Recap: Chava has returned for third session with husband’s support and has identified her goals and objective to alleviate symptoms of her post partum anxiety and depression.

Her therapist assigned homework to establish baseline functioning in order to assess throughout therapy improvement in functioning.

Session Four

“I don’t know why I feel so much better,” Chava says. “It’s not like we did anything yet in therapy. I just talked the whole time and then you gave me this chart to do.”

I laugh.

I love when clients tell me this. Sometimes, when a client really wants to know, I explain what has really occurred in therapy that seems like “nothing.” Therapy really does seem like magic, sometimes, but really, most interactions are designed towards achieving specific goals and objectives in service of the client; although a client may not see what is going on.

Creating a therapeutic alliance, offering hope, ascertain readiness for treatment and compliance, assessment of the problem(s), and establishing a baseline for functioning on which to build are all things we have done in the previous sessions. Because a client is usually so skittish when she comes in for the first few times, scared, nervous, and unsure of what to expect, all of this is accomplished by what appears to be just talk. While a doctor may ask a client to fill out forms to get needed information, a therapist accomplishes the same thing through engaging a client informally. This is crucial because a doctor does not need to have a relationship with his patient in order for surgery to be effective, but a therapist most definitely does!

“How was your week?” I ask. I am probing gently for evidence of her homework.

She takes the bait and draws out the chart from her pocketbook, scrunched into a little four by four square. “I didn’t do it perfectly,” she says. “At the end of the day, I kind of wrote it all down as best as I could remember.”

I wait as she pauses to unfold the paper.

“I realize that not every day it’s hard to get out of bed. I was here last Monday. So Tuesday and Wednesday it was really hard, like a seven, and then by today, it was only a two or three. And I took my baby to the park twice this week.” She stops to peer at her paper. “I also didn’t realize that I change her diaper most of the time. My husband is in kollel, so of course I don’t wait until he gets home to change her. But her changes her in the morning, and gets her dressed. But I told him I want to dress her this week, and it was fine.”

She looks at me in bewilderment.

“I don’t know why I thought I was doing so badly. I even played with her yesterday peek-a-boo and she laughed!”

I am not surprised. Oftentimes, when a client makes a chart, what originally seems like myriads of dysfunctions that are overwhelming and out of her control, suddenly seem smaller, more manageable, and well in one’s control. When the chart actually showed Chava that things like getting out of bed, while possibly difficult, were not insurmountable, and not the intensity of distress she thought, it freed her to even entertain that she was functioning better than she thought. The chart even created a structure that enabled her to get out of bed more easily, take her child to the park, and play peek-a-boo.

But our work was far from finished.

“What made you play with her?” I say. “I thought you said it was hard for you to do that.”

“I don’t know. My mother cooked us supper, as she usually does, and I realized that I have nothing to do, and my mother had gone out to run errands, so I figured, why not.”

Chava sits quietly digesting all that she has just told me, how she has reframed so many of her behaviors that have defined her for so long. “I still feel anxious,” she says, “but it wasn’t so bad this week. And I still find it hard to concentrate at work. And I don’t know if I love her. It’s like I see other mothers making such a fuss about their kids and I look at her and just don’t feel anything.”

I challenge her. “Okay, so you don’t feel anything. Do you think anything when you look at Libby?” I make sure to use her baby’s name, so as to make Libby less of an object and more a person to her, to remind her of her connection to her namesake, Chava’s beloved grandmother.

Chava says, “She is a very pretty baby. My mother even said. And she laughs a lot. She looks like my husband.”

We continue this conversation until Chava is relating funny things Libby has done, how others respond positively to her, and that Libby always wants Chava to hold her.

“Feeling is overrated,” I say, jokingly. “I think you should stop getting hung up on the idea of loving her, and just be present for her.

Chava is startled. “What do you mean?”

I try at this time to repair some cognitive distortions that have made Chava feel an inadequate mother, exacerbating her post partum depression and anxiety. “Love is a new word,” I say. “It used to be that love is what you did for another person, not what you felt. If you fed someone, clothed her, sheltered her, gave her what she needed, that was already love. It’s like Fiddler on the Roof. You know that part where the husband asks his wife is she loves him and she says that for twenty five years she washed his laundry, gave him meals, and cleaned his house. And he keeps asking if she loves him. Finally, she says, “Well, if that isn’t love, what is?”

Chava laughed at that.

“We got stuck in modern times, wanting love, love, love,” I say, “but we fail to realize that it comes with deeds. It’s fine if our mothers love us, but if the love does not come with the bottle, with clothing, with toys, and a visit to the park, then of what use is that love?”

“I never thought of it like that,” Chava says.

“I would imagine if you paid less attention to your feelings of love for Libby,” I observed, “and engage in acts of love, you may be pleasantly surprised how much love you have been giving her all along.”

Suddenly, Chava becomes energized. “I want to be a normal mother this week,” she says determinedly. “Give me a new chart and I want to do stuff and write it down.”

Now Chava begins to list a bunch of things that she had not even entertained thinking about the week before. Cooking supper, going out with her husband, feeding her baby by herself, giving her baby a bath, and concentrating at work on a specific project she was supposed to finish weeks ago.

I slow Chava down.

I help her make a chart that is doable. Supper twice this week. Bath time once this week. Going out with husband once this week. I help her identify what will make these tasks hard to do, giving her tools to cope with possible failure and relapse of symptoms.

For the first time she talks about moving back to own house with her husband and child, musing how supportive and generous her husband has been these trying months; and expressing hope for the future when she says, “When I have my second baby, I will be better prepared so my post partum doesn’t knock me out.”

“Chava,” I say, “often when therapy is going too well, there may be a relapse of symptoms or some regression. Go easy on yourself if you don’t accomplish what you want to this week. Look for your successes and don’t concentrate on your failures.”

Chava barely hears me as she sails out the door on a cloud of relief that her post partum is on its way out and normal living is just within her reach.

Therapy is never this easy or smooth, and I am not naive or that foolishly optimistic to think that my job is done… This session has been wildly successful, so as one can imagine, I wait for our next session with great trepidation.

Session Five and Beyond

Luckily for me, I am not naive, and when Chava walks into the fifth session angrily, informing me that she did not do her homework, she absolutely does not think therapy can help her, and she had a terrible week, I wait out the storm of her frustration and sadness by in the safe, supportive, and protective entity of the therapy room.

I gently remind her of my last words before she exited the therapy session the previous week, in which I warned her of this possibility, or regression, of relapse.

“Really?” Chava says, “You told me this might happen?”

“Yes,” I say. “I did.”

We begin to explore her week in which she couldn’t make supper as planned because her younger sister got engaged, and nobody ate at home that week; how everyone was so stressed out from the engagement that Libby, her baby didn’t sleep normally and just cried incessantly. And when Libby cried, so did she and she just knew she was a horrible mother.

I wait patiently as Chava pours out her anguish and despair in a week gone wrong, of hopes dashed, and of arguments with her mother and her husband who told her to stop acting like a baby and be an adult.

“I was depressed the whole week,” she says. “I woke up in middle of the night and couldn’t fall back asleep. My mother took the baby again for the night, and she hasn’t done that in three weeks. I am such a failure!” she says bitterly.

“So for three weeks, you have been sleeping with the baby?” I ask.

“Yes,” she says. “I was feeling better so I took her for the nights and nursed her once or twice during the night.”

I take heart that those three weeks coincided with her beginning sessions in therapy, although she remains unaware of that supposed coincidence.

“What’s your relationship with your sister?” I ask.

“Not bad,” she says. “We were never really close. We fought all the time. Of course we stopped fighting once we got older, but it’s not like we are best friends or anything. She was always the rah-rah popular type and I was more the quiet, studious one.”

“What kind of boy did she get?” I ask.

My questions are directed in developing her self awareness of how the stress in the house of her sister’s engagement, her relationship with her sister, and her reaction to the engagement may have caused this relapse of depressive and anxious symptoms that seemed to be decreasing since we began our work together.

“He’s a nice boy,” she said thoughtfully. “Not a learner like my husband, but maybe the family has more money.”

Slowly, her values are surfacing. A learning boy. A family with money. Whether these have anything to do with her relationship with her sister, they may have much to do with her relationship with herself, her disappointments, her failures, her joys. Post partum depression may originally be a hormonal imbalance, but depending on the emotional health of an individual, the symptoms can either be alleviated or exacerbated. If different issues would begin surfacing in therapy, they may need to be addressed to help achieve emotional health and equilibrium.

This session is hijacked by her sister’s engagement and the powerful feelings towards her sister that have been triggered by the engagement. No behavioral work is done directly with post partum. As a therapist, abiding by the dictum be where your client is, I am cognizant that where Chava is right now is in unresolved sibling rivalry and jealousy.

Chava ends off the session exhibiting a slightly calmer demeanor and says, “We didn’t do anything about my post partum today.”

“True,” I agree. “Maybe next time. You will decide. But you still have your chart from last week, so you may want to look at it again. Perhaps do another chart just checking on your waking up, dressing, changing, and playing with Libby, as you had done two weeks ago, just to see if anything has gotten worse, better, or stayed the same.”

I am surprised at Chava’s response. “I’m definitely feeling much better overall. Even if this week was a disaster. Even my husband noticed it. He said thanks.”

Chava leaves, softly closing the door behind her.

***

Sessions Six, Seven, Eight, and Nine

In the following session, Chava gets back on track with charting her targeted behaviors, but as she begins feeling better and better, with her symptoms of depression and anxiety receding, and her interactions with her baby improving, she spends less time in therapy discussing post partum and more time on her relationships with her mother, sister, and husband. She explores her pattern of anxiety growing up, feeling depressed when she did not achieve scholastically what she set out to do, when friends received coveted jobs at school, and her ambivalent feelings towards her husband’s dedication to his learning when she realizes she no longer wanted to work to support him, but wants to be a stay-at-home mother.

Chava explores her feelings that her post partum was exacerbated by needing to be perfect, a perfect mother, husband, and daughter, and not knowing how to allow herself mediocrity.

Chava moves back into her own home, much to the delight of her husband and is surprised that her mother is unsupportive of her decision, making her wonder if her mother is also prone to anxiety and unable to allow growth often precipitated by mistakes and failures in her life—in this case, her daughter’s baby steps to independence.

Session Ten

“I think I am finished with therapy,” Chava announces in her tenth session.

“Why do you think that?” I ask, wanting her to assess her progress.

Chava lists her accomplishments. “I make my own suppers, I am finally home, and I am enjoying Libby much more.”

“How do you like Libby?” I ask, knowing the answer.

“What do you mean, how do I like her?” Chava asks, “she’s my baby!”

We both laugh, remembering those early sessions in which she struggled over loving her baby.

A little more exploration and it appears that although Chava feels she is not fully back to herself, and would love the luxury of continuing therapy, she feels guilty using her mother’s money to continue when she is really doing well, and cannot afford to continue on her own. Chava sincerely feels she is able to stop therapy at this time and continue to use the tools she has learned about herself and about dealing with post partum symptoms to continue to get better.

“I think I would love to go back to school,” she says. “Maybe when my husband stops learning full time and goes to work, we can afford it.”

I know what she will say next. Inevitably, when a generally healthy client goes through therapy for the first time, she is so amazed at how therapy works to heal, that she gets the bug to become a social worker—to do the magic she has watched her own social worker doing with her.

“Maybe to go for social work,” Chava says, and in my head, I continue her sentence together with her, “so I can help other women who have post partum.”

“You do that,” I say with a smile. “You will be an excellent social worker.”

Before Chava leaves, she says, “I really don’t know how to thank you. I would have loved to give you a gift to say thank you.”

I say, as I say to most of my clients who have blossomed through therapy into the people they want to be, and sometimes even more than who they were before, “You have been the gift. Thank you.”

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.

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