The Postpartum Experience

Ellen stirs. In the depths of her unconscious, she becomes dimly aware of a noise. She puts her pillow over her head—maybe it’s just a dream, and she can go back to sleep. The noise becomes more insistent. It’s her baby daughter, crying. She sits up and notices her husband sleeping, his features peaceful. She fumbles for her phone to look at the time. It’s 3:17 a.m. She’d only finished the last feeding an hour and a half ago. She stumbles out of bed and lumbers to her child’s room.

Her daughter is five months old and not sleeping through the night. With a sigh, Ellen picks her up and sits down in the glider. The baby greedily seeks out her breast. Ellen stiffens as her daughter’s mouth locks around her nipple, then she wills herself to relax. As the baby settles in and sucks rhythmically, Ellen starts scrolling through her Instagram feed. Her friend Tyra pops up in a post. She’s lying on a beach in Miami, looking relaxed and carefree. Ellen recalls a conversation she’d had with her a week earlier.

“So what’s it like being a new mom?” Tyra had asked brightly.

Ellen had hesitated before answering. “It’s not all it’s cracked up to be,” she’d admitted. “I’m still not feeling like myself.”

“You do sound tired,” Tyra had commiserated. “Do you want to talk about it?”

“Oh, it’s nothing,” Ellen said, struggling to inject some energy into her voice. “I’m sure I’ll feel better once the baby starts sleeping.”

After a while, Ellen realizes it’s time to burp the baby, do a quick diaper change, and start another round of feeding on the other breast. Checking her phone again, she realizes she needs to be up in three hours. Letting out a weary sigh, she resigns herself to the treadmill her life has become.

Unaware that she might be experiencing a postpartum mood or anxiety disorder, Ellen was like many new moms who interpret their lack of enthusiasm in their new role as a temporary issue or a personal failing. I hear countless versions of this story in my practice, with themes of resignation, fatigue, and resentment, as well as a sense of being had. The mothers I work with don’t experience the glow everyone tells them they’re supposed to have as a new parent. They’re exhausted, emotionally worn thin, and continually on edge.

“Your Specialty Will Find You”

I stumbled into my niche as a reproductive psychologist shortly after giving birth to my first child. With an educational background in child psychology and infant development, as well as extensive experience as a play therapist, I thought I was well equipped to be a parent. I also thought I was prepared for the possibility that I’d develop a postpartum mood disorder because of my history of depression, and I made sure to ask my healthcare provider about it. I let my partner know I was at risk, and we developed a plan to ensure I got some sleep.

Enter an actual, living baby, and my whole world turned upside down. While I didn’t have a bona fide postpartum depressive episode, adjusting to this new role and identity packed a wallop. Everyday tasks I’d previously found simple now seemed immensely challenging as I constantly juggled responding to an infant’s needs with trying to attend to my own. I had to learn to tolerate the distress of my child’s cry and to slog through weeks in which I felt I had no choice but to function, thanklessly and endlessly, at the upper limit of what my sleep-deprived body and mind could handle.

Once, a grad school professor told me, “Your specialty will find you. You won’t find it by looking.” Well, my specialty had come knocking on the door.

I started to get training in perinatal mental health when my child was a little over a year old, with a specialization in the postpartum period. Then, when my partner and I decided to grow our family and we experienced recurrent pregnancy losses, my understanding of reproductive mental health deepened, motivating me to also pursue postgraduate training in fertility counseling.

I’ve been working as a reproductive psychologist for 15 years now, and I have a robust clinical practice, centering on aspects of reproductive psychology—with issues ranging from conception to postpartum, and including traumatic events such as infertility, pregnancy loss, and birth trauma. Most of my clients are women, though I work with a few dads, and I see people who identify as heterosexual, lesbian or gay, trans, and cisgender.

The Secret Lives of New Mothers

If most of your clients aren’t childbearing women, you may not realize the unique mental health challenges women face right before and after giving birth, which can impact multiple generations. In a recent New York Times article, Chelsea Conaboy, author of Mother Brain: How Neuroscience is Rewriting the Story of Parenthood, reports that as many as nine percent of mothers develop postpartum post-traumatic stress disorder, while 10 percent of postpartum women develop anxiety. The stakes are high, and most therapists don’t realize that treating depression or anxiety generally isn’t the same as treating these mood disorders in the perinatal period. It’s much more nuanced and complicated.

Not only is a new mom on one of the steepest learning curves of her life as she figures out how to take care of a small, vulnerable human being, but she’s doing it on maybe three consecutive hours of sleep a night. As an added complication, her body might be healing from the birth experience, which can take approximately four weeks after a vaginal birth and six after a C-section. She may also be dealing with physical discomfort, such as engorgement, intense cramping as the uterus returns to its normal size, and perineal pain. On top of everything, a new mom who’s in a relationship may be struggling with her partner about how to share caretaking tasks equitably.

While the DSM specifies that symptoms must last longer than four weeks to constitute a diagnosis of depression, making postpartum individuals wait that long before acknowledging their condition and connecting them with the services and support they need verges on unethical. With this maelstrom of adjustments and changes taking place, four weeks is an eternity. A new mother may not fit the criteria for major depressive disorder, but she might fit well into a “postpartum onset” category.

When working with new moms, therapists need to be flexible and accommodating. It might not be feasible for a woman to come to therapy solo if she is breastfeeding or doesn’t have access to another adult who can stay with the baby. Frequently, babies join our sessions, and it can get messy. In the midst of exploring parents’ overwhelming anxiety about whether their baby is gaining enough weight or getting enough tummy time or hitting developmental milestones—all in whispered tones so the baby doesn’t wake—the baby might suddenly spit up a fountain of warm, white, partially curdled milk. As it splashes on the floor and the baby, startled, starts to cry, the mom might suddenly realize she’s left the spit-up clothes at home, precipitating a stream of exasperated self-criticism.

But having all this play out in the therapy room allows me to gather valuable clinical data. For example, how do parents respond to the throw-up crisis in that moment? Are they flustered? Apologetic? Do they break down? Do they respond with humor? On my end, I need to adjust my expectations for what therapy is supposed to look like. If we can’t tackle our therapeutic goals for a session because a baby is fussing that day, how can I help my client pivot the agenda? In this instance, teaching a parent to self-regulate can extend to them helping the baby through coregulation.

Often, postpartum therapy may mean supporting the entire family, as partners have a one in 10 chance of developing a postpartum mood disorder. This challenges the assumption that people have postpartum depression because of hormonal activity. Partners don’t have these hormonal shifts, nor do adoptive parents, and yet both are at risk for experiencing a postpartum event. And to both I offer guidance like what I give a birthing person around sleep, self-care, and exploring their shifting identities.

Let’s turn to sleep. The typical advice to new moms, in particular, is to sleep when the baby sleeps. Well, that’s easier said than done—especially when the postpartum issue is anxiety. If you’re working with clients who suffer from anxiety that’s unrelated to parenthood, pregnancy, or birth, you might work with them to identify and challenge distorted thinking or to recognize how past traumas are making a harmless situation feel threatening.

With new moms, however, fears often need to be validated and understood as reality based. Babies are very vulnerable: they need constant care, attunement, attention, and the right kind of timely nourishment every single day. Moms are anxious for a wide range of legitimate reasons, including milk supply, returning to work, and managing a baby’s sleep and weight gain. Blithely challenging their thinking as distorted, or moving too quickly to help them figure out how to reduce their anxiety, can feel invalidating and even threatening.

But having all this play out in the therapy room allows me to gather valuable clinical data. For example, how do parents respond to the throw-up crisis in that moment? Are they flustered? Apologetic? Do they break down? Do they respond with humor? On my end, I need to adjust my expectations for what therapy is supposed to look like. If we can’t tackle our therapeutic goals for a session because a baby is fussing that day, how can I help my client pivot the agenda? In this instance, teaching a parent to self-regulate can extend to them helping the baby through coregulation.

Often, postpartum therapy may mean supporting the entire family, as partners have a one in 10 chance of developing a postpartum mood disorder. This challenges the assumption that people have postpartum depression because of hormonal activity. Partners don’t have these hormonal shifts, nor do adoptive parents, and yet both are at risk for experiencing a postpartum event. And to both I offer guidance like what I give a birthing person around sleep, self-care, and exploring their shifting identities.

Let’s turn to sleep. The typical advice to new moms, in particular, is to sleep when the baby sleeps. Well, that’s easier said than done—especially when the postpartum issue is anxiety. If you’re working with clients who suffer from anxiety that’s unrelated to parenthood, pregnancy, or birth, you might work with them to identify and challenge distorted thinking or to recognize how past traumas are making a harmless situation feel threatening.

With new moms, however, fears often need to be validated and understood as reality based. Babies are very vulnerable: they need constant care, attunement, attention, and the right kind of timely nourishment every single day. Moms are anxious for a wide range of legitimate reasons, including milk supply, returning to work, and managing a baby’s sleep and weight gain. Blithely challenging their thinking as distorted, or moving too quickly to help them figure out how to reduce their anxiety, can feel invalidating and even threatening.

A big part of my work with new parents is to help them rest, if not sleep, so that they can give their brains time to organize and integrate the knowledge and experiences from the day. I might use guided imagery or restorative practices, such as putting their legs up against a wall while lying on the floor. Prescribing sleep goes beyond just instructing them to sleep: rather, it’s about giving them permission, adjusting expectations, and developing strategies to allow them to rest during the day as best they can.

A Case of the Blahs

Remember Ellen? She didn’t come to my office until her son was 11 months old. She sought me out because she was feeling “blah.” Her partner and parents were beginning to worry, she told me.

“Blah?” I said. “That could mean a lot of different things. What kind of blah?”

“Just empty and drained,” Ellen replied, leaning forward on my couch with her chin in her hands. “I feel like I’m going through the motions of my life, of being a mom, of everything. And then I feel guilty and ungrateful. I know I should be happy because I have a healthy baby, and she’s thriving.”

“That sounds rough,” I said.

“I know I’m not depressed,” she said quickly. “I was screened for postpartum depression when my son was six weeks old and then again when he was four months.”

“Did your providers follow up with any questions—or just give you the quick quiz?” I asked.

“I answered the questionnaires honestly,” she said. “And they didn’t ask me anything.” Then she grew thoughtful. “Of course, my mom was visiting at the time, and taking care of the baby, so I was sleeping a lot then.”

Screening is a moment in time, and while it can help, the threshold for needing professional help on the Edinburgh Postnatal Depression Scale (EPDS) is a score of 13+, which is quite high. And that common form of screening looks primarily at symptoms of depression, so anxiety is often missed. Also, administering it is usually the responsibility of the obstetric office, which sees new moms only six weeks after birth—or 2 and 8 weeks after, if the birth was surgical. The American Congress of Obstetrics and Gynecologists has advocated for moving these screenings to pediatric practices, since parent mental health is frequently assessed as part of the required newborn well-visit schedule. And yet, even though research shows that perinatal mood and anxiety disorders can persist until the child is a year old—pediatric practices generally stop administering the test after the four-month visit.

An important part of my work with Ellen focused on her sense of worthiness beyond her identity as a mother. Often, women revert to limiting roles around home and hearth when a baby arrives. A woman’s identity, which may have been multifaceted before pregnancy, is now reduced to that of a mother. This reduction often gets compounded when friends and relatives fawn over infants—which reaffirms the sense that a mother is only as good as the baby (and the baby’s behavior). Ellen and I had an important conversation about this identity shift that started with her growing resentment toward her husband.

“He doesn’t appreciate me anymore,” she told me. “It’s like I’m just a food source for the baby, a cook and a cleaning lady, all wrapped into one.” She blew out a loud breath. “Then he expects me to be available to manage his needs too. There’s no space for me.”

Guided by other things she’d shared with me about her husband, I had a hunch that this was a projection. “Is that how you see yourself?” I asked gently. “As a food source, a cook and a cleaning lady?”

Ellen stared at me for a moment, looking shocked. Then, her face softened, and her eyes grew moist. “I guess that is how I see myself sometimes,” she admitted.

Through our work together in challenging these internalized beliefs, Ellen learned to delegate tasks and trust her husband to help with childrearing. This had been hard to do initially, since whenever she’d tried to leave the house, the baby would cry, and she’d quickly rush over to soothe her. Doing this sent a clear message to her husband that she had doubts about his ability to parent. When Ellen didn’t give herself permission to leave the house, when she saw herself in an outdated and limiting role, and when she watched her husband sleep soundly as she got up at night to soothe the baby, it contributed to her growing resentment.

Gradually, Ellen learned how to calm herself enough to take time off from being with the baby. She began to reconnect with interests beyond parenting and work, which helped her value herself as a complex, multifaceted, vibrant human being as well as a mother. She began to feel more like herself and explore family-of-origin concerns that related to her feelings around being a parent.

A common cultural myth holds that parenthood is intuitive, but ask any new parent at 3 a.m. if what they’re doing feels intuitive. Being a new parent, I often tell my clients, is like learning to drive a car. The first time we sit behind the wheel, we’re slow and tentative. We check our mirrors several times. We jerk back and forth between the gas and the brake pedals. As we practice doing all the separate little tasks that allow us to drive, our movements become more fluid, and gradually, driving becomes automatic.

Parenting is similar: it’s a combination of many skills we need to practice and learn through trial and error. In doing so, I help clients explore how they were parented, and identify what did and didn’t work for them. Often, new parents unconsciously revert to unhealthy patterns learned from their parents, and breaking these cycles has lasting benefits, not only for them but for generations to come.

One of the most important things we can convey to new parents is that everyone makes mistakes. Lots of them! And most of them don’t make or break the bond that connects parents and children. Along with the many humbling experiences that come with the new role of parent, those who choose this path have many opportunities to connect with the reality that, by and large, parents and children are resilient and capable of change. Doing our best goes a long way.

Is Breast Always Best?

The pressure to breastfeed from much of society—from social media to parenting books to lactation consultants and even well-meaning family members—enacts a different burden on a new mother. It takes tremendous energy to feed a baby on each breast, make sure your supply is adequate, make sure the baby’s latch is adequate, get lactation help from specialists, pump, clean pump parts, separate milk into bags or bottles, label them, sanitize pump parts (yes, this is a separate chore from cleaning), buy seemingly endless supplies (yes, you need a bustier so you can pump hands-free), and guard against the dreaded clogged ducts and mastitis, where breast tissue becomes painfully infected.

Despite the challenges that accompany breastfeeding, stopping before the baby turns one is a difficult decision for mothers. The American Academy of Pediatrics recommends that children be breastfed up to age two (in alignment with the World Health Organization’s recommendation). No parent wants to feel like they’re failing their child by falling short of the recommended timeline. The sense of shame and guilt that follows is often exacerbated when parents observe others who appear to find breastfeeding easy.

For mothers who’ve already endured a challenging reproductive journey, this experience of shame and guilt is often compounded by what seems to be additional evidence that their body isn’t working. Countless clients have shared with me how much they were looking forward to breastfeeding, only to find that this, too, was difficult. Their takeaway: “I’m not meant to be a mother.” The sense of failure can be devastating.

Breastfeeding, or the lack thereof, can be another trauma point in a person’s parenting journey. So I ask about feeding in an open kind of way, as in, “Tell me about how feeding your baby has been.” In this way, I’m not perpetuating the idea that “breast is best.” Breastfeeding is best only if that is what works best for the dyad. The more inclusive slogan used by maternal health advocates is “fed is best,” which we can all get behind.

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