Gillian White PhD
“I’ll get it right next time”
Childbirth is an overwhelming life changing and highly emotionally charged event that invokes a variety of complex emotions. While the physical, social, spiritual and emotional context for each person directly or indirectly involved in the birth of a child is unique there are some universal emotions that affect us all. A picture of a young baby will usually evoke pleasant, happy emotions; the anticipation of labour will probably evoke a degree of anxiety in a first time mother; a perception of mismanagement at the delivery of his child may provoke anger in a new father. Such examples of emotions may be momentary or long term and demonstrate a single feeling. The reality, however, is that an event as momentous as childbirth evokes a myriad of emotions sometimes complementing each other and sometimes competing with each other. In addition the emotion felt may be ‘in the moment’ or arise from a past experience of which the individual is unconscious. Sometimes the emotion is ‘felt’ somatically as a physical reaction without a mental component, when for instance the person has a vague feeling without knowing what it is or why they have that feeling.
Although the mother is the focus of care during childbirth, a team of people are affected by the birth of a child. Most predominant is usually the father, then there are members of the family, friends, and health professionals. All are feeling both individual and collective emotions which often impact on each other and affect each other.
Many new mothers have an expectation of the emotions they ‘ought’ to be feeling that is historically and socially constructed and when their emotions do not meet their expectation a sense of confusion can arise accompanied by ambivalence and guilt. The picture of the radiant and serene Madonna full of love is not the reality for many women who may not even like their baby. The joy anticipated through breastfeeding may instead be despair. Affected by the displaced emotions of others the new mother often suppresses what she is really feeling. Instead of effectively processing the emotions she feels her usual emotional processing can be disrupted and she may become unhappy and depressed.
As hard as it is to provide an ‘emotional map’ for childbirth it is equally as difficult to resolve and validate the value of emotion. Historically emotions have played an inferior role to reason. “The idea that emotion is as such more primitive, less intelligent, more bestial, less dependable, and more dangerous than reason” is a claim made by Solomon (1993, p.3) as underpinning the early Greek argument that emotion should be controlled by reason. Traditionally in western society emotions were also largely genderised in that women have emotions, men stand by reason. Such a view supported the notion that emotional women were inferior, less intelligent, and dangerous, a view that is still often attributed to new mothers. It is therefore not surprising that some women appeal to reason in the transition to motherhood, prohibiting emotion, and are faced with the fact that a newborn baby is not reasonable!
In this paper emotions associated with childbirth are explored and a hypothesis is raised that failure to process emotions successfully can explain the emergence of conditions such as postnatal depression or post-traumatic stress.
What is an emotion?
It is suggested by Oatley (1993) that there are two complementary approaches to a definition of emotions; social constructionism and naturalism. The former approach derives from the theory that emotions are dispositions to behave in a certain way appropriate to social and cultural norms; the latter approach postulates that emotions have a biological base experienced as a pleasant or unpleasant sensation.
The social constructionist approach objectifies emotion as a ‘something’ which has a name e.g. joy, anger, fear, sadness, jealousy. The naturalist believes there is a biological basis for emotion that gives rise to responses. For example a social constructivist explanation of love might be that we enter a social role that has specific elements and standard rules i.e. what we should and should not do. Associated bodily feelings or disturbances are part of the emotion. Alternatively a naturalist explanation might be that our behavioural expression of love derives from neural mechanisms and that no constructive process could alter the felt emotion. It is clear that neither explanation on its own encapsulates the emotion of love but together they form an adequate explanation for the phenomenon.
A new mother is thought to be biologically prepared to love her baby by the hormone oxytocin released at birth and is expected to enter the mother role according to standard social and cultural rules, yet for some mothers ‘love’ does not happen. Having a baby is considered by society as a joyful event yet the new mother may not feel the joy. Is this a failure of her neural mechanism, a failure of her socialisation, or is there something else happening?
Emotions are subjective. We create meaning out of the context in which events occur. According to Frijda (2001) emotions are multicomponential, the major components being appraisal, state of readiness, physiological response and consequential feelings that are usually part of a larger whole. For a woman her emotions around childbirth will depend on her personal perspective and perceptions, and her appraisal of the situation and environment. Anecdotally women talk about whether ‘the right thing happened,’ or ‘I’ll get it right next time.’
Phenomenologically, emotions are perceptions and ‘just are’. From a functional perspective however emotions are interactive, operating between individuals and their environments so that a relationship between them and their environment is constructed. For example, a new mother may experience joyfulness and seek to implement a particular type of behaviour such as maintaining proximity and attending to her baby; alternatively she may feel distressed and seek to avoid or reject her baby. Such action tendencies are cognitive representations of her subjective experience, her motivation, and her readiness to deal or not deal with the particular environment she finds herself in. Onlookers make inferences from her involuntary behaviours and respond accordingly. Physiological changes usually accompany emotions and are part of the environment for example, tears of joy or tears of distress.
Cognitive appraisal of events that produce emotional reactions occurs in two ways. The event stimulates an affective value such as pain or pleasure; and/or a cognitive response occurs to cues or clues about appropriate action. The nature of the emotion can be modified by changing or extending the cognitive clues.For example, uterine contractions in labour are physiological and are associated with pain. The onset of labour may stimulate an affective value of pain (based on previous personal experience or experienced vicariously through the perceptions of others) and thus increase the pain experience triggering an undesirable emotion and inhibiting the release of the natural endorphin opiates.Alternatively the onset of labour may stimulate an affective value of pleasure (based on lack of fear or welcoming of the event through previous personal experiences or the perceptions of others) thus decreasing the pain experience and triggering the release of endorphins. In this example pleasure readily converts to pain as a result of experiences such as prolonged labour, fatigue, responses of others or a threatened danger. The example also implies that instead of emotional experiences creating a representation of the self they actually create a representation of the world and how ready we are to act in some way or another. In other words, emotions are called forth by our impressions of events as they are appraised and appraisals change as our impressions of our world change thus affecting our emotions. “Emotions are response structures centering upon changes in action readiness, called forth by events as appraised…include[s] recollections and thoughts, as well as perceived bodily changes” (Frijda, 2001, p.44).
In this attempt to define emotion it becomes clear that it is not a simple task. Emotions are not static or uniform. They are contextual, arising from different incentive conditions and associated with different external signs, actions and subjective feeling states. In the English language we are also constrained by specific labels given to emotions like love or joy as if they were a single entity.
In reality, there are a variety of expressions and interactions suggesting there is a family of emotions which make up constructs such as love or joy. Goldsmith (1993) considers the family of fear emotions for example as “scared,” “terrified,” “wary,” and “shy” (p.354). A family of love emotions might be “adore,” find irresistible,” “care for,” and a family of joy emotions might include “delight,” “happiness” and “pleasure.” Goldsmith (1993, p. 354) conclusively adopts the perspective that “casts emotions as processes of establishing, maintaining, or disrupting biologically or socially significant relationships with persons or objects in the environment either personally or at the representational level.”
Occasionally emotional experiences appear non-representational i.e. object-less. The emotion just seems to happen. Our tendency is to simply accept or actively escape. Postnatal depression, post-traumatic stress or overwhelming joy are possible examples. While an event or events may precede the depression, distress or joy it is not always clear what the event is. Instead then of attempting to discover and explain any particular event as causal it may be more beneficial to assess how the emotional reaction is being processed.
Processing emotions or experiences has entered common day language as a concept that says “I am mentally dealing with this…” The interpretation is that I am turning a stimulus (e.g. experience, information, crisis) that has disturbed me into a form that will resolve my mental disruption. The stimulus can be positive or negative such as the elation felt at holding your newborn baby for the first time or the anxiety felt as you realise the weight of responsibility that is now yours.
Rachman (2001, p.165) acknowledges that :
“it is easier to come to grips with failures of emotional processing than with successes. Broadly, successful processing can be gauged from persons’ ability [sic] to talk about, see, listen to or be reminded about the significant events without experiencing distress or disruptions.”
Childbirth is a stressful life event physiologically, psychologically, socially and spiritually. The stimuli experienced by a woman through pregnancy, labour, birth, post-natally and making the transition to motherhood are phenomenal. The appraisal of emotion producing events is consequent upon a constantly changing environment largely driven by physiological and biological components but also strongly influenced by social conditions. While most women appraise the events around childbirth satisfactorily and make the transition to motherhood smoothly there is no information about how maternal emotions are successfully processed. Indeed, if women were not able to successfully process or satisfactorily absorb their emotions they would be in such a state of arousal from their emotions and feelings that they would not be able to concentrate on the daily tasks of looking after their babies. There is no information either about deficient appraisal and processing of maternal emotions and the significance this may have on the course of labour, the transition to motherhood, and the development of postnatal depression and/or post-traumatic stress disorder.
It is usual for new mothers to be emotionally labile in the first few days following birth. They are recovering physically and emotionally and are under the influence of changes in reproductive hormones. Emotional recovery involves correct appraisal of events and processing accompanying emotional reactions. It is important that new mothers are supported and given practical assistance during this phase. Many cultures have traditional rituals after childbirth involving bed rest, controlled temperatures and special foods. Current western societies have largely denied women an undisturbed reflective period after birth to ‘deal’ with their emotions. New mothers worry about their mental confusion, inability to concentrate, and their disrupted behaviour in the early days because they do not know that this is normal.
Rachman (1980) has argued that where emotional experiences are incompletely absorbed or processed then certain signs may appear, for example, fears, obsessions and intrusive thoughts. He suggests there are three criteria to evidence that emotional processing has occurred:
1. An emotional disturbance
2. The disruption has declined
3. A return to normal, undisrupted behaviour
The extent of emotional processing can be tested by attempting to provoke the emotional reaction by presentation of the relevant stimulus. Unfortunately in the birth of the baby and all that follows, there may not be one discrete stressful event to be processed by a continuous unfolding series of new stressors and challenges, each needing to be processed.
Rachman focused mainly on heightened anxiety and post-traumatic stress following a discrete stimulus such as trauma. Thus a traumatic birth meets the criteria for studying evidence of post-natal emotional processing. Postnatal depression however is less closely linked to a discrete stimulus yet there is evidence of an emotional disturbance and also heightened anxiety forms a major component of the clinical features (Puri, 2000). In the following two sections I return to my hypothesis that failure to process emotions successfully can explain the emergence of conditions such as postnatal depression or post-traumatic stress following birth.
Postnatal depression (PND) is defined as a non-psychotic mood disorder manifesting as excessive anxiety, self-blame, sleep and/or appetite disturbances, depressive symptoms and suicidal thoughts or fears of harming the baby. Estimates of 10 – 15% of new mothers suffer postnatal depression with an onset of between 2 – 6 weeks postpartum (Brockington, 2004; Beck, 2000; Cox, 1993).
Teasdale (1999) argues that within the Rachman analysis of provoking the relevant emotional reaction by presentation of the stimulus material the kind of probe required is obvious but in the case of depression it is not. For many mothers post-natal depression is their first experience of dysphoric mood. The patterns of thinking activated may be mild and transient or intensified. Screening tools such as the Edinburgh Postnatal Depression Screening Scale (EPDS, Cox, Holden & Sagovsky, 1987) and the Postnatal Depression Screening Scale (PDSS, Beck & Gable, 2000, 2001) for PND claim to identify mild and major mood disturbances through the validation of specific cut-off points. Some mothers improve with family and peer group support, others with ‘listening’ therapies, cognitive behavioural therapy (CBT), interpersonal therapy (IPT), or other similar treatments, yet others require medication. In the cases where new mothers have previously been diagnosed with depressive illness it is possible that ruminative thought patterns, feelings of low self-worth, requiring approval from others exacerbated by fatigue and physical recovery from birth may occur in response to previous depression causing stimuli. This may explain why women who have suffered previous PND or general depression are more likely to suffer a recurrence in subsequent pregnancies. Teasdale (p.S57) suggests that “emotional processing should reduce the ability of triggering cues to reactivate depressogenic processing cycles at times of potential relapse.” As birth is a major stimulus for emotional reactions it seems clear that successful processing of peri-natal emotions is beneficial. A search of the literature found no references to postnatal depression and emotional processing.
Interestingly Teasdale (1999) in his work on emotional processing and the prevention of relapse of general depression may have an answer. He proposes that there are two qualitatively different levels of meaning and that interaction between the two levels of meaning both maintain emotional states and modify them through emotional processing.
1. Propositional Code pattern.
Meanings are explicit, correspond to single sentence type meaning, are easy to grasp.
2. Implicational Code pattern
Meanings are implicit, higher order, schematic models representing recurring patterns, themes and “deep” interrelationships obtained from experience, are not easy to convey and are associated with intuition.
It is only the implicational code pattern that can directly produce emotions and it is through the reciprocal interactions between proposition and implication that processing continues to develop and evolve.
If a woman has a negative view of herself as a mother i.e. “I failed to have a normal birth,” “My baby does not like my breast milk,” “I cannot keep the house tidy,” “My husband has turned off me because of my body shape,” “I am a bad mother” and is faced with an aversive, uncontrollable situation that will not go away i.e. the constant presence of the baby, the negative processing is likely to generate depression. Negative automatic thoughts feed into the propositional level creating negative specific meanings and reinforce the negative thoughts and at the same time dominate the interactions between the propositional and implicational levels. The information is ruminative, cyclical, focused on self and own shortcomings compared to the desired self, and related to self-blame about perceived personal inadequacies. Effects of depression on the body operate sensory feedback which together with contributions from the cognitive feedback loop endows the whole system with a self-perpetuating depression. As Teasdale states (1999, p.S64) “…the predominant subjective quality of such processing is thinking about the self, about depression-related thoughts and feelings and about how to understand what is going on.” The dominant controlling influence on processing is propositional.
Effective emotional processing demands a modification of the schema that maintains dysfunctional emotion. Full recovery occurs as the modified schematic model is accessed when presented with emotion-producing stimuli, rather than the old model.
Ineffective emotional processing occurs when habitual schema are not modified and become ‘stuck’ in propositional thinking. Mothers with postnatal depression report habitual, ruminative thinking about… Unfortunately, with postnatal physiological and biochemical recovery to cope with, a baby to look after, breast feeding to establish, broken sleep, and fatigue, it is easy to remain at the emotional processing level that offers specific, explicit meaning and that is usually “I am a bad mother.” In my experience a change in emotional processing is noted when the mother starts to ask the question ‘Who am I?’ (White, 2005).
Given that an understanding of emotional processing is essential to mediating emotional laden experiences it is reasonable to believe that failure to process emotions around peri-natal events successfully could explain the emergence of postnatal depression. While not the focus of this paper it is also reasonable to believe that emotional processing mediates the therapeutic effects of various interventions for preventing or treating PND. The hypothesis is therefore supported and now requires testing.
Post-traumatic stress disorder
When the concept of emotional processing was first introduced by Rachman in 1980 he related it to anxiety disorders. Later in 2001, he applied the concept to post traumatic stress disorder (PTSD).
According to the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders: DSM III (APA,1980) childbirth could not be viewed as a stressful event because it was within the normal range of experience. However in the later DSMIV (APA, 2000) a stressful event was defined as one seen as threatening either by the victim or the witness, thereby admitting subjective perception. While there remains doubt as to whether traumatic childbirth can result in full-blown PTSD a number of self-help groups exist internationally for parents who believe they have suffered e.g. Trauma and Birth Stress (http://www.tabs.org.nz); Birth Trauma Association (http://www.birthtraumaassociation.org.uk), and recently Beck (2004) published her qualititative study on “Birth Trauma: In the eye of the beholder.”
More likely to occur following birth is the development of characteristic anxiety, dissociative, and other symptoms suggestive of Acute Stress Disorder which resolve after about four weeks. As the symptoms mimic to some extent those of PND these conditions sometimes go hand in hand, the major differential being hyperarousal in acute post-traumatic stress and dysphoria in PND. Given the emotional lability common after childbirth, the lack of knowledge about normal mood adjustment, and the major component of postnatal depression being anxiety, more research is required to establish a clear differentiation.
In its unadulterated form the trauma in PTSD is exposure to a life-threatening experience. Women and babies die in childbirth: 1,800 maternal deaths in all developed countries and 1 in 48 in all developing countries; and almost 8 million stillbirths and early neonatal deaths (deaths within one week of birth) occur each year (Safe Motherhood: www.safemotherhood.org., retrieved 8/05/06).The perception of a life-threatening event is real for women in childbirth and for witnesses. The temporary loss of a fetal monitor connection can raise fear in a couple that their unborn baby’s heart has stopped. Urgent action and bustle in relation to a postpartum haemorrhage can raise fear of imminent exsanguination. Some new parents report exposure to abuse by maternity care providers or institutions that they have depended on or trusted and show trauma symptoms (Beck, 2004; White, 2005). A diagnosis of post-traumatic distress disorder may seem presumptuous yet the event has caused significant distress, a threat to integrity, helplessness, humiliation, and the scenario may be ‘played’ over and over again. Acute stress disorder may well be felt requiring effective emotional processing to avoid PTSD or PND. It must also be remembered that many women facing childbirth have survived past traumatic experiences which resurface at birth such as rape, sexual violations, torture, and being held down in an apparent hopeless, helpless situation.
Despite doubt over diagnosis it is patent that an understanding of the concept of emotional processing following childbirth can shed light on the potential consequences of disrupted processing be they depression, heightened anxiety, acute stress, chronic stress or post-traumatic stress disorder. Like PND the hypothesis about emotional processing and PTSD following childbirth is supported and now requires testing.
Birth occurs within a complex emotional context about which we know little of normal emotional processing. Emotional adjustments are required and sometimes these adjustments are not successful. That fact we do have evidence of in the prevalence of PND and post birth stress, distress, acute stress and possible PTSD. Thus failure to process emotions successfully could explain the emergence of conditions such as postnatal depression or post birth traumatic stress. The consequences of maternal mood adjustment disorders have a major impact on the social and cognitive development of the child and on marital relations. Indeed, we must not forget the fathers who may witness a traumatic birth event or are supporting partners with PND. They suffer too. Rather than “I’ll get it right next time” research into emotional processing and its effect on the birthing experience can assist new mothers (and fathers) to believe they have ‘got it right’ this time.