(As requested, here is Gana's paper on pastoral counseling and post-partum depression. By the way, he got an A.)
Introduction
In sooth, I know not why I am so sad
It wearies me; you say it wearies you
But how I caught it, found it, or came by it,
What stuff ‘tis made of, where of it is born,
I am to learn
--William Shakespeare
Merchant of Venice, I,1,II. 1-5
Many people seek the advice and counsel of a pastor when going through a depression, a despair or a dark night of the soul. A University of Michigan study found that 4 out of 10 Americans sought help from a clergy member in dealing with a personal problem. Among those who regularly attend religious services the number rose to 53%.(1) “Depression is no respector [sic] of persons. No segment of society is immune.”(2) This “common cold”(3) of mental illness is typically suspected after an emotional life event—loss of a loved one, loss of a job, a move away from family, etc. It is not always suspected after the happy events of life—such as the birth of a child. However, post-partum mood disorders, which can occur in both women and men, are surprisingly common. Sixty to eighty percent of women report experiencing “baby blues” and 20% of those women develop post-partum depression, which can develop into other mood disorders and/or become chronic.(4)
Important to the prevention, treatment and resolution of post-partum mood disorders (PPMD) from mild baby blues to full-blown depression is a supportive environment and a foundation of faith. The thesis of this paper is to show that pastoral counseling can play an important part in the post-partum weeks and months. This paper will aid pastors in identifying the basic needs of a post-partum family and suggest practical ways in which a pastor may assist them.
Because post-partum depression is many faceted springing from spiritual, psychological, physiological and emotional causes—or some combination of them all, the information presented comes from pastoral sources as well as psychology, doula training manuals,(5) as well as personal experience as a certified childbirth educator and a father of six.
Post-partum Depression in the Church
In the ideal situation, a mother and baby are never separated, allowing for optimal bonding. As Melanie Klein and Margaret Mahler emphasize, the first three months post-partum the baby is unaware that mother is other. The maternal-child bond is such that if the mother is near the baby is at peace. If the mother is apart, the baby knows instinctively that something is wrong. The mood and anxiety level of the baby can find a direct correlation with the mood and anxiety level in the mother.(6) For the woman, who is experiencing unexplained sadness after giving birth, her baby can also begin to show signs of anxiety. This can begin a desperate cycle—the mother feels sad even with her baby. This leads to feelings of guilt. Feeling like an unfit mother, the woman feels sad, which leads to guilt, and so on.
While the primary attachment for a baby is to the mother, it is clear that the secondary attachment is to the father.(7) It’s interesting to note that PPMDs can also be found in fathers. According to SadDaddy.com approximately 1,000 men per day are depressed after the birth of their babies. If both mother and father are experiencing PPMD this undermines the infant’s entire attachment and social structure. Depression therefore can cause a breakdown of the atmosphere needed to develop a child’s secure attachment. The consequences for the family and church are far reaching. John Bowlby said, “Adults who have secure attachment patterns will be able to maintain healthy functional relationships of intimacy, and maintain appropriate relationship boundaries.”(8)
Being a Christian links an individual with a larger body of believers. When one rejoices the whole rejoices. When one suffers, all suffer. No church is whole or healthy with families that are not. Peter Steinke wrote:
Shalom is a condition of well-being. It is a balance among God, human beings, and all created things. All parts are interrelated. Each part participates in the whole. Thus, if one part is denied wholeness (shalom), every other part is diminished as well….Health means all the parts are working together to maintain balance. Health means all the parts are interacting to function as a whole. Health is a continuous process, the ongoing interplay of multiple forces and conditions…The various members and subsystems of a congregation interweave, much as do the organs of the human body with the ongoing interaction of cells, blood flow, nerve endings, energy source, and waste products.(9)
Case in point, a student in my wife and my childbirth class who we will call Sue (name has been changed) was actively involved in her church. She served in the children’s ministry, in home groups and volunteered for various events. The arrival of their first child came at a difficult point in their lives. They were between jobs and in transition. In addition, the birth was very traumatic and physically painful for Sue. Soon after birth Sue began to withdraw from church and social activities as she struggled to just maintain the basic functions of feeding the baby and attending to home life. Her husband, although happy to be a dad found that the baby kept him awake much of the night. His work began to suffer. He and his wife began to quarrel more and the fun times they shared pre-baby were now few and far between. They began to resent the change the baby brought to their lives. This caused guilt and frustration for both of them.
This story, although a true case with which we worked, might belong to any number of new parents in any church. It’s very common. How can a pastor help prevent things from getting this bad or aid in healing them when they already are this bad?
The Pastor as the Spiritual Doula
“He shall feed his flock like a shepherd: he shall gather the lambs with his arm, and carry them in his bosom, and shall gently lead those that are with young.” Isaiah 40:11
Although common in many cultures it is just recently gaining popularity in the West to have a doula. Many couples hire a helper for the labor and delivery of their babies. The doula does not act in a medical capacity the way a doctor or midwife would. Instead, she is there for support—emotional, physical, mental, and relational. Many couples are also recognizing the benefit to having a doula after birth when the round-the-clock needs of an infant and recovering woman become all-encompassing.
The word doula (“helper” in the Greek) is from the same word as the Holy Spirit in the Bible, who is called our doulos. A person can represent the Holy Spirit and be a helper to a young family, and who better than their shepherd—their pastor! The pastor often represents God (who is the true shepherd) to the congregation, the pastor is in the midst of the congregation fulfilling a variety of roles, the pastor is to seek out hurting people to help, and the pastor approaches each counseling opportunity with the aim to understand others and to help others to understand themselves.(10)
While maintaining a non-directive approach,(11) it is helpful for the pastor to keep in mind the basic needs of a post-partum couple. Renowned doula and childbirth writer, Jacqueline Kelleher gives a top-ten list which I have adapted here:
1. The mother needs physical support so she can rest.
2. The mother (and father) needs support and encouragement to establish successful breastfeeding.
3. The couple needs support for avoiding and minimizing PPMDs.
4. The couple needs information and education on how to integrate this baby into the family.
5. The couple needs information and education on infant characteristics and infant care skills.
6. The couple (especially the mother) needs someone to listen to her and to honor her birth story.
7. The couple needs a peer group—people who are not only parents, but also parents of young babies.
8. The couple needs patience.
9. The mother needs support while healing physically from birth.
10. The mother and father both need physical touch.(12)
Of course, the pastor cannot fulfill all these needs, nor should he/she try. (“The purpose of pastoral counseling is to offer something new, so that the persons within it will experience some freedom to change, to consider some new alternatives about their lives.”(13) ) However, being aware of these needs the pastor can gently offer the couple leads to resources where they can have these needs met. If the needs of a young family are recognized, the infrastructure essential to meet those needs can be built into a congregation’s unique cultural identity.
Post-partum depression is a sensitive issue in society and Christian circles. To be depressed and guilt-ridden during a happy time is sometimes seen as sin. The pastoral counselor, seen as trustworthy and capable, can offer a lot of help. In this situation, it is good when the counselor is not authoritative—if so, the authority structure of the domestic family could be compromised. Here the pastoral role is the incarnation (doula-ing)—being in the midst.(14) The doula pastor can employ active listening and non-directive counseling to help the couple arrive unscathed at the other side of the blues. Like the birth doula who mothers-the-mother with loving care and a supportive emotional presence, the doula pastor supports the couple with consistent support and faith the in couple’s innate ability to care for their child.
There are times when baby blues develop into full-blown depression and depression into other PPMDs such as post-partum panic disorder or post-partum psychosis. In such cases, a pastoral counselor should know when to refer the individual(s) for other professional help. “If a person appears to be suffering more than a mild depression or a normal grief reaction it is essential for you to have a consultation with a mental health professional such as a psychiatrist, psychologist, social worker, licensed pastoral counselor, or marriage and family therapist, to make a more extensive evaluation and discuss treatment options.”(15)
Even after referring the individual and/or couple, the role of the doula pastor is not over. Because post-partum depression can have many components and causes (such as a traumatic birth, not breastfeeding, family history, hormonal imbalance, past sexual abuse, poor diet, lack of sunshine, breakdown of communication in marriage, etc) the answer is likely to be many faceted. The individual referred will still benefit greatly from the prayers, active listening, and faith traditions the pastor and church can offer.
In conclusion, the needs of the birthing woman and her partner for emotional, physical and spiritual support do not end when they take their child home from the hospital. Where the medical establishment leaves off, the church and the doula pastor can pick up. A supportive environment such as this can prevent depression. A family’s faith can ease the guilt associated with post-partum depression and carry them through to the other side.
**************************************
(1) Andrew J. Weaver, “Depression: What Clergy Need To Know,” Currents in Theology and Mission 20 no 1 F, (1993): 5-16
(2) Dwight W Cumbee, Ph.D., “ Depression as an Ecclesiogenic Neurosis,” The Journal of Pastoral Care Vol. XXXIV, No. 4 (December 1980): 254-267
(3) Weaver, 5-16
(4)Jane Honikman, MS “I’m Listening: Responding to the Emotional Needs of Pregnant and Postpartum Women and Their Families,” (lecture from DONA International Conference, New Orleans, July 24, 2004)
(5) The word "doula" comes from the ancient Greek meaning "a woman who serves" and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period. (www.dona.org)
(6) Dr. Ron Hammer, “Pastoral Counseling” (from class lectures in CN 520), Fuller Theological Seminary, Pasadena, California.
(7) Dr. Ron Hammer, “Pastoral Counseling” (from class lectures in CN 520), Fuller Theological Seminary, Pasadena, California.
(8) Philip Culbertson, Caring for God’s People, (Minneapolis, MN: Augsburg Fortress, 2000) 79
(9) Culbertson, 4
(10) Dr. Ron Hammer, “Pastoral Counseling” (from class lectures in CN 520), Fuller Theological Seminary, Pasadena, California.
(11) “Limited evidence from two RCTs suggests that in the short term (immediately after treatment) non-directive counseling may improve post-natal depression compared with routine primary care. The one RCT with follow-up beyond 12 weeks found no clear longer term benefits (from 9 months to 5 years post-partum) from non-directive counseling compared with routine primary care, individual cognitive behavioral therapy, or psychodynamic therapy.” (Clinical Evidence June 2004, p. 353)
(12) Jacqueline Kelleher, CD (DONA), PCD (DONA), ICCE, “What Women Need During the Postpartum Period: A Top Ten List” (lecture presented at the DONA International Conference, San Francisco, July 25, 2003)
(13) John Patton, Pastoral Counseling: A Ministry of the Church (Nashville: Abingdon, 1983), 107
(14) CN520 Pastoral Counseling class reader, What Makes Pastoral Counseling Pastoral?
(15) Weaver, 5-16