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Postpartum Depression and Other Postpartum Adjustment Problems
by Leslie M. Butterfield, Ph.D.

Approximately 15% to 20% of all women having babies will have some postpartum adjustment problems - and the majority of these will have a strong impact on the formation of the new family, on the marital bond, and on the attachment of mother and baby. Unfortunately, even the most well-intentioned friend, doctor, or educator may not realize that depression is only one of the several postpartum disorders that can affect women in the year after they give birth. Postpartum adjustment disorders can range from mild to debilitating, encompass depression, anxiety, posttraumatic stress symptoms, bipolar disorder or even psychosis in some instances, and they can occur anytime from a few hours after birth up to a full year later. Sometimes, postpartum problems signal their presence through symptoms and distress in the months prior to delivery. However, those apparently enjoying a trouble-free pregnancy may still be surprised by postpartum disorders due to physiological vulnerabilities or external stressors.

A significant amount of postpartum adjustment problems can be averted or reduced by: (1) knowing the circumstances or situations that increase risk for postpartum problems; (2) being proactive in searching out preventive strategies; (3) utilizing available "helping" networks such as support groups or extended family; (4) seeking out healing opportunities through avenues such as journaling, co-counseling, bodywork, one on one talk therapy, or lifestyle changes such as diet and exercise; (5) being open to medication if the above efforts do not provide adequate relief. Following is a necessarily brief discussion of the risk factors for postpartum adjustment problems and a review of some preventive strategies, possible treatment options (as well as ways to overcome common obstacles to receiving treatment), and finally, a discussion of the unique ways in which attachment parenting and postpartum adjustment problems may interact. Listed below are the risk factors that most commonly predispose women to postpartum adjustment problems.

Risk Factors for Postpartum Adjustment Problems

Physiological Factors
  • History in self or family of: depression, postpartum depression, anxiety, and bipolar disorder
  • Pre-Menstrual Syndrome (PMS) of a significant nature
  • Thyroid imbalance
  • Sudden weaning
External Factors
  • Victim of sexual, physical or emotional abuse or neglect
  • Recent stresses (e.g. illness of family member, death of loved one, change in financial status, relocation, etc.)
Psychological Factors
  • Unresolved losses, especially reproductive losses such as past abortion, stillbirth, or SIDS death
Interpersonal Factors
  • Lack of social contacts/social support
  • Relationship problems with partner, especially if they include violence or emotional abuse
  • Relationship problems between the (pregnant) mother and her mother or grandmother
Factors in Relation to the Child
  • Relationship difficulties with the baby (e.g. temperamental differences or challenges)
  • Problems relating to the health of the baby (e.g. colic, illness/injury, developmental delays)
  • Profound differences between expectations of motherhood and the reality of the experience

In order to properly assess your level of risk, it is important to ask for detailed information about your family's history of mood and anxiety disorders, keeping in mind that these problems are often presented vaguely (e.g. grandma's "nerves") or couched in non-specific language (Aunt Mary's "bad days"). Note such problems as alcohol abuse and chronic overworking, which can overlay mood and anxiety disorders.

Of women who suffer from bipolar disorder, nearly 50% will experience their first recognizable episode of depression or mania during the postpartum period. Being able to tell a health care provider that bipolar disorder runs in the family can assure that you get prompt and appropriate care. Review your own emotional history during your pregnancy. Episodes of anxiety, depression, or mood swings - especially around reproductive events (beginning of menses, taking birth control pills, receiving hormonal therapy, previous pregnancies or births) - could signal your physiological vulnerability to a postpartum mood disturbance. While we can't prevent physiological vulnerabilities, we can - by paying attention to our own histories - prevent avoidable difficulties and be proactive in terms of taking better care of ourselves.

Here are some things I strongly recommend that all pregnant women do.
  • Familiarize yourself with the risk factors listed above and determine in what areas you feel most at risk.
  • Begin some stress-reduction strategies now. This could include starting an exercise routine, learning yoga or meditation, attending to your spiritual needs, or any activities that you find physically or emotionally strengthening and self-soothing.
  • Get involved with other women - especially mothers. Family is great - but you need the support and information to be gained from other women. In Seattle, we are lucky to have many networks to choose from, and most of them are open to women who are still pregnant. My suggestions include: La Leche League, Northwest Attachment Parenting (NAP), Attachment Parenting International (API), Mothers & More, Parents Educating Parents (PEPS), and Listening Mothers. I'm sure I've missed some great groups - please be sure to let each other (and me) know of any additional support groups you find.
  • Pay attention to your psychological issues and work on resolving them. Pregnancy is a time of deepening awareness about many family and relationship issues. It is also a time when many women and men are motivated to make changes because they want to be the best parents possible. Attending to emotional, physical, and spiritual matters at this time can really help to clear a path for a healthy birth, and can strengthen a marriage or partnership substantially. Although some people are concerned about grappling with painful emotions, experiencing conflict, or revisiting the past during the time of pregnancy, the evidence suggests that those who have addressed the issues that concern them are more confident, connected, and capable during the birth itself, as well as afterward. Pregnancy is an important time to attend to whatever methods of exploration and/or healing are suitable for both partners.
  • Some possibilities for healing include: self-help workbooks, journaling, bodywork such as yoga, Reiki, chiropractic; nutritional or dietary changes; co-counseling, group, or individual psychotherapy. All of these are equally available to women or couples dealing with postpartum difficulties. Get used to asking for help; begin this now. Many of us do not like to rely on others for help, but new mothers must do so. Realize that you will be able to be a "helper" again in the future, but that for now - others want and need to help you. This is one way they can show love and affection to you and your family. Practice noticing the things that you need help with, writing them down, and learning to ask people for specific things (i.e. making a dinner, doing a load of laundry when they visit, picking up items at the drug store for you).
  • Practice some version of "attachment parenting." It is my sense that the practices of co-family sleeping, extended nursing, and baby-wearing reduce the likelihood of postpartum exhaustion and marital discord that so strongly contribute to the occurrence of postpartum adjustment disorders. These practices both emerge from and enhance the possibilities of responding sensitively to a baby's cries - thereby creating a pattern of parent-child interaction based on attentiveness, empathy, and respect. In addition, they promote attentiveness and harmony within the family as a whole, providing an extra "buffer" of safety for all family members as they are exposed to the challenges life presents to them.
  • Get a doula. Certified birth and postpartum doulas are specially trained to provide the kind of information and support that birthing and new mothers need. They can offer help with practical tasks and emotional issues. They are also trained to notice postpartum adjustment disorders in their early stages and to suggest "first-step" strategies and to make referrals for appropriate help.

It can be hard sometimes for people to recognize a postpartum adjustment problem that may require counseling or medication because almost all new moms struggle with the transition to motherhood. It is normal to feel exhausted at times, to wonder whether or not you can be a good mother, to feel incompetent, to worry often about the safety of your baby. (Actually, these are things that plague most moms I know, myself included, although to a somewhat lesser degree as our children get older). There are a few key elements that can help differentiate the expected level of new-mom feelings of being overwhelmed from a true postpartum adjustment disorder. The first of these is the length of time the "symptom" lasts. For example, a woman who complains of exhaustion in the first few weeks after giving birth is behaving typically. However, a woman who is still complaining of exhaustion four months later is quite likely in need of some external supports (both practical and emotional). A woman who worries about handling her new born for the first few weeks after birth is having a fairly typical experience. On the other hand, a woman who still feels anxious about picking up her baby six weeks later is having a somewhat unusual and problematic experience. A woman who doesn't feel "bonded to" or "in love with" her baby in the first week or two after birth is well within the normal limits of experience. If she reports a lack of attachment two or three months later, she is almost certainly suffering from a postpartum adjustment disorder.

Another identifier of postpartum adjustment problems is the severity of the symptom. For example, many mothers report having worrisome thoughts about harm coming to their babies. This makes sense - newborns are extremely vulnerable, and it is a fairly overwhelming experience to find oneself responsible for the well-being and safety of another human being. If such thoughts begin to restrict normal and expected activities (i.e. the woman is afraid to bathe the baby because it might drown, or she is afraid to take the baby for a walk because he or she might come to some harm), a new mother is probably suffering from a postpartum adjustment disorder. Similarly, this is also the case if such thoughts become repetitive to the point that a woman feels continuously distressed by them or feels unable to cope with them. Some women experience the particularly unhappy situation of thinking that they might harm their own babies. Such thoughts can occur suddenly, without warning, and in some women can become repetitive. They cause a great deal of distress to the woman having them, who may be afraid to discuss these thoughts for fear of appearing "crazy." In truth, such women are likely suffering from a particular type of postpartum adjustment disorder called Postpartum Obsessive-Compulsive Disorder - which can usually be successfully treated with professional help.

Postpartum adjustment problems are also differentiated from normal transition to parenthood by the ways in which the woman and her family and friends experience her symptoms. Most of us react to stress in certain ways that become predictable to our friends and family members over time. Some people become grumpy and irritable, some start finding fault with others, and some retreat into private activities. Whatever our preferred method of self-soothing or responding to stress, it becomes familiar to others that know us. With postpartum adjustment problems, the thoughts, feelings, and behaviors of the affected person seem "different" to those around them. Friends or partners often make statements such as "she's just not herself," "she doesn't seem to be snapping out of it," or "I've never seen her this worried, unhappy, high strung, etc." Often, a partner or best friend is the person who convinces the woman to seek some outside help in understanding and dealing with what is happening.

Finally, indicators of postpartum adjustment problems are symptoms that, while not extraordinary in themselves, are unresponsive to a woman's attempt to solve them. Ordinary levels of worry can be diminished by talking with friends and support groups; ordinary levels of exhaustion can be reduced by taking naps, changing the baby's sleeping habits, or having partners take over some nighttime chores. Ordinary anxieties about baby care or well-being can be handled by reading books, calls to the doctor, or well baby visits. Stress and anxiety can be handled by massage, hot baths, journaling, or exercise. Yet with postpartum adjustment problems, the symptoms don't appear to be much affected by the typical strategies that usually work well for a person. They may remain at the same level of disturbance or get worse over time. This is probably because such problems are often a result of physiological and psychological vulnerabilities combined with external stressors. It usually requires some skilled intervention from a trained professional, and may require a course of medication as well.

It is also important to realize that postpartum problems can co-exist with other emotional difficulties, and that other emotional difficulties can exist during the postpartum time period without developing into postpartum adjustment problems. The most common example of the latter would be grief-related issues. Some women feel grief about the pregnancy or birth experience and have a need to be helped in the mourning process, yet their symptoms do not develop into postpartum adjustment problems. Some women with previous losses, especially loss of their own mothers, have grief that wells up following the births of their own children. On the other hand, women with histories of depression, anxiety, or bipolar disorder may continue to experience these during the postpartum period, and may also develop the additional symptoms or worsening severity of symptoms that make up postpartum adjustment problems.

Postpartum adjustment problems can be quite successfully treated, particularly if they are noticed quickly and treatment is sought promptly. As stated earlier, a well trained therapist can often help a woman feel much better by asking for details about the troubling symptoms (as well as gathering information about the rest of the woman's life), developing careful plans for reducing and/or eliminating symptoms, and working with family members or close friends to support such plans. If these strategies are not successful, several medications are now available that are helpful and work quickly. However, many women are resistant to treatment and the reasons for this are numerous. First of all, as mentioned earlier, the symptoms of postpartum adjustment problems are actually fairly widespread, ranging from depression and manic-depression to anxiety and even posttraumatic stress disorder. Because of this, many women fail to recognize that they are actually experiencing a specific postpartum adjustment problem. They don't realize that their distress is identifiable as a physiological and/or psychological "emergency" that can benefit from immediate intervention. Often, they (and their family members) stumble through these painful times without any real sense of what is happening - just knowing that things are going terribly wrong somehow - and incorrectly attributing this to personal failures or character deficits. Women are repeatedly told that they are "avoiding the responsibilities of motherhood," "being immature," or "exaggerating" their distress. They are misdiagnosed as having the "baby blues" (a condition of sadness and tearfulness that occurs within the first week of birth and remits within three to four days) or dealing with "unconscious conflicts" about motherhood.

In addition to the problem of misdiagnosis - or the failure altogether to recognize the presence of a postpartum adjustment problem - there exists the concern many women feel about breastfeeding while taking any medication. It is a common misconception that taking any type of medication will necessitate weaning. Although some medications clearly pose a threat to the developing infant, there are several antidepressant/anti-anxiety medications that have been shown to enter the breast milk in miniscule quantities, while others show no identifiable traces in breast milk at all. The amount of medication transmitted to breast milk can be further regulated by the timing of feedings, and the time at which the medication is taken by the mother. A psychiatrist or family physician should be able to discuss with a mother which medication would likely be most helpful to her and would have the least impact on her child. Women with concerns about medication need to consider the potential harm done to the baby, the mother-baby attachment, and the marital relationship should they choose not to use medications when the severity or longevity of symptoms point to medication as the treatment of choice.

Finally, and sadly, there are social inhibitions that keep mothers from getting the help they really need. Mothers suffering from postpartum adjustment problems of the obsessive type are often afraid that their thoughts about harming their babies will be used to label them as "unfit mothers" and will result in having their babies removed by Child Protective Services. Women with less dramatic symptoms may still feel that they will be judged unworthy or incapable parents, and will then be subjected to the interference of social service agencies or guardians of the state. Most frequently, however, moms just feel guilty and sad - sorrowful about what they perceive as their personal failures and inadequacies, guilty about what they aren't providing to their babies, ashamed at what they construe as faulty mothering. The downward spiral of self-esteem in women with postpartum adjustment problems is all too common, and often adds to a woman's inability to care for herself through seeking treatment. People with depression and anxiety often have a difficult time making connections, asking for help, and following through. That's why it is so important for each of us to be educated about postpartum adjustment problems and to follow preventive measures prior to the birth of a child.

Attachment Parenting

Where do attachment-oriented parents fall on this spectrum of who gets postpartum adjustment problems, and who doesn't? It is my personal belief that so-called "attachment parents" benefit from some protective factors inherent in their parenting style, but I say this with some caveats about the special vulnerabilities that are also present. And, it is important to realize that physiological vulnerabilities (both those present prior to pregnancy and birth as well as those created by the events of pregnancy and birth) exist no matter what parenting style is chosen. Still, it has been my impression that the four defining characteristics of attachment parenting all offer some protective possibilities.

Breastfeeding upon request, baby wearing, and co-sleeping all facilitate the achievement of the psychological state of mind that lies at the heart of attachment parenting - the ability to listen and observe attentively, and to subsequently respond empathically to a baby's needs. Such response (whether to physical or emotional needs) ensures not only the baby's immediate physical survival and well-being, but protects the growth of the parent-child bond that is pivotal to the sound emotional growth of the child and the overall emotional stability of the family. (Indeed, most of the current therapies aimed at repairing marital or familial relationships emphasize the importance of attentiveness, the ability to soothe, and the ability to view and respond to problems with empathy).

Extended breastfeeding and breastfeeding upon request offer some very real physiological benefits to both mother and baby. The action of suckling on the part of the infant causes a release of oxytocin (the "love" hormone) in the mother. This hormone makes both mother and baby relax, and facilitates feelings of attachment. (Have you ever noticed the strong desire to nap together after a breastfeeding session)? The ongoing presence of oxytocin in the mother is generally believed to help her maintain a somewhat more positive or stable mood in the face of the physical and psychological demands placed upon the mother of an infant. Sudden weaning can cause an increase in depressed and/or sad feelings and may precipitate postpartum adjustment problems. It is also my observation, though I know of no scientific data to support this, that women who have difficulties with breastfeeding tend to have a higher rate of postpartum adjustment problems. It is unclear whether the lack of oxytocin causes this, whether the disappointment and sense of failure causes this, or whether the very circumstance that causes the difficulties with milk production also causes physiological states that are linked to postpartum adjustment problems. No doubt there are likely interconnections among these conditions.

"Baby-wearing," by using a baby-carrying sling, also seems to have some very positive and preventive effects. First of all, the mother and baby are so physically close that it becomes substantially easier to know the baby, read its signals, and understand its needs. (It has been observed in traditional societies, where mothers carry their babies in slings on their backs, that these mothers are so attuned to their child's movements and sounds that they can predict when their child needs to eliminate). When a mother can read and respond to a child's needs, those needs are likely to be met much more promptly, thereby reducing the need for the child to cry or become distressed in some other fashion. Indeed, I would guess that babies who are typically carried in slings cry substantially less than other babies, thus allowing the parent-child relationship to be built through a variety of positive interactions, rather than being limited to comforting actions. (I remember reading that the average baby cries for five to six hours a day; this seems almost unbearable to me). Both my babies were sling-carried and seemed happy most of the time, at least as infants! I can only imagine the feelings that could be aroused by having a baby cry as often as five to six hours a day.

Another benefit of "baby-wearing" is that it can be done by fathers or other caretakers in the baby's life. Thus, other adults have a tangible way of building a close bond with the baby and learning how to read its signals, give comfort, and help the baby respond to change. Not only is this experience one that most fathers don't get enough of, but there is clear evidence that children benefit from close contact with both parents. I believe that slings allow fathers a frequent and effective opportunity to "fall in love" with their child, something many fathers in our culture all too infrequently get. This falling in love has unexpected benefits for the family as a whole, the most obvious one being that a father is more likely to enjoy participating in child care rather than having to be asked to do it, or being seen as a babysitter rather than a parent. Another good thing about the sling is that it can be adjusted to carry children right through toddlerhood, and even into the pre-school years - so that the level of physical and emotional intimacy that it affords parent and child can be sustained throughout early childhood. I remember one occasion on which my husband asked our four-year-old son to go out on a walk. Conor asked to be carried in the sling, and my husband (thinking he might benefit from the exercise) asked if he wouldn't rather walk together. "No," Conor replied, "because when I'm in the sling, I can look into your eyes much better." (As you can imagine, we carried him in the sling until our backs really couldn't take it any longer).

I think that creating the possibility for a father to fall in love with his baby, close to the experience more typical of a mother, is extremely important in sustaining marriages during the transition to parenthood. It should be noted that this period includes the greatest drop in marital satisfaction, and is most often the primary precipitant of subsequent divorce. In our culture, many fathers report feeling incompetent with babies, as well as feeling left out of the mother-baby bonding. They report feeling somewhat envious of that bonding, and missing the tender, loving feelings that used to be shared between themselves and their wives. Their perception is often that those feelings now go to the baby, and that there isn't much left over for the marital relationship. Although the marital bond cannot be replaced, the hurt and anger that accompany such changes can be assuaged by a new love relationship - father and baby. Not only does such a relationship offer some healing from feelings of loss, it offers a special chance for the father-child relationship to grow strong roots that can continue to produce good feelings in the future, when inevitable conflicts occur.

Family co-sleeping offers a similar opportunity in terms of father-child closeness. There is a very special feeling that comes from sleeping with and waking up with someone and this feeling facilitates enhanced bonding between parents and children. The anxieties and ill tempers of the day tend to be washed away during a night of all sleeping together, in which tenderness and vulnerability are safely experienced. For the mother, this same special feeling occurs. In addition, a mother can respond to her infant's need for soothing or breastfeeding without having to wake herself up fully, and get up out of the bed. She can breastfeed right there in the bed, hardly even needing to waken. This can have an enormous impact in terms of preventing the sleep deprivation that is often a significant contributor to postpartum adjustment problems.

In short, attachment parenting may be one of the best strategies for preventing postpartum adjustment problems. However, there are some things to be aware of, because even attachment parenting has its drawbacks, and in any case cannot completely overcome physiological vulnerabilities (though it may decrease them). One thing to consider is the fact that attachment parenting is a time-intensive effort, requiring a large degree of physical output. In cultures where most or all babies are worn in slings and sleep with their families, those babies are carried for part of the day by aunts, cousins, siblings, or grandparents. But in our culture, the attachment mom is usually doing the job with only her spouse to help her, and most spouses are at work for the largest portion of the day. Thus, baby-wearing can be extremely tiring in both the physical and emotional sense of the word, and in many cases there is no obvious relief. Sometimes attachment moms feel "all touched-out" and overwhelmed with a responsibility that may be inadequately shared. Similarly, attachment parents are a lot less likely than the average parent to take a vacation together while their six-month-old stays home with a caretaker. Attachment parents get less private time together - and this itself can lead to problems in the marital relationship unless real effort and creativity is devoted to the marriage as well.

Attachment parents face another difficulty, and that is one that is hard to see - loneliness. Doing anything that the mainstream culture regards as "different" or unacceptable can be a difficult road. A sense of isolation can certainly lead to feelings of self-doubt, shame, or a sense of inherent "wrongness" that can expand into depression or anxiety given the right mixture of other external stressors and/or physiological vulnerabilities. Finally, due to the child-centered nature of attachment parenting (especially when the child is very young), it is important to have what might be termed an "attachment marriage" as well to balance things out. It is very challenging to have a partnership in which one spouse adheres to attachment practices and the other does not. Both spouses must genuinely believe in and support the choices that surround the commitment they are making, and - if they are prepared - can handle the inevitable stresses that occur because they have chosen attachment parenting.

Many attachment-parenting moms who come to me for therapy ask, at some point in their efforts to cope with the stress of being a new parent: "Why am I doing this? Is it really true that my children will be better off? Other people's children seem to be fine and happy also - do I really need to work this hard, sacrifice this much for my children?" As an attachment parent myself, this is a particularly poignant question - and one that reverberates to my very heart. When I became a parent, I had to rely on my instincts and desires, and often felt unsure of my choices - especially when I was tired or discouraged about developmental stages my children were in (or that I was in as a parent). Happily, in recent years more and more "experts" in the fields of child development and psychology have begun to explore the significance of attachment. Research in the field is beginning to yield data that supports the importance of the concepts that lie at the core of attachment parenting. Today I am better able to support myself and the parents I work with in experiencing the joy of following their hearts, combined with the knowledge that science supports them in their quest to nurture loving, creative, and emotionally mature beings. It is my strong belief that attachment parenting isn't just good for the children and families practicing it, but that those who directly benefit from its practice pass onto others the empathy and independent thinking they have learned. I'll never know how my children would have been if I had raised them more typically of others in our culture. But I know that I chose attachment parenting because I believed it would allow me the best opportunity to fall in love with my children, and give me the faith and hope that I could stay in love with them over a lifetime.

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Chrysalis Counseling Services PLLC | Juliana K. Tyler, MA, LMHC, NCC, DAPA, BCPC, CMHS, HBCE, HBFE | Psychotherapist
Certified HypnoBirthing® Practitioner and HypnoBirthing® Fertility Educator, affiliated with the HypnoBirthing Institute
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