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.
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.
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.
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:-
- The baby is not her own (mental) conception.
- The baby is not the one of childhood play, father’s child, brother’s child, etc.
- The baby is not magically produced.
- The baby is a danger to her body in pregnancy and at birth.
- The baby is an interference with her private life, a challenge to preoccupation.
- 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.
- The baby hurts her nipples even by suckling, which is at first a chewing activity.
- He is ruthless, treats her as scum, an unpaid servant, a slave.
- She has to love him, excretions and all, at any rate at the beginning, till he has doubts about himself.
- He tries to hurt her, periodically bites her, all in love.
- He shows disillusionment about her.
- His excited love is cupboard love, so that having got what he wants he throws her away like orange peel.
- 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.
- At first he does not know at all what she does or what she sacrifices for him. Especially he cannot allow for her hate.
- He is suspicious, refuses her good food, and makes her doubt herself, but eats well with his aunt.
- After an awful morning with him she goes out, and he smiles at a stranger, who says: ‘Isn’t he sweet!’
- If she fails him at the start she knows he will pay her out for ever.
- 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 –