Recap: Chava is assessed by her therapist in the first session for symptoms of post partum depression and/or anxiety and learns that she manages to hold onto to her secretarial job despite symptoms. Before Chava leaves the first session, she wants to know if she can ever achieve pre-baby functioning.

I owe Chava the truth, and I give it to her.

“Yes, you can achieve the functioning you had before the baby. But it will take time.”

Chava has one more question.

“Is it safe for me to have another child?” She stands there afraid to hear the answer.

“That is something you will need to assess after you are already feeling better,” I say. “For the most part, yes, you will be able to safely have another child. But there may be a relapse of symptoms. There are things you can do, both with therapy and medication that can minimize the symptoms and protect yourself.”

We agree to meet the following week.

Second session:

When Chava walks into the second session, her anxiety is extremely visible. “My husband doesn’t want me to come to you anymore,” she says. “He said that I am worse since I started coming to you.”

Usually I expect this reaction, but not so quickly. And I hadn’t had time to warn her about it so I could prepare her for it. I needed to do repair quickly and efficiently or else this would be the last time I would see her. And I know that therapy is really important for her at this time as she has many of the symptoms of post partum depression and anxiety and without therapy, the symptoms would probably worsen.

It may seem odd that a husband, who originally sends his wife to therapy, would change his mind so rapidly. But any therapist knows this is not odd at all. Therapy creates changes in a person. When the changes are good, the other partner feels threatened even if he had originally said they want these changes to happen. Even if one partner perceives the change as bad, it may still actually be good changes that they don’t know how to adjust to. It unbalances the marital relationship and the partner not in therapy feels blindsided and threatened. It happens all the time. A woman drags her husband to therapy because he is critical and angry and then when he begins to change, she doesn’t know how to adapt to the new person in her home and she begins to sabotage the therapy to get her old husband back so she can go back the old dance steps she is familiar with.

Or, the opposite occurs. Therapy can initially cause increased anxiety or negative behaviors, or unmask some unpleasant behaviors that have been suppressed until now. It’s usually a limited time, but it’s unsettling for a spouse to see worse functioning as a result of therapy and reacting to that in fear.

And I need to assess what was occurring with my client, what her husband was reacting to and create a plan of action that would not include stopping therapy. Often, when I would not be successful in stopping a client from dropping out due to pressures from parents or a spouse, the client would initially mask the problems that brought her or him to therapy, proving that therapy wasn’t important, and then slowly deteriorate even more dramatically until the situation mandates therapy again. In a worst case scenario of post partum depression and/or anxiety, hospitalization for symptoms may result.

“Tell me why he wants you to stop therapy,” I ask Chava.

“He said that I am having more trouble sleeping,” she says, “and that I started making up all my fears since I began therapy. That until now I didn’t have all these worries.”

“Is that true, that you are having new worries since we began therapy together?” I ask.

Chava hesitates.

“No,” she says. “But since I started coming and you are making me feel normal about the stuff that’s happening, I wanted to talk to my husband about it. I never used to tell him what’s in my head because I was scared he would think I am crazy, but I got my courage from therapy but now he thinks it’s making me worse and he won’t believe me when I tell him otherwise.”

When a woman is feeling vulnerable, it’s difficult for her to stand up against her spouse to do what she thinks is right for her. Especially when she feels cared for by her spouse and knows he wants what is best for her. She begins to doubt her own feelings and experiences and he reinforces her insecurities with his lack of understanding through little fault of his own.

I need to tread carefully. My instinctive reaction here is that her husband was scared, ignorant of post partum, and talking from his fears and not out of a real will to stop her from getting well.

“I am sure he wants what is best for you,” I say. “But he may not always know it. What do you want?”

Chava begins to cry. “I want to continue therapy,” she says. “But if he doesn’t want me to, then I can’t. He helps me so much and takes care of the baby and is so understanding that I just have no energy to fight him on this.”

“What about the older mentor who recommended therapy to begin with?” I ask. “Can you enlist his help to make your husband understand?”

“No,” Chava says, “he regrets listening to that guy and he said that he is not happily married anyway.”

“Is there a rav you can talk to?”

“No,” she says, “He is embarrassed to talk to anyone about this. And he said that anyways things are much better and I don’t need therapy.”

This contradiction is also not unfamiliar to me. Paradoxically, I am certain that there have been a decrease of some symptoms of post partum since I have met with Chava, even just because Chava feels relief at being understood and feeling hope for the first time in many months. So while her husband is afraid of her openness in sharing her symptoms, he is also noticing improved functioning. So while he attributes the former to the negative effects of therapy, he does not attribute the positive effects.

Before I work to empower Chava to make a decision to stay in therapy, I assess if money is an issue (it is not as her mother is paying for sessions), if she herself is ambivalent about returning (she is not as she knows how it is helping her), and if therapy is indeed worsening her symptoms (it is not). We then discuss ways in including her husband in the therapy, by bringing him in for a session, encouraging him to read literature that she can print out from the internet, and giving him the number to call of a local frum organization that helps not only woman cope with post partum depression, but mentors men as well.

Chava expresses surprise that such an organization exists and I give her the contact number, inviting her to access another resource.

Because I do not know if she will return for another appointment, I want to ensure that she has the tools she needs to cope as much as possible. In addition to giving her the contact number for organization and encourage her to call them, I also discuss the option of medication. Usually, I would wait until I have established a firm working relationship with a client before suggesting or discussing medication, as it is a very sensitive topic. Of course, if I have grave concerns about a client and the necessity of immediate medication, I would broach the topic immediately. However, in my assessment of Chava, I feel that medication is just one more tool to help her and not mandated; therefore I had not intended to bring it up as of yet. With this new development concerning her husband, I wanted to make her aware of her options while I still had the opportunity. Although medication in the absence of therapy is not as effective, it can still afford enough relief that may tide her over until she is able to return to therapy, or used in addition to merely the support of these three sessions to find her own way through her post partum symptoms.

I never underestimate the power of therapy beyond the sessions or its ability to impact after termination. As well, I believe in self determination and allow clients to ultimately make their own decisions about their health, believing they are capable of making the right choices for themselves at that time. This situation was no different in my eyes. Chava needs to decide where to put her energies, empowering herself to stay in therapy, into fighting her husband to remain in therapy, or into getting well using the tools she had acquired in the short time we had together. And if medication can help her, I need to let her know.

I broach the subject carefully. “Are you aware that because you are totally normal, and that these symptoms occurred as a result of a hormonal imbalance giving birth, it is also possible to alleviate these symptoms in some measure by medication aimed at these same hormones?”

Chava looks at me. She is uncomprehending.

“After childbirth, a dramatic drop in the hormones estrogen and progesterone in your body may contribute to postpartum depression. Other hormones produced by your thyroid gland also may drop sharply — which can leave you feeling tired, sluggish and depressed. Changes in your blood volume, blood pressure, immune system and metabolism can contribute to fatigue and mood swings,” I say.

“Really?” she says.

“Yes,” I say. “There’s also things like how lack of sleep or emotional or physical support can affect post partum, but there’s definitely the real aspect of how hormones affect post partum women.”

Chava looks amazed. “I did not know that,” she says. “So it’s not just in my head!”

“No,” I say, “although sometimes post partum anxiety and depression can cause a bunch of other things like how you relate to your baby, or your lack of self confidence, and managing the symptoms of post partum depression so you can function normally again. That’s where therapy comes in.”

And then we talk about medications. I encourage her to talk to her primary care physician as well as obtain a full physical. How she can call a psychiatrist to learn about different medications that may work for her, and together with therapy it may alleviate symptoms that are causing her such distress. I give her a few referrals to psychiatrists that work with women suffering from post partum and encourage her to educate herself in all ways possible.

When Chava leaves, she has made an appointment for the next week, and I wonder if she will be successful in keeping it despite opposition from her husband.

NOTE: Due to ethical and legal considerations, confidentiality is strictly upheld in social work practice; therefore this column articles depicting a therapy sessions is fiction. The characters and dialogue are solely imagined and not based on any clients so any similarities to anybody you know is purely coincidental. Although the information regarding post-partum is accurate, treatment in therapy may differ as it is individualized according the specific needs of each client, a therapist's orientation, and the unique relationship created in each therapeutic experience.

NOTE: THIS WAS ORIGINALLY PUBLISHED BY JEWISH ECHO MAGAZINE

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