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Some emotional disorders of the puerperium
journal of Psychosomatic Research.Vol. 12.pp. 101t0 106. Peergamon Press1968.Printedin NorthernIreland
SOME EMOTIONAL DISORDERS OF THE PUERPERIUM GWENTH DOUGLAS * UNIVERSITY COLLEGE HOSPITAL employs psychiatrists in the Maternity Department because the view is held that a woman’s mental state is part of her obstetric condition. The ward sisters include in their reports comments on the patient’s emotional state. knowing that a psychiatrist comes to the ward regularly to see her patients, without The obstetricians, paediatricians and psychiatrists her making a specific request. meet to discuss cases. The close co-operation of obstetrician and paediatrician in itself has a beneficial effect on the patient’s mental state as she is kept well and promptly will talk with the mother informed about an ill or premature baby. The paediatricians at length if necessary, and this prevents many a puerperal breakdown and ensures a continuity of the mother’s interest and concern about her child, which often helps her have a satisfactory relationship with the baby in spite of his illness or prematurity. The psychiatrist working in this way has the opportunity to observe the healthy young mother, and this aids in assessing the distortions and illnesses of the puerperium. Perhaps therefore a short description of the normal mental state of a woman recently delivered in hospital would not be out of place. The night after delivery she may not sleep, from joy and excitement at having her Later she tends to be rather touchy and new baby, and the strain of the labour. vulnerable, sometimes quiet, withdrawn or depressed, rather weepy without knowing why-the well-known “baby blues” that happen on the third or fifth day. She is concerned about her own health and that of her baby and not much interested in anything else. She is not so different from any patient who has had an operation or is seriously ill, being withdrawn in her interest from the outside world, being more narcissistic than usual, so it can be assumed that the physical changes of labour contribute to her state. The big difference, of course, is that part of herself has become a baby and she is particularly concerned about this small and vulnerable part of herself. Winnicott [I] has described this state as “Primary maternal pre-occupation”, and has stressed its importance to the child because it is the beginning of the relationship between the mother and her baby and her commitment to bringing up her child that will go on for many years-an enormous commitment. In health a woman welcomes this and is deeply satisfied by the fulfilment of her instinctual wish and her ability to make it a good reality by keeping and rearing the child in such a way that he will be capable of satisfactions and fulfilments in his turn, a healthy child growing into a healthy adult. In every woman, however, there is a potential conflict because, as Benedek [2], has shown, the wish for a child is instinctive and recurs in the progestrone phase of the menstrual cycle each month, while the ability to care for the child is not instinctive and requires certain conditions and a degree of maturity. My colleague at University
* Sutton Child Guidance Clinic, Sutton, Surrey, and University College Hospital, Gower Street, London
W.C.1. 101
102
GWENTH
DOUGLAS
College Hospital, Dr. Gunther, has shown that even the ability to breast-feed is culturally determined in that it depends on early observation and experience [3] so, leaving aside sexual carelessness, many women want a child and become pregnant but have neither the capacity nor the whole-hearted wish to look after the child, and are shocked to discover that in the puerperium all does not go well. They are emotionally disturbed because of this conflict. I want to stress that the patient is not aware of this conflict or of what it is in her that is interfering with her mothering. We see in the ward a disturbed woman, puzzled at her state. When the cause of her trouble is ascertained, however, it often turns out to be so obvious that one hesitates to present it, but I do so because such ordinary things are so often over-looked. The current attitude of many young women is such that they say: “When I want a baby I will have one”. They are not asking themselves if they are in a suitable situation and emotionally ready to bring up a child, and perhaps their medical advisers ask themselves about this even less, for I often see women disturbed in the puerperium who tell me that they were neurotic and their doctor said : “What you need is a child”. Thus he comes down on the side of her instinctive wish, without regard for her ability to look after a child. Now although a healthy young woman may mature by the experience, caring for a baby is not a cure for neurosis. In fact, it taxes the woman’s resources severely and my experience with puerperal patients as well as in a child guidance clinic leads me to suggest that we should give more consideration to advising our patients to think about their whole life situation and if it is suitable for rearing a child. Some assessment of the woman’s emotional state is indicated to see if she is fit to bring up a family at this time, and advice might well be given much more often that she is not fit to do so, that some psychotherapy may be necessary first. This seems vital, if we really believe that the mother-child relationship is important for mental health and we are concerned to prevent mental illness. Now let us look at the clinical picture and then at these causes of the trouble in more detail. The clinical picture varies in puerperal psychiatric states. Old mental illness may recur, leading to a repetition of symptoms. The content of thought is likely to change and there are common features which seem to me to be distortions of the normal maternal pre-occupation. Often the ward sister reports that the patient has had several sleepless nights, seems agitated, over-active, restless, interfering, unduly complaining and over-demanding, or suspicious and very tense, or that she does not take to her baby, or in other instances that she will not leave the baby alone at all. She may be sure that she or her baby has an incurable illness which nobody is bothering about, or she may be more depressed than usual. When I see the patient, I let her tell me how she feels and also try to get a general psychiatric history to find out what is interfering with her mothering. Many of the patients have aggressive fantasies that the child is being hurt, or that she herself will harm the child. There may be a general difficulty with aggression, but even when this is not the case such fantasies are prominent. Now let us look at these requirements for bringing up a child that I have referred to. The environmental conditions obviously include a place where the mother can give the child the physical care he needs, a settled place that she can take for granted without thinking about it. Perhaps because of our Central London position at University College Hospital we see many girls from over-seas who managed quite
Some emotional disorders of the puerperium
103
well in this country till they had their babies, and then they do not feel sufficiently at ease to devote themselves to their children. Without realizing it, they are still making efforts to adapt to their new culture and this interferes with their ability to be quietly absorbed in their babies, and so to puerperal upset. If a girl is about to move house she may find that she does not take to her child. At another time she could cope with the move and other things too, but real pre-occupation with the baby would not allow sufficient interest to be left over to give to the move. Sometimes her husband has to go over-seas just when her baby is due. Then there can be a conflict between his career and the mother’s need to be unconcerned about anything other than her baby, and so she is likely in these circumstances to become disturbed. If in any way the young mother is not supported by her husband or by an understanding environment, she is likely to have trouble in the puerperium. The disturbance may show in the rejection of the baby which might be considered as an acting-out symptom in this situation. Lomas at the Cassel Hospital studied puerperal breakdown from the point of view of the husband-wife relationship before and after breakdown [4] He found that a particular type of relationship existed with some consistency. The women had dominating maternal attitudes towards their husbands, who were passive and dependent. When the baby arrived these women could not transfer the lookingafter function from the husband to the baby, especially as their particular type of looking-after was bound up with domination rather than acceptance and loving care. We have looked at some of the environmental factors which interfere with the mother’s care of her child. Let us now examine some of the emotional. These are commonly : 1. 2. 3. 4. 5. 6. 7.
A fixation to old relationships, especially with the mother or husband. Identification of the baby with a hated relative. Particular sexual difficulties. Rejection of femininity. General ego weakness. Not being able to lay aside particular interests of her own. A general difficulty with aggression.
A common fixation to an old relationship is where the patient has been dominated by her mother so that she feels she must still conform to her mother’s wishes and is not free to care for her baby. These patients respond well to psychotherapy, which should be started as soon as possible to avoid the relationship with the child being too disturbed, the baby being harmed or battered as happens in so many puerperal depressions. This type of patient is described in detail elsewhere [5]. Let me give an example of a patient who identified the baby with a hated relative. Some patients take a little time to get to know their babies but do so with the help of good nursing care. Others, however, have particular difficulty and become very tense and anxious because they cannot bring themselves to have anything to do with their children. One such patient was having her second baby. She kept remembering how differently she felt towards her first baby, when she had loved him from the start and could think of nothing else, whereas she was now not interested at all and had no tender feelings towards him. Yet she had looked forward to having the second child, who had come at a time that she had planned. She told me that she was brought up by her mother and her grandparents as her father had died before she could remember.
104
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They had all got on well together but later her mother had re-married and had another family. She continued to stay with her grandparents but had gone to visit her mother often and kept in close touch with her. She felt that this was quite a satisfactory relationship. As she was telling me this, she began to remember times when she did greatly resent her younger half-brothers and sisters, and having to look after them. She became very emotional. She said that her mother never knew about these feelings, and she herself was surprised at their intensity. It seemed that she identified herself with the first baby, and her half-brothers with the second. We talked about this and she said it made her feel much worse and want nothing to do with her baby ever. Then later she began to realize how strong the identification was and how unnecessary now. She was able to take to her baby and feel loving towards him, and became settled and pre-occupied in the usual way. At a follow-up interview some weeks later, she was happily living at home with her family and looking after them all with satisfaction As far as one can judge in such a brief contact, this patient was prevented from the first from caring for her child as she had hoped, by this specific identification, and I feel that psychiatric intervention during the puerperium enabled her to have a better relationship with her child than would otherwise have been the case. Particular sexual difficulties lead to anxiety and fear of what the patient might do to the child, which seems to be related to her own childhood. For instance, women who as children were lonely and felt their sexual feelings to be considered disgusting by their parents might have comforted themselves by compulsively masturbating. Such women are often afraid that in their wish to love and comfort their babies they may feel compelled to masturbate them. Sometimes patients can express this fear, when they can be helped by getting at their need to be understood and comforted by their mothers, but often they will be too ashamed or mistrustful to mention it, when they present as depressed, tense patients who are difficult to treat. Rejection of femininity is mentioned in the literature on puerperal breakdown. This has different meanings for various disciplines and so sometimes leads to confusion, especially as there can be acceptance of some aspects of femininity but rejection of the care of children. I will describe one extreme example of a woman who, although physically feminine, rejected her femininity almost entirely. Mrs. L. was seen in pregnancy because she wanted an abortion. She came from another country where she had lived a man’s life, taking part in a war beside men since her schooldays. She was considered a good shot, took considerable pride in this and her toughness and ability to kill. In this country she was pursuing an artistic career but had married a man who admired her spirit and talent. As he did not like women in the ordinary way and found her different, they suited each other well. The patient threatened suicide during pregnancy as she felt being pregnant was unnatural for her as she wanted nothing to do with being a woman. When I saw her after the confinement she told me that although she now had her baby she had not been present at the birth. She had been walking down a road at the time watching men mend the road. She could describe every detail. As soon as she got out of hospital she had been to this particular spot and saw where the road had been mended. She spent a lot of time asking people when it was done, and confirmed to her own satisfaction that while her baby was being born she was standing there watching the road being mended. She became obsessed with this in a way that was not usual for her. The content of her thoughts in the dissociation that took place during the labour seemed to persist and take the place of
Some emotional disorders of the puerperium
105
normal pre-occupation about the baby. She was in an agitated state for some time. She kept the child but never looked after him herself, any more than was absolutely necessary, using a nursery, paid help or her husband to do so, while she went on with her career. All my efforts to treat her and the good nursing care at the Cassel Hospital, both during pregnancy and afterwards, made no difference to her at all. Now let us look at examples of patients who have a general ego weakness which interferes with their mothering. Whereas a mature woman may have day-dreams of her children grown, there is also a feeling for the small, entirely dependent being to which she has given birth, women with general ego weakness cannot always bear this degree of dependence, and persist in expecting an older child and not a baby. One such patient was, at interview, extremely tense and it was difficult to make contact with her. She stood staring under such great strain that even being in the room with her made one feel anxious. It was only later that she could tell me what she saw when she was staring out of the window. It was a little girl playing happily. This was the child she had expected, a child able to play outside the house and at a distance from her, not the clamouring baby that needed her attention and whom she was expected to hold close to her to be fed. She hated to be roused and brought back to the reality of the dependent baby from the pleasure of seeing the happy child who seemed more like a playmate than a responsibility. Once she could talk about the little girl she had hallucinated, she could recognize that it was because she had wished for a grown child. This patient made it clear that if a woman is expecting a grown child, then a baby is a hopeless disappointment, and simple reassurance is not enough for her. She needed much help. Another woman, a chronic schizophrenic, had had a most anxious, tense and aggressive mother who controlled all her children’s lives, and they were all three chronic schizophrenics, well-known to their local mental hospital. Our patient, when in hospital, met another chronic schizophrenic, and when they were discharged they married and had a baby. The husband relapsed and was re-admitted to hospital. The wife caused concern during the puerperium. She could not really feed or wash her baby consistently, but she would not allow other people to do it either. She told me that she was shamed because her baby should be so tiny. She had expected a very much bigger child. Her guilt about her tiny baby made her hide him away under bundles of clothes, depriving the child of air and endangering his life. In some ways this schizophrenic girl was improved in her mental state by pregnancy, but the price that the baby paid was great as his life was endangered. Even after considerable efforts were made to give this patient treatment and support, both practical and emotional, she was not able to lcok after her child, who had to be taken into care of the County. My clinical impression is that an increasing number of patients show a conflict between their wish to pursue a career and their wish to have a child. Girls of all degrees of intelligence up to the highest who are studying or pursuing a career that interests them, want a child and become pregnant. They plan the child quite carefully, from their work point of view, so that it will be born during a vacation or slack period, with the intention of returning to work quite soon. It is only during the puerperium that things go wrong. On examination it becomes clear that they are surprised at the intensity of their feelings. They have little recognition of the child’s needs and the extent of their commitment if they are to bring up a healthy child. One patient said
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she had planned for some time to go away in a couple of years for a prolonged period in connexion with her work. It would not be possible to take the baby with her but she said it would not matter-“After all, he’ll be independent by then”. He would be two! She was, however, distressed at the hostile fantasies she was having towards her child in the puerperium. This happens to secretaries, nurses, doctors, teachers, even nursery nurses, all the common careers for women, so it is not due to the choice of any particular profession or occupation but more to do with the conflict of interests and the lack of concern and even knowledge of the degree of commitment required to bring up a baby to be mentally healthy. That these women have become disturbed in the puerperium does mean that there is a conflict and there is a side of them that wishes to be able to do this job of bringing up a child adequately. It appears that the wish to have a child is deep and persistent, while the ability to care for one is easily upset either by the environment or by the woman’s conflict within herself. REFERENCES 1. WINNICOTTD. W. Collected Papers, Chap. xxiv, Tavistock Publications (1958). 2. BENEDEKTHEREX Studies in Psychosomatic Medicine. Psychosexual Functions in Women, Ronald Press, N.Y. (1952). 3. GUNTHERMAVIS Instinct and the nursing couple. Lancet No. 6864 575 (1955). 4. LOMASPETERThe husband-wife relationship in cases of puerperal behaviour. Br. J. Med. Psychol. 32, (2) 117 (1959). 5. DOUGLASGWENTH Puerperal depression and excessive compliance with the mother. Br. J. Med. Psychol. 36, 271 (1963).
SOME EMOTIONAL DISORDERS OF THE PUERPERIUM GWENTH DOUGLAS * UNIVERSITY COLLEGE HOSPITAL employs psychiatrists in the Maternity Department because the view is held that a woman’s mental state is part of her obstetric condition. The ward sisters include in their reports comments on the patient’s emotional state. knowing that a psychiatrist comes to the ward regularly to see her patients, without The obstetricians, paediatricians and psychiatrists her making a specific request. meet to discuss cases. The close co-operation of obstetrician and paediatrician in itself has a beneficial effect on the patient’s mental state as she is kept well and promptly will talk with the mother informed about an ill or premature baby. The paediatricians at length if necessary, and this prevents many a puerperal breakdown and ensures a continuity of the mother’s interest and concern about her child, which often helps her have a satisfactory relationship with the baby in spite of his illness or prematurity. The psychiatrist working in this way has the opportunity to observe the healthy young mother, and this aids in assessing the distortions and illnesses of the puerperium. Perhaps therefore a short description of the normal mental state of a woman recently delivered in hospital would not be out of place. The night after delivery she may not sleep, from joy and excitement at having her Later she tends to be rather touchy and new baby, and the strain of the labour. vulnerable, sometimes quiet, withdrawn or depressed, rather weepy without knowing why-the well-known “baby blues” that happen on the third or fifth day. She is concerned about her own health and that of her baby and not much interested in anything else. She is not so different from any patient who has had an operation or is seriously ill, being withdrawn in her interest from the outside world, being more narcissistic than usual, so it can be assumed that the physical changes of labour contribute to her state. The big difference, of course, is that part of herself has become a baby and she is particularly concerned about this small and vulnerable part of herself. Winnicott [I] has described this state as “Primary maternal pre-occupation”, and has stressed its importance to the child because it is the beginning of the relationship between the mother and her baby and her commitment to bringing up her child that will go on for many years-an enormous commitment. In health a woman welcomes this and is deeply satisfied by the fulfilment of her instinctual wish and her ability to make it a good reality by keeping and rearing the child in such a way that he will be capable of satisfactions and fulfilments in his turn, a healthy child growing into a healthy adult. In every woman, however, there is a potential conflict because, as Benedek [2], has shown, the wish for a child is instinctive and recurs in the progestrone phase of the menstrual cycle each month, while the ability to care for the child is not instinctive and requires certain conditions and a degree of maturity. My colleague at University
* Sutton Child Guidance Clinic, Sutton, Surrey, and University College Hospital, Gower Street, London
W.C.1. 101
102
GWENTH
DOUGLAS
College Hospital, Dr. Gunther, has shown that even the ability to breast-feed is culturally determined in that it depends on early observation and experience [3] so, leaving aside sexual carelessness, many women want a child and become pregnant but have neither the capacity nor the whole-hearted wish to look after the child, and are shocked to discover that in the puerperium all does not go well. They are emotionally disturbed because of this conflict. I want to stress that the patient is not aware of this conflict or of what it is in her that is interfering with her mothering. We see in the ward a disturbed woman, puzzled at her state. When the cause of her trouble is ascertained, however, it often turns out to be so obvious that one hesitates to present it, but I do so because such ordinary things are so often over-looked. The current attitude of many young women is such that they say: “When I want a baby I will have one”. They are not asking themselves if they are in a suitable situation and emotionally ready to bring up a child, and perhaps their medical advisers ask themselves about this even less, for I often see women disturbed in the puerperium who tell me that they were neurotic and their doctor said : “What you need is a child”. Thus he comes down on the side of her instinctive wish, without regard for her ability to look after a child. Now although a healthy young woman may mature by the experience, caring for a baby is not a cure for neurosis. In fact, it taxes the woman’s resources severely and my experience with puerperal patients as well as in a child guidance clinic leads me to suggest that we should give more consideration to advising our patients to think about their whole life situation and if it is suitable for rearing a child. Some assessment of the woman’s emotional state is indicated to see if she is fit to bring up a family at this time, and advice might well be given much more often that she is not fit to do so, that some psychotherapy may be necessary first. This seems vital, if we really believe that the mother-child relationship is important for mental health and we are concerned to prevent mental illness. Now let us look at the clinical picture and then at these causes of the trouble in more detail. The clinical picture varies in puerperal psychiatric states. Old mental illness may recur, leading to a repetition of symptoms. The content of thought is likely to change and there are common features which seem to me to be distortions of the normal maternal pre-occupation. Often the ward sister reports that the patient has had several sleepless nights, seems agitated, over-active, restless, interfering, unduly complaining and over-demanding, or suspicious and very tense, or that she does not take to her baby, or in other instances that she will not leave the baby alone at all. She may be sure that she or her baby has an incurable illness which nobody is bothering about, or she may be more depressed than usual. When I see the patient, I let her tell me how she feels and also try to get a general psychiatric history to find out what is interfering with her mothering. Many of the patients have aggressive fantasies that the child is being hurt, or that she herself will harm the child. There may be a general difficulty with aggression, but even when this is not the case such fantasies are prominent. Now let us look at these requirements for bringing up a child that I have referred to. The environmental conditions obviously include a place where the mother can give the child the physical care he needs, a settled place that she can take for granted without thinking about it. Perhaps because of our Central London position at University College Hospital we see many girls from over-seas who managed quite
Some emotional disorders of the puerperium
103
well in this country till they had their babies, and then they do not feel sufficiently at ease to devote themselves to their children. Without realizing it, they are still making efforts to adapt to their new culture and this interferes with their ability to be quietly absorbed in their babies, and so to puerperal upset. If a girl is about to move house she may find that she does not take to her child. At another time she could cope with the move and other things too, but real pre-occupation with the baby would not allow sufficient interest to be left over to give to the move. Sometimes her husband has to go over-seas just when her baby is due. Then there can be a conflict between his career and the mother’s need to be unconcerned about anything other than her baby, and so she is likely in these circumstances to become disturbed. If in any way the young mother is not supported by her husband or by an understanding environment, she is likely to have trouble in the puerperium. The disturbance may show in the rejection of the baby which might be considered as an acting-out symptom in this situation. Lomas at the Cassel Hospital studied puerperal breakdown from the point of view of the husband-wife relationship before and after breakdown [4] He found that a particular type of relationship existed with some consistency. The women had dominating maternal attitudes towards their husbands, who were passive and dependent. When the baby arrived these women could not transfer the lookingafter function from the husband to the baby, especially as their particular type of looking-after was bound up with domination rather than acceptance and loving care. We have looked at some of the environmental factors which interfere with the mother’s care of her child. Let us now examine some of the emotional. These are commonly : 1. 2. 3. 4. 5. 6. 7.
A fixation to old relationships, especially with the mother or husband. Identification of the baby with a hated relative. Particular sexual difficulties. Rejection of femininity. General ego weakness. Not being able to lay aside particular interests of her own. A general difficulty with aggression.
A common fixation to an old relationship is where the patient has been dominated by her mother so that she feels she must still conform to her mother’s wishes and is not free to care for her baby. These patients respond well to psychotherapy, which should be started as soon as possible to avoid the relationship with the child being too disturbed, the baby being harmed or battered as happens in so many puerperal depressions. This type of patient is described in detail elsewhere [5]. Let me give an example of a patient who identified the baby with a hated relative. Some patients take a little time to get to know their babies but do so with the help of good nursing care. Others, however, have particular difficulty and become very tense and anxious because they cannot bring themselves to have anything to do with their children. One such patient was having her second baby. She kept remembering how differently she felt towards her first baby, when she had loved him from the start and could think of nothing else, whereas she was now not interested at all and had no tender feelings towards him. Yet she had looked forward to having the second child, who had come at a time that she had planned. She told me that she was brought up by her mother and her grandparents as her father had died before she could remember.
104
GWENTH DOUGLAS
They had all got on well together but later her mother had re-married and had another family. She continued to stay with her grandparents but had gone to visit her mother often and kept in close touch with her. She felt that this was quite a satisfactory relationship. As she was telling me this, she began to remember times when she did greatly resent her younger half-brothers and sisters, and having to look after them. She became very emotional. She said that her mother never knew about these feelings, and she herself was surprised at their intensity. It seemed that she identified herself with the first baby, and her half-brothers with the second. We talked about this and she said it made her feel much worse and want nothing to do with her baby ever. Then later she began to realize how strong the identification was and how unnecessary now. She was able to take to her baby and feel loving towards him, and became settled and pre-occupied in the usual way. At a follow-up interview some weeks later, she was happily living at home with her family and looking after them all with satisfaction As far as one can judge in such a brief contact, this patient was prevented from the first from caring for her child as she had hoped, by this specific identification, and I feel that psychiatric intervention during the puerperium enabled her to have a better relationship with her child than would otherwise have been the case. Particular sexual difficulties lead to anxiety and fear of what the patient might do to the child, which seems to be related to her own childhood. For instance, women who as children were lonely and felt their sexual feelings to be considered disgusting by their parents might have comforted themselves by compulsively masturbating. Such women are often afraid that in their wish to love and comfort their babies they may feel compelled to masturbate them. Sometimes patients can express this fear, when they can be helped by getting at their need to be understood and comforted by their mothers, but often they will be too ashamed or mistrustful to mention it, when they present as depressed, tense patients who are difficult to treat. Rejection of femininity is mentioned in the literature on puerperal breakdown. This has different meanings for various disciplines and so sometimes leads to confusion, especially as there can be acceptance of some aspects of femininity but rejection of the care of children. I will describe one extreme example of a woman who, although physically feminine, rejected her femininity almost entirely. Mrs. L. was seen in pregnancy because she wanted an abortion. She came from another country where she had lived a man’s life, taking part in a war beside men since her schooldays. She was considered a good shot, took considerable pride in this and her toughness and ability to kill. In this country she was pursuing an artistic career but had married a man who admired her spirit and talent. As he did not like women in the ordinary way and found her different, they suited each other well. The patient threatened suicide during pregnancy as she felt being pregnant was unnatural for her as she wanted nothing to do with being a woman. When I saw her after the confinement she told me that although she now had her baby she had not been present at the birth. She had been walking down a road at the time watching men mend the road. She could describe every detail. As soon as she got out of hospital she had been to this particular spot and saw where the road had been mended. She spent a lot of time asking people when it was done, and confirmed to her own satisfaction that while her baby was being born she was standing there watching the road being mended. She became obsessed with this in a way that was not usual for her. The content of her thoughts in the dissociation that took place during the labour seemed to persist and take the place of
Some emotional disorders of the puerperium
105
normal pre-occupation about the baby. She was in an agitated state for some time. She kept the child but never looked after him herself, any more than was absolutely necessary, using a nursery, paid help or her husband to do so, while she went on with her career. All my efforts to treat her and the good nursing care at the Cassel Hospital, both during pregnancy and afterwards, made no difference to her at all. Now let us look at examples of patients who have a general ego weakness which interferes with their mothering. Whereas a mature woman may have day-dreams of her children grown, there is also a feeling for the small, entirely dependent being to which she has given birth, women with general ego weakness cannot always bear this degree of dependence, and persist in expecting an older child and not a baby. One such patient was, at interview, extremely tense and it was difficult to make contact with her. She stood staring under such great strain that even being in the room with her made one feel anxious. It was only later that she could tell me what she saw when she was staring out of the window. It was a little girl playing happily. This was the child she had expected, a child able to play outside the house and at a distance from her, not the clamouring baby that needed her attention and whom she was expected to hold close to her to be fed. She hated to be roused and brought back to the reality of the dependent baby from the pleasure of seeing the happy child who seemed more like a playmate than a responsibility. Once she could talk about the little girl she had hallucinated, she could recognize that it was because she had wished for a grown child. This patient made it clear that if a woman is expecting a grown child, then a baby is a hopeless disappointment, and simple reassurance is not enough for her. She needed much help. Another woman, a chronic schizophrenic, had had a most anxious, tense and aggressive mother who controlled all her children’s lives, and they were all three chronic schizophrenics, well-known to their local mental hospital. Our patient, when in hospital, met another chronic schizophrenic, and when they were discharged they married and had a baby. The husband relapsed and was re-admitted to hospital. The wife caused concern during the puerperium. She could not really feed or wash her baby consistently, but she would not allow other people to do it either. She told me that she was shamed because her baby should be so tiny. She had expected a very much bigger child. Her guilt about her tiny baby made her hide him away under bundles of clothes, depriving the child of air and endangering his life. In some ways this schizophrenic girl was improved in her mental state by pregnancy, but the price that the baby paid was great as his life was endangered. Even after considerable efforts were made to give this patient treatment and support, both practical and emotional, she was not able to lcok after her child, who had to be taken into care of the County. My clinical impression is that an increasing number of patients show a conflict between their wish to pursue a career and their wish to have a child. Girls of all degrees of intelligence up to the highest who are studying or pursuing a career that interests them, want a child and become pregnant. They plan the child quite carefully, from their work point of view, so that it will be born during a vacation or slack period, with the intention of returning to work quite soon. It is only during the puerperium that things go wrong. On examination it becomes clear that they are surprised at the intensity of their feelings. They have little recognition of the child’s needs and the extent of their commitment if they are to bring up a healthy child. One patient said
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she had planned for some time to go away in a couple of years for a prolonged period in connexion with her work. It would not be possible to take the baby with her but she said it would not matter-“After all, he’ll be independent by then”. He would be two! She was, however, distressed at the hostile fantasies she was having towards her child in the puerperium. This happens to secretaries, nurses, doctors, teachers, even nursery nurses, all the common careers for women, so it is not due to the choice of any particular profession or occupation but more to do with the conflict of interests and the lack of concern and even knowledge of the degree of commitment required to bring up a baby to be mentally healthy. That these women have become disturbed in the puerperium does mean that there is a conflict and there is a side of them that wishes to be able to do this job of bringing up a child adequately. It appears that the wish to have a child is deep and persistent, while the ability to care for one is easily upset either by the environment or by the woman’s conflict within herself. REFERENCES 1. WINNICOTTD. W. Collected Papers, Chap. xxiv, Tavistock Publications (1958). 2. BENEDEKTHEREX Studies in Psychosomatic Medicine. Psychosexual Functions in Women, Ronald Press, N.Y. (1952). 3. GUNTHERMAVIS Instinct and the nursing couple. Lancet No. 6864 575 (1955). 4. LOMASPETERThe husband-wife relationship in cases of puerperal behaviour. Br. J. Med. Psychol. 32, (2) 117 (1959). 5. DOUGLASGWENTH Puerperal depression and excessive compliance with the mother. Br. J. Med. Psychol. 36, 271 (1963).