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Post Natal Depression in Mothers & Fathers

In this blog, I want to write about post-natal depression, revisiting and summarising a classic paper by Lawrence Blum, an American Psychiatrist and Psychotherapist. The paper was written originally in relation to post natal depression in mothers, however, because it essentially explores the conflicts aroused in becoming a parent and caregiver, particularly in relation to our own experiences of caregiving.  I think it applies also to fathers and to same sex couples and heterosexual couples where the caring of the infant is more equally shared.

Blum’s paper, titled the, “Psychodynamics of Postpartum depression”, is available on the web.

The paper draws a distinction between baby blues which he defines as the hormonal induced depression resulting from pregnancy and childbirth, and post-natal depression, which has typical features of depression, – ‘sadness, crying, insomnia, or excessive sleep, low mood, low energy, loss of appetite, agitation and self-critical thinking.’ 

He describes the external factors that can contribute, such as prior anxieties and depressions, low external support, difficult relationships, difficulty conceiving, stressful life events, etc. He summarises the studies at the time into the results of different therapies and concludes that supportive counselling, CBT and Psychodynamic Psychotherapy were all superior to the control and that the Psychodynamic therapy had the biggest impact on depression, as defined by the DSM 111. 

The focus is then on the possible  ‘psychodynamics’ of the depression and these are what I shall briefly outline here as these are what can really be usefully explored and alleviated by Psychotherapy. Three principle emotional conflicts are outlined; Dependency conflicts, Anger conflicts and Parent conflicts. 

Dependency Conflicts

In order to care for a baby, there is a need to be utterly depended upon, this is tiring and emotional and benefits from support. If there is a conflict about receiving support, a self-denial of the caregivers own needs, they can seek to repress their own essential vulnerability and needs and get  depressed.

Often people manage this part by becoming carers and end up in caring roles, such as therapists (a good a reason as any why therapists need their own therapy!) This counter-dependent strategy can work until it doesn’t. Someone who seems to be managing everything well, suddenly finds the balance has tipped too far. A baby can stir up the caregivers previously unconscious or sleeping wishes to be cared for, hidden by a display of  independence.

Anger Conflicts

A conflict with feelings of anger, which can feel counter to the role of caregiver. Parents can feel they don’t have a right to be angry, feel guilty about it or frightened of it, yet may have experiences and histories, which have left them feeling angry. Anger can be felt towards the baby, either as a projection of past hurts, or for the very real things it has done to the parents lives; tuned them upside down, deprived them of sleep, money, jobs, sex, etc, while carrying on with its incessant demands obliviously. The danger apart from depression in all of this, is that these feelings are denied and controlled and ‘loss of control can follow from over control as internal pressure builds up”, and has to be released, either threatening the relationship with the baby or more commonly being displaced onto partners.

Feeling the anger, tolerating it, and judiciously putting it into words, easy for the clinician to say, is the difficult and essential task for the person who is looking after the baby.

Parenthood conflicts

Caring for baby can stir up unresolved and unprocessed feelings about the caregivers own experiences of being cared for, whether a mum or a dad by a mum or a dad. Although a negative experience of being cared for can positively inform the ways in which the caregiver feels they don’t want to be, it doesn’t necessarily translate into clear ideas of how or what to be. In addition the caregiver, giving the baby what it didn’t receive, can be gratifying but  can also stir up the wounds of what they, the caregiver, didn’t receive. 

I would like to finish with Donald Winnicott,’s, (a British paediatrician and Psychotherapist), funny but true reasons why a mother, (or father or caregiver), hates their baby, with the intention in which they were written, to provide relief from the day to day conflicts, that can be felt in the rewarding, important but by no means easy job of nurturing an infant:-

  1. The baby is not her own (mental) conception. 
  2. The baby is not the one of childhood play, father’s child, brother’s child, etc. 
  3. The baby is not magically produced. 
  4. The baby is a danger to her body in pregnancy and at birth. 
  5. The baby is an interference with her private life, a challenge to preoccupation. 
  6. To a greater or lesser extent a mother feels that her own mother demands a baby, so that her baby is produced to placate her mother. 
  7. The baby hurts her nipples even by suckling, which is at first a chewing activity. 
  8. He is ruthless, treats her as scum, an unpaid servant, a slave. 
  9. She has to love him, excretions and all, at any rate at the beginning, till he has doubts about himself. 
  10. He tries to hurt her, periodically bites her, all in love. 
  11. He shows disillusionment about her. 
  12. His excited love is cupboard love, so that having got what he wants he throws her away like orange peel. 
  13. The baby at first must dominate, he must be protected from coincidences, life must unfold at the baby’s rate and all this needs his mother’s continuous and detailed study. For instance, she must not be anxious when holding him, etc. 
  14. At first he does not know at all what she does or what she sacrifices for him. Especially he cannot allow for her hate. 
  15. He is suspicious, refuses her good food, and makes her doubt herself, but eats well with his aunt.
  16. After an awful morning with him she goes out, and he smiles at a stranger, who says: ‘Isn’t he sweet!’ 
  17. If she fails him at the start she knows he will pay her out for ever.
  18. He excites her but frustrates—she mustn’t eat him or trade in sex with him. 

Winnicott, D.W. (1949). Hate in the Counter-Transference. Int. J. Psycho-Anal., 30:69-74. 

 

Paul Salvage is Psychodynamic Psychotherapist trained to work with adolescents from 16-25 and adults across a wide range of specialisms including depression, anxiety, family issues, self awareness and relationship difficulties. He currently works with individuals in our private practice in Hove.

 

Further reading by Paul Salvage –

The Therapeutic Relationship and the Unconsious

A Nation Divided

Adolescence: the trials and tribulations

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Is Love a Tameable Force?

Death like birth is a one off life event. We cannot learn through our experience of either to “get it right” next time. Love on the other hand (or the act of ‘falling in love’) is an event amenable to repetition. As such it is also available for re-definition by the forces of culture – political, philosophical and economic.

We no longer imagine or indeed contract for that (romantic) notion of love “till death do us part.” A vision in part predicated on (now outdated) kin-ship structures. These days it seems we care less to tie ourselves into lifetime contracts, or at least not without the freedom to change provider.

Love in a consumer age

One factor involved in the consideration of any investment is the risk attached. The ‘hookup’ model of relationship is a way of keeping (emotional) risk to a minimum. Its strategic focus is on convenience and short term satisfaction. It requires a particular vigilance to any (unruly) emotional undercurrents, with cost/benefit analysis consistently calculated and reviewed. When the initial (emotional ) investment is small there is protection against future insecurity in what can be a highly volatile market.

In his book, ‘The Art of Loving’, Erich Fromm describes how satisfaction in love cannot be attained “…without true humility, courage, faith and discipline” a vision at odds with the consumer age. Now the structures and forces of the market place promise something different. We can barely move for ‘expert’ relationship advice and books, articles and podcasts abound to coach us in the practice of relationship consciousness. In the online marketplace, the otherwise busy consumer may choose from an extensive menu of mouthwatering relational options. Available with an ease of access (and exit) and an abundance of choice, previously unknown. The new ideal of instant satisfaction takes the wait out of wanting with all risk insurance and money back guarantees there to catch us if we fall.

Love and uncertainty (uncomfortable bedfellows)

Love though is an unruly force and resists attempts at mastery or design. Love finds its own meaning in a continual state of becoming. Its creative forces are fraught with risk and like any creative force, we may never be sure where it will end. When we ‘fall’ in love, we enter into a great unknown, we  feel untethered from our usual moorings and suddenly vulnerable in the force field of another’s freedom. Indeed, love navigates a fine line between security and freedom and is threatened by both. ‘Too much security’ may feel like fusion or possession, stifling the creative urge. ‘Too much freedom’ (and a deficit of security) may lead to an overwhelming and agoraphobic sense of uncertainty.

There is then an inescapable duality in love and any attempt to surmount it ends only in its destruction. This paradox lies at the heart of loving. Eros forever haunted by Thanatos like an iron hand clad in a velvet glove.

Love seduces and emboldens us (at least in its opening gambit) to dive into the uncharted waters of ‘otherness’ and engage with the unknown. Love as an antidote to death soothes the ever present human dilemma of separateness. The blessing and the curse of individuality makes a mockery of us and all lovers seek to foreclose the space that separates them from their beloved. It is though in this very act that the death knell to love is sounded. Whatever else love might be a commitment to it inevitably involves the certainty of uncertainty.

To love is to risk and there is no algorithm to square that particular existential circle. The last word on love may perhaps always be best left to the poets.

Source – Erich Fromm, The Art of Loving(1957; Thomson’s, 1995)

 

Gerry Gilmartin is an accredited, registered and experienced psychotherapeutic counsellor. She currently works with individuals (young people/adults) and couples in private practice. Gerry is available at our Brighton and Hove Practice.

 

Further reading by Gerry Gilmartin –

Why does empathy matter?

What is Intimacy?

Love, commitment and desire in the age of choice

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Attachment Styles and How They Affect Relationships

The way we relate to others, including our partners is complex and multi-layered.  It is developed over time and although we can to an extent control what we say and do within our relationships it is more difficult to understand why we behave and feel the way we do in relation to others. 

One way of describing how we function within relationships, is to talk about our style of ‘attachment’. How we attach to others affects everything from the partners we choose, to how well our relationships progress and how they end.  Once we recognise our attachment patterns we begin to understand our strengths and vulnerabilities within our relationships including those with friends and family. 

Attachment patterns are established in early childhood. The developing infant builds up a set of ‘models’ of themselves and others based on repeated patterns of interpersonal experiences with their caregiver (usually the mother and/or father).  These repeated patterns continue to function as ‘internal working models’ for relationships in adulthood. The problem is that much of this is happening at an unconscious level and as such we remain unaware of these models leaving us likely to repeat unhelpful patterns which may, in turn leave us feeling frustrated and hurt.

According to Attachment Theory there are four attachment styles. 

Secure attachment:

Securely attached people tend to have satisfying relationships. Broadly speaking their internal working model gives them a core sense of being safe and secure within themselves.  These people feel more or less good about themselves and their capacity to be effective and create positive relationships. This can also be described as having good self-esteem. This allows them to believe that if they experience a rupture or a falling out with a friend or partner it’s OK. The relationship can be repaired and things will get back on track between them.

Anxious-Preoccupied attachment

These people are often described as being clingy and needy.  Their internal working model does not provide them with a core sense of safety and security.  They look to others to provide this for them. Therefore when they experience a rupture or falling out they feel insecure and unsafe and in their attempt to feel secure and safe again they become demanding and possessive of their friends and partners because they cannot provide themselves with these feelings. Unfortunately this behaviour tends to push people away confirming their worse fear and so the cycle is complete. 

Dismissive-Avoidant attachment

People with this style of attachment tend to distance themselves from others emotionally.  Like people with an insecure-ambivalent attachment style their internal working model does not provide them with a sense of safety and security but they protect themselves from this by becoming ‘pseudo-independent’ and telling themselves that they do not need people.  They have the ability to shut down emotionally and turn off their feelings even in heated arguments with friends or partners. Their relationships often end because their friends and partners experience them as detached and unemotional.

Fearful-Avoidant attachment

A person with this style of attachment fears being both too close or too distant from other people and moves between these two states.  They often feel overwhelmed by their feelings over which they feel they have little control. Their internal working model is that in order to achieve any sense of safety and security they need to move towards people but that if they let people get too close they will get hurt.  This leaves them in a state of confusion as to how to get their needs met although this may not be entirely conscious. What they are conscious of are feelings of being trapped when they get close to people and clinging to people who reject them. Their relationships can end up being abusive.

How psychotherapy can help

By becoming aware of your attachment style, over time you can challenge the insecurities and fears that have formed your ‘internal working model’ and develop new styles of attachment for sustaining more secure and satisfying relationships with others.  This sounds easy but in reality it is more complex. Exploring and understanding your internal working model and resultant core state can be challenging as defensive strategies which have come into play to protect you from psychological pain are hard to change and can leave you feeling vulnerable.

However change is possible within a relationship of trust with a skilled and experienced therapist.  On a very basic level the relationship with the therapist provides a space where repeated patterns of interpersonal experience occur and can be thought about.  The therapist will be able to stand back and reflect what is happening between you with the intention of helping you identify the patterns which so far have remained unconscious and out of your awareness.  In this way over time you are able to choose to do things differently – bit by bit.

 

Anna Reynolds is a UKCP registered Psychoanalytic Psychotherapist qualified to work with a broad range of psychological issues as well as more complex mental health conditions in adults.  Anna works with individuals and couples.  Anna is available at our Lewes Practice.

 

Further reading by Anna Reynolds –

The language of love: how couples communicate

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Family Therapy for Beginners

Professor Richard Layard, one time ‘Happiness Tsar’, wrote, ‘in every study, family relationships, (and our close private life) are more important than any other single factor in affecting our happiness’.

It’s hard to grow and feel safe and content in the world if our family stories are causing us distress and discomfort. This is especially true for children, and young people when their family is their world. When they are struggling with emotional and behavioural problems or maybe unexplained physical ailments a ‘systemic’ approach can be revealing.

Systemic therapy is relational, that means looking at the spaces in between people and their relationships with others, as opposed to looking inside individuals. Systemic therapists are interested in the ‘systems’ that people belong to, such as our families, school, work places, peers and friendships. Exploring the context of tension, distress and unhappiness can help us illuminate the possible causes.

For example we may find stories of divorce and separation, estrangement, sibling rivalry, family illness and disability, bullying, academic struggles, financial problems, loss and bereavement, or drug and alcohol use Family therapy is about having conversations that can be difficult, exposing, controversial, and upsetting.

But also about reconnecting, understanding, sharing and being surprised. Feeling heard, understood, loved and believed. Explaining your side of a story, hearing family stories that help you understand current struggles and appreciating other people’s point of view. Feeling proud and united, relieved and supported and wondering together how you can move on.

Any therapy involves taking a risk; family therapy provides an invitation to be brave and accept that families may be worried, sad or confused about someone they love. Or maybe family relationships are feeling tense and strained, or they are missing someone who played an important role in your lives.

Established, repaired and revisited relationships give families a rich resource for healing.  Family Therapy sessions usually last 90 minutes, and as many family members who are available are welcome.  Work would begin by exploring why it had been decided now was the time for family talking and noting individual and family goals to help focus the work. Some family members may be initially reluctant to attend, its important for them to be aware that just be attending they are showing their support. They do not have to contribute verbally if they do not want to – this could be agreed at the beginning of the session. By just turning up they are able to listen to other expressing their views and will usually join in when they feel comfortable and safe within the process.

A genogram or family tree is usually constructed looking at the current family structure and remembering older generations. This provides a map of the family and a cultural context for the current problems. It generates stories, sometimes forgotten, about how positive and negative patterns and traits may have been inherited by the family in the room. This can be a revealing and emotional, with younger people hearing about relations that may have died before they were born and older ones remembering stories that help build to a clearer understanding of the family’s identity. A time-line constructing a chronology of family births and deaths and other family events is also useful. Again, this begins reveals its own narrative, which can help a family begin to plot the life story of a problem.

Family Therapy is always driven by the goals of the family and continual feedback allows the therapist to ensure that the family are having the conversations they want and need to have. Sometimes it may feel useful for family members to meet individually, in couples or sibling groups as part of the therapy.

It is not necessary to meet weekly; sometimes families find one or two sessions are enough to feel they are able to move forward. In my experience family therapy can be a powerful process with the family leaving more connected with and appreciative of each other.

Sharon Spindler is an experienced Systemic Family Therapist with twelve years experience within the NHS and private practice.  Sharon is available at the Brighton & Hove Practice.

 

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Emotionally Focused Therapy: For Couples in Distress

Emotionally Focused Therapy (EFT) is a short-term evidence-backed therapy with a high success rate in supporting clients to move through difficulties in their relationship. This includes one or both partners who have experienced early trauma. It is shown to to be an extremely effective way of helping distressed couples strengthen their attachment bond, particularly where one or both partners have experienced early trauma.

As a couple in distress you might feel you’ve reached the end of the line, or you are struggling to get past your partner’s infidelity. Perhaps you can’t seem to get your point across without a descent into conflict.  When this becomes a habitual pattern it becomes destructive, affecting how safe you feel which can erode intimacy, desire and emotional connection.

Emotional, or attachment bonds in our relationships are physiological and therefore potent.  Neuroscience is uncovering how important these attachment bonds are to our sense of safety: distance and separation is perceived as threatening and we go into fight-or-flight mode to get what we need.  This emulates our early life experience when we relied on caregivers to survive.  It might not feel like it but arguments are often a way to draw our partner closer when we feel they are not attuned to us.

Modern couples are subject to different stressors than previous generations. Socio-cultural shifts means we have higher expectations that both partners provide for all our emotional needs  as well as the financial and practical elements. Children may or may not be part of the way we configure our relationship.  Paradoxically we also expect to maintain excitement and passion throughout as we strive to emulate the sexually exciting worlds of the movies.  Yet though we know there’s a dissonance between fantasy and reality, disappointment follows and we may wonder if there’s someone better out there.  EFT considers the wider context that affects relationships, looking at the systems  around the couple that influences their relationship.

How does it work?

Our emotions play a key part in making decisions and in signalling to others our desires, feelings and intentions. Paying attention to our emotions can support us to gauge a situation and act in a way that benefits us and others.

One of the strengths of EFT is that it places emphasis on the negative cycle of conflict couples get pulled into rather than apportioning blame to either person.  The therapist works in collaboration with both partners to identify this dance of ‘pursue-withdraw’ or ‘criticise-defend’ as the couple interact in the room. This here and now focus illustrates the triggers, escalation points and underlying feelings that erode attachment bonds but often remain unspoken.

The therapist supports the couple to listen effectively, witness and ultimately validate the other person’s underlying feelings, emotions and desires.  Partners learn to express feelings from a place of vulnerability and ask for what they want and need from each other.

The ultimate aim of EFT is to reduce conflict and  restore a sense of safety, connection and  intimacy.  Whatever the outcome you will learn new skills of communication, increase compassion for each other and re-establish trust and safety.  It isn’t always an easy journey but you will learn a lot about each other and yourself in the process that will help you make clear decisions about your relationship.

If you would like to try out EFT please get in touch.

 

Suzanne Worrica is an experienced psychotherapist who works with individuals and couples. She is available at our Lewes Practice.

 

Resources –

Susan M. Johnson (2019) Attachment in action — changing the face of 21st century couple therapy  www.Sciencedirect.com

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