Postpartum Q&A with Emotionally-Focused Couples Therapist Nikki Lively

 When we started Nyssa, one of the first connections we made was with a wonderful therapist, Nikki Lively, who later joined our Board of Advisors. As Clinical Director of the Transitions to Parenthood program at the Family Institute of Northwestern University in Chicago, IL, Nikki is particularly passionate about supporting people throughout the matrescence/patrescene journey. We asked her some of our burning questions around the ‘taboo’ topics of motherhood such as mental health, parenting confidence, and navigating the changing relationship with one’s partner.

What 'unmentionable' topic(s) do you hear about from your clients that you believe needs much greater exposure and understanding?

The ‘unmentionable’ topic I hear the most often from my clients continues to be that becoming a mother does not make them ‘happy’; rather they report feeling profoundly overwhelmed! This is not a symptom of a postpartum mood or anxiety disorder per se, but rather something I see as partly a function of the way our society is structured, with each individual family living in relatively isolated households, and partly just the reality of how much, and how constant the work is of taking care of a baby! 

The reason this seems to be unmentionable is that women are still under tremendous pressure to ‘be a good mother’. If you are asking, “what does this really mean?” that’s a great question that no one seems to know the answer to, and is a moving target! (I could go on and on about this topic as well!) However, the one thing that everyone seems to agree on is that a good mother loves being a mother. So if women acknowledge that the day to day experience of being a mother is actually rather tedious, maybe even boring at times filled with tasks you would rather not do (like cleaning out a crib full of poop after what I lovingly call a ‘blow out’!) then they fear the shame of feeling and/or being seen as ‘a bad mother’ and then sadly aren’t able to get the emotional support they really need to deal with all of these experiences! I believe that if this topic becomes ‘mentionable’, there will be a true path to happiness in motherhood as we all know that life experiences that can be shared are the ones that bring us the most joy! 

What do you think needs to change for 'taboo topics' in women's health to become normalized and how does the work you do address that need? 

This is a complex question as I feel like the fact that there are taboo topics in women’s mental health at all is a reflection of a social justice issuewomen’s inequality around the world! So, it’s a systemic issue of oppression of women and that will take many coordinated efforts at a macro level to change. However, here in the United States, one system that I believe reproductive mental health experts can impact is our healthcare system. As things stand now, statistically, most perinatal women will never meet me or a psychotherapist like me, but will almost certainly interact with doctors and nurses during pregnancy, delivery, or post-partum. I am a part of several advocacy groups looking to change the stigma surrounding taking medications for depression or anxiety during pregnancy and lactation and at the Family Institute we are working to network with OB-GYNs, midwives, doulas, etc. so that a referral to psychotherapy becomes part of routine, preventive care vs. something that you need to do because ‘something has gone wrong’. I believe if healthcare professionals have easy access to referrals for therapy and talking about taking care of your emotional health becomes part of routine prenatal care, we can start to unravel the taboo nature of mental health issues in the transition to motherhood.

When we spoke recently, you mentioned that Postpartum Depression has become a kind of catch-all term that doesn't adequately capture the nuances and dynamism of the postpartum experience. What would you like to see change, specifically in terms of language? 

Yes, the term ‘postpartum depression’ is often used to describe a range of symptoms that are technically not depressionanxiety during the postpartum period is just as common if not more common, for example! I think this is problematic not only because it doesn’t represent everyone’s experience of mental illness postpartum, but also because there is a connotation about the word depressionusually that it means someone is predominantly down in the dumps or sad and potentially unable to function in their daily lives. This leads to many women saying to themselves, ‘well, I don’t feel sad, so I don’t have postpartum depression’ or ‘well, I’m getting out of bed everyday, so what I’m feeling must be something wrong with me’ and then they may stay quiet about their symptoms even though they are very much struggling! It’s important that we see ourselves and our experiences reflected in our language! Otherwise it can be extremely difficult to reach out for help or even to have a way to describe what you need help with! 

My field has come up with the term Perinatal Mood and Anxiety Disorders (PMADs pronounced Peemads!) in an attempt to be more inclusive it reminds me of the acronym LGBTQIAas a culture moving to represent previously invisible identities surrounding sexuality and gender we’ve developed a way with these letters to begin to acknowledge more fully the lived experiences of people outside the heteronormative mold. Though there are still some categories of experience not represented in the acronym PMAD, it serves a similar function for women that is definitely more encompassing of the most commonly occurring mental health struggles that can occur during pregnancy and postpartum. I’d like to see ‘PMADs’ be the default term used and that we add more letters to this acronym as needed to raise awareness of the diversity of experiences for which women need help and support. 

You also talked about how the most effective way to help new mothers is to treat the whole family. Can you say more about that? 

Sure! I cannot think of a more profound relational and identity shift than that of becoming a mother! Not only is there a brand new relationship forming between the mother and her baby, but every single relationship in her life is also simultaneously being renegotiated as everyone makes space in their sense of self for new identitiesmom, dad, grandparent, aunt, etc. In addition to this, whatever issues may have been present in the mother’s relationships before the baby arrived, usually come into even sharper focus once the baby is here! What I found in my work doing psychotherapy 1:1 with postpartum women is that problems connecting with the people in their liveswhich includes the baby (especially if the baby happens to be fussy and hard to soothe!)cause the most pain, even beyond the symptoms of a mood or anxiety disorder. And the research confirms this! Studies looking at the partner relationship show that high relationship satisfaction can prevent or mediate the impact of depression on the motherso our relationship connections are pretty powerful for our mental health! Through my work with postpartum women, I was inspired to get more training on supporting the parent-infant relationship and the couple/partner relationship and my practice shifted to be at least 50% couples therapy with new or expectant parents as a result, and I love having this opportunity to support that relationship! Now even if I am just working 1:1 with a new mother, I am constantly assessing her sense of connection with important others in her life and helping her navigate these important relationships is a big part of my recovery plan for women with PMADs. 

Many clients come to you a few months after giving birth, when they've already reached rock bottom. What's your advice for pregnant women who are concerned about mental wellness in the postpartum period and want to take proactive measures to care for themselves? 

I know I’m biased, but I believe one of the best things a pregnant woman can do is seek consultation with a psychotherapist if she has any concerns about how the transition to motherhood may impact her. This way, she will already have a relationship with a therapist before the baby comes so she won’t be having to find a therapist, while feeling bad, and taking care of a baby as so many women often end up having to do! 

I was excited that recently the U.S. Preventive Services Task Force came out with their first recommendation that primary care providers should refer all pregnant or postpartum women with risk factors for a PMAD to talk therapy as a means of prevention.( I really hope this recommendation can make a difference to the ways OB-GYNs and other healthcare professionals approach prenatal care so more women will feel empowered and given the resources to be proactive about their mental health as a key piece of their overall health! 

If you could give one piece of advice to help new mothers and their partners prepare for entering the Fourth Trimester, what would it be? 

The biggest piece of advice I might give to help mothers and their new partners is to begin to reflect while pregnant on how you tend to respond to, and cope with stress, and to talk to each other about that. The Fourth Trimester is an incredibly overwhelming time so our natural stress tendencies tend to come out in an unconscious and automatic way! For example, I tend to go into planning and control mode when I am stressed out, while my partner gets analysis paralysis, and copes by waiting to make a move until he has gathered all the available data. These two styles can really be frustrating to each other if we don’t recognize the vulnerability underneath that is driving these coping behaviors! If new parents can recognize the signs of stress in themselves and each other, they can be much more compassionate with one another because they can name that and talk about it vs. getting into blaming or power struggles. 

I would also recommend expecting couples take the class I am offering at The Family Institute called Becoming Us!

It’s a nice companion class to the birthing classes many couples take together to prepare for labor and delivery. This is a class that prepares couples to give birth emotionally to a family, and strategies to stay connected along the way! 

Photo Credit: Nikki Lively by Avis Mandel