder of Mother-Daughter Coaching International LLC (motherdaughtercoach.com), a training organization. She blogs for the American Counseling Association and has presented her mother-daughter attachment model at professional conferences, on Canadian television, and at the United Nations Commission on the Status of Women. Contact her at rosjkehasseldine@gmail.com or through her website at rosjke.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Understanding stillbirth

By Samantha Rouse December 5, 2019

What if there was a trauma that affected 25% of our adult female clients? Wouldn’t we want to know about it? This isn’t just a hypothetical for counselors, yet chances are that we as clinicians are ill-prepared to effectively identify and treat our clients who fall into this population.

In the United States, 1 in 4 women experiences some form of infant or pregnancy loss. Included in this statistic are the more than 26,000 women who experience a stillbirth each year. A stillbirth occurs late term after an otherwise healthy baby could have survived outside of the womb. Stillbirth often is defined as the death of a baby after 26 weeks’ gestation.

Long before my decision to get my education and become a professional counselor, I became one of those 26,000 mothers. It was only natural that the area of stillbirth would become an area of interest for my own research during my doctoral studies. It was my experience in my job, however, that led me to see the gaping hole in our field of professionals who are competent and knowledgeable enough to provide help. Each time a new referral came in that had reported any kind of pregnancy loss, she was immediately referred to me. This was because most people hold one of two positions: 1) The person who has experienced what the client is experiencing is the best person to help the client, or 2) I cannot help someone with something that I have never experienced myself.

This flawed referral process creates an issue with our profession being able to provide quality care to clients who have experienced stillbirth. Referral of these clients solely to those counselors who have experienced stillbirth themselves can be harmful to both the client and the counselor. The counselor may become overwhelmed at the number of clients with this specific need so close to her own traumatic experience, potentially resulting in burnout for the clinician. An equally disturbing result of this referral process is that other counselors are denied the opportunity to treat and learn from this population. This keeps the number of competent counselors lower than is needed.

Understanding the trauma

The death of a child is an unexplainable pain. Author Jay Neugeboren famously wrote, “A wife who loses a husband is called a widow. A husband who loses a wife is called a widower. A child who loses his parents is called an orphan. There is no word for a parent who loses a child. That’s how awful the loss is.” It feels unnatural for parents to outlive their children, regardless of the child’s age when he or she dies. However, stillbirth presents unique characteristics that make this scenario even more complicated for bereaved parents.

The experience of stillbirth has a high level of ambiguity. The death of a baby leaves so much unknown, and mothers often find themselves wondering why their baby died, what their baby would have looked like had he or she grown up, what the child’s voice would have sounded like, and how their family would have been different had the child lived. This ambiguity often leads to the death having a lack of meaning, in that the mother is often searching for the purpose of the child’s life. Mothers might repeatedly ask themselves questions such as “Why me?” or “Why did God give me a baby just to have it die?”

Stillbirth does not involve only grief; it also involves a trauma or multiple traumas. Most people think that stillbirth occurs when the parents are told at delivery that their baby was born dead. This is not the case with modern medicine. Typically, the parents are alerted to the death of their baby before the delivery, and the mother then has her labor induced. The news of hearing that their baby is dead begins the first trauma.

The trauma continues during labor and delivery, which is now the antithesis of the joyful experience the mother had anticipated over the course of her pregnancy. Sorrow and silence replace what were once expected to be feelings of elation and the sounds of a new baby crying. After the painful experience of the labor and delivery, the mother is given the option of seeing her baby. Depending on how long it has been since the baby died, the appearance of the baby might be affected. Some mothers choose to see the baby and will hold, rock and take pictures of their child.

After delivery, the mother is moved into a room that is often located within the labor and delivery area. The trip from the delivery room to her recovery room exposes the mother to sights and sounds such as banners proclaiming “It’s a boy!” and other families’ loved ones cheerfully gathering in the hallways to see their own bundles of joy. The grieving mother’s room is empty and silent. Her door remains shut in an attempt to drown out the sound of crying newborns from other rooms.

After a couple of days of hospital care, the mother is sent home and must tend to her recovering body. In the days that follow, she will develop the same physical response to childbirth that a mother with a living child would. Mothers who have experienced stillbirth are often encouraged to bind their breasts to “dry up” their milk.

Within a day of delivery, the mother must make decisions about the autopsy and burial options for her baby. The mother must wrestle with the decision to keep the casket open or closed during the funeral or burial service. This decision is often based on the appearance of the infant at birth (because the skin of a baby who is stillborn is frequently affected). A tiny casket is often presented and seems out of place in the environment of the funeral home.

If the mother or father is employed, their time off goes by quickly before they must return to what is expected to be their “normal” life. In many cases, paid time off or bereavement leave is not provided to these parents because the stillborn child was never considered a living person. The parents do not receive a birth or death certificate for their child for the same reason. For a birth certificate to be given, the baby must have shown signs of life after delivery, even if it was only for one breath or heartbeat. In most states, a stillborn baby cannot be claimed as a dependent for tax purposes. (Tip: Some states offer a “stillbirth certificate”; this may be a resource for clients if appropriate for their treatment.)

Best practices for screening

In many practices, the intake process includes a generic demographic question for reporting family size. This might include a fill-in-the-blank option for the client’s number of children or number of living children. (Tip: Replace “number of children” with “number of pregnancies, number of live births, and number of living children.” This ensures that all areas — miscarriage, stillbirth or the later death of a child — are covered.)

Screening for stillbirth through the demographic paperwork is the first step. This initial paperwork offers a small glimpse into the client’s full story. Reviewing the paperwork prior to the initial clinical interview will alert the clinician to the need to discuss the client’s experience of stillbirth (if the client discloses it in the paperwork).

The clinical interview can be difficult for both the counselor and the client when it comes to discussing a stillbirth. Because of social expectations and the ambiguity of their loss, women are less likely to report a stillbirth than they are other experiences. It is much easier for a person to put a number on the intake paper regarding number of pregnancies and number of living children than it is to openly bring up a stillbirth during the clinical interview. For this reason, direct questioning on the part of the counselor is vital.

Counselors may initially find it uncomfortable to directly ask clients about any type of pregnancy loss. It is important for counselors to practice using the correct terminology and language appropriate for a stillbirth. Additionally, they should get comfortable with other terms that the mother might use, such as died, death, dead baby, dead child, etc. It may be beneficial for counselors to practice using these terms out loud with a trusted person to become more comfortable saying them. When counselors are comfortable discussing stillbirth and other pregnancy loss, clients are likely to recognize this and move to a higher level of openness about their own experiences sooner rather than later. This allows for the therapeutic relationship to develop at a faster pace, leading to more rapid treatment results and a higher client retention rate.

For many clients, the disclosure of a stillbirth might happen later on or might never happen, due in large part to societal views of stillbirth (e.g., they do not “count,” they never existed, mothers must “move on”). This will hamper the overall depth of the therapeutic relationship and can also prevent appropriate treatment of the trauma.

Need-to-know factors

As counselors, it is our responsibility to ensure that we are knowledgeable about the variety of issues that our clients face. With such a high prevalence of stillbirths, it is important that we truly understand this experience to provide competent treatment. There are several key points of which counselors need to be aware.

>>  Social supports: Not surprisingly, the presence of strong social supports has shown to be an important factor in a person’s recovery following a stillbirth. These supports can include a spouse or significant other, family members, friends, and involvement in a church or religious community. A person’s support system often diminishes following a stillbirth because of the “hushed” nature of the experience.

>>  Use of clients’ language: Mothers of stillborn babies will often give their babies a name. If the client uses the baby’s name in session, the counselor needs to refer to the stillborn child by name and not as “the baby.” The mother may be hesitant to speak the baby’s name, again due to the hushed nature of stillbirth. It can benefit the therapeutic relationship for the counselor to ask, “What would you like for me to call the baby?” This also avoids the question, “Did you name the baby?” which could imply that the mother should feel ashamed if she did not name the child.

>>  Suicidality: Mothers who have experienced a stillbirth often report feeling like “I want to go to sleep and not wake up” or “I don’t want to live anymore.” It is important to understand the difference between these thoughts and active suicidal ideation. This is especially important because these mothers often experience postpartum depression along with the grief and trauma from the stillbirth.

>>  Postpartum depression: Mothers who deliver stillborn babies are not exempt from postpartum depression. This can lead to the complex issue of depression tied with grief, trauma and, sometimes, psychosis. Many people, including clinicians, make the mistake of assuming that these mothers are dealing with “only” grief, “only” postpartum depression, etc.

>>  Trauma: Stillbirth is often thought of as producing grief or depression. Approaching it only from this lens, rather than also understanding the trauma associated with the experience, can cause treatment to be ineffective. This limited approach can also prevent the client from feeling fully understood, leading to a poor therapeutic relationship.

>> Comfort terms: The experience of stillbirth is often silenced and met with a “move on” expectation in society. In part for that reason, it is important for counselors to recognize and avoid using common comfort terms. These include:

  “At least you know you can get pregnant.”

  “This was part of a plan.”

  “Thank goodness you have your other children.”

  “It wasn’t meant to be.”

  “There might have been something wrong with it.”

>>  Long-term presence: The mother’s close relationships may become strained or even dissolve in the aftermath of the stillbirth experience. Divorce rates have also been found to be influenced by the experience of stillbirth. If not dealt with, the trauma associated with stillbirth can manifest as a personality disorder or a substance use disorder.

Treatment considerations

The complex nature of the stillbirth experience often leaves counselors feeling lost regarding the potential direction for treatment. Many interventions used in treating grief are applicable with these clients, and other interventions typically used to treat depression and anxiety can also be used.

For example, let’s say that a counselor has a new client beginning services six months after her first child was stillborn. She was referred by her primary care doctor when she made an appointment with the doctor to obtain medication. She is married with no living children, comes from a large family, and attends a nondenominational church regularly. The client reports that she had to quit her job because she was unable to focus and would cry throughout the day. The client discloses that she had a stillborn daughter named Sarah. A funeral and burial were held, but the client says she is unable to “move on.”

The client’s faith and large family can serve as protective factors because they provide her with a large support system. At the same time, they can also be risk factors by triggering the client and reminding her of her loss. One option is to explore with the client whether she has any frustrations with her support system or any negative beliefs and thoughts about herself when around her support system. The client might reply that she wants to avoid being around babies and small children at family gatherings and church services. The counselor shouldn’t then turn the focus to helping the client find ways to cope with being around babies and children because this might send a message of “get over it” to the client. Instead, the counselor could explore the client’s feelings of unjustness and hurt, both providing validation and normalizing how she feels. The counselor would then allow the client to decide on the small steps she wants to take.

A significant amount of ambiguity accompanies the experience of stillbirth. Some clients are comforted by finding meaning in their loss, while others are not. The counselor can explore this with the client and should be aware that the client’s feelings may change back and forth as time passes. If the client cannot attribute any meaning to her loss or does not find comfort in the meaning, the counselor should validate her feelings of unfairness, hurt and anger and empower her to create her own meaning. For example, how can the client use this meaningless loss for good in the future?

It is often helpful to encourage the use of rituals with clients. This particular client named her baby and also had a funeral and burial for her. The counselor could explore ways the client might use other rituals as a means of keeping her daughter a part of her life. For example, she could hang pictures of her daughter in her home, keep a photo of her daughter in her car, visit the cemetery regularly, have an object such as a candle or decoration that represents the daughter during holidays, and so on.

The counselor could also introduce the client to online resources and supports. This may provide a sense of normalization to the client and counteract her feelings of being isolated in her pain. It may also provide a network that can offer creative ideas for rituals.

There are many ways to approach counseling with these clients, but there are also things to avoid. For instance, counselors should avoid bringing in their own beliefs and expectations for these clients (just as with any clients). These mothers should not feel rushed or be made to feel guilty for not getting “better” sooner. Counselors should avoid using the common comfort terms listed earlier. Counselors must also keep in mind that the therapeutic relationship is more important than any particular technique, and they should allow these clients to be actively engaged in deciding what their sessions are like.

Every mother’s experience of stillbirth is different. The mother’s family, religious beliefs and culture all influence her response to the stillbirth. Additionally, her experience is influenced by the protocol of the medical facilities where she delivered and the attitudes of the health care providers involved. Counselors should address all of these factors in session to ensure that mothers are being treated appropriately for their individual experiences. Our society tends to “hush” these mothers and their experiences because stillbirth is so uncomfortable to address. However, these mothers need to be heard, understood and validated as being mothers, even if they have no other living children. After all, born still is still born.

 

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Samantha Rouse is a licensed professional clinical counselor working for Hosparus Health in central Kentucky. She is a fourth-year doctoral student at Lindsey Wilson College doing research on motherhood and stillbirth. Contact her at samantha.rouse@lindsey.edu.

 

Letters to the editor:  ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

In my work as an outpatient mental health counselor, I have encountered numerous clients over the years with stories about reproductive loss. Not only were these stories fraught with sadness and grief, but some of the individuals were still experiencing acute grief even several years later.

As I branched out into my role as a researcher during my doctoral study, these stories stayed with me. So, I began a line of inquiry on reproductive loss that started with infertility and the accompanying grief. Since then, my research on infertility and miscarriage grief has resulted in numerous professional conference presentations and guest lectures. The purpose of this article is to share information that I have learned about those with infertility and to provide methods for best practice in counseling with these clients.

Infertility is generally defined as a condition of the reproductive system that inhibits or prevents conception after at least one year of unprotected sexual intercourse. To account for the natural decline of fertility with age, the time frame is reduced to six months for women 35 and older. According to the Centers for Disease Control and Prevention (CDC), about 12% of women between the ages of 15 and 44 have “difficulty getting pregnant or carrying a pregnancy to term.” Infertility can affect both men and women, despite a common misconception that infertility is a woman’s condition. Infertility in men may be caused by testicular or ejaculatory dysfunction, hormonal disorders, or genetic disorders. In women, infertility may be caused by disrupted functioning of the ovaries (such as with polycystic ovary syndrome, a condition that prevents consistent ovulation), blocked fallopian tubes, or any uterine abnormalities (such as the presence of fibroids).

Infertility can be categorized into one of two subtypes. Primary infertility refers to when a woman has never birthed a child and thus has no biological children. Secondary infertility refers to when a woman experiences the inability to birth a child following the birth of at least one other child. Both forms of infertility produce a cyclical pattern of strong emotion that is often referred to as a “roller coaster.”

Medical interventions

A number of available interventions may be used to increase the chances of becoming pregnant. The best course of treatment will be different for each couple and may depend on considerations such as whether the infertility is male factor or female factor, the cost and availability of insurance coverage, and cultural customs or beliefs. Some couples decide that pursuing any kind of medical treatment is not the right course of action for them. For others, medical treatment may include any of the following interventions.

  • Medication may be prescribed to stimulate ovulation or follicle growth in the ovaries, increase the number of mature eggs produced by the ovaries, prevent premature ovulation, or prepare the uterus for an embryo transfer.
  • Surgery may be necessary, perhaps to clear out blocked fallopian tubes or to remove uterine fibroids.
  • Intrauterine insemination (IUI), also known as artificial insemination, is a procedure in which sperm are inserted directly into the woman’s uterus. The woman may or may not be taking medications to stimulate ovulation before the procedure.
  • Assisted reproductive technology (ART) refers to fertility treatments in which eggs and embryos are handled outside of the body. This excludes procedures in which only sperm are handled (e.g., IUI). The most common and effective ART procedure is in vitro fertilization (IVF).

Undergoing IVF treatment requires a strong physical, emotional and financial commitment. Generally, medications are prescribed to stimulate egg production and may include a series of self-administered injections. Eggs are removed from the ovary using a hollow needle, and the male partner is asked to produce a sperm sample (or a sperm donor may be used). The eggs and sperm are combined in a laboratory, and once fertilization has been confirmed, the fertilized eggs are considered embryos. About three to five days after fertilization, the embryos are placed into the woman’s uterus via a catheter in hopes of implantation. The CDC reports that women under the age of 35 have a 31% chance of conceiving and birthing a child with the use of ART; the chances are closer to 3% for women ages 43 and over.

The IVF process can be a highly emotional time for the woman and the couple, marked by moments of excitement, hope, disappointment or uncertainty. The IVF cycle may be canceled if certain problems develop along the way, such as having too few or no eggs to retrieve, the eggs failing to fertilize, or the embryos not developing normally. Any of these situations may produce a sense of loss for the woman or the couple. After the embryo transfer, it is generally recommended to wait 10-14 days before testing for pregnancy. In some circumstances, a chemical pregnancy takes place. This is when implantation happens that results in an initial positive result, but then the pregnancy does not progress. In other words, a very early miscarriage occurs.

This section on medical interventions is important to include because these interventions are part of the infertility experience and may affect the emotional or mental health of the client. This is true even for women and couples who choose to not pursue treatment; at the end of the day, a decision was made and they must cope with the implications of that choice. Professional clinical counselors who are knowledgeable about the available medical interventions will have better context for recognizing the myriad decisions that these clients face and the potential losses that may occur throughout the process.

The invisibility factor

Take a moment to think about the grief that occurred for you after the death of a loved one. The relationship you had with your loved one was probably clearly defined, and you have memories of that person to look back on. The loss is easily identified and articulated, not only by you but by others who were aware of the death. You most likely had many people express sympathy and give you their condolences, perhaps verbally or by sending flowers. You may have taken time off work for bereavement and attended a ritual such as a visitation ceremony, wake or funeral that helped to facilitate your grief. Your loss was likely recognized, acknowledged, validated and supported in a multitude of ways.

Now think about the losses associated with infertility. One of the major losses is that of the imagined or expected family. Women with primary infertility, who do not have biological children, face the loss of the entire life stage of parenting. This may include pregnancy, passing on family or holiday traditions, and passing on the genetic legacy or surname, plus the eventual loss of other life stages such as grandparenthood. Counselors should recognize that meaning is often attached to these losses which further compounds the pain. For example, not being able to experience pregnancy means that the woman is also excluded from cultural pregnancy milestones such as going to the first ultrasound visit, thinking of fun and exciting ways to announce the news to family and friends, participating in a baby shower, and throwing a gender reveal party. With infertility, the loss comes from an absence of something that has never been rather than the absence of something that used to be.

The stigmatization surrounding infertility contributes to an atmosphere of silence and invisibility. Infertility and its accompanying losses are not as outwardly visible and may not be well known or understood by others unless the woman discloses them herself. Many women who experience infertility feel a sense of failure or self-blame toward their bodies, and some may withdraw socially, isolate, or struggle with their identity and sense of self. The stigma surrounding infertility can make it difficult for women to reach out for support. As a result, they find themselves navigating the experience alone.

When a woman does talk openly about her infertility, other people may not respond in ways that are validating or compassionate, which may make the situation worse than if she hadn’t disclosed at all. For example, comments such as, “Just relax,” and, “Give it time,” minimize the woman’s pain and invalidate her grief. Asking, “Have you tried (fill in the blank)?” or “Have you considered adoption?” implies that the woman is not trying hard enough to find a solution or that what she has tried already is inadequate. Most of the women with infertility I have encountered over the years acknowledge that people generally mean well and offer such comments in an attempt to provide hope or to decrease their own feelings of discomfort when talking about infertility.

Facilitating the grieving process

Professional counselors have a responsibility to provide compassionate and competent mental health treatment. Each infertility journey is unique, and counseling interventions should be tailored to fit the individual needs of every client. Taking clients’ cultural, religious or spiritual backgrounds into consideration, several interventions may be used to effectively assist these clients through their grief.

  • Counselors, first and foremost, can be present and listen. Typically, this is what is missing when family members, friends, co-workers, doctors or strangers offer comments that end up being hurtful or invalidating to the person or couple experiencing infertility. We do not have to have the answers — even as counselors. Just be there.
  • Counselors can assist clients in articulating what they need from others around them. This may also incorporate methods for helping clients increase their assertiveness or self-confidence.
  • Counselors can help clients redefine their life expectations and conceptualizations of womanhood, family and mothering. This may also include processing how clients perceive lost embryos, chemical pregnancies or miscarriages to fit within the family unit.
  • Counselors can help clients manage the roller coaster of emotions and ongoing stress as they are trying to conceive, rather than focusing on finding closure. Closure usually implies resolution, which may not be possible with the prolonged nature of infertility and the treatment process.
  • Counselors can assist clients in developing their own rituals while trying to conceive, undergoing fertility treatment, or after making the decision to stop treatment. For example, a woman once told me that she threw a party after she and her husband decided to stop IVF treatments. The party signified taking control over their decision to remain child-free and served as a celebration of the effort it had taken to come that far. 
  • Counselors can explore appropriate methods of client self-care, including engaging in hobbies, participating in creative or social activities, and even taking breaks (as needed) from trying to conceive or pursuing medical treatment.
  • Counselors can connect clients with appropriate resources. It may be necessary to provide clients referrals to group counseling if they wish to connect with others who have similar stories, or to couples counseling if they are struggling in their relationships. In addition, location or cost can be barriers to clients obtaining the services that would work best for them, so counselors who are knowledgeable about online resources can provide these options. Collaborating with other health care professionals with whom the client is working can also provide more comprehensive treatment.

This is not, of course, an exhaustive list. Grief is a personal experience. Which methods are the best fit for your client should be explored in a therapeutic setting that considers both individual and cultural contexts.

What do counselors need to remember?

Imagine that you are working in a private practice when you meet a new client experiencing infertility. You are a master’s-level clinician and are fully licensed in your state. You have taken one class in your graduate program on grief and loss but have no further specialization or experience with infertility. The client has heard numerous comments, questions and suggestions throughout the years regarding her infertility. She is unsure of how counseling might help, but she feels the need to seek support.

This scenario, while general, is a realistic picture of a possible situation that any clinician could experience. As such, I will provide thoughts on what every counselor should keep in mind when it comes to the areas of infertility grief. I am not attempting to reinvent the wheel when it comes to essential counseling tools; rather, I am striving to provide context for effectively using these tools with clients affected by infertility.

>> Convey empathy and understanding. If I could share only one thing I have learned in my work with women affected by infertility, it would be that so many of them feel and believe that you cannot possibly understand what infertility is truly like unless you have been through it yourself. Many women have asserted to me that they just need someone willing to sit with them through the anguish. Counselors who are attempting to provide encouragement and hope may instead end up inadvertently dismissing their clients’ pain or minimizing their grief. It is also possible that counselors end up avoiding a deeper exploration of the experience completely because they do not know what to say. Do not underestimate your basic counseling skills when working with these clients. Acknowledge, reflect and empathize.

One way that counselors can suggest understanding is through the careful use of language. For instance, matching the client’s chosen language of “baby” or “child” is more appropriate (and accepting) than using the more medically correct terms of “embryo” or “fetus.” Language can also offer a reframe from a label of “an infertile woman” to “a woman affected by infertility.” This choice of words depersonalizes the condition and acknowledges that her identity is separate from the condition.

>> Become familiar with client issues related to infertility. Clients who talk about their infertility journey will use a variety of terms and acronyms. For example, you may have clients talk about the time they were “TTC,” which stands for trying to conceive. They may also mention medications, medical procedures or basic biological functions with the assumption that the counselor is generally informed on these topics. Although asking clarifying questions of clients can help paint a clearer picture of their experience, it is not the client’s job to educate the counselor. Take the initiative early in the working relationship with a new client to learn about infertility in areas in which you are deficient. That way, you will be able to understand the client’s journey and experience in greater context.

>> Validate the loss. The invisibility of infertility may cause some women to wonder whether their losses are real or valid. For example, I met a woman during my research who had elected to try IVF after three years of actively trying to conceive, and she gave birth to a healthy baby after just one round. Still, she felt a sense of loss over the fact that her memories of the conception did not entail a moment of passion and love, but rather recollections of shame and fear. She referred to her husband having to masturbate in isolation to provide the needed sperm sample and her experience of lying on a cold table waiting for the doctor to transfer the embryo. She did not feel that she could verbalize this sense of loss to others, however, because it might make her sound ungrateful. A counselor could validate the loss of the ideal conception story and help her articulate feeling both sad for that loss and grateful for her baby at the same time.

The invisibility of infertility also means that some women may not have the vocabulary to identify and articulate their losses. Women with primary infertility endure the losses of pregnancy, delivery, parenthood and eventual grandparenthood but may not be able to understand for themselves that they are mourning the loss of an anticipated and desired life stage. Counselors can assist clients with developing language for their losses if they are struggling to verbalize their grief.

>> Get comfortable. Discussions about infertility may overlap with other taboo topics such as sex, masturbation, miscarriage and abortion. Many of the women I have met who have been affected by infertility have had miscarriages along the way. This brings about an additional — but connected — situation of grief and loss. Talking about miscarriage can be difficult to do without also bringing up abortion, given overlapping language (e.g., spontaneous abortion) and medical procedures (e.g., dilation and curettage). These topics can be slippery territory for personal bias, but counselors should regulate their own reactions and practice reflection to maintain appropriate neutrality and support. Engaging in self-care can be particularly important when counseling those affected by infertility.

Challenging infertility stigma

More and more, childbearing is being viewed as a choice rather than a societal or marital expectation, yet not having children is still considered to be somewhat taboo. Women are socialized from a young age to prepare for eventual motherhood through childhood play that often fosters a nurturing and caretaking role. Other cultural narratives suggest that women have an ability and responsibility to control their fertility. This contributes to self-blame and shame when they are unable to conceive. Infertility is infrequently discussed publicly and thus carries a sort of social stigmatization. Counselors can contribute to destigmatizing infertility by normalizing conversations about infertility, challenges to conception, fertility treatments, and miscarriage.

Stories related to infertility gained widespread media attention throughout 2018. That March, a fertility clinic in Ohio experienced a technical malfunction that caused the destruction of more than 4,000 eggs and embryos, a loss that most certainly had potentially devastating implications for the affected families. Then, in August, a rare visual of the emotional and physical struggle of trying to conceive was captured in a photograph that went viral of a newborn baby surrounded by the 1,616 IVF needles that it took to conceive her. In the months that followed, actress Gabrielle Union opened up about her emotional fertility journey that included numerous miscarriages and surrogacy, and former first lady Michelle Obama revealed her story that included miscarriage and IVF to conceive her two daughters.

These stories bring visibility to infertility and normalize conversations about the challenges that can come with attempting to get pregnant. Counselors can contribute to destigmatization by engaging in discussions and posing curious but sensitive questions about how resources and support can be bolstered for affected women and couples.

Conclusion

Each infertility story is unique, and no one-size-fits-all solution exists when it comes to helping women and couples work through their infertility grief. Whereas an obvious loss from the death of a loved one usually includes rituals and social support, the invisibility of infertility makes it difficult to identify the losses, often leaving women affected by these losses to deal with them in silence and isolation. Counselors can help clients find the vocabulary to articulate the losses they are grieving, give voice to what they need from the people around them, and create ways to process their grief in a warm, nonjudgmental atmosphere.

 

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Tristan McBain is a licensed professional counselor and licensed marriage and family therapist. She is a recent graduate from the Counselor Education and Counseling Psychology Department at Western Michigan University in Kalamazoo. Contact her at tristanmcbain@gmail.com.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Letters to the editor: ct@counseling.org

 

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Related reading on this topic, from the Counseling Today archives: “Empty crib, broken heart

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

New maternal mental health certification available to counselors

By Bethany Bray April 25, 2019

It’s estimated that 1 in 9 American mothers experience peripartum depression.

Because maternal mental health issues are so prevalent, many counselors’ caseloads include clients who are struggling during the first weeks and months of motherhood. However, few practitioners are well-trained enough to fully understand the unique needs and risks this population presents, says Birdie Meyer, the director of certification for Postpartum Support International (PSI), a Portland, Oregon-based nonprofit established to raise awareness of and connect people to resources for maternal mental health issues.

“There are a lot of nuances to this stage of life,” says Meyer, a registered nurse with a master’s degree in counseling. “You can really do damage if you send someone to a therapist who doesn’t know perinatal mental health … [And] There aren’t enough providers out there.”

Worse yet, a practitioner who treats perinatal clients but hasn’t completed comprehensive coursework or trainings in this area can risk doing harm to mothers at a vulnerable time of life. In her decades working in perinatal mental health, Meyer says she’s witnessed horror stories of women being reported to their local department of social services by a practitioner who mis-read the symptoms of peripartum distress – which can include feeling ambivalent toward a new baby or, in severe cases, thoughts of harming the baby or themselves.

“The despair that comes with [peripartum depression] feels like life will never be better, never be the same again. Many times, women seek help but don’t get someone [a practitioner] who understood, or the woman didn’t know where to turn,” says Meyer, who recently retired as coordinator of the perinatal mood disorders program at Indiana University Health, a large hospital system based in Indianapolis.

For this very reason, PSI has begun to offer a certification for helping professionals in perinatal mental health. It’s a project that has been three years in coming, and Meyer was closely involved in the certification’s development and launch.

PSI’s new Certification in Perinatal Mental Health became available in August to counselors, social workers and other mental health practitioners, as well as prescribers (medical doctors, psychiatrists), doulas, midwifes, lactation consultants and other affiliated professions. So far, 130 practitioners have become certified but hundreds more have begun collecting the hours of coursework required to qualify to take the certification exam, Meyer says.

Before a practitioner can list PMH-C after their name, they must pass a rigorous exam and have at least two years of experience in their field. They must also show proof of completion for 14 hours of continuing education in a subject related to maternal mental health. Finally, applicants must participate in an intensive, six-hour training that PSI offers in locations across the U.S., or a pre-approved course equivalent.

PSI has partnered with Pearson VUE, a company with testing centers across the U.S., to proctor the certification exam. The cost to sit for the exam, a test of 125 multiple choice questions, is $500.

PSI developed and refined the certification exam with several teams of subject-matter experts, including professional counselors, Meyer says.

“The test is rigorous,” says Meyer, “but if you’ve had the training that is required you should be able to pass.”

In order to keep up the PMH-C certification, a practitioner will have to complete at least six hours of continuing education each year, she adds.

Meyer believes that the PMH certification will ensure that more and more practitioners are qualified and available to give parents get the help they need in a most critical and vulnerable time of life.

The certification came to fruition after the family of Robyn Cohen, a woman who passed away as a result of a maternal mental health issues, donated to PSI to fund the project in her memory.

 

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Find out more about PSI and the Certification in Perinatal Mental Health at postpartum.net

 

Email questions about the PMH-C to certification@postpartum.net

 

Listen to an extended interview with Birdie Meyer on the Mom & Mind podcast (episode 104): drkaeni.com/podcast/

 

 

 

Related reading: For more on the unique mental health needs of peripartum clients, see the feature article “Bundle of joy?” in the April issue of Counseling Today.

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

 

Follow Counseling Today on Twitter @ACA_CTonline and Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

Bundle of joy?

By Bethany Bray March 28, 2019

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.”

Baby blues

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.”

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Contact the counselors interviewed in this article:

 

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Additional resources

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)

  • Women’s Interest Network

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.