Psychological Process in Pregnancy and Postnatally: Predicting who might have difficulties

A Project in Primary Care

Joan Lee
London, England
British Association of Psychotherapists, Jungian Section

This is a short presentation, so much that is historical, philosophical and psychological will not be mentioned: this does not mean that I am not aware of the width and depth of the background influences on my thinking.

The presentation is arranged in paragraphs of thoughts and musings for us all to think about and to make our own associations. I will speak first of the Pregnancy Study Research, the format, the context, and why it is being undertaken. Secondly, I will try to link the study to the theme of the Congress; “Edges of Experience, Memory and Emergence”. Thirdly, I will report a 1993 conversation with Mary Warnock, philosopher, when she introduced me to Gerald Edelman’s “Bright Air, Brilliant Fire”. Fourthly, I will give a summary of factors in the lives of the thirty patients in the study who have been in difficulties during the first year of the Study; these factors are part of their experience, their life events. Finally, I include a piece written by a patient who has given her permission for it to be read.

Firstly: The Preganancy Study

We are in the middle of a two-year Research Study on Pregnancy in General Practice in Greenwich, London funded by Greenwich Primary Care Trust. The following is the format:

Practice Based Services For Common Mental Health Problems

For the past nine years there has been a service for prenatally and postnatally depressed women. Patients have been detected antenatally by the sensitive observation of the General Practitioners (GPs) involved in antenatal care and the practice nurse who does the initial booking.

The Edinburgh Post Natal Depression Scale (EPDS Cox et al, 1987), a self-report questionnaire, has been administered postnatally at six weeks. Health visitors also make referrals. Psychological treatment has been provided both short term and up to a year by an Analytical Psychotherapist who is also a Chartered Psychologist. The funding for this treatment service has ceased under General Medical Services (GMS). We wish to maintain and extend this service. We are making evidence based proposals.

Aims and Objectives:

1. Evidence: Between 10% and 15% of women experience an episode of major depressive disorder in the weeks and months following childbirth (Cooper & Murray 1998). In spite of contacts with midwives, health visitors and general practitioners, half of these episodes go undetected (Seely, Murray & Cooper, 1996). Even when detected, the treatment offered by GPs (antidepressant medication) is often unacceptable to the mothers (Appleby et al, 1999). Women who are depressed make less use of mother and baby clinics set up by health visitors than do well women (Seeley et al, 1996)

There is much evidence that the health of infants of postnatally depressed women is adversely affected compared with infants of mothers who are well (Murray & Cooper, 1997). The children of depressed mothers have poorer cognitive development, exhibit behaviour problems and show an insecure pattern of attachment to their mothers at eighteen months. At four to five years, cognitive deficits have been found in postnatally depressed mother’s children (Coghill et al 1986). Boys are more likely to demonstrate these traits (Sharp et al., 1995) and in addition have raised rates of behavioural disturbance at school (Stuart & Murray, 1998).

2. Aims: In the Vanbrugh Group 2000 there are on average 125 births per year. There are six referrals a year of mothers suffering from postnatal depression when the expected number would be between 12 to 18 based on existing research. There are 3 to 4 referrals during pregnancy. Patients treated antenatally do not usually have depression postnatally. It would appear that half of the mothers with psychological difficulties are not being identified and referred.

During the past nine years experience of providing psychotherapy to mothers, factors which would predict postnatal depression have been repeatedly observed: these are life experiences and current circumstances which result in vulnerability. This is evidence from clinical experience. Approaching from a wider population route, a number of epidemiological studies have been conducted in the United Kingdom, which has consistently identified a number of personal and social risk factors for postnatal depression (Cooper & Murray, 1998). This work has led to the development of a predictive index (Cooper et al, 1996), a 17-item questionnaire, validated on a large population base. This can be used at 32 weeks pregnancy. In a population identified as vulnerable using this screening questionnaire in the 15-20% most at risk, then the rate of postnatal depression is one in three.

Intervention

Midwives, health visitors, and the two GP partners who provide care for pregnant patients are proposing that they be involved in the detection of depression and psychological problems during pregnancy and the postnatal period working with the psychotherapist.

Targets would be:

  1. Predicted Index (Cooper et al., 1996) completed at 32 weeks pregnancy by GPs and/or midwives.
  2. Blues Questionnaire (Kennerly & Gath, 1989). Women experiencing severe “blues” in the first week postpartum are at raised risk of a subsequent depressive disorder (Cooper & Murray, 1998). Midwives or health visitors would administer this questionnaire at the end of the first postpartum week.
  3. Mother and Baby Scale (Wolke & St James Roberts, 1988). This to be administered one week postpartum by the health visitors. Recent work has shown that certain infant factors raise the risk of depression (Murray et al, 1996).
  4. EPDS (Edinburgh Postnatal Depression Scale) to be administered at 6 weeks at the Baby Clinic by either the health visitors or GPs.
  5. Prenatally, patients, partners, husbands are to have a structured interview with the Analytical Psychotherapist/Chartered Psychologist who has been working with this group for the past nine years.

Treatment

For the past nine years patients have received supportive therapy and worked individually and successfully in analytical psychotherapy.

We propose that this treatment continue to be given by the psychotherapist. General practitioners and health visitors who are interested in working in a supportive psychologically therapeutic way would have their treatment supervised by the same psychotherapist in group meetings.

Evaluation

Outcomes:

  1. Increase in the number of women with prenatal and postnatal depression being identified for treatment.
  2. Improved mental health and functioning for these women with important benefits for the cognitive, emotional and social development of their infants; secondary benefits for their husbands and family.
  3. Early systematic observation of the mother/infant interaction so that those in difficulties are identified for early intervention.

Clinical benefits for the patient:

  1. Increased understanding of her own difficulties.
  2. Aetiology identification of these difficulties.
  3. Learning to recognise when these difficulties may arise.
  4. Learning to mobilise the resources, skills, and confidence within her to manage the ordinary and exceptional problems in her life.

Benefits for the professionals:

General practitioners, health visitors and midwives:

  1. Increased knowledge of the psychological processes and changes in the patient during pregnancy and for the first two years of the infant’s life.
  2. Learning new therapeutic and communication skills.
  3. Learning some basic psychological treatment skills.

Scientific and theoretical knowledge:

The hypothesis is that past life events and current circumstances as measured by the questionnaires will affect the mental state of the patients during pregnancy. It is proposed that adverse life experiences will increase patient’s vulnerability and susceptibility to antenatal and postnatal depression.

Life experience and present circumstances of husbands/partners will affect their mental state and attitude to the pregnancy and their wife/partner.

The study is being undertaken in order to set up a sensitive system for identifying psychological difficulties in mothers and fathers during pregnancy and postnatally. The system includes General Practitioners, midwives, health visitors, and an analytical psychologist.

A secondary aim is to describe the psychological processes in pregnancy. Much is known about the medical, physical, and physiological processes and these are closely monitored, but little is known about the mental and psychological changes and processes; unless these are known appropriate treatments cannot be introduced.

Secondly: The theme of the Congress, “Edges of Experience: Memory and Emergence.”

What part does memory play in pregnancy? From observation women seem to become very sensitive, possibly in all senses, e.g., taste and smell. They are also vulnerable and perceptually finely tuned. I think it happens that in preparation for the baby, the mother “remembers” but not at an aware level how it was when she was a baby, and before that, how she was in the womb. This is economic because she will understand and be able to communicate with her baby. This is what I think Gerald Edelman describes as “primary consciousness”. From treating new mothers I think they become, for a while, 75% infant and 25% grown up: the intelligent professional woman for a time goes out of the window. They have fully recovered within two years.

psychological_process_in_pregnancy_1 A good metaphor of the mother’s psychological state is Leonardo Da Vinci’s cartoon, “The Virgin and Child with Saint Anne and Saint John the Baptist” in the National Gallery, London. Mary is holding the infant on her lap and she is sitting in her mother’s lap. Anne, looking the same age as Mary, is looking at her infant Mary.

If things have gone well in the mother’s infancy then all is well so long as the present environment is good enough: if there is a disaster in the external environment such as the death of her mother, or desertion of the father, then because of the vulnerability and sensitivity of the mother her response is huge: she is overwhelmed. She responds as if she were an infant, as if she would die; babies who are abandoned die. The response to the death of a new baby is intense in both the mother and father.

If the new mother’s experiences were not good when she herself was an infant, if she were in an incubator in special care, if there were important deaths around her birth, if her mother became disturbed or ill, this disturbing feeling comes into consciousness and the task of the therapist and patient is to sort out what belongs to the present and what is coming from elsewhere, sometimes what is her and what was her mother. “To bring consciousness and unconscious together and so arrive at a new attitude.” (Jung 1916/58 p. 146/from S.A. Joseph)

In the same way experiences in the father re-emerge. If a mother of a man became mentally ill when he was born, he may not be able to remain with the mother and baby.

Third: Conversation with Mary Warnock

I recall a discussion with Mary Warnock, philosopher, in December 1993. I told her of my experiences of memory: of a very sick friend who in a very weak body state and great vulnerability became afraid of her nurse. As a child and thus vulnerable she had been afraid of her mother. I told her also of a young man patient who had been referred because of his enormous anxiety: after a few months of work together, one Saturday morning I felt very sick in the session and I asked him if he were feeling sick. He then remembered how as a baby he had an operation for pyloric stenosis. We then discussed the environment of anxiety around this sick baby. I suggested that a present constellation – feelings, environment, body states brings up similar constellations from the past and it all floods into the present and can be overwhelming. The process is one of recognition and discriminations. The therapy is to sort all this out in many ways. Mary Warnock suggested that I read Gerald Eelman’s “Bright Air, Brilliant Fire”. Edelman writes about consciousness and higher order consciousness. Primary consciousness we share with all animals and is probably the consciousness working in pregnancy if all goes well. He describes consciousness the remembered present; his developmental theory of the brain is emergent as I understand it: nothing new is needed to account either for its ability to form concepts or for the phenomenon of consciousness itself. As the frontal cortex of the brain evolved, so the ability grew to receive more and more stimuli and remember them, and to rethink what had gone before and to generalise it. The maps in the brain are across many areas and are continually reconstructing themselves; it is a wide open system, which appears to make comparisons, thinks in analogues and metaphors.

Higher order maps could be made of the first order maps of brain connections. Where there has been trauma the higher order thinking has been blocked and the individual has not been able to make sense of life, and this is at the root of disturbance.

Fourthly: Summary of Factors

I will summarise the difficult life experiences of the 30 patients who have been referred for treatment prenatally and postnatally during the study so far:

  1. Mental illness in the patient’s mother
  2. Failure of family support for new parents
  3. Desertion by new father
  4. Father of one of new parent is alcoholic
  5. Father of new mother mentally ill
  6. Traumatic birth of baby
  7. New baby sick
  8. Emotion deprivation in new parent
  9. Poor relationship between couple
  10. Drug abuse in the father of baby
  11. Mother not in her own country
  12. Death of baby
  13. Intergenerational grief
  14. Important death
  15. Sex abuse in the mother’s past
  16. Feeding difficulties in the baby

Some of the patients have as many as five of these experiences in their lives.

Finally: Writing By Patient

The birth: The feelings I was going through at the time were frightening. I was happy yet scared about what I was going through. The pain I will go through will not leave me. When I was in the room ready to push with each painful contraction I was scared because I had not been through this before. I had my first child by caesarean section and will not forget that either. I was afraid of what to expect next, so I was given gas and air to relieve the pain. I did not feel like I was in the room no more, I was beginning to see things, seeing myself being born and other things that happened to me in my childhood. These were things I really could not remember happening to me as a child. There was one incident I could not forget, as I never thought I would have to remember.

The strange thing is that I was watching myself go through all these incidents; I was feeling sorry for myself. It all flashed by me like a short film about me. At this time I was breathing heavily on the pain relief. I did have a happy childhood. I was full of energy and always finding things to do. I saw myself as a little girl about two maybe three years old putting beads into my ear and other things. I had to go to hospital to get them out and for when I cut myself when I was about five years old.

There was me watching a little me getting up to allsorts. I also saw an incident I did not wish to remember. I was sixteen and I never thought it would happen to me, I was raped by one of my friend’s friends. At this time I was seeing someone that made her jealous, what she did was cruel and ended our friendship. I felt really angry at this time in hospital I gave a great big push and a scream, my baby still was not born. I would say I saw most of the incidents I did not remember or wish they never had happened.

When I was seeing what I saw I thought I was going to die, I was afraid and thought why am I seeing myself go through all that. I saw me trying to push the baby, it felt like I had left my body and was seeing myself go through all that pain which made me frightened about whether I was still alive. Things from my memory that I will never forget will be remembered, I would rather forget the rape incident. I did not tell anybody at the time because I felt dirty and scared also that no one would believe me. I have told my husband about it and I felt like I could be myself again.

When my baby was born I couldn’t explain what I had seen and felt during that time. I needed to tell someone about what I saw and needed an explanation.

References

  1. Appleby, L. et al (1997). “A controlled study of fluoxetine and cognitive behavioural counselling in the treatment of postnatal depression.” British Medical Journal 314, 932-936.
  2. Coghill, S.R. et al (1986). “Impact of maternal postnatal depression on cognitive development of young children.” British Medical Journal 292, 1165-1167
  3. Cooper, P.J., Murray, L., Hooper, R., & West, A. (1996). “The development and validation of a predictive index for post partum depression.” Psychological Medicine 26, 627-634.
  4. Cooper, P.J. & Murray, (1998). “Postnatal Depression.” British Medical Journal March/April 1998.
  5. Edelman, B.M. (1992). Bright Air, Brilliant Fire. Penguin Science, 1992.
  6. Edelman, G.M. (2004). Wider than the Sky. The Phenomenal Gift of Consciousness. Allen Lane, 2004.
  7. Kennerly, H. & Gath, (1989) “Maternity Blues: detection and measurement by questionnaire.” British Journal of Psychiatry 155, 356-373.
  8. Seeley, S., Murray, L. & Cooper, P.J. (1996) “Postnatal depression: the outcome for mothers and babies of health visitor intervention.” Health Visitor 69, 135-138.
  9. Sharp, D., Hardy, D., Pawlby, S. et al (1995) “The impact of postnatal depression on boy’s intellectual development.” Journal of Child Psychology and Psychiatry 36, 1315-1337.
  10. Sidoli, Mara (2000) When the Body Speaks. London: Routledge, 2000. (Chapter 1) Winnicott, D.W., Collected Papers: Through Paediatrics to Psychoanalysis, p. 243-254.