Psychoanalytic Psychology

© 2022 American Psychological Association 2023, Vol. 40, No. 3, 159–167

ISSN: 0736-9735 https://doi.org/10.1037/pap0000426

Impacts of the COVID-19 Pandemic on Pregnant and Postpartum Women:

Where Is the Village?
Elizabeth Fritsch, PhD
Training and Supervising Analyst, Contemporary Freudian Society, McLean, Virginia, United States

As the COVID-19 pandemic took hold of the United States, pregnant women and mothers of infants were
among those most affected by fears of the virus, the disruption of health care systems, social isolation, and
the collapse of social supports. This article describes how a group of psychoanalysts and psychoanalytic
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

therapists in a community outreach initiative, the SPRING Project, worked to meet these mental health
This document is copyrighted by the American Psychological Association or one of its allied publishers.

needs by providing affordable psychotherapy at this critical time. Two case reports highlight the ways the
pandemic magnified postpartum distress as well as the relevance and efficacy of a psychodynamic clinical
approach in resolving such distress. In addition, the author chronicles how early in the pandemic the
SPRING Project launched support groups for pregnant women. Participants in this virtual village helped
offset the painful isolation of these women and supported their emotional development during their
pregnancies.

Keywords: postpartum depression, maternal mental health, community outreach, perinatal therapy

In her novel, Department of Speculation, Offill (2014) depicts the
emotional overload and complex identity shift of a new mother.
Asked about the impetus for this work, Offill described her painful
sense of alienation when she had a baby and her inability to connect
with other new mothers.
Early on, I took my colicky baby to one of those new-mothers’ groups. I
wasn’t sure how to connect with them, but I desperately wanted to. The
affect seemed odd. The new mothers seemed to be talking in these
falsely bright voices … no one seemed to feel like a bomb had gone off
in their lives and this made me feel very, very alone. (O’Grady, 2014)
Offill recounts turning to her writing as a way of processing her
experience of dislocation and fragmentation. “I had to figure out a
way … to capture this new fractured consciousness on the page.”
Offill’s fictional protagonist, a new mother, muses “What did you do
today, you’d say when you got home from work and I’d try my best
to craft an anecdote for you out of nothing.” For those in the
maternal mental health world, Offill’s depiction of her profound
dislocation, the feeling that a bomb had gone off in her life, is
familiar and compelling. It is especially relevant to understanding
the dislocations and, for many, the accompanying emotional dis-
turbances of new mothers trying to find their way during the
COVID-19 pandemic.
In March 2020, as the COVID-19 pandemic took hold in the
United States, health and social support systems for new mothers
and families with young children became strained, and many
collapsed. Pregnant women and parents of infants were among
those in the United States most affected by the pandemic. Families
This article was published Online First December 8, 2022.
Correspondence concerning this article should be addressed to Elizabeth
Fritsch, PhD, Training and Supervising Analyst, Contemporary Freudian
Society, 6723 Whittier Avenue, Suite 307, McLean, VA 22101, United
States. Email: drelizabethfritsch@gmail.com
were fragmented. Grandparents stopped seeing their children and
grandchildren. Aunts and uncles were out of reach. Schools shifted
to virtual learning. Neighbors shut their doors to friends and
children. Health protocols and health systems were upended. Hos-
pital stays and medical appointments became times of heightened
risk for pregnant women and new mothers. Lactation consultants no
longer made home visits. Health providers were overwhelmed and
frightened about their own health and survival. If indeed “it takes a
village to raise a child,” the village was decimated. Myriad new
worries, fears, and uncertainties were introduced to pregnant women
and parents responsible for a new life. Griffin, reflecting on the
psychological impacts of the pandemic, describes a “form of
bombardment by unseen threats … difficult to metabolize and
symbolize” (2022, p. 9). As of August 2022, COVID-19 is a disease
that had infected over 93 million Americans, with a death toll
exceeding 1 million Americans.
Throughout the pandemic, and especially in the terrifying first
year, the number of pregnant women and new mothers with
perinatal mood disorders skyrocketed. This dramatic increase has
been documented in studies (Shuman et al., 2022), which estimate
that a third of women who had babies in early to mid-2020 reported
experiencing postpartum depression. This number represents a
threefold increase in identified levels of postpartum depression as
compared to prepandemic levels. New mothers suffering with mood
dysregulation, loss, and trauma felt largely on their own. They
presented clinically as stretched to the breaking point and with
disabling levels of depression and anxiety. Deprived, sad, angry, and
confused by the impacts of the pandemic, many felt impossibly
isolated. Couples struggled to make sense of how to best stay
engaged in the world protecting their livelihoods and maintaining
social support while protecting their own health and the health of
their developing baby or child.
The pandemic also starkly exposed the U.S. workplace’s un-
supportive attitude toward new mothers in the workforce. Prior to
the pandemic, de Marneffe observed, “it is clear that as a society we
are grudging and cramped about the practical adjustments required

159
 160 FRITSCH
by motherhood, continually treating them as incidental and incon-
venient” (2019, p. 20). More than ever, parental couples during the
pandemic were forced to contend with an impossible level of
familial and work demands as offices closed down, health risks
escalated, and childcare systems became unreliable due to frequent
COVID outbreaks. The uncertainties and unpredictability of their
world brought often unmanageable levels of stress. Known risk
factors for perinatal mood disorders include a history of anxiety or
depression, stressful life events, and inadequate social supports. The
strain and stress associated with economic instability, limited access
to reliable and affordable child care, and limited access to quality
health care created higher risk for perinatal mood disorders in
economically disadvantaged pregnant women and new mothers
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than economically advantaged women during the pandemic. Addi-
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tionally, the increased likelihood of mental maternal health strain
for pregnant and birthing Black women due to the cumulative
effects of systemic and interpersonal racism as well as dispropor-
tionate adverse childbirth experience is now documented, presum-
ably increased in the pandemic, and is gaining national attention
(Villarosa, 2022).
In this article, I will describe how a group of psychoanalysts and
psychoanalytic therapists in the SPRING Project, an outreach
initiative focused on maternal mental health sponsored by the
Contemporary Freudian Society (CFS), worked to meet the needs
of mothers and families at this fraught time. I have directed the
Project from its inception along with a dedicated steering committee.
During the COVID-19 pandemic, the number of pregnant women
and new mothers reaching out for help to the SPRING Project and
seen by Project therapists has increased dramatically. Early in the
pandemic, Project members heard directly from practitioners in the
obstetric world that they were seeing an increase in emotional
distress among pregnant women and new mothers. The pandemic
also created an environment in which parental partners assumed
more active parenting roles as both parents stayed at home and
worked remotely, or childcare settings outside the home became
fraught with COVID-19 infection and hence less desirable. As
parental partners struggled to cope with these increased parenting
demands, health uncertainties, and social isolation, some of them
reached out to a SPRING Project therapist in referrals facilitated by
the mother’s therapist. In response to these developments in the
SPRING Project, we began to explore ways to develop greater
knowledge and expertise in our therapists about postpartum adjust-
ment reactions in parental partners and ways to support parental
partners and the couple. I will also discuss the SPRING Project’s
launch of the Pregnant2Parent (P2P) groups early in the pandemic.
The P2P groups are small therapist coled groups offered on a virtual
platform for pregnant women.
In what follows, I hope to give a glimpse of the challenges for
new mothers during this calamitous period of time. I will discuss
how our clinical work with mothers experiencing perinatal mood
disorders is characterized by urgency and permeability and present
cases that illustrate the efficacy and relevance of a psychodynamic
treatment model. Mood disturbances in pregnant women and new
mothers are a common occurrence (Wisner et al., 2013). Raphael-
Leff tells us the “tight circumference of babycare reactivates
profound anxieties in parents struggling to preserve a fragile sense
of adult self against breakthrough of repressed emotion and
trauma” (2000, p. 9). Pregnant women and new mothers often
downplay these difficulties due to their wishes to conform to
idealizations of motherhood as well as their realistic aspirations
to be a good mother. As Likierman suggests, “It is a double blow
for a woman to greet her newborn with depression. She suffers
both for herself and for her infant” (Likierman, 2003, p. 301). Yet,
as I will describe in this article, women who enter therapy in
perinatal mood distress are often accessible to depth emotional
work with impressive therapeutic results in a short-to-medium-
term (6 months to a year) length.
Launched in 2016, the SPRING Project is a community outreach
initiative focused on maternal mental health sponsored by the CFS.
The SPRING Project offers treatment options for women and their
families experiencing pregnancy loss, fertility challenges, and peri-
natal and postpartum mood disorders. SPRING is an acronym for
Support for Pregnancy/Raising Infants/Navigating Growth. The
SPRING Project was developed after a critical period of organiza-
tional study. In this inquiry, the CFS identified a need for an
outreach program that could be widely supported by society mem-
bers and candidates that would position the society more directly in
relationship to the community (Eskin & Fritsch, 2017). We chose to
focus our outreach efforts on mothers and families coping with the
impacts of perinatal mood disturbances. Mental health intervention
for the distressed mother and couple is critical and can be transfor-
mative for the developing family. As psychoanalysts, we are
profoundly aware of how emotional disturbances in early
parenthood—in the mother or the parental couple—impinge on a
baby’s development and the health of the family. Our chosen focus
developed from our recognition of the need cited by the maternal
mental health providers in our locale for more affordable and
accessible treatment options for this population.
A key component of the SPRING Project is that our therapists in
are offered free training opportunities and discussion groups
several times a year on topics related to perinatal mood distur-
bance. The programs have varied. For example, we have offered
presentations by perinatal psychiatrists and midwives. We have
also featured detailed clinical case presentations from SPRING
Project members of clinical work with both pregnant and postpar-
tum patients suffering emotional breakdown. Additionally, we
have held film and book discussions. Our ongoing educational
programs for our members have contributed to the success and
sustainability of our effort. Therapists in private practice, often
siloed in their therapy offices, are vulnerable themselves to effects
of isolation from colleagues and the larger community. By pro-
viding opportunities for study and exchange, we have built a
learning community in which dedicated therapists deepen their
expertise. They enjoy a forum with a familiar group of colleagues
for building clinical knowledge.
Psychoanalysts from both within CFS and other psychoanalytic
institutes together with psychoanalytically trained psychotherapists
with a maternal mental health interest or expertise now comprise the
SPRING Project therapist group. The therapist cadre of the SPRING
Project now numbers over 80. The project operates in New York City,
New Jersey, the Washington, DC, metropolitan area, and Baltimore.
Women and/or couples seen through the SPRING Project are offered
a reduced fee, if needed, for up to 1 year. The project interfaces
with medical centers and health providers working with this popula-
tion including pediatricians, obstetricians, gynecologists, maternal
reproductive psychiatrists, and midwives as well as community
organizations.
 WHERE IS THE VILLAGE?
Requests for therapy to the SPRING Project steadily increased
over the time of the first 2 years of the pandemic and have remained
very high. Here are some examples of these requests:
• I have a 7 week old baby girl and a two and half year old
boy. I feel like a bad parent. I have no social network and
can’t meet any one because of COVID. My family lives in
(European country). My husband works long hours. I am
experiencing intense episodes of anger. I can’t find a
therapist who I can afford or who has time.
• I moved to this area 2 months ago and had to give up my
job, a job I loved. I am struggling. I just had my third child. I
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have chronic mastitis. I am having a hard time. I feel alone.
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• I am 3 weeks postpartum. I am struggling with what to do
with childcare due to COVID concerns when my husband
returns to work—is it safe to have my baby in daycare? My
mother died 7 years ago. I am feeling great grief over her
death now.
• I went through 2 years of infertility and was critically ill
during my pregnancy, ending with a hospital stay, 6 weeks
of bed rest, and a premature baby who is now doing
extremely well at 3 months. But my job has been eliminated
due to COVID. I know my anxiety is not in the realm of
“what everyone expects of a new mother” anymore. My
husband and my parents are concerned.
The pain and desperation heard in these requests were echoed in a
great many of the inquiries we received in these pandemic years. In
what follows, I will present two brief case reports to illustrate features
of the clinical work SPRING Project members did with women
experiencing perinatal mood challenges during the pandemic.
Case 1: “A Horrible Year”
“Sawyer,” a married 32-year-old mother of a 2-month-old girl,
reached out to the SPRING Project for help in December 2020, 9
months after the pandemic began. COVID-19 vaccines were not yet
available. In a routine post childbirth visit, her obstetrician picked up
Sawyer’s likely postpartum depression through her use of a routine
depression screening checklist. New mothers contacting the
SPRING Project frequently say that they have been identified by
a medical provider as struggling with a postpartum mood disorder
with the provider’s use of a symptom checklist. Such routine
screening is recommended by the American College of Obstetri-
cians and Gynecologists. Newborn care appointments are viewed as
a key time for obstetricians to ask mothers about mood. However, at
the same time, new mothers with a positive screening for postpartum
depression often report being given little in the way of resources by
their obstetric providers who seem stretched with the demands of
their medical practice and tend to leave the next steps up to the
depressed mother. Fortunately, Sawyer’s obstetrician offered her a
list of therapists with identified perinatal mental health expertise.
Sawyer contacted me via email with the following note,
I am two months postpartum. Each day has felt like an overwhelming
struggle to just do daily life—with feelings of intense sadness and anger
that I can’t shake. I know that 2020 has been a horrible year for most
161
people but the losses and stresses of my life this year feel like they’ve
caught up to me. Please let me know if you have any availability.
In our first meeting, held on a video call as were subsequent therapy
sessions, Sawyer started the session by telling me that she had in fact
minimized some of her depressive symptoms with her obstetrician.
She was struggling with depressed mood more than she felt she
could let on. She said she sometimes had thoughts of wanting to die
and also felt out of control with her angry outbursts. I acknowledged
how risky it might feel to disclose these negative thoughts and
feelings to me. I also internally noted that this was both realistic and
self-protective. To reveal thoughts about self-harm could trigger an
unwarranted and unwelcome level of monitoring and/or interven-
tion. Additionally, I thought she was telling me that opening this
deeper conversation with me—the type of conversation that Offill
longed for—was one she both felt to be necessary and hopeful but
disturbing. She went on to tell me that she did not feel like holding
her baby. I conveyed to her that I was impressed that she could tell
me about her rejecting feelings toward her baby and that I sensed a
strong interest in finding her way as a new mother.
Depressive thoughts about one’s worthlessness, hopelessness,
existential doubt, and thoughts of self-harm can be part of the
presentation of an emotionally distressed postpartum mother. At
those times, the therapist needs to make a crucial assessment about
the risk of self-harm and to evaluate the sufficiency of a patient’s
family and relationship support. The therapist might suggest a follow-
up an initial meeting with conjoint session including the mother’s
partner. In the initial consultation, the therapist will also be making
decisions about a possible referral for a psychiatric consult if it seems
medications might be useful. There is a subgroup of psychiatrists who
specialize in perinatal psychiatry who can help women with the
complex decisions about psychopharmacological medications during
pregnancy and if nursing a baby. In the case of Sawyer, I felt she was
highly unlikely to act on her suicidal ideation. I was reassured by the
presence of an involved husband who was tuned in to his wife’s
postpartum struggles and supportive of her effort to get help. He was
an active and engaged new father providing collaborative and
generous help with baby care.
In this initial session, I asked Sawyer to tell me the story of her
pregnancy. Married and in her early 30s, she became pregnant
immediately after she and her husband decided to try to have a baby.
She experienced the immediacy of this conception as a shocking
event despite her conscious recognition that this was a “planned”
pregnancy. When women become immediately pregnant, many find
such a development difficult to metabolize. It is also not uncommon
for women when first pregnant to experience doubts, confusion,
regrets, and disbelief as well as excitement and to feel highly
conflicted about these mixed reactions (Birksted-Breen, 2000).
Sawyer had worked hard to secure a position as an assistant
professor, after a detour in her educational path, and felt having
a baby might require she defer this prized work opportunity. She
found this very unsettling. She was unsure of how she could handle
her demanding work role while parenting a baby. At times, her first
images of her baby were as a perceived invader. More deeply, my
sense was she was trying to work out how she could care for a baby
without being emotionally overwhelmed and swamped by the
baby’s needs.
Soon after learning she was pregnant, Sawyer experienced a
profound shock of a different magnitude. She received news that her
 162 FRITSCH
mother, in her mid-60s, was diagnosed with late-stage lung cancer.
The patient experienced this news as catastrophic and unimaginable.
She had identified her mother as a pillar in her family of origin, a
steady source of emotional support, whereas her father, who suf-
fered from debilitating and untreated alcoholism, was chronically in
poor health, needy, and unstable. This event greatly complicated
Sawyer’s pregnancy. As Sawyer said, it was after this series of jolts,
“the pandemic struck.” Fears of the potentially life-threatening virus
now dominated her life. Her work situation shifted to virtual
teaching, an arrangement she found taxing and difficult.
This new mother’s capacities to contend with a newborn and
establish a maternal identity were upended by a series of challenges
that were further magnified by the onset of the pandemic and its
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accompanying stresses. When she became pregnant, even though
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she and her husband were “trying,” her pregnant status led her to feel
she would lose her newly rooted professional identity. At a deeper
level, her felt unreadiness seemed related to vulnerabilities in her
emotional development. At one level, she had sailed through
developmental periods in her life, feeling accomplished and having
made good choices. She felt particularly satisfied in her choice of a
stable and loving husband and her work proficiencies. She had
established an anchoring identity as the competent and responsible
oldest child in her family. However, she had not yet processed the
full impacts of her disappointments and sense of betrayal in her
father and her mother’s disavowal of her father’s instability. She also
had struggled with an unacknowledged level of unmet need for care
and support as she grew up. Her mother was now on the brink of
death, just as Sawyer needed her support in this new period of
development. Sawyer had to process simultaneously the arrival of a
baby and her mother’s grave medical diagnosis cut off from social
supports. I saw Sawyer’s entry into therapy as courageous and
motivated by her wish to be a good mother. She found her levels of
rage frightening and foreign. She told me “nobody talks about things
in my family.” She had never previously been in therapy. As I took a
receptive, containing stance, Sawyer relied on her therapy as a space
where uncomfortable and disturbing feelings could be acknowl-
edged and metabolized.
One of the challenges for a new mother is learning how to balance
her own physical and emotional needs with meeting the needs of her
infant. Likierman (2003) observes that a new mother needs to
constantly negotiate how much she invests in her infant (feeding,
attention, holding, nurturing). This negotiation is ongoing. Many
new mothers present for treatment not having found a healthy
balance. For example, they may have an overidealized view of
what a mother is to provide and find their efforts to maintain this
exceed their capacities. Sawyer often struggled with how to juggle
meeting her own needs and responding to the needs of others such
that either she felt short-changed or worried about short-changing
others. This was an ongoing and important part of the emotional
work with me in her therapy. She spoke about her wish to spend as
much time as possible with her dying mother. However, she
experienced this need as taking precious time away from her
baby. She also wanted to ensure her efforts at work allowed her
to hold on to and advance in her career. I could see an underlying
persecutory vulnerability for Sawyer at this time of heightened stress
fueling her rage reactions.
Sawyer provided breast milk to her baby by pumping (not
nursing) exclusively. She extended her breast milk pumping to a
very lengthy and trying 6 months. She was determined to give her
baby some level of protection derived from the COVID-19 vaccine
once she was immunized. This was an exhausting process, one we
discussed and explored in the therapy sessions. In many ways,
Sawyer’s maternal orientation was that of the regulator mother
described by Raphael-Leff (2015). The regulator mother orients
toward mothering in a highly proficient way. Sawyer was deter-
mined to make every possible effort to protect her baby’s health
from COVID-19 by providing her breast milk. This effort also
helped her contend with her inability to protect her mother
from dying.
As her therapy unfolded, Sawyer expressed and processed her
ambivalence about caring for a baby and developed her preferred
orientation to being a mother. She gradually experienced an increas-
ing sense of competence in her mothering and, as she did so, she felt
less persecuted by the demands of her baby. Her intense anger and
sadness greatly diminished. She established a greater degree of a
healthy separation from her family of origin and placed a fuller
emotional investment in the family unit she and her husband created.
One of the heartening changes in Sawyer was that toward the end of
the therapy, she let me know how she enjoyed holding her baby,
sometimes bringing her into the sessions on camera and interacting
with her with evident delight. Sadly, her mother died just a few
months after we first met. In our sessions after this difficult death,
she spoke openly and movingly about her grief and took an active
role in helping her family and loved ones come together to mourn
and remember her mother.
In my clinical work with Sawyer, I aimed to provide an open
attitude to my patient’s experience. I sought to tolerate my own
discomfort and concern as my patient often disregarded her baby
while tending to her own losses and experience with family mem-
bers and her work. Her baby, often cared for by her husband, felt like
an afterthought at times. I kept in mind Feldman’s (1993) view of the
hazards of reassurance, namely offering to help too quickly to
restore the patient’s equilibrium in what can amount to a false
reassurance, for example, saying “it will get better.” These moments
of false reassurance can arise from our difficulty in tolerating an
inability to help immediately or contend with uncertainty and
painful feeling. The pressures on a therapist working with a dis-
tressed mother, given the therapist’s concern for the baby, heighten
this pull toward reassurance and quickly making things right. The
therapy provided Sawyer an opportunity over time to work out her
experience of being a mother, with attendant ambivalence, confu-
sion, fears, and losses, on her own terms. Charles has written about
the importance of the therapist knowing her place, “that we can be
relied on not to confuse psychic reality with the need for action”
(2017, p. 192). Charles observes that it is in such a context, when the
individual is free to move outward and return in accordance with her
own needs and feelings, “that she can begin to negotiate the internal
and external territory that is requisite for developing a secure
identity” (2017, p. 192).
Over the course of our weekly sessions, Sawyer’s emotional
functioning markedly improved, and her relationship with her baby
dramatically changed. She established a new boundary around her
developing family, no longer feeling pulled toward responsibility
for her family members. She set limits with those in her work
environment and was assured that the university would welcome her
to move into the more senior teaching position as she felt ready for
the position. After 6 months in therapy, Sawyer said she felt ready to
end her sessions. She was enjoying her baby and often lovingly
 WHERE IS THE VILLAGE?
spoke about her in the sessions. She reported experiencing pleasure
and success in her work position and a deepening in her marriage as
she and her husband invested in their own family unit and future
together. Still reeling from the painful reality of her mother’s death,
she expanded her time spent with her two siblings and a beloved
friend of her mother. She also moved away from the overambitious
caretaker role she had played in her family of origin.
Case 2: My Anxieties Are Sky-High
Early in the pandemic, some former patients returned for therapy
with their SPRING Project therapist, citing a resurgence of symp-
toms and difficulty in everyday functioning. Others already in
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therapy with perinatal distress, now buffeted by overwhelming
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health-related fears, loss of familial support, and social isolation,
relied on their ongoing therapy to help them navigate and process
these experiences and what they stimulated.
“Emma,” a married 34–year-old woman of a 4-month-old baby
girl, began therapy with me in 2019, 6 months before the pandemic
started. I was able to meet with her in person for the first phase of her
therapy, which later shifted to virtual sessions. In our first meetings,
I thought Emma quite clearly conveyed her ambivalence and fears
about her entry into therapy expressing both a wished for and feared
dependency. We had a quite remarkable beginning. To my surprise,
Emma appeared in my waiting room for what she thought was to be
an initial in-person appointment at a time I thought was to be a phone
screening. What made this even more complicated is that my own
daughter had gone into labor overnight at a nearby hospital and I was
preparing to go to the hospital as soon as I heard the news of what
was an imminent birth. In meeting Emma and sensing how impor-
tant this first meeting was to her, I opted to see her for this
appointment rather than suggest we find another time. It seemed
to me that her mix-up about our arrangement suggested both a great
urgency as well as an intense anxiety about asking for help. In my
countertransferential experience, I was acutely aware of my own
preoccupations. I worked to put them aside as best I could so I could
attend to Emma. I did not say anything to her about my own
situation. As it would turn out, this stance may have differentiated
me from the patient’s internalized mother who often burdened her
with her own worries. These initial efforts to make contact started us
off on what proved to be a fruitful therapy.
Emma told me that she was struggling with her anxieties more
than usual and had been trying to work through them on her own.
Anxiety was “clouding” her everyday experience with her new
baby. She was often tearful. She worried that her overanxious state
left her insufficiently available to her husband. This led to recurring
thoughts and worries that her marriage might end. Her husband
often tried to reassure her about her worries and their relationship,
usually to no avail. I felt she was letting me know about a worry that
her needs might become too much for me as well. In the beginning
of our work, as Emma told me about herself, she said she did not
want to be perceived as a “complainer.” Though she had experi-
enced mild to moderate levels of anxiety episodically throughout her
life, she had never previously sought therapy. She had once tried a
course of antidepressants but found the side effects unpleasant and
discontinued the medication. Emma let me know that she grew up
in a very insecure familial environment, worrying that her parents,
both previously married and with children from those marriages,
would not stay together. She felt responsible from an early age for
163
emotionally supporting her mother and holding her parents’ mar-
riage together. Her parents divorced when she was an adolescent.
This was a difficult event for her at many levels, and it led to a
splintering of her blended family.
As Emma began to talk about her birth experience, it emerged that
a traumatic c-section delivery activated many unprocessed child-
hood experiences. In her extensive studies of postnatal mothers,
Raphael-Leff has found that “traumatic experiences during labor …
may crack open ossified infantile capsulations … with consequent
eruptions of unprocessed primal anxieties” (1996, p. 396). Emma
felt dissociated and out of control and in poor contact with the
medical staff as the unexpected emergency c-section was initiated.
Although her newborn was healthy, the delivery experience itself
felt like something no longer hers, arbitrarily steered by the medical
authorities and frightening. In her therapy, she was able to link the
helplessness she experienced in this delivery to a number of
childhood experiences in which she felt helpless, terrified, and
without appropriate support. She identified what was mishandled
in this medical experience, especially ways her activity might have
been supported, and expressed a wish to give this feedback to the
providers. While she did not take action on this recognition, she held
on to a less idealized view of medical providers and a more
empowered sense of her own identity. Over the initial months of
therapy, she made many steps in processing this birth trauma and
consolidating her new identity as a mother.
Just as Emma was emerging from the postpartum emotional cloud
that led her to seek therapy, the COVID-19 virus took hold of our
community. Her anxieties again spiked and interfered with taking
pleasure in her life. She described her anxieties as “sky-high.” Every
choice was fraught for Emma—how to handle medical appoint-
ments or whether to forego gatherings with grandparents. She
suffered from having no framework on how to evaluate these
decisions. The unknowns, fears, and terrors accompanying the
pandemic stimulated a resurgence of intrusive thoughts about her
child dying or a catastrophic health event for someone in her family.
In her ongoing therapy, we continued to address her unconscious
fantasy of protecting her parents, especially her mother, from all
danger. These fears had been fueled by her mother’s emotionally
childlike stance. The emotional fractures of these early years were
underneath the challenges she now faced as an adult mother in a
world with great uncertainty and risk.
During the pandemic, Emma had to work again to modify an
overidealized version of being a parent. She began to find the
balance of protecting her baby from harm with her needs to live
her life. She had felt painfully cutoff from her family of origin and
friend supports. She missed going to the office and seeing people as
well as social experiences with friends. She and her husband could
not rely on the usual outings and social experiences to enjoy adult
time together. These competing needs created significant tension for
her. She yearned for a parent who would tell her what to do. Through
the process of a year-long therapy, she ultimately reestablished a
resilient adult self and was able in alignment with her husband to
work out responsible ways to manage these competing priorities.
Commentary on Cases of Sawyer and Emma
The sense of urgency created by maternal breakdown as well as
an increased interplay between the unconscious and conscious,
inside and outside, contribute to the efficacy of psychodynamic
 164 FRITSCH
psychotherapy with an attuned therapist during the perinatal period.
Even when women seeking help at this critical time are in a near-
desperate state of mind, a therapist available both to explore and
contain what pregnancy, childbirth, and the demands of caring for
an infant evoke can readily help recovery and psychological
growth. The report of the clinical work with Sawyer and Emma
is illustrative of such accessibility, motivation, and recovery seen
with women working with SPRING Project therapist with perinatal
mood disorders during the pandemic. These two cases also high-
light the spectrum of clinical presentations affecting mothers
postpartum. While postpartum depression is the most widely
recognized type of postpartum disorder, severe anxiety disorders
are very prevalent. Many women are adversely affected by trau-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
matic birth experiences that reactivate earlier trauma and, as a
This document is copyrighted by the American Psychological Association or one of its allied publishers.
result, experience pervasive anxiety and hypervigilance.
A woman in the perinatal period, prenatal or postnatal, is con-
tending with an upsurge of somatic flux and reactivation of earlier
unmentalized psychic experience. The flux of somatic experiences
contributes to the overload of perinatal experience. As one of my
patients recently said, her childbirth experience was “chaos.” And
then, she added “one day, after the birth, my breasts changed two
sizes.” For many, there is a too-muchness of experience that is
overwhelming, more than they can manage. Bion (1962) recognized
the imperative of the psyche’s need to deal with the influx of
perceptual input and somatic input to maintain emotional stability.
If we can’t stand our perceptual and somatic experience, we try to
avoid, eject, or numb this experience. However, when pregnant or
with an infant, it is virtually impossible to avoid somatic and
perceptual experience. Hence, persecutory anxieties develop, and
breakdown ensues if it is felt there is no way out.
As these two case reports detail, Sawyer and Emma were
suffering from levels of psychic experience that they were ill-
equipped to manage and that were heightened by pandemic strain.
The physical retreat required to keep safe was emotionally costly
and cut off much-needed support. Griffin points out when contend-
ing with primal fears stimulated by the pandemic, “the symbolizing
function is taxed, making it less possible to articulate and truly
reflect upon what is happening to us” (2022, p. 10). Both of these
patients benefited significantly from having a therapeutic space to
process and reflect, which was especially valuable during the
pandemic strain. Sawyer who simultaneously gave birth and lost
her mother moved from a position of feeling assaulted and perse-
cuted to a depressive position in which she could begin to establish a
more secure attachment with her baby. Emma’s overall emotional
functioning stabilized. She processed earlier traumatic and anxious
concerns that occupied her mind activated by childbirth and parent-
ing as well as the pandemic fears. She was no longer possessed by
what Fraiberg et al. (1975) termed the “ghosts in the nursery.” In
both couples, there was evidence that the couple was able to develop
as a couple with the arrival of a baby and manage the stress and
tensions of this new development. As I heard about the couple
through the work with the mother, I felt there was evidence of what
Morgan has called “the creative couple,” namely a couple where
“there are two people, separate and different, who come together, are
changed by each other, and have the capacity to produce a third
between them” (2016, p. 199). The fathers did not express a need for
additional emotional support from a therapy for themselves or
conjoint couple sessions.
The experience of therapists in the SPRING Project is that
psychodynamic psychotherapy has much to offer an anxious or
depressed new mother. While many of the mothers reaching out for
help at this time to the SPRING Project have previous treatment
experience, many do not, as was the case with both Sawyer and
Emma. Balsam (2000) suggests that it may be that mothers dis-
tressed and overwhelmed by their experience are especially open to
processing their maternal experience. She states, “Perhaps intro-
spection is more possible for a patient who is troubled by some
aspect of the mothering experience and is actively seeking help for
it” (Balsam, 2000, p. 470). Her suggestion is fully supported by our
clinical experience in the SPRING Project. A therapy model ori-
ented to the containment of primitive mental states and reprocessing
of unmetabolized early experience and previous developmental
crises is suited to women presenting with perinatal depression
and/or anxiety.
Rebuilding the Village—The Development of the
SPRING Project P2P Groups
When the spiraling maternal mental health needs resulting from
the overwhelming disruptions of the pandemic became apparent in
March 2020, our SPRING Project leadership was eager to offer
something more to help the new mothers in our community. Dr.
Jennifer Grosman, a clinical psychologist and codirector of the
Center for Maternal Wellness, and a SPRING Project steering
committee member proposed that we develop small psychoeduca-
tional support groups for pregnant women. She suggested these
groups be therapist-led, time-limited, and offered virtually. In her
practice, Dr. Grosman had envisioned these therapist-led groups for
pregnant women well before the pandemic struck. In her extensive
clinical work with postpartum women, she could see that greater
emotional preparation for women during pregnancy helped offset
the disequilibrium and challenges of motherhood.
The SPRING Project leadership team quickly agreed to act on this
proposal. Within a month, we had established a group format, and
eight therapists from the SPRING Project stepped forward to colead
evening groups. We called this new offering the P2P groups. We
notified both our established contacts in the mental health and
maternal health community as well as mothers who were on
mothers’ listservs about this new offering. We described the groups
as “an opportunity to connect and reflect on the experience of
pregnancy and expectations for what lies ahead as a new parent.”
Participants were invited to have “deeper conversations” and to talk
about pregnancy stories and the “inside experience” of pregnancy,
both physical and emotional. We included sessions on expectations
about delivery, changing relationships with partners and family of
origin, and a chance to consider the question “what kind of mother
will I be?” Our announcement called attention to the heightened
uncertainty and fears about the coronavirus affecting preg-
nant women.
The response from our community to the launch was resound-
ingly positive. In late April 2020, we started four therapist-led P2P
groups of 8 to 10 members. We found these small groups of
pregnant women connected immediately and powerfully. These
women had been greatly affected by the loss of ordinary social
contact and the naturally occurring opportunities to process their
experience of pregnancy. They described a difficult challenge that
can be conceptualized as balancing their efforts to stay safe with
 WHERE IS THE VILLAGE?
their efforts to keep from being claustrophobically trapped with too
little contact with the outside world. The terror of contracting
COVID-19 was paramount in the minds of these women. This
fear was especially acute in the year before a vaccine was available.
This terror was also, of course, present in their family members. The
group participants expressed a deep appreciation of this opportunity
to speak about their experiences of pregnancy—positive and
negative—as well as to give voice to their anxieties and concerns.
They felt pained by the lack of ordinary social discourse and
conversation. As one member vividly put it, “When I go into the
waiting room at the obstetrician’s office, everyone averts their eyes.
No one wants any contact.”
Highlighting an unusual pandemic phenomenon, Krueger (2022)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
penned a New York Times piece entitled “Oh, By the Way: I had a
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Baby.” She observed that many pregnant women, namely those
working remotely and cut off from families, had the opportunity to
decide when and whether to share news of their pregnancies with
others. Krueger interviewed mothers who chose “not to tell” as a
way of silencing unwelcome advice, judgments, and unsolicited
conversations about their pregnancies. Krueger’s anecdotal data
suggest that some pregnant women with a history of pregnancy
loss or connection with unsupportive families took advantage of
such a news embargo about their pregnancies to contend with
unwanted input.
By contrast, the participants of the P2P groups identified a need
for their pregnancies to be recognized by others. The fact that the
groups were therapist-facilitated may have increased the sense of
safety for these women and perhaps was a factor in their seeking out
this group experience. It is possible that some of the mothers
interviewed by Krueger also might have welcomed a P2P group
experience if the same had been offered to them. One P2P member
put her experience this way, “It was a loss not to have any public
acknowledgement of my impending transition—even on the metro
or during in-person grocery runs.” Another participant lamented, “I
feel as if I am back in the nineteenth century where my pregnancy is
something that is hidden—as if it conveys sexuality and has to be
disavowed.” Often the P2P members had a moment where members
stood up and showed their pregnant bodies to each other on camera.
In the groups, these women also had the opportunity to develop
reliable ways to manage unwanted or intrusive social or familial
interactions. We viewed this as an important step in the psychologi-
cal process of “becoming a mother.” In Birksted-Breen’s view,
“pregnancy is a time of psychological as well as physiological
preparation” (2000, p. 17). As the group experiences deepened, the
P2P members often affirmed the benefits of having the opportunity
to share with their pregnant peers the details of their pregnancy
stories and inside experience. One participant declared her group “a
lifeline” at this “completely isolating time.” They embraced the
deeper conversations afforded by these groups. Another member
reflected, “My friends only talk about their pregnancies with rose-
colored glasses.” They talked about miscarriages, deaths, disloca-
tions, and fears about their marriages. They also discussed the more
ordinary parts of their pregnancy experience like their delivery plans
and how their partners were reacting. They described their group
experience as “grounding,” “community-building,” and “hopeful.”
Our group participants steadied each other in these turbulent times
of fear, panic, and social contagion (Green & McCallum, 2020).
They often cited the work of Emily Oster, author of Cribsheet, who
provided regular newsletters and op-eds related to COVID-19. She
165
offered families a way to think about navigating choices in living
that was similar to her approach to decision-making presented in her
previous writing for expectant parents. She set out a decision
framework for making choices during the pandemic that focused
on assessing risk. She wrote, “Everyone’s questions are different.
You don’t need an answer. You need a way to decide” (Oster, 2020).
As the pandemic went on, our group participants often explored
their COVID-19 questions and decisions with each other. As one
member reflecting back on her P2P experience wrote,
There were times when I logged into our virtual sessions after arguing
with my parents about when they could visit the new baby. Hearing how
other new mothers were thinking about safety and boundaries helped
me trust my own instincts.
In one of the most affecting conversations in our groups, a
participant received news that her baby had a 25% chance of having
inherited a life-threatening genetic condition. The group held her
week-to-week as she awaited the results of genetic testing. Soon
after the formal group sessions ended, she shared with the group she
had received the worst news, the baby had inherited this devastating
condition. She ultimately went on to make a decision to terminate
her pregnancy. She later wrote to the coleaders of the group
I want to thank you again for the space you cultivated that allowed me to
share part of this journey with others. I really benefitted from being part
of your group, both before and after things took a turn for the worse …
the most painful weeks of my life.
She had also formed a special friendship with one of the other
pregnant women in the group. Months later, this group member
shared a blog that she and her husband wrote which told, “the whole
story” of losing their baby.
The P2P groups evolved over time. Participants asked that
sessions be increased from the initial five to seven sessions. Subse-
quent seven-session groups asked for eight sessions. Group leaders
reported that all the groups established group chats in which they
shared resources from doulas to daycare to preferred leggings or
followed up on developments in each others’ lives. Additionally,
many of the groups went on after the formal sessions finished to
have regular social get togethers with their babies. We have heard
that these moms gathered for periodic dinners and invited each other
to their toddlers’ birthday parties. And there is now an “alumni
group” for P2P “graduates.” A P2P village was created!
Discussion
The first year of the COVID-19 pandemic had a severe adverse
impact on overall mental health throughout the world. The mental
health of pregnant women and new mothers was especially strained
during this time. New mothers were unmoored by their dependence
on a health care system that was disrupted and an imperative to keep
themselves and their babies safe as they were surrounded by a highly
contagious and potentially fatal virus with unknown qualities and no
vaccine protection available. The social isolation and distance from
family members resulted obliterated the proverbial village resulting
in a loss of anchoring experiences and support. In the SPRING
Project, we saw these impacts through hearing from the concern of
maternal health practitioners about the emotional health of their
patients, as well as the increasing numbers of patients reaching out to
us for help struggling with perinatal breakdown.
 166 FRITSCH
Becoming a mother is an adult developmental phase (Benedek,
1959). As such it is a period of crisis involving profound psycho-
logical as well as somatic changes (Birksted-Breen, 2000). De
Marneffe contends that “motherhood calls for a transformed indi-
viduality, an integration of a new relationship and a new role into
one’s sense of self” (2019, p. 20). She observes women increasingly
turn to their own mother as “reference points” as they rethink their
identity. Six decades ago, Bibring (1959) speculated that improved
medical conditions at that time perhaps accounted for a waning
concern with the psychological changes that took place during
pregnancy. The Year 2020 once again took pregnant women and
parents of newborns to a place of grave medical concern. The
conditions of the pandemic were such that serious medical com-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
plications and dangers were universally reintroduced to expectant
This document is copyrighted by the American Psychological Association or one of its allied publishers.
and new mothers complicating their entry and journey through this
period of development. For many, they also did not have access to
parental figures who could provide “reference points” during this
critical time.
What internal resources helped new mothers best cope with these
pandemic challenges? According to Raphael-Leff (2015), a British
psychoanalyst who has studied mothers for decades, there are three
distinct maternal orientations: regulator, facilitator, and reciproca-
tor. The regulator mother prefers help from many caretakers for her
newborn and greatly struggles when feeling entrapped in a closed
psychic space with her infant. By contrast, the facilitator mother
prefers to be the exclusive caregiver and readily embraces the topsy-
turvy and disruption of the newborn world. However, she is also
vulnerable to becoming overextended as demands increase. The
reciprocator mother, described by Raphael-Leff as having a mature
and flexible psychological style, relates to the baby as separate, as
being an agent with his or own individuality. The reciprocator
mother can largely tolerate her ambivalence toward the baby without
becoming overtaken by unremitting guilt. Also, she orients to
reprocessing her own attachment relationships as she becomes a
parent. As she works out the matrix of new relationships with her
baby, her partner, and her wider family relationships, she is
thoughtful about these changes and how to best navigate them.
The features that Raphael-Leff found in the reciprocator mother are
those that we can surmise helped in the adjustment required for
parents in the flux, terrors, and strain of the pandemic.
Additionally, the therapists in the SPRING Project saw that the
disruption of the health care system itself created cascading strain
for pregnant and birthing mothers. Pregnant women were not
allowed to have their partners present for prenatal sonograms and
medical visits. For a brief period of time in New York City and
Washington, DC, birthing mothers were not allowed to have their
partner in the delivery room. For a much more extended period time,
birth doulas were excluded. Maternal fetal medicine specialists
observed that preeclampsia—a surge in blood pressure in the later
stages of pregnancy that endangers both mother and baby—
increased in the early stages of the pandemic putting further strain
on health care providers and expectant mothers (Winter, 2022).
Postnatally, women could not meet in person with lactation con-
sultants. Often new parents were not able to have family members
present with their newborns for some weeks out of fear of COVID-
contagion. For many of those mothers with emotional fragility,
previous loss, difficult life circumstances, or unprocessed trauma,
these strains created conditions of emotional breakdown.
Conclusion
At a time of a global pandemic, the SPRING Project, a well-
established community resource in the Washington, DC, and New
York metropolitan areas focused on maternal mental health sponsored
by a psychoanalytic organization was poised to contribute to the
escalating community need for help with perinatal distress. Twemlow
and Parens (2006) observe that the psychoanalyst in the community
learns that both flexibility in engagement and a commitment to
respond to the kind of help the community needs are essential to
being “a community psychoanalyst.” They write “when people feel
they are being helped, they become appreciative, even respectful, of
us, our training and clinical background” (Twemlow & Parens, 2006,
p. 434). The Project responded to the soaring rates of prenatal and
postpartum emotional distress by providing affordable therapy to
pregnant women and postpartum mothers. We also offered a new
community initiative, the Pregnant2Parent support groups, that
offered the opportunity for deeper conversations during these turbu-
lent times.
The deeper conversations provided by the SPRING Project to
scores of pregnant women and new mothers both in therapy and
small support groups during the COVID-19 pandemic have been life
changing and life giving. The SPRING Project is a vibrant, cohesive
community of psychoanalysts and psychoanalytic therapists dedi-
cated to helping new mothers. Our capacity as a community to hold
together and give generatively during the pandemic was also renew-
ing and sustaining to the SPRING Project members. As Green and
McCallum (2020) suggest in highlighting the importance of renewed
relationships in emerging from the pandemic, “there is nothing more
powerful than the reality of mortality to bring forward conversations
with another that are fraught with pain, conflict, hurt … and trauma
to reach a different level of mutual health.” In helping to rebuild “the
village” at this time of pandemic collapse, in the SPRING Project, we
too found the restorative power of human contact and connection.
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