Stressful episodes in the lives of the affected woman and/or stress in current life situations or during pregnancy and after the birth generally contribute significantly to the emergence of a peripartal mental disorder. It is often sensible to seek psychotherapeutic treatment in order to deal with these experiences and to transform them into new, positive thoughts, feelings and behaviour.
In Germany, such treatment may be carried out by psychological psychotherapists (with the title "Dipl.-Psych". or "Dr. phil."), medical psychotherapists (with the title "Dr. med.") as well as alternative practitioners specialising in psychotherapy (with the title "HPG"). These occupational groups should have completed a further education programme lasting several years in at least one method of psychotherapy and should be continuing to improve their knowledge via regular advanced training.
There are many different psychotherapeutic treatments, but there is no such thing as "the best method" for treating mental disorders in the peripartum period. The best help for those women affected depends on their basic problems and their individual needs and dispositions. But it is generally the case that the relationship between the patient and the therapist is the key to successful treatment, i.e., how well, safe and understood the patient feels with the therapist.
In Germany, psychotherapy for the treatment of mental illness is essentially a standard benefit of the statutory health insurance system (Kassenärztliche Vereinigung), with the condition that the treatment is carried out by a psychological or medical psychotherapist who is acknowledged by the statutory health insurance system and this only for three of the approximately 400 therapy methods currently offered worldwide. The therapy methods paid for by statutory health insurance companies are analytical psychotherapy, psychodynamic psychotherapy and behaviour therapy. These cases do not require a referral from a physician, but it is possible, if the quarterly surgery fee has already been paid here. There can be up to five "trial sessions" (eight for analytic therapies) at each of the relevant therapists in order to determine the need for psychotherapy and the diagnosis, and above all to check whether both sides can build up a trusting relationship on which to base the treatment. Once these trial sessions have taken place, the patient has to apply for the therapy at the respective health insurance company. It is difficult to change therapist during treatment and there has to be a compelling reason for the change. There is a limit on the number of hours of treatment that can be approved, depending on the type of therapy. Psychotherapies offered by naturopaths or by psychological psychotherapists who do not work within the statutory health insurance system are not covered, though if the latter offer one of the three approved methods there is the possibility of applying to the health fund for the reimbursement of costs, the key precondition being that an acknowledged therapist cannot provide treatment within a reasonable waiting time. And therapy is then only possible if self-financed, the costs of therapy range from about 60 to 100 euros and the frequency of sessions as well as the required number of sessions differs dramatically depending on the therapy method and the disorder being treated. This investment may be worthwhile for women whose condition did not improve with the traditional methods. "Freelance" psychotherapists can usually offer appointments without or with only short waiting times.
Private health insurance companies cover the costs of psychotherapy on a very individual basis. Those requiring treatment should consult their respective private health insurance company.
By way of initial guidance, you will find below some criteria outlining the differences between the various strategies. The information aims to simplify the search for a suitable form of treatment. Individual strategies are given that in reality are occurring less and less in their purest form. In recent years, the trend, even in Germany, has been to use multidisciplinary methods in psychotherapy, regardless of the fact that this is not covered by the statutory and private health insurance systems, So it is possible, for example, that a psychological psychotherapist with a background in behaviour therapy uses methods similar to those of a colleague trained in psychoanalysis and with a medical background in order to treat particular symptoms. Under certain circumstances, this joint experience may be helpful to those affected, firstly as a way of stabilising the current life situation by changing behavioural patterns and training the patient in coping strategies, and then by treating the causes in the person's life history. The best thing to do is to get your own impression of psychotherapeutic treatment provider, possibly on the recommendation of another person who is affected by the same disorder. It may also be worthwhile to inquire about other methods offered in addition to the main treatment. The Schatten & Licht website provides a helpful, Germany-wide list of experts based in doctors' surgeries (see).
Strategies based on life history vs. strategies based on current behaviour
The focus of treatment in the former is on dealing with life experiences, mainly in childhood, which can unconsciously affect current problems. They include mainly analytical methods (e.g. psychoanalysis and analytical psychology) and the psychodynamic methods developed from them (e.g. transactional analysis, hypnosis psychotherapy and guided affective imagery (GAI, also known as Katathym Imaginative Psychotherapy)). The latter focus on current behaviour and experience and try to change it through recognition and the targeted training of new behaviour. They mainly include behaviour therapy methods (e.g. cognitive-behavioural therapy (CBT) and Dialectical Behavioural Therapy (DBT)).
Strategies based on interaction vs. proactive patient strategies
In the former, the therapist intervenes to a greater extent with questions and comments; the patient and therapist work together to determine the patient's problem. They include, for example, behavioural and psychodynamic therapy methods. With proactive patient strategies, the therapist intervenes only rarely, while the patient speaks openly about her problems and the associated thoughts and feelings (e.g. traditional psychoanalysis).
Language-based strategies vs. body-based strategies
In the former, problems are handled by "speaking about them" (e.g. conversational therapy, behaviour therapy and analytical strategies). Body-based strategies assume that the body reflects mental conflicts that can be exposed and treated via targeted movements, massage and/or touch. They include, for example, biodynamic body psychotherapy, Hakomi, concentrative movement therapy, Casriel Bonding Psychotherapy and Somatic Experiencing). Body-based strategies are currently regaining significance as a result of new cerebro-biological knowledge. In the broadest sense, these can also include, in the broadest sense, music and creative therapy, in which the body expresses itself via a creative medium.
Disorder-based strategies vs. resource-based strategies
The former focus on the treatment of symptoms and the disturbed personal development, or the deficient way of behaving, thinking and feeling that has caused them. These include, for example, traditional analytical strategies, behavioural therapy methods and psychodynamic therapy methods. Resource-based strategies take as a basis the abilities the person has already developed to cope with stressful experiences and offer guidance as to how to strengthen them. The basic idea is that everybody has the necessary power and strategies to heal themselves and these can be activated, developed and modified. Symptoms are interpreted more as attempted solutions in a condition of illness. These include, for example, psychodynamic imaginative trauma therapy, EMDR and ego state therapy.
General strategies vs. issue-based strategies
While the former deal with problems independently of the type and cause of the disorder, issue-based strategies are based on specific clinical pictures and their causes, in particular including methods to treat traumatic experiences that can be relevant in PPD cases. This concerns women that have suffered extremely stressful and unresolved experiences in their own personal history, e.g. their own birth as premature baby, long hospital stays as child, early experiences of separation from or neglect by parents, sexual, physical or mental abuse and traumatic birth experiences as a mother. It is sensible in these cases to take up specialised trauma therapy, such as EMDR, psychodynamic imaginative trauma therapy and dialectical behaviour therapy (DBT). The addresses of certified specialists can be found at www.degpt.de.
Further guidance can be found in a flyer produced by the Arbeitskreis Frauengesundheit e.V. (AKF), a women's heath research group. Entitled "Qualitätskriterien für eine frauengerechte Psychotherapie" ("Quality criteria for appropriate psychotherapy for women"), the flyer can be downloaded as a .pdf document under the Publications rubric at www.akf-info.de.
But here is a brief summary of some of them:
This is not a complete analysis of the personality but takes into account some of the patient's life experiences in order to clarify the origin of the conflicts that have triggered the symptoms and to train new behaviour. The therapist plays a relatively passive role. The patient remembers, fantasises and recounts,
EFT – Emotional Freedom Techniques:Based on the principles of acupuncture, EFT uses a tapping technique to stimulate certain meridians while the patient repeats sentences of self-acceptance and acceptance of his/her troublesome feeling. EFT has a direct impact on this feeling. The aim is to remove it and develop new possibilities for modifying the patient’s emotions and thereby also their behaviour. Fear and withdrawal can become confidence and happiness. EFT can release a great deal from inside, for example buried memories from a person’s childhood. It is important to be alert and attentive when using EFT in order to recognise this release effect as early as possible and to integrate the emotions that are being produced. EFT is also used to stabilise patients, particularly after traumatic experiences.
Family therapy/ systemic therapy
The idea here is that disturbed family relationships rather than individual disorders make people ill. The result is subtle, combative methods. It is therefore important to observe the whole system of relationships. The family's traditional way of communicating is analysed and new forms of communication and relationship patterns are tested.
The person treated is not a patient but a client. Talks between the therapist and the client are characterised by openness, sympathy, non-judgemental understanding and authenticity. The talks focus on current experiences and feelings, which are accepted and handled positively. The client's self-respect, self-esteem and self-consciousness are boosted by the sensitivity and non-judgemental acknowledgement of the therapist.
The present is important, the past is gone. Current feelings count, you don't have to investigate the causes behind them. Experience is more important than explanation. It must be possible to recognise real needs and live them out freely. The targets are to experience feelings, to perceive surroundings and other people, to deal with issues consciously, to support oneself through an inner dialogue and to act independently. All people and feelings are given their own voice, all of them represented by the client. The therapist's role is to support and stimulate.
Body psychotherapy is a form of therapy that finds ways to access problems which are otherwise hard to treat, and that opens up healing opportunities when verbal dialogue and reflection are not working. This applies especially to, but is not limited to, psychosomatic complaints, symptoms and illnesses. As our attitudes, emotions, feelings and moods are only partially influenced by our comprehension and reason, and are mostly influenced by conscious experiences by the whole organism, body psychotherapy offers a path of growth and change. A neck that has been hunched due to fear of being hurt or humiliated and that has shortened over the years cannot be made permanently straight through reason or manual therapy. Only when the “fear” within the neck has been released, and been experienced instead of held, can the contraction cease. The old fear - expressed in a present clearly recognised as non-threatening - now discovers that the danger is no longer there. The resolution of stuck feelings and the strengthening of self-regulation are approached differently during therapy, as they are individual; the interaction between these two aspects leads to the resolution of “old burdens”, to intense experiences and clear actions, to an absorption of the pulse of life’s energy.(www.koerperpsychotherapie-dgk.de)
It is mostly offered as group work. Scenes from the past, the present or dream scenarios are acted out with the leading actor, called the protagonist, playing his or her own role and using each person in the group as actors in the scenes. Conflicts and problems are played out and different solutions are tested. Feedback is given at the end.
ROMPC – Relationship-oriented, meridian-based psychotherapy and counselling: ROMPC is a method of trauma therapy that links awareness of the beneficial relationship and cognitive reappraisal of a traumatic experience with the limbic system. The limbic system is the part of the brain responsible for quick, pre-conscious reactions to threats and consequently for ensuring our survival. ROMPC aims at the decoupling of the triggers that come into effect after a traumatic experience and thereby give rise to excess stress and panic in endless repetition. Accessing the brain as well as the patient’s awareness makes it possible to develop a complete solution and free patients from emotional stress and its triggers.
The key theme here is solving current conflicts and problems. Memories of childhood and youth are revived. The therapeutic relationship is stronger than in the analytical psychotherapy. The therapist takes part in the conversation, asks for details and informs the patient of his/her observations. New strategies and forms of behaviour are then developed and put into everyday practice.
An individual's personality consists of three ego states that have to be kept in balance in order to achieve a mentally healthy life: the child ego state is characterised by child-like experiences and should be spontaneous; the adult ego state should react neutrally, thoughtfully and sensitively to current situations; and the parent ego state, that is characterised by parents, authorities and social norms and should be constructive and preventive. If interactions between people always stem from the same ego states, because one ego state is dominant, "games" arise that fix people in seemingly unchangeable and harmful behaviour. The need for care and sympathy must be satisfied all life long so as not to become emotionally stunted and so as to develop and maintain self-esteem and self-responsibility. The relationship between the therapist and the client is therefore affectionate and full of care.
Behaviour is learnt but it can also be "unlearned" by practising healthier behaviour. Specific targets of the therapy are discussed and analysed on three levels: in cognition, in behaviour and in body symptoms. The therapist and patient then work together to develop a treatment plan and methods to practise new ways of thinking, behaving and communicating.