Behind the mother façade: when it’s not only perinatal anxiety and depression

Even before Amy* delivered her much-wanted, planned, second child, Elissa, she was feeling like she was losing a bit of herself every day. Her two year old, Jed, was exhausting; and no one seemed to be hearing  her concern that something was wrong. Doctors told her ‘he’s just an active child’ and ‘It’s too early to make a diagnosis’. Friends and family offered their own suggestions: ADHD, autism and, of course, poor parenting.

By the time Amy had been home with Elissa for a week, recovering from a caesarean, a haemorrhage and a blood transfusion, her anxiety was ‘through the roof’ and she was constantly telling herself ‘I can’t do this’. She had all the features of postnatal depression and anxiety (PND) that affect one in seven women—but she also had another symptom, one not as common. As much as she wanted to, she didn’t experience warm feelings towards Elissa, just as she hadn’t with Jed. She’d have been happy to have someone else look after her daughter. All the time. Is this part of the depression—and does it matter?

Research shows that Elissa, like all infants, need a primary carer who is sensitive to her needs in order for her to have a solid sense of self for all later relationships. If this attachment relationship to her primary carer is impaired in the first year of life, it can significantly affect later mental health.

Mothers might feel they start on an even playing field, but in reality, mothers start off from very different places. Most have less preparation than they get to drive a car. Antenatal classes focus on labour but after that everyone rushes to Google and their child health nurse.

Those with higher levels of education are more likely to ask for help—and to find it. More support, from mother and partner, decreases the risk of anxiety and depression. A family history of depression and anxiety may have given you a genetic predisposition. If your mother was seriously anxious or depressed—or taking drugs or alcohol—in pregnancy, this may affect your temperament and stress responses from the time you are born. And just as important, the sort of childhood you had—the mothering role model, the exposure to violence, abuse and bullying—shape who you are, and the lens through which you see your own child. And it can go from generation to generation. All mothers I see want to be the best mother they can be—some just don’t know how.

Amy is lucky. She has a supportive mother and partner, and no genetic predisposition she knows about. So why then is she struggling to feed Elissa, freezing around her and unable to persist when she refuses the bottle? Their interactions are tense and there appears to be little joy; Amy says she’s trying to ‘fake it until she makes it’—but there is a gulf between them. Why does Jed’s mess at the dinner table overwhelm her? Why does she thinks he hates her?

For Amy, from the moment she held each child in her arm,  their cries and their neediness opened up a painful chasm that had been deep inside her since she was a baby. Then, her mother had been grappling with four children and a divorce; Amy was left to cry, left for her older sister to care for, and had been encouraged to settle quickly, simply because her mother didn’t have the emotional space to give her what she needed to make Amy feel secure—to feel that someone was there for her and that she was worth it, the basis of secure attachment. Amy was also given food to ‘quieten her’. Food—and having things—became what helped her cope when bullied and inappropriately touched by her mother’s partner. But nothing every filled the void that said I’m not good enough.

Amy’s presentation is an example of Complex Post-Traumatic Stress Disorder. Like war vets with PTSD, as a child would have easily startled, been hypervigilant and anxious a lot of the time—but this started when she was an infant, so the stress response (cortisol levels) altered her biology permanently, and because it occurred through childhood, it shaped her personality, which formed around lack of trust and with the survival tools she needed. Treating the depression and anxiety won’t be enough, because her symptoms are core to her and how she relates to everyone—and how she brings up her children. Many of these cases slip under the radar, or get only partly diagnosed as PND or a personality disorder. On top of this are the more severe cases; many of the 300,000 cases of substantiated abuse cases each year involve parents with this disorder—and children who are developing it.

We don’t have a quick fix and treatment usually needs a mixture of medication—though as Amy told me, there’s no ‘magic happy pill’—and therapy. Therapy in Complex PTSD needs to address how you see other’s motivation. In new mothers, it especially needs to address how they see and parent their children. Amy has worked hard with a therapist and most of the time recognises triggers and what ‘emotional stuff’ belongs to her and what belongs to her child. Jed running to his dad rather than her does not mean he is rejecting her—but that he needs both parents, and that he has been confused as to why she has been in hospital with the baby and not him.

Amy isn’t ‘cured’. But she can see the light at the end of the tunnel.

And going towards the light means not just her feeling more confident as a mother, but that her children will have a better chance at having solid building blocks of their sense of self, that will protect them from later anxiety and depression. And stop the intergenerational transmission of trauma.  

 *names throughout and some details have been changed to protect the woman and children’s privacy

Want help with attachment security between you and your child? There are a number of individual therapists who work with attachment theory, and many maternal child health centres run attachment focused groups such as the Circle of Security (also see circleofsecurity.org ) and CHUGS (ask your maternal child health nurse or see piri.org.au). Some parenting books (eg Good Enough Parenting by Andrew Wake) work from an attachment theory base.

The Long Shadow is a rural psychological thriller set around a postnatal depression attachment group. Old sins cast long shadows…

Professor Women’s Mental Health, Austin Health, University of Melbourne,  author of the Natalie King Trilogy and The Long Shadow, out April 28th 2020. Co-author with husband Graeme Simsion of Two Steps Forward.

Even before Amy delivered her much-wanted, planned, second child, Elissa, she was feeling like she was losing a bit of herself every day. Her two year old, Jed, was exhausting; and no one seemed to be hearing  her concern that something was wrong. Doctors told her ‘he’s just an active child’ and ‘It’s too early to make a diagnosis’. Friends and family offered their own suggestions: ADHD, autism and, of course, poor parenting.

By the time Amy had been home with Elissa for a week, recovering from a caesarean, a haemorrhage and a blood transfusion, her anxiety was ‘through the roof’ and she was constantly telling herself ‘I can’t do this’. She had all the features of postnatal depression and anxiety (PND) that affect one in seven women—but she also had another symptom, one not as common. As much as she wanted to, she didn’t experience warm feelings towards Elissa, just as she hadn’t with Jed. She’d have been happy to have someone else look after her daughter. All the time. Is this part of the depression—and does it matter?

Research shows that Elissa, like all infants, need a primary carer who is sensitive to her needs in order for her to have a solid sense of self for all later relationships. If this attachment relationship to her primary carer is impaired in the first year of life, it can significantly affect later mental health.

Mothers might feel they start on an even playing field, but in reality, mothers start off from very different places. Most have less preparation than they get to drive a car. Antenatal classes focus on labour but after that everyone rushes to Google and their child health nurse.

Those with higher levels of education are more likely to ask for help—and to find it. More support, from mother and partner, decreases the risk of anxiety and depression. A family history of depression and anxiety may have given you a genetic predisposition. If your mother was seriously anxious or depressed—or taking drugs or alcohol—in pregnancy, this may affect your temperament and stress responses from the time you are born. And just as important, the sort of childhood you had—the mothering role model, the exposure to violence, abuse and bullying—shape who you are, and the lens through which you see your own child. And it can go from generation to generation. All mothers I see want to be the best mother they can be—some just don’t know how.

Amy is lucky. She has a supportive mother and partner, and no genetic predisposition she knows about. So why then is she struggling to feed Elissa, freezing around her and unable to persist when she refuses the bottle? Their interactions are tense and there appears to be little joy; Amy says she’s trying to ‘fake it until she makes it’—but there is a gulf between them. Why does Jed’s mess at the dinner table overwhelm her? Why does she thinks he hates her?

For Amy, from the moment she held each child in her arm,  their cries and their neediness opened up a painful chasm that had been deep inside her since she was a baby. Then, her mother had been grappling with four children and a divorce; Amy was left to cry, left for her older sister to care for, and had been encouraged to settle quickly, simply because her mother didn’t have the emotional space to give her what she needed to make Amy feel secure—to feel that someone was there for her and that she was worth it, the basis of secure attachment. Amy was also given food to ‘quieten her’. Food—and having things—became what helped her cope when bullied and inappropriately touched by her mother’s partner. But nothing every filled the void that said I’m not good enough.

Amy’s presentation is an example of Complex Post-Traumatic Stress Disorder. Like war vets with PTSD, as a child would have easily startled, been hypervigilant and anxious a lot of the time—but this started when she was an infant, so the stress response (cortisol levels) altered her biology permanently, and because it occurred through childhood, it shaped her personality, which formed around lack of trust and with the survival tools she needed. Treating the depression and anxiety won’t be enough, because her symptoms are core to her and how she relates to everyone—and how she brings up her children. Many of these cases slip under the radar, or get only partly diagnosed as PND or a personality disorder. On top of this are the more severe cases; many of the 300,000 cases of substantiated abuse cases each year involve parents with this disorder—and children who are developing it.

We don’t have a quick fix and treatment usually needs a mixture of medication—though as Amy told me, there’s no ‘magic happy pill’—and therapy. Therapy in Complex PTSD needs to address how you see other’s motivation. In new mothers, it especially needs to address how they see and parent their children. Amy has worked hard with a therapist and most of the time recognises triggers and what ‘emotional stuff’ belongs to her and what belongs to her child. Jed running to his dad rather than her does not mean he is rejecting her—but that he needs both parents, and that he has been confused as to why she has been in hospital with the baby and not him.

Amy isn’t ‘cured’. But she can see the light at the end of the tunnel.

And going towards the light means not just her feeling more confident as a mother, but that her children will have a better chance at having solid building blocks of their sense of self, that will protect them from later anxiety and depression. And stop the intergenerational transmission of trauma.  

 *names throughout and some details have been changed to protect the children’s privacy

Want help with attachment security between you and your child? There are a number of individual therapists who work with attachment theory, and many maternal child health centres run attachment focused groups such as the Circle of Security (also see circleofsecurity.org ) and CHUGS (ask your maternal child health nurse or see piri.org.au). Some parenting books (eg Good Enough Parenting by Andrew Wake) work from an attachment theory base.

The Long Shadow is a rural psychological thriller set around a postnatal depression attachment group. Old sins cast long shadows…

About annebuist

Anne Buist is the Chair of Women’s Mental Health at the University of Melbourne and has 30 clinical and research experience in perinatal psychiatry. She works with Protective Services and the legal system in cases of abuse, kidnapping, infanticide and murder. Medea’s Curse is her first mainstream psychological thriller. Professor Buist is married to novelist Graeme Simsion and has two children.
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