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

In this episode, Dr. Puder talks with reproductive psychiatrist and psychoanalyst Dr. Alyson Gorun and Dr. Fredric Busch about postpartum depression and problem-focused psychodynamic psychotherapy. They focus on the five core conflicts (difficulty tolerating anger, idealized expectations of parenthood, struggles with dependence, fear of separation and abandonment, and fear of intrusion) that often underlie symptoms, shame, attachment reactivation, and stuck behaviors in the perinatal period. This episode explores: -How these dynamics emerge even when parents know what they "should" do -How to integrate psychodynamic insight with medication, sleep, social support, and evidence-based care -Practical ways clinicians can help mothers and fathers mentalize their experiences, reduce guilt, and improve bonding. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-279-postpartum-depression-and-problem-focused-psychodynamic-psychotherapy-understanding-the-five-core-conflicts Link to YouTube video https://youtu.be/ZPRN9fFStSM By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined today with two psychiatrists. We are going to be talking about postpartum depression and the psychotherapy component of postpartum depression. Alison Goran is a psychiatrist, doctor, psychoanalyst, who is a reproductive psychiatrist. And as well, we have Dr. Frederick Bush, who is a psychiatrist, doctor as well, who was on prior. 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. Alison,

• 0:56David Puder?

  why don't you introduce yourself, really, maybe a little bit, just how you're interested in this topic, your background, and then Frederick, I'll have you do that as well.

• 1:05Speaker 01

  Good 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 complement 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 psychiatry. So, this is sort of one out, sort of outposting that in the sort of OBGYN, reproductive psychiatry territory.

• 1:48David Puder?

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

• 1:56Speaker 02

  Yeah, so I played through how many, again, by the way, and have an opportunity to talk about, about this book, which, by the way, I just, 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, we'll talk more about that. But as you, as we've talked about before, I've done a lot of work on problem-focused psychodynamic psychotherapy is, and a more general approach and focusing on specific topics like depression, panic, trauma. And

• 2:41Speaker 02

  Alison came to me and said, hey, we need, we really need to do something on postpartum psychodynamic psychotherapy, because it's such a, there's some, such a broad and difficult problem. There's not, there's not adequate treatments. And we also learned that there wasn't a whole lot out there in terms of manualized focus approaches to, to postpartum difficulties. And, well, this is, this is really important, you know, given limitations and availability of care. We gotta, we gotta work on this. So, that's how we came to do it. It's been a great collaboration.

• 3:22Speaker 01

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

• 4:05Speaker 01

  them wanting to, it's like there was some force pulling them backwards. 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 complex. 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.

• 4:49David Puder?

  Okay. So, how would you like to kind of start out in terms of like, introducing this idea of like, how this kind of fits into the larger thing of, you know, there's, 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, how does it kind of fit into the big picture to think about therapy and to think about, you know, how, how we, 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?

• 5:27Speaker 02

  Well, maybe I could give an overview of a little bit of the, of the approach. And certainly, you, you were talking about also, you know, differential diagnosis, I mean, and is the treatment appropriate? Certainly, you know, we look at issues of, if there's great, you know, severity of these, of these problems, then we want to think about other kinds of measures, medication, you know, safety interventions. Those are, those are critical upfront. But, you know, assuming that these are depressive or anxiety syndromes that are more mid-range or under some control or impact with medication in some instances,

• 6:12Speaker 02

  the first thing we want to do is work to identify, you know, the range of problems or particular problems that people are having. So, do they have, you know, self-criticism, anxiety, you know, lack of self-care, behavioral issue, are they struggling around breastfeeding? Are there, are there problems with their partner? And then we start to look at, you know, where do these problems arise? Is it, you know, kind of, is this a situation? Certainly, we know the major stressor is the new, is the new baby, but there are problems

• 6:52Speaker 02

  around the baby crying, you know, over worry about the baby and, and, you know, separation, you know, pressures to, to care for the baby that are, that the person's struggling with. And, and look to outline or identify these issues with them. And then we start to look at, which we'll talk more about, explore, you know, what are the factors that are affecting it? And we do, we are looking at that people have are heavily influenced by underlying attachment issues, conflicts, trauma that they dealt with growing up or with their

• 7:33Speaker 02

  parents that are affecting them, that they may not, they may not be aware of. So, we begin to think about that in our, in our approach.

• 7:42David Puder?

  Yeah. Alison, kind of like, what are, what are you listening for, for the deeper, for the deeper things that are going on, you know, beyond symptoms? What are you listening for?

• 7:54Speaker 01

  One of the things that I, that to me tips me off that there's something sort of deeper going on is, of course, you know, sort of in classic psychodynamic theory, but, you know, intense affect. So, you know, sometimes women, and by the way, I'm using, 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. So, just, just want to say that. But, so, yeah. So, if, you know, so if a woman comes in and she's sort of telling me about, you know, something that, yes, might cause some distress to most mothers, but it just seems so much harder than what it should be. Like, you

• 8:37Speaker 01

  want to go out and get a coffee, you know, for a few hours and then come back. But there's so much distress about it. Like, she just can't do it. That tips me off. There's something else going on here that's amplifying this kind of normal, you know, parental developmental task in some way. So, when that happens, I really kind of laser focus on that and that, try to explore sort of, you know, variables around that.

• 9:05David Puder?

  Okay.

• 9:06Speaker 02

  Yeah, I would, I would add it like an instance in terms of tolerance of feelings. So, we'll talk about certain core dynamics that people can struggle with, brothers can struggle with in these circumstances. And, and, you know, kind of by the top of our list is, is angry feelings. So, you know, there's, 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, you know, tolerating those feelings, or, you know, feel tremendous

• 9:45Speaker 02

  guilt, or, you know, you have struggle with, try to, try to back away or deny them. So, that may be, that, that would be another thing that I would be looking for, you know, people having such intolerance that, that they then, you know, are taking extra efforts to care for the baby, or that they can't, they're having trouble tolerating or experiencing any kind of, you know, crying, or, you know, any, any kind, that the, that the baby's needs feel overwhelming to them. And they're, you know, oh, you know, doing everything

• 10:26Speaker 02

  they can, wearing themselves out just to try to avoid that, those sort of painful feelings.

• 10:35David Puder?

  Yeah, I appreciate, I appreciate you bringing that up. The anger, it's, it's almost like taboo for someone to think like, I should, I could ever have any frustration or anger towards my infant.

• 10:50David Puder?

  Allison, 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?

• 11:01Speaker 01

  Definitely. I'm so glad you're bringing that. That is one of the, one of the primary kind of psychodynamic themes that we see in the postpartum that causes a lot of distress. So one of the things that I, you know, I say to women, just like you said, is that, you know, it's, it's 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 could have mixed feelings about people. You can love them to death and sometimes you just hate them. Sometimes you just wanna, you know, box up your baby, put them in a package, send them to your in-laws, right? So there's something about kind of putting

• 11:44Speaker 01

  it into words for them that is more sort of acceptable, that it just lowers the tone. This is something everyone feels in every relationship. So of course you'd also feel it about your baby. And, and that it doesn't mean anything about you. A lot of women think that maybe, you know, 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 sort of expressed,

• 12:29Speaker 01

  then it can kind of lead to all these issues. And, you know, I have been happy to see that in social media and in sort of mom groups, it's been a lot more normalized, I think, to just be like, this is really hard. Sometimes I want to break. Sometimes I don't want to see my kid. And so I think, I think that actually helps a lot that it's not, it's, it's getting a little less reinforced kind of in the culture than it used to be.

• 12:54Speaker 02

  Just to follow up on it, a piece of that, I mean, of course, if there are issues around, you know, impulse, control and management, then you, that you wanna, you gotta take that very seriously. But most moms are coming in, we are more with, with struggles around having these feelings. And it just is though that part of what Allison's referring to, you know, a second of these dynamics, the first being anger, sort of idealized expectations of oneself as a mom or, or the baby, you know, that, that, you know, this kind of this pressure, super mom, you know, pressure, or I shouldn't

• 13:38Speaker 02

  be having angry feelings. I should be able to take care of everything. I should always be able to, you know, to breastfeed. You know, the baby should be just right or everything perfect. You know, people, obviously, you know, every, you know, people wanna do a good job as a mom, but some people feel not only a tremendous pressure, but they also feel like I'm, I'm failing. I'm not, they, their, their eternalized standard is so high that no matter what they're doing, they feel, oh, I, that's not good enough. I'm a bad mom. And that's something where we, we got, you know, it's very important to look for and intervene.

• 14:23David Puder?

  Okay. So, 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 Allison, 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 tension. 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.

• 15:01Speaker 01

  Yes. So, you know, I think that what, I mean, if you think about what a baby is, it's, a baby 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, and by the way, this happens with everyone, with, you know, daycare workers, nannies, teachers, this is like constantly happening to babies and kids. And so what happens is that there is a lot of shifts in identifications that happens. It can get very complicated sometimes. I talk about this with my patients. So on the

• 15:41Speaker 01

  one hand, suddenly you as the mother, you know, you, you, 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. 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

• 16:25Speaker 01

  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 fore 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, what am I going to be like as a parent? How am I going to relate to this baby? Am I going to do the same things my parents did? Am I, do I want to do something different? Am I afraid to be like this part of that? You know, 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

• 17:08Speaker 01

  as my parents were? It just gets, 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.

• 17:20Speaker 02

  Absolutely. And I would just add to that, that, that the baby holds for, you know, very powerful feelings. So certainly, you know, anger, total, total, you know, the tendency of the baby, you know, have separation, abandonment fears. And, and whatever issues that someone's been had with regard to their own attachment, let's say there's a parent who was, you know, rageful, that, that they may think, well, I'm not gonna, I'm not gonna have that kind of thing with my baby, or I'm not gonna get mad, you know, again, going to this other kind of idealized expectation of themselves

• 18:04Speaker 02

  to not, you know, be like the parent, or they may feel like their parent did something, oh, I, I do want to be like that. So, and then whatever issues people may have around, you know, dependency, which is a kind of a third core dynamic, would be reactivated because the baby's totally dependent. So some that might trigger inside the son of the moms and things, fathers as well. There are all 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 be put, how will happen, what about, how am I going

• 18:49Speaker 02

  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 hindrance, independence. Oh, I have to do everything because I can't depend on anyone to, to help me. So those are, you know, these very powerful kinds of feelings get reactivated. And whatever issues one would have along those lines, those are, those are likely to be triggered in a significant way.

• 19:27David Puder?

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

• 20:09Speaker 01

  Yeah, I think the two, the two themes that kind of pop up for me for someone who maybe has a history of, you know, emotional neglect are issues with, it's going to be a dependency and then also with separation um from the baby. So, you know, in terms of dependency, like what Fred was saying, if you sort of didn't always have the, your, 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.

• 20:48Speaker 01

  And what happens in the postpartum is maybe you were able to kind of get along in your life by being completely self-sufficient. You know, you could kind of figure it out, you could kind of do it on your own. And then you have a baby and it's really impossible. 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 being, 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.

• 21:27Speaker 01

  And then thinking about, you know, the theme of kind of separation. So, you know, if you um grew up with sort of a bond that was more fragile and more consistent, then you be, you may be more concerned about disrupting the emotional bond between you and your baby. So, you know, things, again, like kind of going back to work or, you know, 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. It might feel like catastrophic almost in terms of how much it might disrupt the relationship. And that's because to you, these little moments with your parents, they, they, it, it,

• 22:12Speaker 01

  it never felt stable enough. Like it never felt like sort of 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 making sure that you're always feeling connected.

• 22:27Speaker 02

  Yeah, I, we, we talked about an example of someone who had grown up and told the father had, you know, left the family, abandoned her when uh she was um a baby. And that had, you know, several consequences. First of all, at one point where 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, to get out of there, but, but because she felt so much guilt and pain in terms of what she experienced, that she felt, oh, this is, this is terrible, the way that I behaved.

• 23:12Speaker 02

  And also that she had learned from her mother uh 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 this help or, or that, or that kind of support because I, I need to be, I need to keep quiet about this. And, you know, this ended up creating tremendous anxiety for her in terms of, you know, all the pressure that she felt to, to uh everything. And she began to get depressed too

• 23:51Speaker 02

  because she'd say, oh, yeah, she couldn't possibly do all the things that she needed to do to feel okay or to feel like a good. 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.

• 24:18David Puder?

  Good, yeah. So, okay, so kind of getting deeper on this theme of like how the infant kind of like stirs up the mother's own attachment stuff, maybe on 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 do, how are you going to, in this model, work with the mother and help them work through that conflict?

• 24:49Speaker 02

  Yeah, I, I, I mean, maybe I'll, maybe I'll, I'll start with that. I mean, one of the things we want to um identify about that their struggle with angry feelings. It's 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 like, okay, well, uh, look, your angry feelings cause extremely, you know, discomfort for you, guilt, or you get anxious about them. Uh, and because people oftentimes, they don't recognize that these things are going on,

• 25:33Speaker 02

  you know, sort of under, under the radar or automatically. So you, you help them to recognize that piece. Then, as Allison was saying, partly through kind of reassurance or partly saying by, 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, I'd say, towards your partner if you're frightened of doing that. Or maybe if you reduce the pressure on yourself, you will, you know, feel so much of it towards the baby.

• 26:15Speaker 02

  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 go, you had a rageful, this rageful parent. And so you'd say, oh no, I shouldn't have any anger because I don't, I don't want to be anything like that. Or all the anger I felt was dangerous, but I don't want to, so I should, I should be shutting it out entirely. And that, that's, that's not a possibility 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.

• 26:59Speaker 02

  Help them understand that they're conflicted about the anger, that they feel overly negative towards themselves. And then even to, 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, our dynamic approach also includes that we want to affect the, you know, the behaviors that they have in their relationships because those are so crucial. So we, we definitely be also, we want to emphasize how these struggles, you know, affect those things and what changes they might make.

• 27:37Speaker 02

  Allison, do you, would that correspond?

• 27:40Speaker 01

  Definitely. And the other thing that I, you know, that I would definitely do also is part of this approach is really focusing it. So where is this coming up practically that is making things really hard for you? And your experience with postpartum is very difficult. So, let's say, you know, one place that I see this pop up a lot is, it's like 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, you know, there's definitely, I just want to say this, there's definitely um gender differences here. There's something, I think, evolutionarily with hormones that make women much more sensitive to the baby's cries.

• 28:23Speaker 01

  But putting that aside, if it, if it feels intolerable, well, off, sometimes what's behind that is actually the, the mother's feeling angry at the baby for crying because they can't soothe them. 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. So if you kind of can just help them see like 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.

• 29:05Speaker 01

  Sometimes the baby just cries. And sometimes there's nothing you can do to stop the baby crying. You don't need it almost like, 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. Just another kind of common example, thinking about, you know, kind of common problems that happen. Maybe a mother's feeling is sort of disconnected, like doesn't want, really want to be around the baby as much. And, you know, one sort of synthesized way that I've seen this happen is make, you know, if there's issues with feeding, sometimes women sort of have an expectation or a desire to really breastfeed

• 29:45Speaker 01

  and have that bonding moment, that's those like loving feelings that, you know, 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, some, 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. And then you can kind of reframe that. Yeah, you're kind of, you're kind of upset at the baby that they, you know, you can't, you guys can't do this together. But that's just because you really want to feel bonded to them.

• 30:25Speaker 01

  That's, 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, 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.

• 30:46Speaker 02

  David, I want to emphasize one piece of what Allison said about specificity. We're looking for, you know, where do these feelings come up specifically? How is the person being affected? Because partly we're saying like, okay, if you have anxiety or 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 know, you're feeling too negatively about yourself and you shouldn't feel so negatively. But in it, we're saying with these particular ways, these manifests have meanings and that

• 31:28Speaker 02

  understanding those meanings help people to have a better understanding of what's going on in themselves and often in the baby, what we call, you know, mentalizing the baby and the mom developing those skills or the father, you know, developing those skills so that someone's, if they have anxiety, it might be about the baby's health and worry. 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? What way? What's our understanding of that? It's not just a generalized symptom.

• 32:11Speaker 02

  It takes a specific form and meaning for them that's important for them to understand.

• 32:18David 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, you know, 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, I think this is like a very different framework for a lot of maybe my audience, nurse practitioners, PAs that are psychiatric nurse practitioners, psychiatrists, you know, we're wanting to do the right thing for the mother.

• 33:02David Puder?

  I think there's a lot of anxiety that providers have, especially in this time, in this moment with the core cases going on, like, are we doing the right thing? Are we, you know? And yeah, 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, there's 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, mothers have, an infant's having an issue latching, well, is there a tongue tie, right? Or is there a lip tie? You know, like if you, if you put your finger at the bottom of the lip and you feel this

• 33:43David Puder?

  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, like, okay, there could be a medical issue here that versus, you know, this is a thing that psychotherapy could take place? Or one of my other thoughts is I'm, sorry, maybe I'll, maybe I'll just pause here and let you address some of these things.

• 34:07Speaker 01

  Yeah, so one thing I would say is that definitely, and you know, the first thing, the first thing, just context wise, is that, you know, being a parent, especially for first time parents, you've never done this before. And you have to give the patients benefits of the doubt that they actually don't know certain things. So a lot of psychoeducation has to happen first. You get, you know, meaning like you need to sleep and yes, wait, okay, 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 to whatever, there's something in your diet, you know, get a consultation, whatever it is. So you kind of start out first with providing the evidence-based interventions that you

• 34:52Speaker 01

  already know about. So you need to evaluate for medication. Are they not, you know, do they have the opportunity to sleep, but they cannot fall asleep? Is that, you know, 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 medications 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,

• 35:35Speaker 01

  but then they can't do it. They 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, you know, the crying shouldn't irritate them as much as it does, but it just does. They want to be able to, you know, they're, wish the baby was different in some way. They know they shouldn't be feeling that way. And despite you kind of telling them like, it's okay, you don't know what they're, you know, 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 supportive interventions, and they can't

• 36:20Speaker 01

  use them. That's sort of what I would say. So, you know, everyone should kind of 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 it's like, they just can't. They get there and they're thinking about them all day long and is it okay? Trying to go check on that, you know? Okay, like, let's talk about this, what could be going on there behind the scenes.

• 36:47Speaker 02

  Yeah, and I would, I would, you know, add to that. I mean, again, first of all, as I said earlier, we wanted to, you know, very careful initial evaluation around safety, around, you know, impulsivity, you know, were there any thoughts that are, you know, I mean, obviously if they're psychotic, then we need to emphasize, you know, safety, medication, those are, those are part of an initial evaluation. And people may need antidepressants and anti-anxiety medication to do this kind of work because some of their, if their symptoms are problematic enough, they're so pervasive, it's hard to

• 37:32Speaker 02

  identify the meaning. You know, it's hard to take out from here or to work with it because they're so affected by it. So those are, 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. These are universals, you know, anger and self-expectations and dependency and separation, abandonment. And this can provide, you know, a framework that people can think about to help them to understand and to communicate, you know, to the mom, oh, you know, look, I think you're

• 38:16Speaker 02

  really, you know, stuck on this one area, you're overstating the danger that surrounds separation and 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, how do you set boundaries? And somebody feels they can't set boundaries or they can't get help and they feel the baby's always having their space and their life is taken away.

• 39:00Speaker 02

  And, you know, 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, you know, I think that's, that's the way that people can use this framework or think about this framework and work with it alongside there, as Allison points out, the other approaches that they use.

• 39:39David Puder?

  Yeah, Alison, do you want to speak about the fear, the fears of intrusion anymore? Any, any more thoughts come in your mind?

• 39:46Speaker 01

  Yeah, I mean, one, you know, one, one thing that we want to do is make this really, you know, almost like a Cliff's Notes version, sort of psychodynamic themes that can happen in 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, feeling trapped by the situation I'm in, or, or even I'm feeling controlled by the baby, like I can't be, or I'm, you know, like, or something bad's gonna happen. That, to me, is a signal that there's something overwhelming about the baby's needs, and they feel like they

• 40:26Speaker 01

  don't have control over, like, modulating that for some reason, when you do, you know, you can, you know, put the baby down or give the baby to someone else if you want a break, right? But it, it, but it doesn't feel that way to patients. So, um, so that's, you know, 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, you know, specific kind of abuse in some way, where their, you know, 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

• 41:07Speaker 01

  holding, I mean, if you're, you know, 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, you know, 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. So that can be very hard to sort of acknowledge. But again, we, we kind of gently go through, you know, sort of, you know, what's the reality of, you know, what the baby's feeling? The baby's just wanting, you know, some comfort, but you can also, you know, play with the baby or do something else. It is feeling

• 41:51Speaker 01

  overwhelming. So that, that's sort of where I see that pop up a lot.

• 41:55Speaker 02

  And, and anyway, I should, I should add, as long as, you know, working on the psychoanalytic standpoint, I picked up on something Alison said, you know, another area that can be a problem is, you know, sexual feelings. There can be a lot of discomfort about, you know, sexual feelings towards the baby. Sometimes they kind of put out of their mind, or they, people have thoughts, oh, okay, you know, but other people, that can be quite, you know, very uncomfortable, uh, you know, for them to experience or threatening. And, and as Alison mentioned, particularly there, if, if they experienced abuse, they may be

• 42:39Speaker 02

  very fearful that could they abuse the baby? Now, well, people are gonna say, oh, oh, no, I, I don't want that to, uh, you know, to happen. And that they can experience normal kind of holding and closeness and physical feelings as, oh, is something, hey, is this not okay? And this can cause conflict and distance. So that's, it's another area that can emerge. And Alison, I think you said about, you know, people who are, can be fearful about reporting some of their feelings, right? That's another factor that, that they can, that you have to manage sometimes.

• 43:21David Puder?

  Right. I, I, 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, like OCD, in postpartum OCD, which is something that I've treated in a number of people, it's like, the obsessionality and the, 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, yeah, and I think especially with, uh, what's in the news, it's like, if you, what, if I've had these thoughts, does that mean

• 44:04David Puder?

  I'm gonna do this? That could be very, very scary. And so, yeah, any thoughts on this, Alison?

• 44:11Speaker 01

  Yeah, definitely. Uh, you know, there's, I gotta tell, there's just so much shame with becoming a parent. It's just, it's, you know, there's so much pressure. Everyone wants to be a good parent. So if there's anything that you're thinking or doing that goes against your, your image of that, it can be so hard to talk about. It can be so hard to experience. And especially if you, you know, the idea of sexual intrusive thoughts is part of OCD, most people don't even know about that or that exists. So, um, I definitely proactively bring up a lot of very common kind of shame inducing feelings or thoughts

• 44:51Speaker 01

  that, you know, women or parents can have. So absolutely, when I'm sort of 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. Is that something that you've had? So I just lay it out on the table. The other thing that, you know, 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, uh, you know, all these other psychological conflicts. So that's also something that

• 45:35Speaker 01

  I'll actually be very explicit about and ask directly. You know, this can be symptom, actually. So, you know, 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 for, you know, is that something that you're experiencing?

• 45:55Speaker 02

  Yeah, I, I think in terms of this, you know, this approach, the problem focused approach, um, we have focus on identifying problems. So it's like, oh, here's your problem, A, B, and C that you report, uh, 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, that's part of the process. Or they might think a problem is just, is normal. Well, of course, I'm not getting any sleep because

• 46:39Speaker 02

  you have to be up the whole night taking care of the baby, you know, completely not, you know, recognizing or normalizing, you know, that it's something that they're struggling with just because they think, well, that's, that's the way it, you know, that's the way it works. And like Alison said, well, that doesn't have to be the way it works. Yeah, Alison, I think you, and it may be, we've talked about this, but I, I was also saying that you have said needing to keep in mind that some people, they actually worry about if they bring up certain things that they might get reported, or, right? That's another.

• 47:19Speaker 01

  Definitely. Yes. The, the worry about, you know, I just call it different things to states, but, you know, child protective services be called. I mean, it's really, it can be a fear that might actually be reality based, based on your, you know, background, your ethnicity, it's more likely to be called in some ways. Or it might be amplified by kind of internal, you know, very harsh criticism of yourself or fears of being punished in some way. And that, you know, that's, that's a kind of a common kind of transference, countertransference, you know, dynamic that really needs to be explored. Like, you know, I did this thing, but if I tell you about it, I'm concerned that you're gonna think

• 48:02Speaker 01

  that I'm an unfit parent, and you're gonna try to take my, you know, take my child away from me or something like that. And, you know, why I always do in that situation is you, you kind of just want to be really transparent and kind of let them know, you know, these, this is, this is actually the, you 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, you know, they were angry at the, at the baby and they just, they didn't put them down as gently as they usually do. Or maybe they removed a sibling who was being aggressive. They kind of like abruptly moved them over

• 48:45Speaker 01

  and they become afraid that that was something really aggressive, uh, really bad. And that that would be a reason that, you know, I would call, you know, some authority on them. So, you know, I think kind of setting the frame of like, this is actually what's a problem and this isn't can sometimes give, you know, a little bit more space for us just to kind of explore it non gently to what actually happened.

• 49:12David Puder?

  Yeah. And you could see how with all that sort of internal self criticalness, rumination, you know, that sometimes gets really black, really black, right? So all or nothing thinking, they could kind of go all bad on themselves. They might even imagine that here's some authority figure who's going to, you know, 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 kind of more details, if you've sensed this is the issue, right? If you sense they have this fear into like, hey, I'm not gonna report you unless you actually abused your kids and you could

• 49:55David Puder?

  potentially describe what that would look like, right? Is that what I'm hearing?

• 50:00Speaker 01

  Yeah, that's exactly right. Like this, this would be the reason why if you were like, if you hit your child and your child is in danger, uh, you know, yeah, what, what it sort of usually ends up happening. Yeah.

• 50:12David Puder?

  Yeah. And, and, you know, in psychotherapy, we, we keep things in words and we actually find that even if you're angry, if you can put it to words in, in a psychotherapy office, it'll actually give the parent more control. If a, 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?

• 50:46Speaker 02

  Yeah, I mean, yeah, I mean, certainly just, I mean, and maybe, maybe talk about, you know, diff- different elements, you know, but one, you know, one, what we call, you know, refer to reaction formation, sort of going out of their way to do, to do extra or more to the point of, you know, wearing themselves out to try to not be experiencing anger or, you know, try, try to, you know, dismiss feelings that, you know, out of their mind, you know, or even sometimes, you know, do things that are self-punitive, that are not

• 51:27Speaker 02

  very good defenses, but, you know, that allow themselves enough sleep for something, there's one person we talked about, kind of this way of punishing herself for, for these feelings without really being aware that, that she was doing that. I mean, maybe Alison would give other defenses that are.

• 51:48Speaker 01

  Yeah, I think the other really common one is avoidance. So, you know, so doing anything that might elicit that thought or taboo thought, you just stop doing. So, and the way that you can really assess for that is, and I always do this, is I do a very specific, sort of like counting of what their day is. What are you, what are you doing in the morning? How are the division of responsibilities that so, and then, you know, 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. And then, you know, again, in some, one example that we have, it's, well, there's a concern that that's when, you know, when you're undoing the diaper,

• 52:33Speaker 01

  that that's when sexual abuse might happen. So that you just stop changing the diapers, that you don't feel that way.

• 52:40Speaker 02

  Yeah, just to bet you, I, I left out one, I'm sorry, but, you know, it could be displaced toward, towards the partner. And, and that is another piece that we emphasize. How do these things get played out with the partner? There's what, for instance, one person that we were, well, we're talking about is, you know, angry at the partner for not getting up to take care of the baby during the night, but then, but then not really giving him the opportunity to, to do it, you know, because of her, some of

• 53:21Speaker 02

  her ambivalence or her struggle around that, or all the anger at the baby's getting displaced onto him, and more not talking to the partner because of, you know, fears of asking for having help, that the partner's not going to be responsive. So then they avoid, like, I was saying, dealing with these issues with the partner, talk, sort of talking them out, or hey, what can we do to do this? So that, I, I, I see that's a very important piece of the work that we, that we, that we do.

• 53:58David Puder?

  You know, one thing that whenever I start to have these sort of thoughts in my, or these kind of conversations, I think to myself, how much of these problems are uniquely USA problems compared to like places like Sweden, where they have, you know, more than a year paid time off when you have a child? Like, how much does this kind of like, a social structure that we have in the US that hasn't really prioritized women's health postpartum, how much, how much that is at play, you know? And how do we balance this, these kind of like deeper things of like, okay, I'm having maybe some attachment

• 54:42David Puder?

  issues with my parents, and because of that, like, they're playing out in the child, whereas like, how much of this is just the structure that we're in? Do you have any thoughts on this, Alison? Maybe I'll start with you then.

• 54:52Speaker 01

  Yeah, oh, definitely. I mean, like, 100%. Sometimes that's the only issue. It's like, they just, they need more time off from work, or like, they need, you know, they need some, some ability to, they need a vacation, they need a sleep, they need someone who can watch their baby while they, you know, take a nap. That there's so many structures in place, and, you know, it's like, that makes it really hard for women to take care of themselves. And, so, you know, but, you know, you do a bias psycho-social formulation with these patients. You think about the biological aspects, does this person need medication? You know, is this, is this OCD? And then you should really be doing, you know, exposure response, you know, prevention therapy and CBT, what is going on here? And

• 55:37Speaker 01

  then you think of the social, just like what you're talking about, like, it's just something in their environment that's causing this, that if, you know, things were different, they would feel this way. But what I, what I found is that, you know, sometimes I get, you know, but I get these patients that they actually, you know, they 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, it's not just the environment, the structure. But you, you kind of always want to start there. You want to see if you can improve their environment, access to resources, psychoeducation, you know, a group. You kind of, you want to start there and see if that, if that helps, if that works. But if it doesn't, again, it's sort of, well, then what do you do?

• 56:22Speaker 01

  There are these kind of residual symptoms. Well, then maybe that's when you need to think about a psychodynamic approach.

• 56:29Speaker 02

  And Alison, I just want to, you know, that there is, there we do have a chapter on, on cultural factors, and I maybe want to speak, say a little bit about that, about taking that into account as well.

• 56:46Speaker 01

  Absolutely. Yes. So with a lot, and with one 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 sort of, you know, cultural expectations around that, or how much the families fall, not fall, you know. So with certain Western, we might think that that's, you know, too much family involvement, but, you know, for them, that's actually how it should be. So, so when you're assessing these problems, you want to definitely keep in mind sort of, you know, how cultural aspects might be influencing the problem and its expression, and, you know, sort of not, you know, pathologize

• 57:31Speaker 01

  something that's actually quite sort of novel for, you know, kind of as part of childbearing practices.

• 57:38Speaker 02

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

• 58:15David Puder?

  There was one study, I was wondering if I could just bring it up here and see what you guys think of this, kind of 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 as low as 3%, and some as high as 38%. And that

• 58:57David Puder?

  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, like, this idea that like, a lot of the difference in the rates in different countries is because of these things that like, seem very hard for psychiatrists to change, right? It's like, we can only do so much. So, yeah, I'm guessing, like, I think we've kind of already answered this question, but any thoughts on that, or any kind of reflections on that

• 59:42David Puder?

  study in particular?

• 59:44Speaker 01

  Yeah, definitely. I mean, one, one thing I'd say is that, you know, like, depression isn't always depression, isn't always depression. So, you know, we use the word depression for a lot of things. So, you know, like, just not having enough money to feed your baby, you know, it's that, you know, that's going to make someone feel really down, really inadequate, like, not doing enough. But like you're saying, is that really depression? Or is that sort of response to sort of what's happening? And then I see, you know, the high rate of infant mortality, you know, in certain countries. Well, that sounds like there's going to be a lot of grief and trauma as well. It's probably getting picked up as postpartum depression. So, you know, and then, you know, these psychodynamic factors

• 1:00:28Speaker 01

  as well. Yes, it's kind of under the heading of depression and depressed need, but it's more like psychological conflicts that are happening, that are causing you to feel very down. So, just, you know, just wanted to add that.

• 1:00:41Speaker 02

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

• 1:01:28David Puder?

  Yeah, we do what we can. Yeah. And I think, I think this kind of like attach, the kind of the attachment base, 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, are there big sort of categories of things that you guys think about that we haven't touched on yet?

• 1:01:53Speaker 02

  Well, let me, let me get a piece just about, you know, mentalization. I mean, mentalization based approaches are, you know, we emphasize those, those are people brought out by, you know, other authors as well, that, that, that piece by helping the parent to, to understand about that, okay, the baby isn't like mad at them, or they may say like, oh, the baby, he's just like his dad, he's such a, he's such a jerk, you know, trying to help them understand, well, yeah, that's not really, that's not what's kind of, baby isn't mad at you, or, or one mom was deeply affected by a sense that about being rejected

• 1:02:37Speaker 02

  when the, when the baby would turn away, or the baby's not, or not, we'd always be smiling, not always smiling. So try, helping them understand how, what's going on with the baby and the baby is not directly that turns in. That's a very, that's a very important piece because that can fit in with their guilt, bad mom feelings. So I do, I want to, I want to emphasize that, that piece. And one thing that we haven't talked about is also is countertransference. So what are the feelings the practitioner is having?

• 1:03:16Speaker 02

  And that people can have their own reactions to these very powerful kinds of issues that are struggling with, with their babies. And, you know, it's important to, you know, be aware of that. And maybe if you, Alice, you know, comments about that. But also, how do you, how do you work with that? How do you be alert to that, to understand, you know, that you, maybe you're struggling with something that's coming up and, and be able to communicate that in some way to the, to the patient?

• 1:03:50Speaker 01

  Definitely. And I think, you know, very common countertransference responses that can happen just from working with parents, babies, is, you know, there can be like an ident, almost an identification with the baby and sort of a concern that the parent is doing something wrong, almost like an overreaction, wanting to be overly protective. And, you know, that's really what the parent is already feeling. They're already feeling like, you know, 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, you know, first of all, you're coming to me for help and you're doing the best you can. You know, you learned, you

• 1:04:32Speaker 01

  learned this way of coping, reacting for some reason. There, maybe there's a good reason that you are responding in this way. And now just trying to help you introduce some choices. Let's introduce some flexibility here and how you can respond, ways to look about this. So, you know, I always keep that in mind if I'm having a very strong countertransference of, you know, feeling like I need to somehow protect this child, this baby from this parent. It sort of reframes that for me and helps me have, you know, some empathy.

• 1:05:08David Puder?

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

• 1:05:36Speaker 01

  Yeah. So one thing, so one thing that I'll do is, you know, you always want to have a foot in reality with these patients. So, you know, I will be very explicit and sort of listing the good things that they're doing, or sort of what I'm seeing as indicating that there's good, you know, a secure attachment kind of developing. And then I'll sort of say to them like, huh, so I'm kind of wondering why there's a disconnect here between how you're viewing yourself, what's going on, and then what's sort of the reality going on. Let's be kind of curious about that together. Let's, 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 kind of tell me what comes to their mind and what, and what maybe,

• 1:06:20Speaker 01

  what actions, what things have happened in the past, what behaviors that doing, that they think are evidence that there isn't a good attachment of that they're doing something wrong.

• 1:06:30David Puder?

  When it, let's, you know, it's, 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 like psychoeducate the mother, like, we're not going to talk about certain things today because you're, you know, because the infant's in the room? Or like, how do you feel about that personally as a provider?

• 1:06:50Speaker 01

  Oh, that's such a great question. You know, it's something that a lot of mothers ask me, like, is it okay to have the infant in the session and if they understand anything? And it really, I mean, it depends on the age. I'm assuming it's under one, one years 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, you know, like you're saying, it's actually very useful for me sometimes to observe the interaction, kind of comment in real time, how the baby seems comfortable, seems calm, you're sort of tuned to them, or whatever else I am observing. But, you know, I will explore if there are certain topics or thoughts that they're sort of afraid of talking about

• 1:07:35Speaker 01

  because the baby's there. That actually is really good data for me. That tells me that those might be some of those more, you know, taboo or, or thoughts that they're ashamed of. They're sort of like, I wouldn't want my baby to hear you say X, Y, Z. Okay. Well, that's interesting. Like, we should sort of explore what those things are.

• 1:07:55David Puder?

  I, I was thinking as well in terms of like, levels of like dysregulation, like, it's like, do you want to, to enter into certain like 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 like run the session differently?

• 1:08:17Speaker 01

  Yeah. So I sort of, you know, before entering into any psychodynamic treatment, I definitely want to sort of assess their capacity for emotion regulation. And if it seems like, you know, 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 as focus more on sort of skills, learning how to regulate, you know, before I sort of enter into that more for exploration. So I am always monitoring that, but it feels like it's sort of overwhelming the patient in a way that is really effective. I'll immediately kind of shift my, my stance, take a step back, do a grounding skill, whatever

• 1:09:01Speaker 01

  is needed to sort of break the patient back.

• 1:09:04David Puder?

  Okay. Very good. Okay. So we talked about kind of these five, five areas, and I wanted to make sure we, we kind of hit them in a way that you felt like was meaningful for this. So the first one is like experiencing, struggling with the mother's or the father's own anger. Then it was like 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 like is still kind of floating in your mind that you really want to share?

• 1:09:39Speaker 01

  Yeah. I mean, I guess, guess that, you know, with sort of difficulty tolerating anger, there's sort of two categories you can kind of fall into, which is some people may be completely unaware that they're angry. It's really deep down and it's really sort of out of their awareness. And, and then there's people who it's like a little bit more conscious. They're aware that they're angry, but then they feel sort of guilty about that or critical about themselves about that. So those are the sort of almost two different levels of severity, and that might change kind of your approach with that. And then with the idealized expectations, definitely idealized expectations of what

• 1:10:23Speaker 01

  parenthood was going to be like, what it was, you know, what, what, how things were going to feel. But it can also, you know, sometimes get directed to the baby as well through perfectionistic standards. So, you know, there's a lot of, a lot of tension sometimes around milestones. Are they meeting their milestones on time? Are they kind of checking off the list? I have to, you know, teach them sign language and I have to make sure they're doing this, that on time. And so that can definitely be a place where idealized expectations or perfectionism can kind of come up as well. Or, you know, alternatively, it's, there can be a worry that, you know, there's they sort of, there's something wrong with their baby, there's something defective about them. And so it can kind of go in a

• 1:11:08Speaker 01

  lot of different directions.

• 1:11:10David Puder?

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

• 1:11:21Speaker 01

  Definitely. Well, and we didn't, you know, well, we would leave them alone somewhere safe, right? Not, but like in a, in a crib, like just leave.

• 1:11:31David Puder?

  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. That's what I'm, I'm thinking of. Okay.

• 1:11:40Speaker 01

  Exactly. Right. Exactly. But that, but it's funny you did that because that, that's how it feels to women. That's how it feels to parents. Like they're leaving them alone. Is there?

• 1:11:48David Puder?

  You're like, Dr. Peter, we're not going to leave the baby alone. Okay. We're not going to do that.

• 1:11:55Speaker 01

  Yeah, it can, but it can feel that way. Like if you're, as the parent, aren't there, it's like the baby's alone. Even if they're with a trained professional at a daycare, or even if they're with your, your partner. And so that's, so that's really interesting. And, and sometimes that's an intervention, which is like, they're not, 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. You know, they learn, the baby learns a lot about that. Um, so there can be, but so then there can be a reason why that person needs to maintain that belief that only they can do it, right? Um, so there's a lot of different reasons for that, you know, wanting to be special, feeling like that's necessary for want.

• 1:12:40Speaker 01

  But one of the biggest kind of psychoeducation sort of I give around that with the separation fears is that, you know, a lot of times, the, the reason this is coming up is because the parent has had an experience of an abandonment, either a real abandonment or, you know, a, a loss, like grief, or some kind of emotional abandonment that happened. Maybe the parent was sick, or, you know, there was a divorce or something like that. And, you know, 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.

• 1:13:25Speaker 01

  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, baby learns that you're there when they come back. So to give some sort of the 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 separation and the return, rather than something that could be really harmful.

• 1:13:54David Puder?

  Yeah, that's good. I was, like, let's say a person has a huge conflict with leaving their child alone with someone who's probably trustworthy, you know, 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, right? So it's like, one of the things in my practice, I, I think it's like really good to find trusted people. But then I think what you're, what you've hit on in this talk with me so far, and I'm, I'm like reflecting on, it's like, oh, there's probably a good reason why they're having difficulty leaving their child alone with someone.

• 1:14:38David Puder?

  So what, so yeah, any other thoughts on that?

• 1:14:42Speaker 01

  Yeah, that, that's exactly right. And I, and I always say this is a way to reduce shame. It's like, there's a reason, there's a real reason for you. 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 sort of an imagining of something that, you know, sort of how you kind of understood certain events in your life, how you kind of put things together. So, yeah, so it's, it's important to sort of, you know, like, like you did, you kind of reality check, where it's like, well, do you, is this person trustworthy? You know, and sort of have that, again, put in reality, yes, you do trust this person. And yet you can't leave the baby with them.

• 1:15:26Speaker 01

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

• 1:15:49David Puder?

  Yeah, and, and for good reason, for good reason, you know, and.

• 1:15:52Speaker 01

  Right.

• 1:15:53David Puder?

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

• 1:16:20Speaker 01

  Luckily, they all, they all overlap. You know, they're all kind of integrated into each other, but it, it helps that I really like what I do. Um, so it's all, you know, interesting and fun. Um, but, you know, that was the, you know, thing that I had to work through, my work-life balance.

• 1:16:37David Puder?

  Oh, yeah, that's good. Well, okay, so yeah, any other final thoughts as we kind of bring this to a close?

• 1:16:44Speaker 01

  I don't think so.

• 1:16:46David Puder?

  Okay, well, this is great. It's been great to connect with you and Frederick. And, um, yeah, we will, I'll just put a final plug for your book, you know? It's, it's a good place to kind of dive into this topic different. It's called Postpartum Problem-Focused Psychoanalytic Psychotherapy. And also, if you're in, you know, Columbia, is, is, uh, do you guys do Zoom? Or do you have to be in person for your Psychoanalytic Institute?

• 1:17:14Speaker 01

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

• 1:17:20David Puder?

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

• 1:17:31Speaker 01

  Yeah, I'm planning it. Well, this, this book just actually came out about a week ago, so we're hoping to, you know, get a lot of lectures about it and workshops, you know, be able to answer people's questions about it. So much for that.

• 1:17:44David Puder?

  Very cool. Well, we'll put on the website, different links to your, uh, your website and if anything other link, any other links you want to give me, I'll put, put them on there. Are you on social media?

• 1:17:56Speaker 01

  I am, I'm on LinkedIn, yes.

• 1:17:58David Puder?

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

• 1:18:01Speaker 02

  Thank you.

• 1:18:03Speaker 01

  Thanks for having me.

• 1:18:03Speaker 02

  Bye.