Out came the Sun

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I’d like to start with a quick hello and to briefly mention that I’ve been rather busy with a new charity recently. It’s called Hope and Homes and it’s particularly close to my heart. I mention this merely to explain the dearth of reading matter in recent months for anyone who might enjoy this blog.

I’ve been meaning to write about perinatal depression for some time, perhaps since the beginning, but somehow I haven’t got around to it. It was Adele’s recent support for her friend’s witty yet heartbreakingly described (online) account of her battle with postpartum psychosis that got me thinking about writing something myself. It’s great that Adele has shone a light so brightly on her friend’s message, which is not to say that her support lends the subject any more legitimacy or gravity, but rather anything which starts a conversation is an immeasurably good thing. Postnatal depression is often labelled, dismissively to my mind, as the ‘baby blues’, which makes it sound slightly whimsical, like a fluffy cloud that will soon blow away. It is however so much more complex and profound than a mere mild feeling of depression. Indeed, sometimes at the extreme end it can be life threatening.

The statistics tell us that postpartum psychosis (PP) affects one in 1,000 new mums, although it is more likely to affect women who already have a mental health condition, such as bipolar disorder. Of course this is a vital aspect of perinatal mental illness, so I will spend a moment to outline what it is. However, the majority of this blog will focus on perinatal depression, which although arguably less acute, can be no less devastating in its consequences and has a wider prevalence of between 100-200 in every 1,000 mums. Before that, I think it’s worth mentioning that it is often not apparent what trauma the body and mind endure in the act of carrying and delivering a child. We often see the images of a new mummy intensely holding her newborn, an ecstatic look of joy on her face as relief and chemicals combine in an effort to redact and shape the foregoing narrative, but make no mistake (as all mothers know), the toll taken can be immense.

Postpartum Psychosis most commonly occurs during the weeks before or after a baby is born. The psychotic episodes associated with the condition are characterised by hallucinations, delusions, confused and disturbed thoughts and a lack of insight and self-awareness. Symptoms of PP can also include high mood (mania) which involves talking and thinking too much or too quickly or a low mood which includes depression, lack of energy, loss of appetite and difficulty sleeping. We can see here that the relation between perinatal depression and PP is really one of severity rather than type. Adele’s friend, Laura Dockrill, recalls severe anxiety attacks, frantic mania and a series of erroneous beliefs which ran the gamut from suspecting she was having a heart attack, to a belief that her post pregnancy stitches might suddenly split wide open at any moment, to a debilitating and pervasive thought that her son was in imminent danger of death because she wasn’t feeding him enough. This culminated in an accusation against her boyfriend of kidnapping their son. This last example is extreme, but for many pregnant and post pregnant mothers the paranoia and anxiety stemming from perinatal depression is a constant companion which is terrifying, confusing and isolating. It is in many ways a hidden illness, and those looking in from the outside can’t begin to fathom the turmoil within. It can begin in the third trimester and extend months or even years post birth. For those that find their way out of this quagmire, the six month milestone can feel like the greatest victory. For some the victory never quite comes.

All of this puts me in mind of the new Facebook ads, you know, the one disingenuously apologising for the fact that they have been wilfully harvesting your data before cheerfully restating their supposed mission statement that FB was intended to bring people together and to function as a digital repository of all that is good in the world of man. As my brother sees it, it is the exact opposite of this or as he puts it… ‘a deeply alienating, vacuous, self-hating (why else invent a false self?), self- aggrandising, crap disseminating cancer on the ass of humanity.’ Now perhaps I wouldn’t go that far. I am partial to a bit of social media, but I think there is a valid point here. FB makes everything seem shiny and perfect. Glistening new mothers handling the vagaries and vicissitudes of parenting with consummate ease. To a mother battling perinatal depression , this can only amplify and exacerbate her feelings of shame, fear and inadequacy. Indeed, most mothers, if honest, feel great anxiety, worry and overwhelming feelings at one point or another.

An interesting paper by Valentina Meuti et al and published on the Hindawi.com website relates the increased incidence and severity of perinatal depression and psychosis to dysfunctional or disorganised attachment dynamics. Of specific prevalence among these was the ‘fearful-avoidant attachment’ pattern. As you know by now, I believe that early healthy attachment is the cornerstone of a healthy individual and his or her ability to form healthy relationships and become a healthy parent. So what is the above? Simply put, fearful-avoidant attachment has its genesis in childhood. It occurs when a child instinctively seeks out nurture from a parent in times of distress or need but fails to get the appropriate emotional validation for this state. The specific way this validation is denied need not be anything as extreme as physical or sexual abuse (it can and often is sadly), but rather a lack of appropriate response, unresponsiveness or unattunement to the child. It can me a present absence, one in which the parent is physically present but emotionally distant. The emotional dysregulation that takes place here as a result of these interactions is played out over and over (often unbeknownst to the individual) in subsequent adult relationships. Such a dynamic may of course be broken or mitigated through a later healthy life attachment, one which affords the individual time to work through some of these early dysfunctional interactions. Unfortunately, this often does not happen and can place an enormous strain on a relationship, often scuppering it before it has time to flourish. The ‘come here and go away’ individual is one who craves love but simultaneously rejects it out of fear that they will be forced to revisit the early care giving response that left them so confused, fearful and discombobulated. Interestingly, the study found that the severity of depression increases proportionally to the degree of attachment disorganisation. Therefore, attachment history is both an important risk factor as well as a focus for early psychotherapeutic intervention.

The study by Valentina Meuti et al, suggests that the risks and causes of perinatal depression are multi-factorial, encompassing psychology, biology, environment and social aspects. These can include psychological history and current living circumstances such as financial circumstances, the strength and makeup of the marital relationship, the extent of the support system and so on. The early attachment experience i.e. the responsiveness of early caregivers, however, are a key part of this, as it is these which inform the way we perceive and manage what is happening. They form our internal working templates, our expectation of support and our ability to seek it out. As I mentioned, attachment orientation is not necessarily static. It can change throughout any period in one’s life, but this can be a difficult process. The old internal models are persistent and they continue to influence adult relationships and the attempts to build meaningful connections. This fearful-avoidant attachment pattern leads to expectations that support will not be there or at least that it will be unreliable and that asking for it will not result in its provision. As in all types of mal-attachment there may be high levels of anxiety, avoidance and mistrust of others i.e that they cannot be depended upon. This can result in maladaptive behaviours to keep a relationship going or distancing, a process in which they devalue and distance themselves from a partner in order to avoid interpersonal discomfort. These individuals may seek to excel in an academic or another chosen field, seeking gratification elsewhere, which can leave them vulnerable to achievement related stressors during which they are ill equipped to seek out the needed support.

Becoming a mother is a stressful life event both physically and emotionally. Everything can seem like it is up in the air. The feeling of instability in the third trimester is a very vulnerable time. Everything, from one’s relationship, to one’s mind and body, must be reframed and reorganised to meet the coming change. It is particularly prone to the development of affective disorders of varying intensity. Add to this mix an insecure attachment pattern and the risk increases exponentially.

The results of Valentina Mueti’s research (I’ll eschew the statistical analysis, talk of control groups and outcome integrities and get down to the bullet points) confirms the presence of psychiatric disorders such as a family history of such disorders (especially those circling the anxious-depressive group of disorders) in the medical histories of new-mothers who develop perinatal depression. She concludes that the transgenerational nature of these conditions have their roots in biology and early care-giving experiences. She believes the representation of motherhood modelled during these early experiences are in essence reactivated during the later stages of pregnancy and the early stages following birth as new mothers look to reframe their own internal working models. This can trigger earlier attachment trauma and potentially affect the new infant-mother dynamic. This is not to say that this is a complete or even satisfactory answer to those in the grip of perinatal depression. Far from it. Disorganised early attachment and psychiatric history is merely a potential predictor. We are after all in constant flux, alternatively escaping and succumbing to psychology and biology, but for those mired in it, it can be terrifying. The first step is to talk about it, only then can we propose more effective strategies for identification and early intervention in perinatal depression.

Valentina Meuti et al recognises that we need to see ‘the attachment pattern as an important factor in the development of depressive symptoms during the transition to motherhood. Such observations will allow us to identify potential predictors for the development of psychopathology in the perinatal period and to plan preventive interventions, focusing on attachment and relational patterns during prenatal psychoeducational courses for the “at risk” population. By addressing the mother’s unresolved attachment conflicts with an attachment based psychotherapeutic intervention, it is believed that the development of a more adaptive parenting and a more secure and less disorganised attachment between the mother and her infant is facilitated, as well as a better couple relationship.’

I’m reminded of Brooke Shield’s autobiography ‘Down Came The Rain: My Journey Through Postpartum Depression’. I’m also reminded of a life changing seminar I had the privilege of attending with Janina Fisher, a highly esteemed clinical psychologist, professor and lecturer whom I spent the day with in London. The attendees were allowed to bear witness to an amazing reunion between mother and child. Previously, the mother had nearly died in child birth and the resulting trauma to both mother and baby was profoundly disturbing. Needless to say, an awful lot of interpersonal and environmental history was covered but in a nutshell, Janina was able to facilitate and help a highly distressed mother and her catatonic (emotionally disengaged) baby find each other when the connection had been so severely lost. She worked with them both slowly, patiently, and with great care and understanding to repair the rupture. I can’t help but feel, quite optimistically, that there is great hope here. Talking, exploring and processing all thoughts and feelings with both mother and baby in mind can bring out the sun and dry up all the rain.

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