Postnatal Depression

Fac in g th e Parad o x o f L o ss, H ap p in essan d M o th erh o o d

Dr Paula NicolsonU n iversi ty o f Sh ef fi eld

J O H N W IL EY & SO N S, L TD

C h ich ester • N ew Yo rk • W ein h eim • B risb an e • Sin g ap o re • To ro n to

Innodata0470849371.jpg

Po stn atal D ep ressio n

Because your family matters . . .

F amily matters is a brand new series from Wiley high-lighting topics that are important to the everyday livesof family members. Each book tackles a common prob-lem or difficult situation, such as teenage troubles, newbabies or problems in relationships, and provides easilyunderstood advice from authoritative professionals. T heF amily Matters series is designed to provide expert adviceto ordinary people struggling with everyday problems andbridges the gap between the professional and client. Eachbook also offers invaluable help to practitioners as exten-sions to the advice they can give in sessions, and helpstrainees to understand the issues clients face.

T itles in the series:

Paula Nicolson Postnatal Depression: F acing the Paradox of L oss,Happiness and Motherhood

John Coleman S ex and Y our T eenager: A Parent’s GuideDavid Cohen T he F ather’s B ook: B eing a Good Dad in

the 21st Century

Bob O’Connor L iving Happily Ever After: Putting Reality intoY our Romance

Postnatal Depression

Fac in g th e Parad o x o f L o ss, H ap p in essan d M o th erh o o d

Dr Paula NicolsonU n iversi ty o f Sh ef fi eld

J O H N W IL EY & SO N S, L TD

C h ich ester • N ew Yo rk • W ein h eim • B risb an e • Sin g ap o re • To ro n to

Copyright © 2001 by J ohn W iley & S ons L td,Baffins L ane, Chichester,West Sussex PO19 1UD, England

National 01243 779777I nternational (+44) 1243 779777e-mail (for orders and customer service enquiries):cs-books@ wiley.co.ukVisit our Home Page on http://www.wiley.co.uk

or http://www.wiley.com

All Rights Reserved. No part of this publication may be reproduced, stored ina retrieval system, or transmitted, in any form or by any means, electronic,mechanical, photocopying, recording, scanning or otherwise, except under theterms of the Copyright, Designs and Patents Act 1988 or under the terms of alicence issued by the Copyright L icensing Agency L td, 90 T ottenham CourtRoad, L ondon W1P 0L P, UK , without the permission in writing of the Publisher.

Other Wiley Editorial Offices

John Wiley & Sons, Inc., 605 T hird Avenue,New York, NY 10158-0012, USA

WIL EY-VCH GmbH, Pappelallee 3,D-69469 Weinheim, Germany

John Wiley & Sons Australia, L td, 33 Park Road, Milton,Queensland 4064, Australia

John Wiley & Sons (Asia) Pte L td, 2 Clementi L oop # 02-01,J in X ing Distripark, Singapore 129809

John Wiley & Sons (Canada) L td, 22 Worcester Road,Rexdale, Ontario M9W 1L 1, Canada

British Library Catalogu ing in Pu blication DataA catalogue record for this book is available from the British L ibrary

ISBN 0-471-48527-6

Project management by Originator, Gt Yarmouth, Norfolk (typeset in 11.5/13 Imprint)Printed and bound in Great Britain by Biddles L td, Guildford and K ing’s L ynnT his book is printed on acid-free paper responsibly manufactured from sustainableforestry, in which at least two trees are planted for each one used for paper production.

http://www.wiley.co.ukhttp://www.wiley.com

Contents

About the author ix

F oreword xi

Acknowledgements xvi

Introduc tion 1Who should read this book and why 1

1 Being depressed 11What is depression? – official and unofficial

definitions 11What it feels like to be depressed 15Who gets it and what causes it? 16Explaining depression 19

2 What is postnatal depression?Disc overing the paradox 25Different theories and different kinds of

depression 25

T he baby blues 29Postnatal distress and depressed moods 32Postnatal depression 36

3 What c auses postnatal depression?Why m e? Why now? 41Different approaches to understanding

women’s postnatal experiences 41T rauma following birth 42F actors influencing PT SD 49Worrying about the baby’s health and welfare 51Getting the best support over the postnatal

period 53Coping with depressed moods 55F inding social support 57Not all company is supportive 58Getting support to prevent PND 60What has happened to me? 62Motherhood and the arrival of self-confidence 73

4 Happiness and loss: the paradox ofpostnatal depression 75Introduction 75T he experience of loss 77T he healthy grief reaction 79L osing sleep 82L osing time 83Bodies 85Breastfeeding 87F eeling too fat 90L osing your looks 92L osing your ‘mind’ 92L osing my self 97

v i C o n ten ts

Being clear about who you really are 100F inding yourself as a mother 105

5 Being a ‘good’ m other:the paradox of sac rific e 107Introduction 107What is the truth about the maternal instinct? 110Is maternal instinct a biological drive? 111Is there a paternal instinct? 115Is biology destiny? 115Were you born knowing how to bath a baby? 117T he father’s role 118Is a good woman the same as a good mother? 120But, what does make a good mother? 123Negotiating the boundaries between self

and other 127Voices of the experts 132

6 Postnatal depression by proxy 137Introduction 137T he paradoxical burden 140Women’s rage: gender relations or PND

by proxy? 143What do women expect? 150Penelope’s story 151Wendy’s story 156Isobel’s story 160Understanding PND by proxy 164

7 Challenging the paradox and getting onwith your life 165Introduction 165T aking control: when and how? 166

C o n ten ts v i i

Social support 169Emotions fitness 170F inding the help you need 173Cognitive–analytic therapy (CAT ) 174Cognitive–behavioural therapy (CBT ) 175Physical fitness 176Where to go from here? 178Conclusions 179

Portraits of the women 183

Useful books, addresses and websites 213

Notes and references 215

Index 221

v i i i C o n ten ts

About the author

Dr Paula Nicolson is a psychologist who has beenresearching in the area of women’s reproductive healthand postnatal depression for over 20 years. She is cur-rently Reader in Health Psychology at the University ofSheffield School for Health and Related Research. She issoon to become a grandmother.

In memory of Barbara Gullick

Foreword

My GP friend was expecting her first baby. She and Iwere part of a small group who were setting up acompany. My friend said, ‘When I finish work beforethe baby’s born I ’ll take over the company’s correspond-ence. I ’m busy now but once the baby’s born I ’ll haveplenty of time.’

I said, ‘No you won’t. You won’t have any time andyour brain will have turned to mush.’

She ignored me. T ime passed, her daughter was born,and the usual sleep and feeding problems followed. Myfriend was besotted with her baby. One day, when wewere trying to discuss some business matters, she said tome, ‘My brain has turned to mush.’

My friend has always been a competent, self-confidentthough modest person. On the scale of difficult babieshers is at the easy end. My friend has a very supportivehusband, parents and parents-in-law. Yet, even she hasfound it impossible to maintain her usual level of self-confident, clear thinking. How much more difficult itmust be for women who come to childbirth with serious

doubts about their worth and competence, and who arenot well supported by family and friends.

When we feel self-confident and competent, we areaware that there are a number of matters competing forour attention. We can put these matters in order ofpriority and focus appropriately on each as the needarises. T hus, we can deal with ‘What shall I weartoday?’ quickly and move on to planning our day’swork. When, in motherhood, our brain turns to mush,many matters which might need our attention disappearfrom the world we are inhabiting, and our focus isabsorbed completely by a scrap of humanity who is nowour one huge responsibility.

Moreover, when we feel self-confident and competentwe can keep from our consciousness all those troublingthoughts, emotions and memories which, if we dwell onthem, will undermine our self-confidence and sense ofself-worth. But, once our brain turns to mush, thesetroubling thoughts, emotions and memories can breakinto our consciousness and attach themselves to ourconcerns about our baby and our ability as a mother. I fyou’ve been lucky enough to have had truly loving andsupportive parents, if as a baby and child you had mostlygood experiences of mothering (no mother is perfect: ifshe were her baby would have no reason ever to learn tolook after himself) and if you’re surrounded by peoplewho constantly show you that you are loved and valued,troubling memories and feelings are not likely to be anymore than a momentary problem. But, parents who didnot love you, or if you’ve grown up telling yourself thatyour parents did love you while secretly fearing that theydid not, if your own experiences of being bothered werenot pleasant, if in childhood adults treated you badly andif now you are surrounded by selfish people concernedonly with their own welfare, then, when your brainturns to mush, you can find it extremely difficult to keep

x i i Fo rew o rd

at bay that host of horrible memories with their train ofmiserable, self-condemning thoughts and feelings.

I t is self-condemnation which turns misery andsadness into the prison of depression. I f you havelearned, as many woman have, how to be an expert infeeling guilty and blaming yourself for whatever disastermight occur, you can, at any time in your life, turn thesadness which naturally follows loss and disaster intodepression. F or all women, motherhood involves theloss of freedom, the loss of irresponsible youth and theloss of the belief that you are always in control of your lifeand your body. F or each individual woman, other lossescan occur, while any woman who demands perfection ineverything she sets out to achieve will find being theperfect mother a goal utterly beyond her reach.

F or the expert in feeling guilty, self-blame comes intooperation far more quickly than conscious thought canever operate, and so depression can seem to appear outof the blue without any apparent reason. However, if weunderstand ourselves, if we recognise our well-practisedskill in blaming and condemning ourselves, if we areaware how certain trains of thought, particularly aboutcertain past events, can lead us into misery, then we canlisten to the way we talk to ourselves and learn how tocontrol and change our pernicious self-talk. Never againwill we tell ourselves that we are useless, wicked andworthless. I f, at the same time, we recognise how ournearest and dearest can hurt and belittle us, we can learnnot to accept their bad feelings as our just punishment.T hen we can devise strategies to protect ourselves againstthat hurt. T here is no law that says you have to telephoneyour mother every day or that you must not confront yourpartner with his selfishness.

T hese are matters which are best dealt with beforeyour baby is born. One of the many myths aboutpostnatal depression used to be that pregnant women

Fo rew o rd x i i i

should not be told about the existence of PND, becausethen they would worry about it. T his myth prevailedwhen the medical profession believed that PND couldbe explained solely in terms of changes in hormonelevels. (T here is no difficulty or disaster in a woman’slife which a male doctor cannot blame on the state of thewoman’s hormones.) Now it is recognised that hormonalchanges alone cannot explain why one woman becomesdepressed after childbirth and another does not. What isnow recognised as being extremely important is how thewoman sees herself and what kind of support she getsfrom professional staff, family and friends. A womancannot do anything about her hormonal changes,butthere is much she can do in checking and perhapschanging how she sees herself and what kind of supportshe is being given.

What has been greatly needed by pregnant women, bythe professionals who look after them and by the woman’shusband or partner and her family and friends is a bookwritten simply and clearly setting out what needs to bedone if the woman is to meet the huge challenges ofmotherhood without her blaming herself for her failuresand thus falling into depression. T his is such a book.Paula Nicolson has combined a highly readable accountof the concepts and research now forming the leading edgeof the study of PND with reports of her sensitive andrevealing interviews with women trying, and sometimesfailing, to cope with the impact of motherhood on theirlives. Other people’s stories tell us much more than anyrecounting of facts, however skilfully that might be done.Out of these accounts and out of the practical advicewhich is found throughout the book, and added to at theend, every woman can give herself an excellent chance ofexperiencing fully the joys of motherhood.

T his book should be read by every person, of whateverprofession, who is involved in the care of mothers and

x iv Fo rew o rd

babies, by men who can be shocked by the discovery thatbecoming a father involves more than one small sexual act,by older women who had their babies at a time when newmothers were not listened to but merely told what to do,and by every woman who wants to understand the mar-vellous and extraordinary process of becoming and beinga mother.

Dorothy Rowe

Fo rew o rd xv

Acknow ledgements

I want to thank all the women who took part in the studyand told me their own stories of pregnancy, childbirth andpostnatal depression. I am also grateful to Dr VivienWard, who gave me the opportunity to write this book,to Sheila K itzinger for her supportive and constructivecomments and to my family and friends who ensured Ihad the time and support to finish it.

Introduct ion

W h o sh o u ld read th is b o o k an d w h y

T his book is about women’s experience of the first yearafter childbirth and the feelings and changes in emotionand relationships that motherhood provokes. Researchershave shown that between one and two out of every tenwomen becomes seriously depressed during this periodof their lives. T his is only a small part of the picture. Asmany as 90% of new mothers experience some degree ofweepiness and anxiety, especially during the first fewdays after delivery and most women become depressed,disheartened or feel lowfor short but significant periods oftime at least once during that first year of motherhood.T his is not only true of first-time mothers. Depressioncan occur every time someone has a baby or after somepregnancies and not others. Some women, for examplethose who are socially isolated, have very low incomesand poor housing, or who have a history of emotional

illness, are more at risk than others. Even so – depressionafter childbirth can affect anyone.

Depression during that first postnatal year is usuallyreferred to as postnatal or postpartum depression. T his isnot the same as the psychiatric condition postpartum orpuerperal psychosis that affects a small minority ofwomen who literally ‘lose their minds’. T he mass mediahave made much of this illness and referred to it as PND.I have no desire to deny the extent and intensity of thedistress that this state causes to all concerned. But it onlyhappens to 1 or 2 women in every 1,000. Experts continueto debate whether puerperal psychosis is a separate mentalillness or just the extreme end of PND. T hey still do notknow for certain.

Health-care experts generally define PND as a depres-sion that occurs during the first 12 months followingchildbirth. Some say that it is ‘atypical’ – that is, that itis dissimilar from any other kind of depression that theindividual woman would have experienced before. Otherexperts disagree. T hey see PND as distinct from othertypes of depression only in so far as it is associated withthe aftermath of childbirth and the life events and changesbrought about through motherhood. Recently, psycho-logists have argued that many women experience depres-sion in the last stages of pregnancy and what is identifiedas PND might actually be pre-natal depression caused bybodily changes and psychological reactions to beingpregnant. T heories about the causes of PND vary, fromthose who argue that PND is an illness caused byhormonal disruptions which take place during childbirthand early lactation to those who suggest that it is the socialconditions of motherhood itself that are depressing towomen. T he majority believe that, probably, PND hasseveral causes and that the life history and social circum-stances of each woman give clues as to the origins of theirdistress.

2 In t ro d u c t io n

What most women want to know is ‘will it affect me?’and if it does ‘what should I do?’ I t is these issues that arehighlighted in this book. I t answers some importantgeneral questions. Why are some women depressed inearly motherhood and others not? What causes PND? Isit easily diagnosed or cured? Is it the result of hormonal orother biological problems? Is it ‘madness’ or is it simplythe result of women ‘wanting it all’? Are there any otherexplanations as to why as many as nine out of ten newmothers find themselves in tears and feel ‘down’ shortlyafter they have their babies, and at least one out of ten findthemselves seriously depressed at some time during thefirst year of motherhood?

More particularly, the book takes a first-hand look atmothers’ experiences of stress, anxiety and depression andanswers their questions ‘Why me?’, ‘Why do I feel thisway?’, ‘How can I feel better?’

T he book is based upon the stories of 24 women whotalked to me while they were pregnant and several timesduring the first year after the birth of their babies. T heycame from all walks of life. T hey all lived in and aroundL ondon in the UK , although some lived in the inner cityand others in suburbs. Some of the women had full-timecareers, some gave up work to become full time mothers.Several worked part-time to fit in with childcare arrange-ments. All had a relationship with the father of their baby,but not all were married to him or stayed married over thecourse of our meetings. Not everyone I talked to could bedescribed as having PND. However, everyone had hadsome periods of feeling down, irritable, confused andanxious and some were very distressed at times. T heirfeelings and emotional reactions to their situations werefor different reasons in every case and their expressions ofdistress took more than one form. What they had incommon was that they were trying to negotiate theirlives as mothers. T hey talked to me about the difficulties

W h o sh o u ld read th is b o o k an d w h y 3

they faced with their self-esteem, relationships, self-confidence, work, practical aspects of their lives and thechanges that becoming a mother can bring to all of theseparts of our lives.

I t is not only first-time mothers who face these kindsof problem. Some women manage their way through thetiredness, physical strain and change of lifestyle with onlypassing irritability and the occasional uncharitablethought. However, a woman who had sailed through aprevious experience of new motherhood, might findherself seriously depressed after the birth of a subsequentchild. And vice versa. I t is the apparent lack of logicsurrounding PND that taxes the mind of health pro-fessionals and researchers as well as those who aresuffering.

Here I show how women can understand more fullythe realities of motherhood from the psychological to thebiological. What can women expect from their bodies,health-care services, their friends, partners and otherfamily members?

Most importantly though, from my perspective as apsychologist, I illustrate the many available ways ofgaining a clearer sense of self-knowledge to help copewith depression after childbirth, and how this links intoother aspects of emotional life. Understanding PND andlearning about feelings which emerge at this stage can alsoenable insight and a broader self-awareness. F or example,one of the most difficult things for many women is recog-nising what they themselves want. New motherhood is atime when we learn how to care for another – someonewho could not survive alone. T his is a great responsibility.Sometimes, this is combined with increased domesticduties, which involve, again, doing things for others.L osing sight of your own needs is easy. Developing yoursense of self-worth and making (reasonable) demands thatreflect your needs is difficult.

4 In t ro d u c t io n

A great deal has been written and talked about PNDover the past 10 years; much of which has indicated that,somehow, depressed women are suffering from ‘ragingfemale hormones’ or are mentally unfit. T hey chosemotherhood and then cannot cope. T hey becamemothers and then complained. I f they remain depressed,their children may suffer intellectually and emotionallythrough lack of attention and stimulation. T heir relation-ships suffer because it is very difficult to live with or havea close friendship with a depressed person, particularly ifthey appear to have everything they want and are stillunhappy. Sympathy for a bereaved, divorced, sickperson or accident victim is typically far greater than forsomeone with PND. But having PND is particularlydistressing if combined with fear, guilt and self-blame.‘I wanted this baby and I should be able to cope.’

Having a baby and being a ‘good’ mother is taken forgranted by most people as being the central part of being awoman. Despite the range of lifestyle choices available tocontemporary women, many become parents. T his is notnecessarily because women all want babies withoutquestion. I t is quite normal to be fearful about risksof infertility, pregnancy, giving birth and taking care ofbabies and children. We also know more now than inprevious generations about the potential instability ofmarriage, difficulties surrounding child-rearing frominfancy to adolescence and the opportunities for thosewomen who remain childless. Motherhood is a seriouschallenge, but one which the majority of women stillembrace.

Many women today, though, experience motherhoodoutside the traditional marriage, sometimes but notalways as a matter of choice. I t is generally acceptable tobe a single mother, mother within a lesbian relation-ship, cohabit with the baby’s father or live in a‘re-constituted’ family with a partner who is not the

W h o sh o u ld read th is b o o k an d w h y 5

father of your children. Contemporary women also expectto play some part in life outside the home in paid employ-ment. Again, patterns vary and some women only workonce the children are in school, while others maintaincareers following only brief maternity leave. F ewerwomen, though, than ever before remain in the traditionalhousewife/mother role.

What happens to you when faced with motherhood forthe first time? F ew women experience the kind of concep-tion, pregnancy and birth they expected. F ew ‘bond’immediately with their baby, and that can be amajor setback. Individual physiological, psychological,emotional, economic and social circumstances vary enor-mously, and all of these things influence the way womenmother children. Health professionals frequently advisewould-be mothers that they are unlikely to conceive thefirst few occasions they try. However, many women do so.Many women never conceive, or take years before theybecome pregnant. Some conceive with ease the first timeand never manage it again. T here is no consistent route tomotherhood.

Similarly, there is no uniformity about postnatalexperience. After labour, many find it difficult to careabout the infant that has been the cause of this pain andexhaustion. Of the women I talked to, most wanted toavoid that immediate post-birth time alone with thebaby – they wanted to scream out ‘take it away, please!’Others felt tears of joy and tenderness towards the infant.F eelings about the very new baby ranged from intensehatred, through ambivalence, awe and anxiety about itswell-being. In the majority of cases, warmth and affectionemerged before too long. T hese first encounters, though,may have far-reaching consequences. Samantha told mehow distressed she had been for several weeks after adifficult delivery. F orceps were used to ease the babyinto the world. But when she found herself faced with

6 In t ro d u c t io n

this ‘distorted’, ugly red thing that was supposed to be herbaby, she ‘freaked’. T he guilt of those early feelingstowards her baby remained with her for several months.

Many new mothers are confronted by a further andmore enduring paradox: the new baby is exciting andmuch wanted. But daily life can be devastating. I t mightfeel to the mother that she has lost everything she oncehad and expected for the future. But there is no goingback. You cannot return the baby. Motherhood, with itsdilemmas and stresses, is not any indication of feeling forthe baby. I t is common to love the baby, but hate thethings you have to do for it and the domestic ‘captivity’that motherhood frequently imposes.

Postnatal depression, which is the label given to thesefeelings, comes in several forms and hits you hard. I tcomes when you least expect it and are least equipped tocope. You have had a baby, you are tired, anxious aboutyour new skills and worried about the time you no longerhave for your partner, your friends or yourself. Manywomen feel this way, as shown through the stories ofthose I interviewed.

F elicity was preparing for Christmas four weeksbefore her first baby’s expected arrival. All of a sudden,as she was making the beds, she went into labour andwithin two hours ‘I was lying there with this strangerbetween my legs – I had no idea what to do’. Her mindwas still focused on preparations for her parents’Christmas visit to launch her maternity leave from workas a government scientist. ‘Everything was upside down –I panicked. I had no idea how to cope.’ She thought shewould never get her life back to normal again.

Wendy’s baby was born on time and according to plan.She and her partner were delighted. However, neither hadimagined how much new parenthood would interfere withthe renovation of their large Victorian house. T hey hadboth seen Wendy’s maternity leave as a chance for rapid

W h o sh o u ld read th is b o o k an d w h y 7