Episode 279: Postpartum Depression and Problem-Focused Psychodynamic Psychotherapy: Understanding the Five Core Conflicts

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There are no conflicts of interest for this episode.

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Introduction: Postpartum Depression and Psychodynamic Psychotherapy (00:00)

Puder:

All right, welcome back to the podcast. I am joined today by two psychiatrists. We are going to be talking about postpartum depression and the psychotherapy component of postpartum depression. Dr. Alyson Gorun is a psychiatrist, doctor, psychoanalyst who specializes in reproductive psychiatry at Weill Cornell. She is an expert in this. And as well, we have Dr. Fredric Busch, who is a psychiatrist doctor as well, who is a returning guest on the podcast [see episode 264]. We talked about problem-focused psychodynamic psychotherapy. They have co-written a book together on Postpartum Problem-Focused Psychodynamic Psychotherapy. And it is good to have both of you in the room. Alyson, why don't you introduce yourself maybe a little bit, just how you're interested in this topic, your background, and then Fredric, I'll have you do that as well.

Gorun:

Happy to do so. So thank you for having me. So, like you mentioned, I'm both a psychoanalyst and a reproductive psychiatrist. And so I'm really lucky to be able to combine the two of those specialties and really think about how they can compliment each other. I'm also the acting director of the Aaron Stern, MD, PhD Program in Psychodynamic Psychiatry. And that also has a focus on using psychodynamic concepts, across all medical specialties, not just with psychiatrists. So this is sort of one sort of outposting of that in the sort of OB/GYN productive psychiatry territory.

Puder:

Great. Okay, Fredric, anything you want to add to your, how you're interested in this topic and specifically and how you guys got connected?

Understanding Postpartum Problems: From Symptoms to Underlying Conflicts (01:46)

Busch:

Yes. So, thanks for having me again, by the way. And, to have an opportunity to talk about this book, which by the way, I just want to emphasize upfront that it is about depression, but also about the range of issues that people have in the postpartum period. So depression, anxiety, behavioral issues, relationship problems. I mean, we'll talk more about that. But as we've talked about before, I've done a lot of work on problem-focused psychodynamic psychotherapies and a more general approach and focusing on specific topics like depression, panic, trauma. And, you know, Alyson came to me and said, "Hey, we really need to do something on postpartum psychodynamic psychotherapy because it's such a broad and difficult problem. There's not adequate treatments." And we also learned that there wasn't a whole lot out there in terms of manualized, focused approaches to postpartum difficulties and, well, this is really important, given limitations and availability of care.

Busch:

We have got to work on this. So that's how we came to do it. It's been a great collaboration.

Gorun:

And I think one of the things, that I can just add, that what I was saying was that with my patients, I was recommending the evidence-based things to do in the postpartum. Like, "Okay, you need to get enough sleep. All right, you’ve got to take off some of this workload, childcare workload, and give it to your partner." Or they were recommended to supplement with formula while they were breastfeeding. It's a way to sort of, you know, either because the baby had weight issues or, there's something going on with feeding. And then what I found was that despite me, in a sort of supportive intervention way, telling them, "This is what you really need to do." They weren't able to do it. They were getting kind of stuck.  And so despite them wanting to, it's like there was some force pulling them backwards.

Gorun:

And me, with my psychoanalyst hat, it's like, “Okay, there's probably something unconscious happening here that is kind of pulling them in the other direction.” And it kind of forced me to put on my psychodynamic hat and say, "Okay, we need to really use psychodynamic concepts to get these problems fixed because not sleeping, not taking care of yourself, is really driving this depression or anxiety or relationship conflicts." So that's sort of where the idea came from and I thought, “Wow, this problem-focused framework is such a good place to kind of put that where you're really focused on there's a lot of stuff going on here, there's a lot of problems we have to fix, and we kind of have to do it quickly.”

[Postpartum blues are common, peak around day 5, and are not a disorder of function. If symptoms last past two weeks or inhibit function (Earls et al., 2019; Pearlstein et al., 2009).

Postpartum psychosis is a different illness: about 1–2 per 1,000 births, often in the first days to 2 weeks, and an emergency—not a “severe PPD” (ACOG, 2023; Earls et al., 2019; Rai et al., 2015).

A 4-to-6-week “PPD” screen is not a postpartum-onset diagnosis. In Wisner’s 10,000-woman Pittsburgh series, among home-visited screen-positives, onset was 40.1% postpartum, 33.4% in pregnancy, 26.5% before pregnancy (ACOG, 2023; Wisner et al., 2013).

PPD frequently occurs in women with a history of depression, although first episodes also occur. Reviews often cite a figure near 78% as relapse of prior MDD (Holden, 1996; cited in Batt et al., 2020).

A depression-only workflow misses anxiety. In a Croatian cohort, 75% of anxious women at 6 weeks were also depressed, and 68.9% of depressed women were also anxious (Nakić Radoš et al., 2018). Rai et al. (2015), citing Matthey et al. (2003), wrote that puerperal anxiety is “in fact more common than PPD”, no anxiety/OCD.]

Puder:

Okay. Yeah, so how would you like to start out in terms of introducing this idea of how this fits into the larger thing of, there's a person that's coming in who's probably sleep deprived, who's probably working really hard, who has maybe a lot of internal self-critical thoughts. How does it fit into the big picture to think about therapy and to think about how we think through: Is this a biological issue? Is this a psychotherapy issue? So what are your… how do you start to think through that?

Busch:

Well, maybe I could give an overview of a little bit of the approach and certainly, you were talking about also, differential diagnosis, and is the treatment appropriate? Certainly, you know, we look at issues of if there's great severity of these problems, then we want to think about other kinds of measures, medication, you know, safety interventions. Those are critical upfront, but assuming that these are depressive or anxiety syndromes that are more mid-range or under some control or impact with medication in some instances, the first thing we want to do is work to identify the range of problems or particular problems that people are having. So do they have self-criticism, anxiety, lack of self-care, or behavioral issues? Are they struggling around breastfeeding?

[Putnam et al.’s (2017) (N = 663) severe anxious-depression cluster (32%), 209 of 211 women endorsed self-harm thoughts. Onset in the first 8 weeks was enriched for anxious-anhedonia and very severe scores. 

Among EPDS ≥10 women who completed a home SCID, 22.6% had bipolar disorder (Wisner et al., 2013). That is why ACOG’s (2023) strong recommendation is: screen for bipolar disorder before starting antidepressant monotherapy.]

Busch:

Are there problems with their partner? And then we start to look at where these problems arise. Is this is a situation, and certainly we know the major stressor is the new baby, but are there problems around the baby crying, over worry about the baby, and separation, pressures to care for the baby that the person's struggling with and look to outline or identify these issues with them. And then we start to look at, which we'll talk more about, explore what are the factors that are affecting it. And we are seeing that people are heavily influenced by underlying attachment issues, conflicts, trauma that they dealt with growing up or with their parents that are affecting them that they may not be aware of.

Busch:

So we begin to think about that in our approach.

Puder:

Yes. Alyson, what are you listening for? The deeper things that are going on, you know, beyond symptoms? What are you listening for?

Gorun:

Definitely. I think that one of the things that tips me off that there's something sort of deeper going on is, of course, you know, sort of in classic psychodynamic theory, but intense affect. So, you know, sometimes women, and by the way, I'm using “women,” you know, because that's just for ease of use, but this book is really for parents in general. It could be for fathers and all sorts of family configurations. I just want to say that. But, so yeah, so if a woman comes in and she's sort of telling me about something that might cause some distress to most mothers, but it just seems so much harder than what it should be. Like, you want to go out and get a coffee for a few hours and then come back, but there's so much distress about it, like she just can't do it.

Gorun:

That tips me off. There's something else going on here that's amplifying this kind of normal, parental developmental task in some way. So when that happens, I really kind of laser focus on that and then try to explore sort of all of the variables around that.

Maternal Anger, Guilt, and the Idealized Experience of Parenthood (08:59)

Busch:

Yes, I would add it as an instance in terms of tolerance of feelings. So we'll talk about certain core dynamics that people can struggle with, others can struggle with in these circumstances. And, you know, kind of at the top of our list is angry feelings. So there's inherently going to be angry feelings at the baby. That's just part of how it works. But, you know, is that some people have a terrible time tolerating those feelings or feel tremendous guilt or struggle with trying to back away or deny them. So that may be another thing that I would be looking for, you know, people having such intolerance that they are taking extra efforts to care for the baby or they're having trouble tolerating or experiencing any kind of crying or…any kind that the baby's needs feel overwhelming to them and they're doing everything they can, wearing themselves out just to try to avoid that, those sort of painful feelings.

Puder:

Yes, I appreciate you bringing that up. The anger, it's almost like taboo for someone to think, “I could never have any frustration or anger towards my infant.” Alyson, what do you say to mothers to allow them to express that safely in the session or decrease the internal shame of having those feelings?

Gorun:

Definitely. I'm so glad you're bringing that up. That is one of the primary kinds of psychodynamic themes that we see in the postpartum that causes a lot of distress. So one of the things that I say to women, just like you said, is that actually having ambivalence in any relationship is completely normal. There's actually a whole literature around maternal ambivalence and that's the idea that you can have mixed feelings about people. You can love them to death, and sometimes you just hate them. Sometimes you just want to box up your baby, put them in a package, and send them to your in-laws. Right? So there's something about kind of putting it into words for them, that is more acceptable, that it just lowers the tone, “This is something everyone feels in every relationship.”

Gorun:

“So, of course, you'd also feel it about your baby. And that doesn't mean anything about you.” A lot of women think that means maybe, for whatever internal reasons about their past or conflicts that they have, "I'm a bad mother. This anger could hurt the baby. I need to sort of stay away from them.” You know, or feel very guilty about it, very self-critical, and then kind of overcompensate, “I have to be with the baby all the time." So, you know, if it's not able to just be expressed, then it can kind of lead to all these issues. And, I have been happy to see that in social media and in mom groups, it's been a lot more normalized, I think, to just be like, "This is really hard. Sometimes I want a break.”

Gorun:

“Sometimes I don't want to see my kid." I think that actually helps a lot, that it's getting a little less reinforced kind of in the culture than it used to be.

Busch:

Yes, I mean, I think just to follow up on it, a piece of that, I mean, of course if there are issues around impulse control and management, then that, you got to take that very seriously. But most moms are coming in, you know, more with struggles around having these feelings. And just a note that part of what Alyson's referring to, you know, a second of these dynamics, the first being anger, sort of idealize expectations of oneself as a mom or the baby, you know, this kind of pressure, supermom pressure. Or, “I shouldn't be having angry feelings. I should be able to take care of everything. I should always be able to breastfeed. The baby should be just right or everything [should be] perfect.” So obviously, you know, people want to do a good job as a mom, but some people feel not only a tremendous pressure, but they also feel like, “I'm failing.”

Busch:

Their internalized standard is so high that no matter what they're doing, they feel, "Oh, that's not good enough. I'm a bad mom." And that's something where we know it's very important to look for and intervene.

Puder:

Okay. So, yeah, we're talking about kind of idealizing our own sort of experience that we will have as parents, and then kind of coming into the reality of having some more complicated feelings. And then, Alyson, I appreciate how you talked about how ambivalence is normal, mixed feelings is normal. Actually, it's very healthy, right, to be able to hold those tensions. 

[Parenting stress after birth is predicted more by current postnatal depression than by the antenatal risk list once antenatal BDI is in the model (Leigh & Milgrom 2008). The idealized-parent crash and the EPDS are not two different stories.]

Puder:

Okay. So talk a little bit about how the baby can reactivate the parent's own attachment history. Let's talk about that a little bit.

Gorun:

Yes. So, I think that if you think about what a baby is, it's a baby. It isn't able to communicate in any coherent way other than just saying, "I'm distressed," or, "I'm hungry." So it's kind of like the perfect blank thing to project everything into. And, by the way, this happens with everyone with, you know, daycare workers, nannies, teachers. This is constantly happening to babies and kids. And so what happens is that there are a lot of shifts in identifications that happen. It can get very complicated sometimes, and I talk about this with my patients. So on the one hand, suddenly you, as the mother, you've been the child up until this point in your life. And then you have a baby, and suddenly you're in the role of parent, and then you have a child and everything kind of switches a little bit.

Gorun:

And then you're somehow, "Wait a second, now I'm kind of in a really abrupt way almost mentalizing with my parents' experience of what it must have been like with me." And so there can be this funny, it's like this role, almost like a role reversal where you're suddenly now you're the parent looking at this baby as if it was your parent looking at you, but you're still you, and the baby is actually separate from you. So it kind of brings all of that back in some way. It makes it all much more alive again. And a lot of people will revisit their childhood, their relationships. It kind of gets really put to the forefront of their minds when they have a baby, and that's one of the reasons why these things get reactivated, because you're sort of renegotiating everything. "What am I going to be like as a parent?”

Gorun:

“How am I going to relate to this baby? Am I going to do the same things my parents did? Do I want to do something different? Am I afraid to be like this part of that? When the baby cries and I decide I want to take a break, does that mean that I'm not going to be as responsive as my parents were?” Everything gets kind of renegotiated, and you sort of have to learn about yourself as a parent and how you're going to interact with the baby.

Busch:

Yes. They absolutely do. And I would just add to that, the baby holds for you very powerful feelings. So certainly, you know, anger, total dependency of the baby, kind of separation and abandonment fears, and whatever issues that someone's had with regard to their own attachment. Let's say there's a parent who was rageful, and they may think, "Well, I'm not going to have that kind of thing with my baby. Or, I'm not going to get mad." You know, again, going to this other kind of idealized expectation of themselves that to not be like the parent, or they may feel like their parent did something, "Oh, I do want to be like that.” So whatever issues people may have around dependency, which is a kind of a third core dynamic, would be reactivated because the baby's totally dependent.

Busch:

So some that might trigger inside some new moms, some fathers as well, their own wishes to be taken care of that they're fearful of whether they'll be able to manage. And instead of taking care of the baby, they have, “How am I going to be taken care of?” Or others may have had experiences with parents who are not terribly responsive to their needs, and they may have a kind of a hyper-independence. "Oh, I have to do everything because I can't depend on anyone to help me.“ So those are, you know, these very powerful kinds of feelings that get reactivated, and whatever issues one would have along those lines, those are likely to be triggered in a significant way.

Attachment, Dependence, and Difficulty Asking for Help (19:25)

Puder:

Okay. Yeah, I want to, maybe we can talk a little bit about how, let's say their early experience. Let's say the parents’ early experience, because, and I do like to say “parents”, because I think the father will have this as well, and the mother. So you could have, let's say you had a lot of neglect growing up. How could that show up and now you're taking care of a child and you're aware, maybe you've done some therapy, maybe you've worked through some of this, but nevertheless, it's going to show up in a unique way all of a sudden with the first child. Right? And it's like you're aware of things in maybe new ways. How have you seen that show up?

Gorun:

Yes, I think the two themes that kind of pop up for me for someone who maybe has a history of emotional neglect, are issues with, it's going to be a dependency, and then also with separation from the baby. So, in terms of dependency, like what Fred was saying, if you sort of didn't always have your needs met by your parents, there wasn't that responsiveness there, then you may be afraid to say your needs, to say that you need help, to rely on other people because you're so afraid that they're not going to be able to meet that need. And what happens in the postpartum is maybe you are able to kind of get along in your life by being completely self-sufficient, you know? You could kind of figure it out, you can kind of do it on your own, and then you have a baby, and it's really impossible.

Gorun:

You have to depend on other people. You need to be able to ask for help and ask for things. And so, I commonly see that this pops up with people having difficulty kind of asking for help, asking for support, delegating things to someone else. They feel like they just want to be able, and they should be able to kind of do it all on their own. So that's sort of one big category, I would say. And then thinking about, you know, the theme of separation. So, if you grew up with sort of a bond that was more fragile and more inconsistent, then you'd be more concerned about disrupting the emotional bond between you and your baby. So, again, going back to work or going away and letting your partner take over, you may be more afraid of how much of an impact that's going to have on the baby.

Gorun:

It might feel catastrophic almost in terms of how much it might disrupt the relationship. And that's because, to you, these little moments with your parents never felt stable enough. It never felt like enough. So you're always worried about, "I don't want my baby to ever feel that way with me." So you're very vigilant to that, to make sure that you're always feeling connected.

Separation Anxiety, Abandonment, and Fear of Leaving the Baby (22:20)

Busch:

We talked about an example of someone who had grown up and told the father, who had left the family, abandoned her when she was a baby, and that had several consequences. First of all, at one point she got very upset and left the house with the baby, but the father felt like, "Oh, no, now I've abandoned my baby." And this wasn't abandonment, it was just she needed to get out of there. But because she felt so much guilt and pain in terms of what she experienced that she felt, "Oh, this is terrible the way that I behaved." And also that she had learned from her mother that she needed to not express any kind of needs and be the good kid. So she didn't feel safe. She thought, "Well, I can't bring up with my husband that I need his help or that kind of support because I need to….”

Busch:

“I need to keep quiet about this." And this ended up creating tremendous anxiety for her in terms of all the pressure that she felt to do everything. And she began to get depressed, too, because she's like, "Oh, my God,” she couldn't possibly do all the things that she needed to do to feel okay or to feel like a good mom. So it was very important to spell out those dynamics and that history to help her to understand where these feelings were coming from and how she got into trouble with them.

Puder:

Good. Yes. So, okay, so kind of getting deeper on this theme of how the infant stirs up the mother's own attachment stuff, maybe own her own trauma that hasn't been processed. Let's say, specifically with the mother starting to feel anger and then feeling guilt about the anger, how are you going to, in this model, work with the mother and help them work through that conflict?

Busch:

Yes. I mean, maybe I'll start with that. I mean, one of the things we want to identify about their struggle with angry feelings is part of what we're working to do is help people to develop these skills to observe what's going on internally and understand about themselves. And that we identify, “Okay,  look, your angry feelings cause extreme discomfort for you, guilt, or you get anxious about them.” And because people, oftentimes they don't recognize that these things are going on sort of under the radar automatically. So you help them to recognize that piece. Then, as Alyson was saying, partly through reassurance or partly saying you're overly threatened by these feelings. They're not creating the kind of danger that you feel they're creating or the kinds of problems where you could find a way to express your anger, let's say towards your partner if you're frightened of doing that.

Busch:

Or maybe if you reduce the pressure on yourself, you won't feel so much of it towards the baby. And then we want to be linking it to their past experiences. So helping them to understand, okay, here's where this comes from. You're trying to…you had this rageful parent, and so you think, “Oh no, I shouldn't have any anger because I don't want to be anything like that.” Or, “All the anger I felt was dangerous, so be shutting it out entirely.” And that's not a possibility and that doesn't need to be done in that way. So, you know, with those, it's a series of things, a series of steps to help them understand that they're conflicted about the anger, that they feel overly negative towards themselves.

Busch:

And then even to think about how does that affect them with their partner with getting the help that they need, the pressure they put on themselves. Our dynamic approach also includes that we want to affect the behaviors that they have in their relationships because those are so crucial. So we definitely, also want to emphasize how these struggles affect those things and what changes they might make. Alyson, would that correspond?

Gorun:

Definitely. And the other thing that I would definitely do, is part of this bridge is really focusing in. So where is this coming up practically that is making things really hard for you and your experience with the postpartum very difficult? So let's say, one place that I see this pop up a lot is really having a hard time tolerating a baby crying. Like, it's just too much. They cannot do it. It's like nails on a chalkboard or something. And, there's definitely, I just want to say this, there's definitely, gender differences here. There's something I think evolutionarily with hormones that make women much more sensitive to the baby's cries. But putting that aside, if it feels intolerable, well, sometimes what's behind that is actually the mother's feeling angry at the baby for crying because they can't soothe them.

Gorun:

It's making them feel inadequate and making them feel like a bad mother, like they're failing and they're angry at the baby for making them feel that way. And so, if you kind of can just help them see the baby is not communicating that they're really angry at you or that you're doing a bad job, sometimes it's almost like that's when the baby's crying, it's like they're communicating that to the mother. If you can kind of break that down and just be like, "The baby just cries. Sometimes the baby just cries and sometimes there's nothing you can do to stop the baby crying. You don't need to take it personally.” Then you can kind of help reduce, sort of understand the anger, feel okay with it, and then help reduce it. And there's a lot of different places this can pop up.

Gorun:

Just another kind of common example of thinking about common problems that happen. Maybe a mother's feeling sort of disconnected, like doesn't want to really be around the baby as much. And, one sort of synthesized way that I've seen this happen is maybe if there's issues with feeding. Sometimes women sort of have an expectation or a desire to really kind of breastfeed and have that bonding moment, those loving feelings that are sort of supposed to come with it. But some babies just can't breastfeed. There's a difficulty with the latch. Your supply isn't right. You know, it just doesn't work out. And then either you have to pump or you have to use formula, but you're kind of disappointed by that. You feel upset at the baby that you guys aren't able to have that bond.

Gorun:

And then you can kind of reframe that, "Yeah, you're kind of upset at the baby that they, you can't, you guys can't do this together, but that's just because you really want to feel bonded to them. That's what's really behind it is a desire to feel close, desire to feel connected. And how can we help that happen in other ways?" So you sort of just normalize the anger. Usually what's behind it, there's a good intention there. And then you try to see if you can kind of come at that from somewhere else.

Busch:

David, I want to emphasize one piece of what Alyson said about specificity, where we're looking for, you know, where do these feelings come up, specifically? How is the person being affected? Because partly we're saying, "Okay, if you have anxiety and depression," and a lot of approaches these days, it's like, "Okay, well, you know, medication is indicated or let's talk about how you're feeling too negatively about yourself and you shouldn't feel so negatively." But, in it, we're saying these particular ways, these manifests have meanings and that understanding those meanings help people to much better have a better understanding of what's going on in themselves and often in the baby, what we call mentalizing the baby and the mom developing those skills, or the father developing those skills so that someone's, if they have anxiety, they might be worrying about the baby's health.

Busch:

So what's the meaning of that? Or they're depressed, they're like, "I'm a bad mom." “Well, how are you a bad mom? In what way?” You know, what's our understanding of that? It's not just a generalized symptom. It takes a specific form and meaning for them that's important for them to understand.

The Five Core Conflicts in Postpartum Psychodynamic Psychotherapy (32:07)

Puder:

Really good. Yeah. And I think going through just the list of the five core conflicts might make sense. Difficulty tolerating anger, idealizing expectations of being a mother and the baby, difficulties with dependence, fear of separation and abandonment, and fear of intrusion. Okay. So we talked about, we sprinkled through all of these a little bit. Right? But I think this is a very different framework for a lot of my audience: nurse practitioners, PAs that are psychiatric nurse practitioners, psychiatrists, we're wanting to do the right thing for the mother. I think there's a lot of anxiety that providers have, especially in this time, in this moment with the court cases going on, are we doing the right thing? Are we…? And, so it's like how do you go from, okay, there's a very depressed, anxious mother here, to okay,  there's other threads we can pull out that are deeper.

Puder:

There's other reasons for these deeper feelings. Right? And, I think one of the other conflicts I have as I'm listening to this is like, okay, an infant's having an issue latching. Well, is there a tongue tie, right? Or is there a lip tie? You know, if you put your finger at the bottom of the lip and you feel this kind of cordish thing that's tying between the gum and the lip it might be harder for the baby to nurse. So at what point do we think through as physicians, okay, there could be a medical issue here that versus this is a thing that psychotherapy could take place. Or I know one of my other thoughts is, I'm sorry, maybe I'll just pause here and let you address some of these things.

Integrating Psychodynamic Therapy With Biological, Social, and Evidence-Based Treatments (33:54)

Gorun:

Yes. So one thing I would say is that definitely, the first thing, just context-wise is that being a parent, especially for first-time parents, you've never done this before, and you have to give the patients the benefit of the doubt that they actually don't know certain things. So a lot of psychoeducation has to happen first. You know, meaning, you need to sleep and yes, let's evaluate the difficulty with feeding. You need to see a lactation consultant. Is there a tongue tie? You know, you need to talk. Is there something in your diet? Get a consultation. Whatever it is. So you kind of start out first with providing the evidence-based interventions that  you already know about. So you need to evaluate for medication. Are they not sleeping? Do they have the opportunity to sleep, but they cannot fall asleep?

Gorun:

Is the difficulty with bonding so much, it doesn't kind of come and go, it's just kind of persistent? Are there suicidal thoughts? So you kind of go through, you know, mild, moderate, severe. You figure out if medication's needed. And you do a lot of supportive interventions first. You problem solve. You come up with a schedule for the day. Okay, when the baby's sleeping, this is when you're going to try to go to sleep. You do all that, but then this is where you know the psychodynamic part has to come in. You're going through all this, you're giving the recommendations, you're problem solving, but then they can't do it. Logically, they want to do it. They want to do it, but they can't. They know what's good for them. Somewhere they know that the crying shouldn't irritate them as much as it does, but it just does.

Gorun:

They want to be able to. They wish the baby was different in some way. They know they shouldn't be feeling that way, and despite you telling them, it's okay, you don't know what they feel like; it's like they can't accept it. There's something stuck. So that's the point where you really want to consider using these psychodynamic interventions. It's like you've done everything else. You've done the supportive interventions, and they can't use them. That's what I would say. So, everyone should keep doing what you're doing, but we want this as an additional tool for if you're getting stuck. They want to drop off the kid at daycare, but they just can't. They get there and they're thinking about them all day long, and is it okay, and trying to go check on them.

Gorun:

Okay, let's talk about this. What could be going on there behind the scenes?

Busch:

Yes, and I would add to that. I mean, again, first of all, as I said earlier, we want to do a very careful initial evaluation around safety, around impulsivity. Are there any thoughts that are, I mean, obviously, if they're psychotic then we need to emphasize safety, medication. Those are part of our initial evaluation. And people may need antidepressants and anti-anxiety medication to do this kind of work because if their symptoms are problematic enough, they're so pervasive, it's hard to identify the meaning. You know, it's hard to say, take out from here or to work with it because they're so affected by it. So those  interventions are crucial. But I think for someone working this to have these frameworks in mind, that they're inherently going to pop up.

[Cochrane antidepressants for postnatal depression: SSRI vs placebo response RR 1.27, 95% (CI 0.97-1.66), symptom-score  SMD −0.30, 95% CI -0.55 to -0.05  (Brown et al., 2021).

Sertraline (or paroxetine) is the usual first-line in breastfeeding across Pearlstein’s Comment and Berle’s pair compilation (sertraline ~145 pairs, relative dose 0.5–3%, infant plasma usually undetectable) (Berle & Spigset, 2011; Pearlstein et al., 2009). Look up current LactMed; the Sachs AAP report was retired June 2025 (Sachs, 2013).

Do not switch a pregnancy-effective SSRI at delivery just to chase a lactation table. In-utero levels are cited as 5- to 10-fold milk exposure (Berle & Spigset, 2011).]

Busch:

These are universals, you know? Anger, and self-expectations, and dependency, and separation, abandonment. And it can provide a framework that people can think about to help them to understand and to communicate to the mom, "Oh, look, I think you're really stuck on this one area that you're overstating the dangers around separation. You think, ‘Oh, I'm going to abandon the baby,’ when you're not doing that.” And those are elements we want to understand more about. I do want to, because we hadn't mentioned intrusion, and because of the way I think about this stuff, just to emphasize another inherent universal, how do you set boundaries, and somebody who feels they can't set boundaries or they can't get help and they feel the baby is always kind of invading their space and their life is taken away.

Busch:

And, we have an example in the book of one person whose mother was very needy and dependent, and she felt pressured that she needed to be the one taking care of the mother. And this added to the pressure she felt and the intrusion that she experienced and made that the most powerful element. So I think that's a way that people can use this framework or think about this framework, and work with it alongside their, as Alyson points out, the other approaches that they use.

Puder:

Yeah. Alyson, do you want to speak about the fears of intrusion? Any more thoughts come to mind? 

Gorun:

Yes. I mean one thing that we want to do is make this really almost like a cliff notes version of sort of psychodynamic themes that can happen in the postpartum. So the most common kind of thing that women say to me that's a tip off for me for intrusion is, “I'm feeling trapped.” Like, “I'm feeling trapped by the baby. I'm feeling trapped by the situation I'm in.” Or even, “I'm feeling controlled by the baby, like I can't leave or something bad's going to happen.” That, to me, is a signal that there's something overwhelming about the baby's needs, and they feel like they don't have control over modulating that for some reason. When you do, you can put the baby down or give the baby to someone else if you want a break. Right?

Gorun:

But it doesn't feel that way to patients. So that's the most common way that I see it. And I think the other place that intrusion can pop up is for parents, women who have histories of specific kinds of abuse in some way where their bodily boundaries maybe weren’t being respected by those around them. And, you know, having a baby is very physical. There's a lot of holding. I mean, even if you're holding the baby while you're feeding, they need to be rocked. It's just, there's a lot of touch involved. And for some people, not feeling like they have control over their bodily boundaries can be very overwhelming. And it's confusing and upsetting to have sort of abuse memories come up when you're holding your baby as well.

Gorun:

So that can be very hard to acknowledge. But again, we kind of gently go through what's the reality of what the baby is feeling. You know, the baby is just wanting some comfort, but you can also play with the baby or do something else if it is feeling overwhelming. So that's sort of where I see that pop up a lot.

Postpartum OCD, Intrusive Thoughts, Shame, and Confidentiality (41:36)

Busch:

And David, I should add, as long as working on the psychoanalytic standpoint and picking up on something Alyson said, another area that can be a problem is sexual feelings. There can be a lot of discomfort about sexual feelings towards the baby. Sometimes they kind of put out of their mind or people have thoughts, you know, but for other people, that can be quite very uncomfortable for them to experience, or threatening. And, as Alyson mentioned, particularly if they experienced abuse they may be very fearful that they could abuse the baby now. And some people are going to say, "Oh no, I don't want that to happen," and they can experience normal kind of holding and closeness and physical feelings as something like, "Hey, is this not okay?”

Busch:

And this can cause conflict and distance. So that's another area that can emerge. And Alyson, I think you said about people who can be fearful about reporting some of their feelings. Right? That's another factor that you have to manage sometimes.

Puder:

Right. My experience is, if you don't ask, they're not going to usually tell you some of the darker thoughts that they've had. Right? And, especially when I'm assessing OCD and postpartum OCD, which is something I've treated in a number of people, it's like the obsessionality and the obsessive thoughts, the unwanted obsessive thoughts are sometimes very graphic, distressing. Sometimes they've never had to deal with obsessive thoughts of this type of nature, violent thoughts or sexual thoughts. It's ego-dystonic. Right? So they don't want to have these thoughts. So I think especially with what's in the news, it's like, "What if I've had these thoughts? Does that mean I'm going to do this?” That could be very, very scary. Any thoughts on this, Alyson? 

[Pregnancy/postpartum raise OCD onset and exacerbation. A meta-analysis of 19 studies put perinatal OCD about 1.5–2.0% above general-population rates (Gershkovich, 2019, citing Russell et al., 2013).

Untreated PPOCD persists: Miller et al’s  (2013) prospective series (cited in Gershkovich): 11% met OCD criteria at 2 weeks postpartum; 45% of those were still symptomatic at 6 months (Gershkovich, 2019).

Content is usually ego-dystonic harm-to-baby (accidental or intentional). Compulsions and avoidance are aimed at preventing the thought from “coming true.” That is the opposite of a psychosis in which the idea is believed (ACOG, 2023; Gershkovich, 2019; Rai et al., 2015).

Screening that is depression-only will miss PPOCD.]

Gorun:

Yes. Definitely. You know, there's, I got to tell you, there's just so much shame with becoming a parent. It's just, you know, there's so much pressure. Everyone wants to be a good parent. And so if there's anything that you're thinking or doing that goes against your image of that, it can be so hard to talk about. It can be so hard to experience. And especially if you have the idea of sexual intrusive thoughts as part of OCD, most people don't even know about that or that exists. So, I definitely proactively bring up a lot of very common shame-inducing feelings or thoughts that women or parents can have. So absolutely, when I'm assessing for intrusive thoughts, OCD thoughts, I'll be very explicit. Like, “Sexual thoughts about the baby or doing something sexual is a really common example of an intrusive thought.”

Gorun:

“Is that something that you've had?” So, I just lay it out on the table. The other thing that might not be as obvious is feeling a difficulty with bonding or feeling disconnected from the baby. That can be really hard for parents to talk about, because that also, I think, induces a lot of shame. But that's a really common symptom of depression, all these other psychological conflicts. So that's also something that I'll actually be very explicit about and ask directly, “You know, this can be a symptom, actually. So, is that something that you sometimes feel?” So yes, I completely agree with you. You have to be really proactive about it and you kind of have to make suggestions, “Is that something that you're experiencing?”

Busch:

Yes. I think in terms of this approach, the problem-focused approach, it's not, "Oh, here's your problem, A, B, and C that you report.” That people can be so embarrassed or ashamed or fearful about certain kinds of feelings, or in denial about them, that it can take a while to identify what the problems are. So that's part of the process. Or they might think the problem is normal. “Well, of course, I'm not getting any sleep because you have to be up the whole night taking care of the baby.” You know, completely not recognizing or normalizing as something that they're struggling with just because they think, "Well, that's the way it works.”

Busch:

Well, that doesn't have to be the way it works. Also, I think you and maybe we can talk about this, but I would also say that you said, needing to keep in mind that some people may actually worry about if they bring up certain things that they might get reported. Right? That's another….

Gorun:

Definitely, yes. The worry about, it's called different things in different states, but, child protective services being called. I mean, it's really, it can be a fear that might actually be reality-based based on your background, your ethnicity, and sort of more likely to be called in some ways, or it might be amplified by kind of internal, very harsh criticism of yourself or fears of being punished in some way. And that's a kind of a common kind of transference, countertransference dynamic that really needs to be explored. Like, “I did this thing, but if I tell you about it, I'm concerned that you're going to think that I'm an unfit parent and you're going to try to take my child away from me,” or something like that.

Gorun:

And, what I always do in that situation is just want to be really transparent and let them know the boundaries of our confidentiality. These would be the reasons why I would need to call if you actually hurt the child in some way. But sometimes it ends up being something like they were angry at the baby and they just didn't put them down as gently as they usually do, or maybe they removed a sibling who was being aggressive. They kind of abruptly moved them over and they become afraid that that was something really aggressive, really bad, and that that would be a reason that I would call some authority on them.

Gorun:

So, you know, I think kind of setting the frame of, “this is actually what's a problem and this isn't” can sometimes give a little bit more space for us just to kind of explore it non-judgmentally to what actually happened.

Puder:

Yes, and you could see how with all that internal self-criticalness, rumination, that sometimes gets really black, really black. Right? So, all or nothing thinking, they can kind of go all bad on themself. They might even imagine that there's some authority figure who's going to take my baby away or report me, and that could be a nightmare. And so what I hear you saying is that you go into more details if you sense this is the issue. Right? If you sense they have this fear, like, "Hey, I'm not going to report you unless you actually abused your kids and you could potentially describe what that would look like.” Right? Is that what I'm hearing?

Gorun:

Yes, that's exactly right. Like, this would be the reason why: if you hit your child and your child was in danger.

Puder:

Yes. And, you know, in psychotherapy, we keep things in words, and we actually find that even if you're angry, if you can put it to words in a psychotherapy office, it'll actually give the parent more control. If a parent has these taboo thoughts, and then because of the taboo thoughts, they're defending in different ways against having the thoughts. Right? What are some of the more common ways that you see parents defending against the negative thoughts, and then that may create problems in and of itself. Right?

Busch:

Yes, I mean certainly just maybe talk about different elements. But one kind of thing, what we refer to as reaction formation, sort of going out of their way to do extra or more to the point of wearing themselves out to try to not be experiencing anger or trying to dismiss feelings out of their mind, or even sometimes do things that are self-punitive that are not very good defenses, but not allow themselves enough sleep for something. There's one person we talked about as a way of punishing herself for these feelings without really being aware that she was doing that.

Busch:

Maybe Alyson, you know other defenses that are….

Gorun:

Yes. I think the other really common one is avoidance. So, doing anything that might elicit that thought or taboo thought, you just stop doing. And the way that you can really assess for that is, and I always do this, is I do a very specific sort of accounting of what their day is. "What are you doing in the morning? How are the division of responsibilities done?” So then, you might discover, "Wait a second, this person's never changed the baby's diaper.” Okay, that's not typical. Is there something getting avoided there? And then you can kind of explore it that way. One example that we have, there's a concern that when you're undoing the diaper, that that's when the sexual abuse might happen.

Gorun:

So then you just stop changing the diaper so that you don't feel that way.

Relationships, Culture, and Social Determinants of Postpartum Mental Health (52:08)

Puder:

Yes.

Busch:

I would just like to mention that that could be displaced towards the partner, and that is another piece that we emphasize. How do these things get played out with the partner? Because, for instance, one person that we were talking about is angry at the partner for not getting up to take care of the baby during the night, but then not really giving him the opportunity to do it, because of some of her ambivalence or her struggle around that. Or all the anger at the baby’s getting displaced onto him, and we're not talking to the partner because of fears of asking for any help that the partner's not going to be responsive. So then they avoid dealing with these issues with the partner, sort of talking them out or, "Hey, what can we do to do this?" So I see that's a very important piece of the work that we do.

Puder:

You know, one thing that whenever I start to have these sorts of thoughts, or these kinds of conversations, I think to myself, how much of these problems are uniquely U.S.A. problems compared to places like Sweden, where they have more than a year of paid time off when you have a child? Like, how much does this kind of social structure that we have in the U.S., that hasn't really prioritized women's health postpartum, how much that is at play. You know? And how do we balance these kinds of deeper things like, “Okay, I'm having maybe some attachment issues with my parents and because of that, they're playing out in the child.” Whereas, how much of this is just the structure that we're in? Do you have any thoughts on this, Alyson?

Puder:

Maybe I'll start with you, and then….

Gorun:

Yes. Oh, definitely. I mean, like 100%. Sometimes that's the only issue. Like they just need more time off from work or they need some ability to… they need a vacation. They need sleep. They need someone who can watch their baby while they take a nap. And that there's so many structures in place in the United States that make it really hard for women to take care of themselves. And, so, you know, you do a biopsychosocial formulation with these patients. You think about the biological aspects, does this person need medication? Is this OCD? And then you should really be doing exposure response prevention therapy (ERP) and CBT. What is going on here? And then you think of the social, just like what you're talking about, like, is this just something in their environment that's causing this, that if things were different, they wouldn't feel this way.

Gorun:

But what I found is that sometimes I get these patients that they actually have a lot of support. They have a lot of family around, but they can't utilize it. So then that tells me it's not just the environment and the structure. But you kind of always want to start there. You want to see if you can improve their environment, access to resources, psychoeducation, a group. You always want to start there and see if that helps, if that works. But if it doesn't, then what do you do? There are these residual symptoms. Well, then maybe that's when you need to think about a psychodynamic approach.

Busch:

And Alyson, I just want to emphasize cultural factors and maybe you want to speak, say a little bit about that, about taking that into account, as well?

Gorun:

Absolutely. Yes. So with a lot of these issues, you want to have a lot of cultural humility because, for example, you know, practices around co-sleeping or sleep training, there's a lot of cultural expectations around that or how much the family's involved or not involved. So with sort of a Western view, we might think that that's too much family involvement, but for them, that's actually how it should be. So when you're assessing these problems, you want to definitely keep in mind how cultural aspects might be influencing the problem and its expression and not pathologize something that's actually quite normal for postpartum childbearing practices.

Busch:

Yes. Or you might need to help someone who feels a certain cultural expectation deal with that. Let's say, for example, someone where the culture thinks there's a lot of involvement of the family, but they feel intruded upon or boundaries reached and how did they contend with this internalized expectation of the culture and their own needs or wishes to do things a little bit differently from that?

Puder:

There was one study, I was wondering if I could just bring it up here and see what you guys think of this.  Thinking about the cultural aspect. It was economic and health predictors of national postpartum depression prevalence, a systematic review meta-analysis meta-regression of 291 studies from 56 countries. So in the findings, they found that there is a very different prevalence of postpartum depression in different countries. It's around 17.7%. Some countries have as low as 3% and some as high as 38%. And that nations with significantly higher rates of income inequality, maternal mortality, infant mortality, or women of childbearing age working greater than 40 hours a week have higher rates of postpartum depression. Together, these factors explain 37% of the national variation in postpartum depression prevalence, which I thought was pretty significant. This idea that a lot of the difference in the rates in different countries is because of these things that seem very hard for psychiatrists to change (Hahn-Holbrook et al., 2018) . Right?

[Updated EPDS pool: 19.18% global, range 3% to 44% (Fish-Williamson & Hahn-Holbrook, 2023). Mixed-definition global map: 17.22% (Wang et al., 2021). 

LMIC community postnatal rates were 39.4% versus 13.6% in tertiary hospitals (Fisher et al., 2012).

Partner violence during pregnancy, pooled unadjusted OR 3.1 (2.7–3.6) for later probable postnatal depression  (Howard et al., 2013).]

Puder:

It's like we can only do so much. So yeah, I'm guessing, I think we've kind of already answered this question, but any thoughts on that or any kind of reflections on that study in particular?

Gorun:

Yes, definitely. I mean, one thing I'd say is that depression isn't always depression. So we use the word depression for a lot of things. Just not having enough money to feed your baby, you know, that's going to make someone feel really down, really inadequate, like, not doing enough. But you're saying, is that really depression or is that a response to what's happening? And then I see the high rate of infant mortality in certain countries. Well, that sounds like there's going to be a lot of grief and trauma as well that's probably getting picked up as postpartum depression. So, and then thinking about some of these psychodynamic factors as well. Yes, it's kind of under the heading of depression and depressed mood, but it's more like psychological conflicts that are happening that are causing you to feel very down.

Gorun:

So I just wanted to add that.

Busch:

Yes. And obviously, really to emphasize the need for social support, mental health support, all kinds of things in terms of targets or goals that are important for moms, from standpoints of what might be done otherwise, from the political standpoint, just to help in those circumstances. That's important as well. And obviously, there's also, like you say, there's limits around what we can do too. But we do what we can.

Puder:

Yes, we do what we can. Yeah, and I think this attachment based, you know, helping the mothers mentalize better what's really going on, decreasing the shame, decreasing the guilt, these are themes that are coming up a lot in what we're talking about. Are there big categories of things that you guys think about that we haven't touched on yet?

Mentalization, Countertransference, and Observing the Parent–Infant Relationship (1:00:58)

Busch:

Well, let me get to a piece just about mentalization. I mean, mentalization-based approaches, we emphasize those. Those are even brought up by other authors, as well. That by helping the parent to understand that the baby isn't mad at them, or they may say, "Oh, the baby's, he's just like his dad. He's such a jerk." You know, trying to help them understand that the baby isn't mad at them, or my mom was deeply affected by a sense about being rejected when the baby would turn away or the baby's not always smiling. So try helping them understand what's going on with the baby and the baby is not directing that towards them. That's a very important piece because that can fit in with their guilt, bad mom feelings.

Busch:

So I do want to emphasize that piece. And one thing that we haven't talked about is countertransference. So what are the feelings the practitioner is having, and that people can have their own reactions to these very powerful kinds of issues. That people are struggling with their babies. And it's important to be aware of that. Alyson comments about that. But also, how do you work with that? How can you be alert to understand that maybe you're struggling with something that's coming up and be able to communicate that in some way to the patient?

Gorun:

Definitely. And I think very common countertransference responses that can happen just when working with parents and babies is there can be almost an identification with the baby and sort of a concern that the parent is doing something wrong, almost like an overreaction of wanting to be overly protective. And, you know, that's really what the parent is already feeling. They're already feeling like they're talking about all these shameful things and that they're doing a bad job. So I always come in with a lot of empathy, like, “First of all, you're coming to me for help and you're doing the best you can. You learned this way of coping, of reacting for some reason. Maybe there's a good reason that you are responding in this way, and now I’m just trying to help you introduce some choices.”

Gorun:

“Let's introduce some flexibility here in how you can respond and ways to think about this.” So, I always keep that in mind if I'm having a very strong countertransference of feeling like I need to sort of somehow protect this child, this baby from this parent. It reframes that for me and helps me have some empathy.

Puder:

Okay. So let me kind of… I'm curious, you know, when you have a mother coming in with her child to your session, and let's say you see some good attachment going on, but the mother maybe has a perception that she's not really attached to this child or that she's not a good mother. How do you utilize what you observe between the mother and the infant in how you're helping the mother?

Gorun:

Yeah, so one thing that I'll do is you always want to have a foot in reality with these patients. So I will be very explicit in listing the good things that they're doing or what I'm seeing that's indicating that there's good, secure attachment developing. And then I'll say to them, "So I'm wondering why there's a disconnect here between how you're viewing yourself and what's going on, and then what's the reality that’s going on. Let's be curious about that together. Let's try to explore that and understand it." And then I'll just try to open it up and say, "Where could that have come from?" And let the patient tell me what comes to their mind, and what actions, what things have happened in the past, what behaviors they're doing that they think are evidence that there isn't a good attachment or that they're doing something wrong.

[Untreated PPD is associated with bonding difficulties in a majority of the attachment studies Slomian et al. reviewed, plus breastfeeding problems in 22 studies. That is a vote-count, not a pooled RR, and successful treatment of PPD “may not be sufficient” to repair attachment (Slomian et al., 2019).

Earls et al. tells pediatric primary care to screen at the 1-, 2-, 4-, and 6-month well-child visits and names dyad treatments: child–parent psychotherapy, Circle of Security, Attachment and Biobehavioral Catch-up (Earls et al., 2019).]

Bonding problems are among the most replicated infant-facing associations of untreated PPD; improving depressive symptoms  may not automatically repair the relationship (Saharoy et al., 2023; Slomian et al., 2019).]

Puder:

When a mother brings an infant into a session, are there certain topics you don't talk about? Are there certain things that maybe you don't, you kind of psychoeducate the mother, like, "We're not going to talk about certain things today because the infant's in the room." How do you feel about that personally as a provider?

Gorun:

Oh, that's such a great question. You know, it's something that a lot of mothers ask me, "Is it okay to have the infant in the session and can they understand anything?" And really, it depends on the age. I'm assuming it's under one year old, if they're bringing them to the session. “Baby can't understand anything. They don't know what's going on. So you can really feel free to say whatever's on your mind.” And, like you're saying, it's actually very useful for me sometimes to observe the interaction, kind of comment real time, how the baby seems comfortable, seems calm, you're sort of attuned to them, or whatever else I am observing. But, you know, I will explore if there are certain topics or thoughts that they're afraid of talking about because the baby's there.

Gorun:

That actually is really good data for me. That tells me that those might be some of those more taboo or thoughts that they're ashamed of. If they're sort of like, "I wouldn't want my baby to hear me say X, Y, Z." “Okay, well, that's interesting. We should explore what those things are.”

Trauma, Emotional Regulation, and Applying the Five Conflicts in Treatment (01:06:56)

Puder:

I was thinking as well in terms of  levels of dysregulation. Like, do you want to enter into certain traumatic memories, for example, when the infant's in the room, in a way that would make the mother maybe dissociate or be more dysregulated? Or do you find that you kind of run the session differently?

Gorun:

Yeah, so before entering into any psychodynamic treatment, I definitely want to assess their capacity for emotion regulation. And if it seems like going into traumatic memories, or they just sort of are having issues with emotion regulation, then I might not do a psychodynamic psychotherapy approach with them as much, and focus more on skills, learning how to regulate, before I enter into that more deeper exploration. So I am always monitoring that. If it feels like it's overwhelming the patient in a way that is really effective, I'll immediately shift my stance, take a step back, do a grounding skill, whatever's needed to bring the patient back.

[Intimate Partner Violence (IPV) during pregnancy is one of the strongest observational perinatal mental-health signals (Bauman et al. PDS 33% vs 13%; Howard et al. OR ~3; Xu et al. IPV OR 2.5) (Bauman et al., 2020; Howard et al., 2013; Xu et al., 2026).

ACE as a PPD risk factor: Xu et al. OR 2.31, Class IV, GRADE very low (Xu et al., 2026). Hutchens and Kearney list abuse among the most frequently appearing factors across 21 reviews (Hutchens & Kearney, 2020).

History of abuse predicted antenatal BDI; history of depression predicted postnatal BDI even when it did not predict the pregnancy score (Leigh & Milgrom, 2008).

A 4-month “low” score does not close the case (Netsi et al., 2018; Putnick et al., 2020).]

Puder:

Okay. Very good. Okay, so we talked about these five areas, and I wanted to make sure we hit them in a way that you felt like was meaningful for this. So the first one is, experiencing struggling with the mother's or the father's own anger. Then it was, idealizing the experience of what it would be like to be a parent, and then the reality of the parent, the mismatch. Anything from those two that you feel is still kind of floating in your mind that you really want to share?

Gorun:

Yes, I mean, I guess that with difficulty tolerating anger, there's sort of two categories that can kind of fall into, which is that some people may be completely unaware that they're angry. It's really deep down, and it's really out of their awareness. And then there's people who it's a little bit more conscious. They're aware that they're angry, but then they feel guilty about that or critical about themselves about that. So those are almost two different levels of severity, and that might change your approach with that. And then with the idealized expectations, definitely idealized expectations of what parenthood was going to be like, what it was, how things were going to feel, but it can also sometimes get directed to the baby as well, perfectionistic standards.

Gorun:

So, you know, there's a lot of tension sometimes around milestones. Are they meeting their milestones on time? Are they checking off the list? I have to teach them sign language and I have to make sure they're doing this and that on time. And so that can definitely be a place where idealized expectations or perfectionism can come up as well. Or, you know, alternatively, so there can be a worry that there's something wrong with their baby, there's something defective about them. And so it can go in a lot of different directions.

Puder:

Okay. What about the panic of leaving the baby alone? When there's that panic of leaving the baby alone how do you work with the mother with that?

Gorun:

Definitely. Well, we would leave them alone somewhere safe. Right? In a crib, like to sleep or something.

Puder:

No, no. Good, good point. Let's specify what we mean by that. I mean, like it could be like leaving the baby alone with your partner, is what I'm thinking of. 

Gorun:

Okay, right, exactly. But it's funny you did that because that's how it feels to women. That's how it feels to parents. Like they're leaving them alone.

Puder:

Right? You're like, " Dr. Puder, we're not going to leave the baby alone, okay? We're not going to do that." 

Gorun:

Yeah, but it can feel that way. Like, if you as the parent aren't there, it's like the baby's alone, even if they're with a trained professional in a daycare, or even if they're with your partner. And so that's really interesting. And sometimes that's an intervention, which is they're actually not alone. They're being very well taken care of. And actually, there's a benefit for them to be taken care of by multiple people. The baby learns a lot about that. So there can be, but then there can be a reason why that person needs to maintain that belief that only they can do it. Right? So there's a lot of different reasons for that, you know, wanting to be special, feeling like that's necessary for the bond.

Gorun:

But one of the biggest kinds of psychoeducation I give around that with the separation fears is that a lot of times the reason this is coming up is because the parent has had an experience of an abandonment, either a real abandonment or a loss, like grief or some kind of emotional abandonment that happened. Maybe the parent was sick or there was a divorce or something like that. And what's missing is the leaving and then the coming back part. So it's almost like the coming back part is missing for the parents. You leave and then you come back. And actually, that's a really important lesson for the baby to learn. That's a skill that they're going to be able to flex for the rest of their life. And the idea is that when you leave and come back, the baby learns that you're there when they come back.

Gorun:

So it gives them confidence. It kind of helps them develop their independence in some way, which you want. So it's just reframing it as actually a positive thing to sort of practice the separation and the return rather than something that could be really harmful.

Puder:

Yeah. That's good. Let's say a person has a huge conflict with leaving their child alone with someone who's probably trustworthy. Like there's no reason to not think that this person is trustworthy, but they just don't want to leave them alone with another person, outside of their spouse, ever. So it's like, one of the things in my practice, I think it's really good to find trusted people, but then I think what you've hit on in this talk with me so far, and I'm reflecting on, is like, there's probably a good reason why they're having difficulty leaving their child alone with someone. So any other thoughts on that? 

Gorun:

Yes. That's exactly right. And I always say this as a way to sort of reduce shame. “There's a real reason why you're afraid. It might not be related to what's actually happening, but something. There's an emotional logic for you that you're sort of following here based on something that either happened to you or an imagining of something that, how you understood certain events in your life, how you put things together. So it's important to, you know, you did a kind of reality check. Is this person trustworthy?” You know, and sort of have that foot in reality. “Yes, you do trust this person, and yet you can't leave the baby with them.” And that engages the patient's curiosity.

Gorun:

“There's something else going on here. Maybe it's something with my unconscious, my experiences that are making me really afraid.” And there's a whole long list of reasons why someone might have that energy of wanting to protect their child from harm, which is how they're kind of viewing it.

Puder:

Yes. And for good reason. Right?

Puder:

Okay. So let's wrap it up. This is good. This was amazing, just meeting you. Gosh, I wish you lived in Florida so I could send you some people. It's so nice to meet with you, and you're doing so many things. How do you balance everything that you're doing? You know, Columbia, psychoanalytics, private practice?

Final Thoughts on Postpartum Problem-Focused Psychodynamic Psychotherapy (01:15:02)

Gorun:

Luckily, they all overlap. They're all kind of integrated into each other, but it helps that I really like what I do. So it's all interesting and fun. But, that was my own thing that I had to work through, my work-life balance.

Puder:

That's good. Well, okay. So any other final thoughts as we bring this to a close?

Gorun:

I don't think so.

Puder:

Okay. Well, this is great. It's been great to connect with you and Fredric. And I'll just put a final plug for your book. You know, it's a good place to dive into this topic. It's called Postpartum Problem-Focused Psychodynamic Psychotherapy. And also, if you're in Columbia, do you guys do Zoom or do you have to be in person for your Psychoanalytic Institute?

Gorun:

Some of it's in person and some of it's on Zoom, but they have some programs that are completely virtual.

Puder:

So that's a great opportunity, I imagine. And, are you going to be giving any other lectures anywhere sometime soon?

Gorun:

Yes, I'm planning it. Well, this book just actually came out about a week ago, so we're hoping to give a lot of lectures about it, and workshops, and be able to answer people's questions about it.

Puder:

Cool. So I'll look at that. Very cool. Well, put on the website different links to your website and if there are any other links you want to give me, I'll put them on there. Are you on social media?

Gorun:

I am. I'm on LinkedIn.

Puder:

Okay. We'll leave it there for today. Thank you so much for coming on.

Gorun:

Thanks for having me.

Additional Pregnancy and Postpartum Episodes

• Episode 013: Postpartum Depression with Dr. Pereau

• Episode 033: Perinatal Mood and Anxiety Disorders

• Episode 184: Pregnancy Planning for Patients Taking Psychiatric Medications or with a Mental Health History

• Episode 276: Postpartum Psychosis: Symptoms, Warning Signs, Risk Assessment, and Treatment with Dr. Furey and Dr. Puder

• Episode 278: Postpartum OCD vs Postpartum Psychosis: Intrusive Thoughts of Infant Harm, How to Screen, and Lithium Prevention with Dr. Katie Unverferth

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