ABSTRACT: An area that seems to have been overlooked in family therapy is that of postpartum psychosis. This article looks at bringing together the medical theories and intrapsychic accounts into a systemic perspective of postpartum psychosis (PPP). A case study will be used to draw the threads together, and treatment suggestions are put forward.
Current Medical Research Into PPP
Brief Family History
Reasons for a Family Approach
An Object Relations Explanation
“Surely no affliction appeals more strongly to our sympathy than this fearful disease, which, when a household rejoices at the happy issue of its matron form the ‘hour of Nature’s need’, turns its joy into mourning by the approach of a far greater evil than just vanished – where the fulfilment of the maternal function, woman’s crowning joy and glory, forms the alembic in which is distilled a most bitter cup of sorrow. Gundry (1859)
The theme of this paper is that psychological knowledge has a certain priority over the biological, a priority in the sense of sequence of observations. That is, the more inclusive, imprecise psychological observations precede the less inclusive, more precise biological observations. Thus this paper focuses on the psychological nature of postpartum psychosis, not the biochemical one. Before discussing my ideas on postpartum psychosis (PPP), I will attempt to offer a definition of PPP in a clinical context.
In the medical literature much has been written about PPP. Kumar’s (1988) research shows that postpartum psychosis was discussed at length before the 19th century after which psychiatry, in my view, started to focus more on the bio-chemical and less on the psychological make-up of a person. At present, Psychiatry does not include conditions relating to childbirth in its clinical Classification system, the DSM-III-R. Due to unclear definitions, we are faced with confusion around what people are referring to under the catch-cry of “postnatal depression”. Are they referring to maternity blues, a depression following childbirth with psychotic features, postnatal depression or indeed PPP?
Postpartum psychosis has very distinct clinical features, which includes a symptom-free phase usually experienced for up to 4 days after giving birth (Hamilton, 1982). It appears that symptoms begin when lactation begins, onset should be roughly between the 4th and 14th day after puerperium. The mother may appear confused, delirious or may have hallucinations as well as insomnia. A state of changeability and unpredictability seems to be present. Both the delirium as well as the hallucinations may appear and disappear. Yet hallucinations can stabilise into states which resemble paranoid schizophrenia. Deep depression can move to a state of apparent lucidity. A temporary clearing of symptoms could lead to a mistaken impression of recovery; this error could lead to premature release from a controlled hospital environment, or worse, the cessation of medication and the opportunity for a suicide attempt. Thus, the main features are the often marked changes occurring very rapidly and spontaneously.
Kumar and Brockington (1988) offer useful definitions of puerperal conditions. They postulate that these “disorders” fall along a continuum that ranges from mild to severe. On the mild end one finds maternity blues, somewhere along the middle postnatal depression and on the severe end postpartum psychosis (PPP). Only these 3 terms will be used in this paper as they seem to be the most commonly used in the research literature. Kumar et. al. (1988) is using the new term “puerperal depressive psychosis”; which in the above spectrum would become a sub-category of PPP. This, the reader will see later, fits with ideas presented in this paper, namely that a recovery from PPP often involves moving through a depression, or was a psychotic depression in the first place. The author is of the opinion that a depression is a psychologically healthier adaptation than a psychosis, if viewed in developmental terms.
The first mention of PPP appears when physicians wrote about “puerperal insanity”. This idea stemmed form the sudden onset of extreme mental derangement in formerly normal women. The word ‘puerpera’ comes from the Latin and means ‘a women in labour’ (puer= child, parere= to bear). Thus, puerperal became ‘relating to childbirth’.
Brockington and Kumar (1982) believe that PPP occurs in one or two women of every thousand. They also report that postnatal depression occurs in 10% of all women that give birth, while they believe that maternity blues is a condition that every second women who has given birth would have experienced. Yet in-spite of increasing awareness of the risk of these conditions in childbearing women, the majority of sufferers neither seek, nor are given, appropriate help at this critical time for themselves, their baby nor their families.
Hamilton (1982) argues for PPP as a disease entity to be recognized in the DSM-III-R. He says that illness after childbirth can present itself as depression, mania, delirium, with delusions and aberrant thinking resembling schizophrenia. The closest diagnosis to PPP one can obtain in the DSM-III-R is: Schizophrenic disorder, brief reactive psychosis, major affective disorder, depression with psychotic features or organic brain syndrome.
The ways in which childbearing may be linked with psychiatric disorders remain uncertain and controversial. The antenatal period would seem to provide an ideal opportunity for prevention. The question that will be investigated is what form this prevention could take in order to be most useful for the client and their families.
CURRENT MEDICAL RESEARCH INTO PPP
In the most recent literature Vindogradov and Csernansky (1990) report estrogens influence dopamine receptor function. Two cases of PPP are put forward, where both were found to be accompanied by abnormal extrapyramidal movements; thus Vindogradov and Csernansky (1990) advocate that dopamine receptor supersensitivity may have been induced by prepartum increases in endogenous estrogens and unmasked by postpartum estrogen withdrawal.
Hamilton (1982) suggests that the endocrine system must be involved. Evidence of his pointed to the gonadotrophic hormones. He also states that PPP was associated with prolonged amenorrhorea and that when patients began to recover their periods recommenced; a vulnerability to the illness seemed to remain at premenstrual times, thus it was advocated hormones played an important role. Evidence to support the contribution of hormones to PPP has been mixed (O’Hara et. al., 1991).
More recently Kumar (1988) has tried to link PPP with a bipolar condition, thereby explaining why depression is present as well. For example, in the setting from which the following case is described later, current treatment seems to be the use of neuroleptics, lithium or both and if no response is obvious within 1 month ECT (4-10 treatments) are administered. Yet there exist no data to show whether ECT is effective (Brockington, Winokur and Dean, 1982).
In this paper I would like to recommend a ‘psychological treatment adjunct’ to the commonly used medical treatments for PPP, which in my experience are drawn-out and mostly produce little change in the client. Yet I also believe that therapy could be very difficult without the help of lithium and other major tranquillisers.
The type of psychological treatment I would like to put forward is based on systemic thinking, where hypothesizing is mainly used according to psychoanalytic and object-relations frameworks. A Milan systemic family approach is used during treatment of the family. In Anna’s case individual sessions were used as an adjunct. This was possible because two therapists interview the family, one of which had been working with Anna since she became ill and another therapist that just entered for the family interviews, as well as the team who could view the family in a once-removed position.
A way in which PPP was positively connoted was that when thinking dynamically, PPP can be seen as something very courageous that the mother allows herself to enter into, in order to repair the world around her, which is always followed by a depressive phase as part of the developmental process towards integration in therapy. Another theme was the invisible loyalties that each family member had to their family as they perceived it, to their old culture and customs and to the host culture for some.
At this point the author wishes to acknowledge that this is not the only way to view and treat PPP. That other treatment modalities may be quicker and possibly more effective, due to the nature of individual therapy and the many hours that may be involved here. It is only offered as a way for clinicians to compare their ways of working with each other, and hopefully to advance discussion on PPP and its non-medical treatment side. An analytic framework alone is not efficient enough nor sufficient in most settings (due to the amount of time an analysis takes and its ignorance of the other family members); thus a systemic way of working with the family and agencies may be the preferred way of operating.
The setting is a Community Health Centre. A woman aged 22 was referred by the registrar from the local hospital for follow-up. The referral was allocated to the Child and Family Team because they were running groups for women with postnatal depression. The referral stayed in the system for a few days, until Anna’s sister rang me, a member of the Adult and Family Mental Health Team (AMHT), stating that Anna was not well and “what were we doing about that?”.
We went to the home and encountered a distressed young mother (Anna) now 5 days postpartum. She said that she had been fine for the first few days after giving birth, but then began to hear voices and experienced great distress. It seemed unusual that a person in such a state was allowed to leave hospital, especially with a history of PPP (Anna had suffered from PPP for 2 years after giving birth to her first child, Kit, at this time 4 years old).
Auditory hallucinations of a persecutory type were observed, Anna described feeling edgy, nervous, scared and having a certain feeling of doom. She begged not to be put into hospital and agreed, reluctantly, to taking oral medication (it meant stopping breastfeeding her baby boy, Charlie). Her mother, Sandra, had come to stay with Anna and was looking after the baby. Sandra promised to take care of things. For a family genogram please refer to Figure 1. Anna was put on medication (Haloperidol) and was visited daily by our team for 7 days.
The family was very worried about Anna, yet she appeared to recover quickly. The Early Childhood Sister was asked to check that the baby was all right. Kit was referred to a child psychologist (on the Child and Family Team) because both Anna and Sandra complained about his unmanageable behaviour. The bilingual mental health worker became involved also, with the aim of him eventually taking over the case, the rationale being that he spoke their language and knew the culture. Unfortunately,due to his unforeseen resignation, this worker only stayed with this case for one month.
Three weeks after our initial involvement the bilingual worker called me. Anna was again unable to sleep and was “shouting at her mother”. Four days later she appeared fine again. Then, five days later she felt very anxious about having to go to an engagement party and all symptoms returned. During these times the family had daily phone-contact with me and were visited on alternate days. At 7 weeks Sandra brought Anna to me. Anna was in a semi-catatonic state. This state appeared to be only broken occasionally by yelling at imaginary people or the TV even though it was not turned on. After spending one day attempting to admit Anna voluntarily into hospital, there was no other choice but to schedule her with her baby. This effort was in vain because grandmother managed to be in the unit that night and take the baby from Anna.
Ten ECT’s later, plus 10 kilo’s heavier, Anna was discharged. She attempted to take her life, was re-admitted and 3 weeks later, while on weekend leave, tried again. Sandra always rang, letting me know that Anna had tried to take her life again. After another 12 ECT’s and 7 weeks in hospital, Anna and I started our weekly therapy sessions, all of which she has attended and is starting to use very well. The doctors left Anna in my care stating that they had done everything that they could, that she had not improved much and that they could not keep her in hospital for ever.
BRIEF FAMILY HISTORY
Anna was married off by her parents when she was 17 years. She describes hiding her marriage and following pregnancy from her school friends. She completed her HSC with a higher then average mark. Anna describes her childhood as one where her father was extremely abusive and unpredictable. She had to look after her sister when her parents were out working, and remembers her father as mostly drunk which resulted in domestic violence daily. Anna recounts nights where her father would take the dinner Sandra was cooking and throw it out the window. (The women always slept in the same room, with Sandra sleeping on a mattress that she would put against the door). Anna says that she always stayed at home so that her mother would not get beaten (she did instead) while her little sister always left the house. When she married Tom, he became the escape route for all three of them. Therefore, as soon as Anna married, Sandra left her husband with Elli and moved in with the newly-weds.
As part of an engaging process the therapist felt that she had to regain Anna’s trust before asking for a family interview, after having taken Anna from her house by police escort. The individual sessions preceded family meetings which aided the therapist in also getting to know the culture in which Anna was living.
It is recognised in this paper that culture is a significant variable which influences the conceptual and practical base of family work (Breunlin, Cornwell and Cade, 1983). In this case the author found Sluzki’s (1979) advice very useful, namely that if the therapist is not familiar with the culture of origin of the family, s/he should explore the norms of child rearing, role definitions and habits, before attempting an intervention (p388); the individual sessions described later served this purpose.
Sluzki (1979) also emphasized that three cultures concur in the therapeutic situation (ie. values of the society of origin, the values of the new society and the therapist’s own cultural values). The three cultures that met in this therapeutic context were Macedonian, Australian and German. The context of treatment was made more complex because English was the second language for all and Sandra, Tom and Kit did not speak English at all. Constant interpretation had to take place during family sessions. Ramondo (1991) takes Sluzki’s concept even further and proposes that the interface of therapy with different cultures becomes even more complicated when spouses have grown up in different cultures (Tom & Anna) and offspring (Anna) have taken on at least some of the values of the host culture while the rest of the family (Tom & Sandra) have remained identified with their culture of origin. The last difficulty was the co-therapy relationship because the therapists were also from different cultures and had never worked together. Planning and hours of preparation took place before the first family session was scheduled, simply for the above reasons, yet during this time Anna needed something and the individual sessions seemed at least to serve as a holding function for her.
Weekly sessions have consisted mostly of a Rogerian kind of reflecting back to Anna what she was saying, as well as practical/supportive work which at times was quite directive. I chose not to work with the transference because I could not commit myself to being at the centre for the next 10 years, the time she may have needed in an intensive psychoanalytic therapy. There would also be the issue of the cost born by the service for such an intensive therapy.
Up to this date Anna has had 17 individual sessions and has remained well. During this time her medication had been stabilised and later reduced. Thus instead of two years on heavy medication as during her first episode, we now were able to reduce her medication after 7 months. Most of the discussions centre around her husband, mother and father, all of whom can be seen as quite abusive characters in Anna’s eyes. Themes have been her guilt for being “defect” as a mother and her decision to bear no more children which causes her great grief and distress. Another theme is that of becoming a mother too soon (and without any control in the decisions) and not having had an identity through a career first. The latest issue is the emerging physical, as well as emotional abuse to which Anna and Kit are subjected to by Tom.
Our new bilingual worker has recently commenced counselling with Sandra, her story is very different and just as sad. Concerns for her centre around exploitation of her by Tom and not being able to trust nor live her life as she wishes while she resides with them. Sessions were scheduled out of normal working hours to allow Tom’s attendance. Another session with Sandra, Elli and Anna may also take place as much friction seems to be present in this triangle. All these meetings will be in the hope that communication will be more open and constructive; and possibly for Anna to gain some insight, to develop other more appropriate defenses and to provide more resources, so that she no longer has to flee and seek sanity in a psychosis.
REASONS FOR A FAMILY APPROACH
“The family is an interface where youth meets age and birth and death are juxtaposed, linking the inner with the outer world, the individual with the group.” Skynner (1976) p383
A family approach was chosen for various reasons. Firstly, because it seemed the next progressive step after Anna becoming stabilised. For real change to occur in the wider system, the lens that had focused on biochemistry and the individual/intrapsychic conflicts was widened in focus. Thus the next ‘minimum sufficient network’ needed for successful intervention, as Skynner (1987) puts it, was the family.
Skynner (1987) states that in families which function in a primitive way, and have a member that has become psychiatrically ill, there often will be a collusive use of certain typical defences by the whole family, i.e. a shared denial of the same basic problem. This could be applied to Anna’s family, in that possibly the reality of the Australian culture starting to permeate and change their lives was being denied by all. Another denied difficulty in this family seems to be that of leaving the family, ie. no-one is ever really allowed to grow up or leave. It seems that the people that have “left” their families are only those that moved to another country.
Skynner (1987) goes on to say that these families are best suited for family therapy because in such families, different psychological functions (or controls) are located in different individuals and may move from one to another. The functioning unit is no longer the individual but the family, in that only the family as a whole contains the necessary psychological structures by which a mature individual operates.
Secondly, a family approach was also used because genuine movement toward independence (improvement) can often threaten the unconsciously desired family symbiosis through loss of the needed object (Boszormenyi-Nagy, 1987). Boszormenyi-Nagy (1987) says that the client represents for the parent/partner an internalized parental love object that must be possessed, so that the original feelings of attachment to the parent can be restored. Conversely, the psychotic, in her delusional dream-world, remains in the company of the intrapsychic representations of a more gratifying family circle than her actual family could be. The author believes that even if therapeutic coalition is good and one gets symptomatic improvement, unless the unconscious motivational forces of both the patient and the parent/partner are dealt with a full recovery will not occur. Any well-meaning effort can be defeated, be it from the therapist, patient or parent/spouse. This all too often seems to be overlooked in symptom-orientated treatment programmes.
A third reason for family therapy has to do with boundaries. The formation and preservation of individual identity requires effective boundaries (or defences). Families containing a psychotic member have excessively permeable boundaries, yet excessively impermeable boundaries between them and the outside world (Skynner, 1987). In retrospect, therefore, it appears that the individual sessions helped to gain the confidence of the whole family and once Anna’s therapist requested a family discussion as the next step in treatment all attended. This compared well with the one previous family session which was held 4 months ago, when only Tom and Anna arrived.
Kit’s sessions with the child psychologist appear to have consisted of a playgroup placement being arranged for him. His behaviour continues to be a concern for all and it is hoped that this may also be addressed in the family sessions.
In hindsight the author is of the opinion that family sessions could in fact have started while Anna was in hospital. It may have increased the speed of her recovery. It would also have been beneficial to have had a consultant to monitor the wider professional system. That is, to facilitate the work of all the health professionals involved (Psychologist, Bi-lingual Counsellor, Early Childhood Sister, Child Psychologist and Psychiatrist) to make for a more united approach. It was as if the professional team mirrored the family since there was very little communication and much animosity between them.
The type of family approach that was chosen was of the systemic/Milan school. The author felt that this approach would provoke the least resistance from the family due to its neutrality stance and technique of circular questioning. The nature of the presenting problem was such that strategic family therapy would have been too solution focused. It was also feared that a structural approach would produce rebellion and non-compliance in the family. A systemic model was thought to leave most power within the family to decide about change, rather than forcing the values of the host culture onto them.
In systemic family therapy the meaning a family gives to the symptom is examined and the symptom is related to all parts of the system. Major interviewing principles involve circularity, hypothesizing and neutrality. There is no absolute reality, but rather reality is relative. Difficulties are perceived as being located in the pattern of interaction rather than the individual (Hayes, 1991). The main frameworks that were used for hypothesizing were of psychoanalytic and object relations origin, and some of the family dynamics are suggested below.
AN OBJECT RELATIONS EXPLANATION
Object-Relations theory is a psychoanalytic theory of personality development that does not simply focus on intrapsychic processes. From birth onward, individuals need to form attachments and relate to others. Each relationship serves as a feedback loop to enable further intrapsychic development. If the arrest in development occurs in infancy, the individual as an adult may have a psychotic reaction as a result of a loss in a current relationship. Therefore, it seems no mystery why family therapy originated in work with more psychotic clients, who are unable to separate and individuate, and who remain excessively vulnerable to their current family system of relationships to sustain their ‘sanity’.
At this point an introduction of Melanie Klein’s theories might help to broaden our understanding of normal infantile positions, and this in turn will help in understanding the development of psychosis. Klein (1946) put forward the view that in early infancy anxieties characteristic of psychosis arise which drive the ego to develop specific defence mechanisms, namely splitting and projective identification. These psychotic anxieties can have a profound influence on development. Klein differed from Freud, in that she believed that object relations exist from the beginning of life, the first object being the mother’s breast which to the child becomes split into a good (gratifying) and bad (frustrating) breast. This relation implies introjection and projection. Lately, another view has been put forward in which Whyte (1991) argues that the uterus/placenta is in fact the first object.
Nevertheless, Klein proposed that the motivating force for personality development was the need to relate to the mother. Klein divided infant development into the ‘paranoid-schizoid position’ which lasts till about 6 months, and argued that it precedes the ‘depressive position’ which lasts until about 30 months. If, however, persecutory fears were very strong, and for this reason the infant could not work through the paranoid-schizoid position, the working through of the depressive position is in turn impeded. This Klein saw as the foundation of severe psychosis.
The author would like to suggest that women who suffer from maternity blues show the healthiest development, and Anna may have got stuck very early on. Klein (1946) also hypothesizes that psychotic and manic-depressive (now bipolar) disorders are more closely linked developmentally than are psychosis and depressive positions. This fits the medical theories that PPP appears to be more like a bipolar disorder (Kumar,1988)
Winnicott (1956) another object-relations theorist, puts forward the thesis that in this earliest phase we are dealing with a very special state of the mother; this state he termed “Primary Maternal Preoccupation”. He describes it as a state that gradually develops and turns into a heightened sensitivity during the end of the pregnancy, and the first few weeks after birth. He goes on to say that: “This organized state (that would be an illness were it not for the fact of the pregnancy) could be compared with a withdrawn state, or a dissociated state, or even with a disturbance at a deeper level such as a schizoid episode in which some aspect of the personality takes over temporarily“, Winnicott(1956) p302. He says that a woman must be healthy in order both to develop this state and to recover from it as the infant releases her. This preoccupation serves to enable the mother to adopt delicately and sensitively to the infant’s needs at the very beginning. The mother’s failure to adapt in the earliest phase does not produce anything but an annihilation of the infants self (Winnicott, 1956). Anna probably did not get this specified type of mothering (as will be explained later), and now when she is confronted with mothering her own infants she does not know how to provide something she never received (Bowlby,1961). It might also be that she enters this special state but then becomes one with the infant and his primitive anxieties. Thus she is left unable to return to reality as she has re-entered her own fears she had as an infant.
Winnicott (1958) goes on to say that if the mother does not provide the security of the ‘holding function’ and is actually unresponsive, the infant cannot internalise a comforting good mother, and thus lacks ego integration. For the sake of survival, the infant develops a “false self”, one that is compliant.
Object Relations theory, therefore, can be seen as a circular process. The child’s subjective experience of actual interpersonal interaction is internalised into the intrapsychic sphere. Then this internalised representation is projected externally into the child’s perception. Finally the interpersonal interaction is re-internalised to sustain the integrity of the individuals inner personality (Slipp, 1988).
In Anna’s case we know that at least one, if not both, parents have not internalised the good mother, so as to be able to self-regulate their identity. Parents, therefore, remain dependent on external objects (eg. their children). Often a parent will attempt to sustain their equilibrium by splitting in order to avoid the threat of the loss of the spouse. Slipp (1988) argues that aggression is denied toward the spouse and split off and displaced into the child, who is seen as the demanding bad object. The child is therefore induced into the role of family scapegoat (as Karl did to Anna & Tom/Anna do to Kit). The child internalizes and functions as a container for this negative introject, thereby developing a negative self-identity.
The bad object is subtly projected onto the child, who feels they are a burden that the parent is unable to handle (Anna/Kit). Thus the child experiences itself as a bad demanding person, and feels responsible for the parents emotional abandonment. As an infant, Anna recalls that she felt guilty for existing, as she does now because she gets sick. She recalls feeling bad for having needs of her own because her mother was so stressed nursing her own mother. Anna became the good girl and has never swayed from this path. When her parents argued, no-one was there for her, she became a non-person, and psychotic. Her psychotic state is a withdrawal, which brings her close to suicide, ie. to fulfil her mother’s and fathers wish that she did not exist.
In Anna’s family, she and Tom can be seen as equalling the Greek myth of Narcissus. Tom is looking for mirroring and needs an Echo (Anna) who is submissive, undifferentiated, almost a part of him, and who can repeat the words he needs to hear to feed his grandiose image. Tom is a very controlling father, as Karl was. He too denigrates Anna and fights with Sandra. Yet Anna says she loves Tom and would do anything for him (even go mad). When Anna is sick Tom and Sandra argue and it is as if Anna is the little girl again whose parents are arguing. Thus in some way she is recreating her own intrapsychic world, as it had been when she was little.
Ferriera (1963) speaks of ‘family myths’ or fantasies shared by a family which preserve self-esteem at the cost of self-deception and breakdown of some of its members. Anna’s family myth is that her father was the cause of all evil. This colludes with Sandra against her being confronted of why she as a mother did not protect her children and leave earlier? I predict that if Sandra were ever confronted about this, she would have the breakdown, not Anna.
The referring person was Elli, and as Palazolli says, beware of the referring sibling – she holds the key. In our family work we have as yet never tried to include Elli. She has been the more favoured child and she was not beaten by her father. In Anna’s family we seem to have a repeat of the second child being favoured, as Kit is the ‘bad one’ and Charlie is now even Anna’s favourite. (Yet in a way, by Anna consenting for me to write this paper, she is getting some prestige and has created fame for herself). It is also of interest to note that the favoured daughter left the mother and went to live with the mother-in-law; she has no need for her own mother. Anna, therefore, has to provide some meaning for her mother by giving her her own children to look after.
Anna described her 2nd pregnancy as a happy time, when she was coping well with Kit, and was painting the house. Yet we wonder whether after a delivery, where the baby’s head appeared at home after the mother had been sent back home by the hospital staff, “because she was not dilated enough”, the infant may have been experienced as threatening and demanding. During pregnancy the baby had been a special object for Anna, and had given her a special identity as a pregnant woman, now it was no longer so. It seems the son, once born, became the persecutory object, while inside he is the good object. (He like every other male, Anna experiences as dangerous).
Sandra’s role of looking after the children would become redundant if Anna got well. If Anna became a functioning mother, she would show off her own mother. Mother, for Anna however, is a figure that has to be placated, if she got too well, Sandra’s life purpose would be gone. In some sense Anna has, therefore, provided children for her mother.
Sandra, like Anna, sacrificed her own children for the sake of her own mother. Because Sandra nursed her own mother, she missed out herself on mothering her own infants; and the same seems to be repeating for Anna who misses out on nursing her infants, but recovers once they are past infancy. Sandra is able to move out only through a dispute with Tom, whom she then blames for asking her to leave. It appears therefore, that Anna provides her mother with children, which in some way lets her of the hook of having to look after her own mother, as she has done all her life.
Both girls have never internalised a mother that protects them, thus neither are able to protect their children from their abusive husbands (and I would like to add here, mother) nor are they able to defend themselves against their husbands. Anna is the parentified child for her mother and issues around loyalty and break-away guilt exist. Anna was never really allowed to start her own life, as her mother followed as soon as she got married.
The whole system appears to be about control. Anna’s withdrawal could be seen as aggression towards her mother and husband. That is exposing the mother as an inadequate mother, as she has turned out so sick. And leaving this unsupportive loud husband to fend for himself as his impregnation has made her sick again! Thus Anna’s control comes from threatening to suicide and annihilation.
“The unconscious is an ever open question that is silenced by the symptom. The silence is compensated by the noise the symptom makes. The analyst must hear the noise of the open question behind the regressive demands of the analysand” Benvenuto (1989).
I would like to argue that the psychotic state is not necessarily a misfortune. When I first started thinking about this paper I set out to understand why a mother having done such a wonderful thing, i.e. giving birth, has to do such a violent act and withdraw into a psychosis. Her ‘true self’, one can only hypothesize, must have been very hurt and damaged. I would like to put forward some ideas of why a mother has to retreat, insulate and hide inside her psychosis. I would like to advocate that the retreat into a psychotic state is an attempt to repair the world, to give it some meaning. It is an attempt to save something and thus to keep the mind alive. In my view, a women has to be admired for the capacity to enter a psychosis in order to repair herself. Her pain should be acknowledged, and the expectation should not be one of change, ie she should not be forced to get better (through ECT, medication or therapy for that matter), she should be allowed to keep her psychosis until she feels ready to give it up. The arrival of a baby can push one into one’s own babyhood, and this time can be very frightening. Winnicott (1954) saw psychosis as the means by which some individuals shed their false fronts in order to reach a new and vital relationship with themselves and the world. In Anna’s case, therefore, it may be useful to focus more closely on psychotic interactions, and now I will look at that between mother and daughter.
Nini Herman (1989) argues that a crucial theme of boundaries is involved in the mother daughter dyad. That is, if you (a mother) have a replica (ie. a daughter, whose body is the same), how is difference instituted (how can a daughter separate) while sameness is maintained? “Is it not her flesh and blood daughter that a mother is bound to most deeply, most reluctantly and joyfully, with harrowing ambivalence?”Herman (1989).
Herman (1989) proposes that especially when a daughter is in the transition of becoming a mother herself, she is thrown back onto her mother, both because she will identify with her and because she will feel a baby herself again. Especially now she will not resist her mother, ‘knowing’ that hurting her implies that the same could be done to her by her own child. It is not only the mother’s life history that is resonant in the women’s expectations about herself or about her own child, but also that of her grandmother and even great-grandmother (Halberstadt-Freud, 1989).
This entanglement, Herman (1989) hypothesizes, may serve as a defence against envy. For where a mother feels fulfilled and adequately satisfied with the achievements of her life, there is little need to seize on her daughter’s life, like a vulture on its prey, shamelessly laying claim to her daughter’s achievements to steal them and in the deepest sense and to initiate infanticide. Anna has never been able to keep her achievements. Her HSC and children were both interfered with by her mother (and husband). Separating from the mother always brings fears for a daughter: will mother collapse? feel empty and redundant, or perhaps retaliate by withdrawing her support for all eternity? (Herman, 1989).
Halberstadt-Freud (1989) proposes that daughters are doubly bound to their mothers, and believes this can explain why a women’s development is often threatened by regressive tendencies. If a daughter is unable to sever the symbiotic ties, she may reproduce this pathology from one generation to the next. She also goes on to say that the mother may make all the demands on her daughter, which she was never able to meet with her own mother. When the daughter has grown up her mother may still be making all the demands on her which she would have liked to have made upon her own mother, which the last never met. This could be the case in this family. It leads to a situation in which the daughter is expected to provide, as a mother would, all the support and love which her mother needed as a child and still craves. Such a complete reversal of generational relations causes the daughter to feel guilty for her inability to provide her mother with all that she lacks (Halberstadt-Freud, 1989).
As a consequence of this scenario, the girl now grown into a mother herself may come to feel insufficient for being unable to give her child what she needs: an inability due to the fact that as a mother she feels she cannot give what she never received herself. Here the baby would stir up too much envy and hatred in its mother (ie. Anna). Anna’s psychosis may have helped her to contain the anger she felt against her mother (and baby). As a psychotic woman shouting at her mother and pushing away the responsibility of her baby, Anna could avoid assuming responsibility for her hostility and never had to risk rejection.
The sameness of gender and absence of sexual difference provide ample opportunities for mother and daughter to engage in mutual identification without separation. When Anna stayed home to protect her mother from being beaten she was identifying with her mother. Such primary identification prevents the formation of a separate identity and individuality. The girl’s continuous repetition of her identification with her mother implies that she will come to resemble her mother more with each step forward. Anna is going through the same phases and experiences of womanhood that her mother went through, therefore once more she feels re-identified with her mother. This ‘separation-identification paradox’ is a recurring one (Schwartz, 1986). The development of a separate identity is continuously under threat: this is why women – as a mechanism of defence – so often complain about fearing that they resemble their mothers.
It is hoped that this paper has offered some ideas in relation to treating PPP. It is emphasised that this paper’s intention was mainly to stimulate research and discourse in this area. It has tried to integrate different viewpoints/treatment modalities for the clients’ benefit. The theories are seen as complementing each other, only that the focus of the lens we view treatment through gets adjusted. It is recommended that more longitudinal multigenerational studies are conducted and pilot intervention programmes are introduced into maternity wards.
It is interesting to note that at least 40% of first mothers describe delays of several days before they begin to feel affection for their newborn (Kumar, 1988). A maternity ward may be the best place to start an intervention, treatment through a Community Health Centre may follow. It has been shown that treatment at home or of mother/baby admission is less potentially damaging to the mother-infant relationship (Oates,1983). Often mothers wish to be nursed at home if they have other children at home (as was the case with Anna). Thus with the establishment of extended hours and crisis teams it may become possible to provide intensive treatment at home. Successful home-based treatment for postnatal depression has been reported by Millar and Evelyn (1985).
In addition, the author would like to suggest therapy for the mother as well as the whole family for the reasons outlined above. In Anna’s case, she was seen weekly, her mother was seen fortnightly by the bilingual counsellor and the family will be seen in co-therapy monthly with both children present.
It is the author’s hope that this article has served as a summary of present knowledge on postpartum psychosis, and as a stimulus for those interested in working with puerperal conditions. Because of the pervasive effects of PPP on the family and on the psychological development of young children, this is a matter which deserves our best efforts.
In this paper the author hopes to have shown that human development contributes first and foremost to PPP, while biology is an actor that may enter later. The crucial issue is not the onset of psychosis but the developmental arrest that results. A loss of reality testing that defines the onset of psychosis is but a slight further regression of an already impaired character formation. Yet something must be added in order to permit an individual to sever his/her relations to the external world. That something may well be of biological origin.
A family therapy approach, in conjunction with individual therapy is suggested because it is believed that real recovery cannot occur unless the whole family is seen together. Reasons for this were outlined in the paper. A Milan/systemic approach is advocated due to its neutrality stance and openness to other theoretical frameworks. A detailed case study was used to illustrate theoretical concepts.
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