What is Psychotherapy?
Talk therapy or psychotherapy refers to the many ways that speaking with another person can help with emotional/psychological/psychiatric problems – whether formally diagnosed or not. Psychotherapy has long provided people with a way to express their personal experiences and help them conceive new ways of seeing themselves and their lives by helping them shift their thinking, feeling, and behaviour. In fact, the earliest forms of psychotherapy probably emerged in ancient Greece, pre-dating the advent of Judaism and Christianity.
Answers to the question of how and why psychotherapy works are as varied as the unique individuals who undertake it. It is generally thought that it helps give the individual someone they can trust, to explore their problems with; enabling them to see themselves and their environments in new ways, and then move forward toward possible solutions. When successful, psychotherapy can help reduce the severity of troubling thoughts and/or emotional states, or even eliminate them so that one can function the way that they want and meet their goals. Research suggests that up to 75-80% of people who enter into psychotherapy show at least some benefit from it. Our success rates at Elle Psychotherapy consistently meet this success standard and frequently exceed it.
What is Perinatal Psychotherapy and How Can it Help?
Psychotherapy plays a special role in promoting the mental health of mothers during pregnancy and the postpartum period. Throughout this time, women prefer psychotherapeutic treatments over medications because of their concerns about the potential impact of pharmacotherapy (medications) on their fetus and/or infant.
In the perinatal (pregnancy and postpartum) period, psychotherapy is most commonly used to help women overcome difficulties with depression (i.e., low mood), worry and anxiety, interpersonal problems, and the transition to motherhood. It can be delivered in individual format (i.e., one-on-one), in couples, or in groups.
There are many different types of psychotherapy. While they differ in the scientific theories that they are based on, most are about equally effective for depression when delivered by trained therapists. The different psychotherapies are often classified as short or long-term. Short-term therapies (e.g., cognitive behavioural therapy/CBT, interpersonal psychotherapy/IPT) range from a single session to ~15 visits, while longer term treatments (e.g., psychodynamic psychotherapy) can continue from months to years. Typically, single sessions last 50-60 minutes, and individuals who successfully undertake psychotherapeutic treatment feel better in about six to 12 sessions (about 50% of clients improve after eight sessions).
While much research has looked at the effects of specific types of psychotherapy on depression and/or anxiety during pregnancy and the postpartum period, many are surprised to learn that only about 25% of the impact of psychotherapy is due to the specific type of treatment (e.g., CBT, IPT, etc.) used. There are actually more important or essential factors that lead to successful outcome in therapy. This serves to emphasize the importance of the quality of the relationship between the therapist and the client.
These ‘essential ingredients’ of psychotherapy relate not to the type of therapy, but the therapist and the environment that they provide. While these non-specific factors are not sufficient on their own to promote recovery (i.e., choosing the appropriate type of psychotherapy is required), the essential ingredients that are the most important to effectiveness include the collaboration between the therapist and client, the expression of empathy, affirmation/positive regard by the therapist, the therapist’s genuineness (i.e., being authentic), and the alliance that develops between client and therapist. Our therapists have years of experience working with and engaging clients from a wide range of backgrounds and understand the importance of these essential ingredients of successful psychotherapy. At Elle Psychotherapy, we believe that each client is unique, and deserves to be listened to and understood without judgment.
The Uniqueness of the Perinatal Period (and Why Psychotherapy is Important then)
The perinatal period is marked by profound social, emotional, biological, and psychological adjustments for women and families. Women are told that they should feel an immediate strong bond with their infant and enjoy every waking moment. Not advertised are the sleepless nights, feeding difficulties and relationship changes that occur as couples become families. Although one doesn’t necessarily change as a person when they become a mother, their roles certainly do. They now have a child to look after and experience the loss of many freedoms, as well as income, status, mobility, social contact, partner intimacy and time.
Up to one in three women will experience a new onset depressive or anxiety disorder or the worsening of a previous problem during pregnancy and/or the postpartum period. Not only are these associated with significant psychological and emotional suffering, but they can persist well beyond the first postpartum year. In fact, up to 40% of women will have symptoms that persist until their children enter school.
Perinatal depression and anxiety are particularly important because they occur at a critical time in the lives of the mother, her infant and her family. Left untreated, depression and/or anxiety problems during pregnancy are associated with an increased risk of poorer nutrition, less optimal medical care, and recreational substance misuse. It is also linked to poorer labour and delivery outcomes, more complications after birth, and impairments in the mother-infant relationship. Postpartum depression (PPD) and anxiety (PPA) can increase the risk of mental health problems in one’s partner, as well as more emotional, behavioural, and school problems in offspring.
Given these significant adverse effects, it is not surprising that women are keen to receive psychotherapy not only to help themselves feel better, but to try to benefit their families. Indeed, emerging evidence from our research group and others suggests that the benefits of psychotherapy undertaken during pregnancy and/or the postpartum period may occur for both mothers and their child(ren).
How do I Know if I Need Psychotherapy?
Many people are unsure when they need psychotherapy. While there are no ‘hard and fast rules’, if the problems one is experiencing are causing substantial distress, then an initial assessment by a mental health professional can be very helpful. If one’s symptoms interfere with their ability to function (i.e., completing the tasks of their day), it may also be worth exploring treatment options. Other reasons to seek psychotherapy include persistent feelings of sadness, worry, helplessness or of being overwhelmed. If one’s problems don’t seem to get better despite their efforts and the help of one’s family of friends, treatment should be sought. The therapists at Elle Psychotherapy have worked with women struggling with symptoms across the entire range of severity and can help you determine if and when psychotherapy is needed (and when it is not).
What Treatments do Perinatal Women Prefer?
Most people struggling with depression and/or anxiety prefer psychotherapy over antidepressant medication when psychotherapy is available. In the perinatal period, these preferences may be even stronger, with up to 90% of women stating that they want psychotherapy first.
The choice of which treatment is ideal for perinatal depression and anxiety should be guided by the severity of illness (more severe illness sometimes responds better to medication), the effectiveness of a treatment, one’s previous response to treatment, and their treatment preferences.
The staff at Elle Psychotherapy are skilled providers of CBT, IPT, and a range of other psychotherapies for both depression and anxiety. We also have an on-staff psychiatrist who can provide OHIP-covered (i.e., free) medication consultations for interested client.
The Evidence for Perinatal Psychotherapy
Research suggests that over half of women who receive a full-course of CBT (for perinatal depression or anxiety) or IPT (for depression) will have their symptoms completely resolve (i.e., remit). As stated previously, an additional 25% will experience a noticeable improvement.
Multiple large studies have compared the relative effectiveness of CBT and IPT and they reveal that both are equally effective for perinatal depression. As a result, one’s first choice of psychotherapy should be guided by their symptoms, their preferences, and the availability of a good therapist. There are also no clear differences in effectiveness between individual and group treatments, and both approaches have their own benefits and drawbacks. Finally, research suggests that psychotherapy delivered online is as effective as treatment delivered in person.
Barriers to Receiving Psychotherapy in the Perinatal Period
Other than a widespread lack of availability of psychotherapy in publicly funded healthcare settings, women face a number of challenges in accessing it in the perinatal period. One important barrier is having to travel to an office or hospital setting for 15 (or more) psychotherapy sessions. Getting time off work, securing childcare, and/or packing up infants and dropping them off or taking them to appointments also present significant challenges. Stigma, worries about judgement, concerns regarding child protective service involvement, long waitlists, and the need for referrals can interfere as well. Moreover, despite recommendations that all women be screened for PPD, this is not universal. Finally, since many women are not aware of the signs and symptoms of PPD and PPA, getting help can be very difficult.
Women’s perceptions of healthcare providers can also impede treatment-seeking, as can time and skill limitations relating to the delivery of psychotherapy on the part of these providers. Physicians’ prescription of medications, the time-limited nature of physician visits, along with other factors have led some women to feel as doctors will miss (or even dismiss) their symptoms.
In combination, these barriers result in the fact that just one in 10 women with a perinatal mental health problem gets evidence-based care (i.e., treatments that have been shown to be effective based on research evidence). Among the most significant challenges facing the field is how to help women become aware of their struggles and find safe, accessible, effective and engaging psychotherapy. Here at Elle Psychotherapy, we are committed to improving access to evidence-based care for women during these important life stages.
A lack of awareness of the symptoms of perinatal depression and anxiety, and confusion about when to seek help often also conspire to prevent women from seeking treatment. It can also be difficult in many cases to differentiate symptoms from the physical and other changes accompanying pregnancy and delivery. Hearing (or believing) “Oh you’re okay, it’s just the baby blues!” can also be a powerful impediment. Moreover, low rates of screening by professionals and the complexities of existing healthcare systems also contribute.
Many women find the process of help-seeking difficult and it seems for good reason! While the involvement of traditional and public health professionals offers the promise of greater access, efforts are rarely coordinated and can increase confusion about who provides what. In worst-case scenarios, one system sees things as the other’s responsibility, and little gets done.
Unfortunately, there are relatively few psychotherapeutic options available to women in publicly funded healthcare systems (e.g., Canada). In this system, physician referrals are required for service and so pathways to receiving psychotherapy involve:
A woman realizing she has a perinatal mental health problem,
Seeking help for it,
Having a healthcare professional identify, assess and agree that depression and/or anxiety are the problem,
Being referred, and
Being seen for treatment (with accompanying wait times).
By the time these steps are traversed, months can pass and problems can either worsen or become chronic (or mothers have become so disillusioned with the system that they don’t follow through).
In response to the barriers that systems impose, millions of self-help books are purchased every year by mothers with perinatal depression and/or anxiety. An increasing number of women are also signing up for online self-help programs (or use mobile smartphone apps) to access psychotherapy. While these are certainly accessible, significant time and discipline are required for success. As a result, these treatments are marked by high dropout rates. Additionally, when online or app-based resources are used in the absence of therapist involvement, they have relatively limited effectiveness. Clinician-guided or supported treatments are more effective, though the ideal ‘dose’ of therapist involvement is not yet known.
At Elle Psychotherapy, we not only accept but encourage self-referrals. There is no need to consult and get a referral from a physician, nurse, midwife, or other healthcare professional to use our services.
Finding a Therapist and Succeeding in Therapy
There are many excellent therapists who can help women recover from perinatal depression and/or anxiety. While they do not necessarily have to specialize in perinatal mental heath, there are advantages to working with someone with specialized expertise. These include a familiarity with the many presentations of perinatal mental health struggles, an awareness of the common issues present during this time, and the skillful application of techniques specific to women’s unique needs.
In Ontario, finding a good, experienced therapist can be challenge. In the setting of universal healthcare, finding a publicly funded therapist is difficult as they are generally restricted to physicians and mental health counsellors attached to hospitals. There is more choice when it comes to private therapists (who are paid out-of-pocket or using insurance benefits), though it can be challenging to identify who might be best.
Recommendations from family doctors, nurses, social workers, or community mental health workers can be helpful, as can those from leaders of spiritual or religious organizations, mental health associations, and self-help groups. The Psychology Today website contains profiles of many potential therapists if you aren’t able to access names any other way.
When you do reach out to a therapist, it can be helpful to interview them to see if they are a good fit for you. Asking questions about their education and professional training, the number of years of experience they have, any specialized perinatal training or expertise, and the type(s) of therapy they can deliver will help.
You should also find out how many sessions they think will be needed, how much the treatment will cost, and if their services are eligible for insurance coverage. As we know, the therapeutic relationship is essential to good outcomes in psychotherapy, so the act of interviewing potential therapists can be the first opportunity to see how you feel when you communicate with this person. The importance of taking this step cannot be overstated! Finally, you will want to know their policies around things like missed appointments, contact between sessions, and rescheduling.
Once you have selected a therapist, you can increase the likelihood of success by answering the following questions: How would I like to be different by the end of therapy? What do I want to see change? This can relate to changes at work, at home, in relationships, and which symptoms or other problems you would like to see improve. During therapy, one can maximize effectiveness by being open and honest. In therapy, any act of sharing your thoughts or feelings only serves to deepen the therapeutic bond and provide more ‘grist for the mill’. Completing any homework that is assigned will also lead to better outcomes – psychotherapy is very much about learning new ways of thinking and behaving, and so practice is essential. If you have the time, you can also ask if there are any supplementary materials you would benefit you (readings, workbooks, etc.) and complete those as well.
If things are not improving, do not hesitate to raise these concerns with your therapist. Mentioning this can help them to optimize your treatment and make additional recommendations. In some cases, you may choose to end therapy early or switch therapists. Some great therapists are simply not a great fit for everyone, and they understand that.
MomsOverMatter: Free Health Information to Improve the Lives of New Mothers and their Families
Designed in consultation with physicians, psychologists, nurses, social workers, and women who have recovered from postpartum depression and anxiety, MomsOverMatter is a free web application that delivers information regarding personalized treatment options for postpartum depression and related disorders based on user-generated responses to validated questionnaires.
Changes in infant emotion regulation following maternal cognitive behavioral therapy for postpartum depression
Maternal and Infant Performance on the Face-to-Face Still-Face Task following Maternal Cognitive Behavioral Therapy for Postpartum Depression
Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly
Evaluating the effectiveness of a brief group cognitive behavioural therapy intervention for perinatal depression