Postnatal depression (PND) occurs following the birth of a child. The trigger is the birth but the depression itself can be caused by any number of things. It is often viewed as a special category within the depression spectrum but we would argue that, despite its unique trigger, becoming depressed post-partum is still depression and should be supported as such.

The symptoms of PND are often categorised as low mood, unhappiness, tearfulness, irritability, tiredness, insomnia, appetite changes, lethargy, loss of interest in sex, negative or guilty thoughts, and anxiety. What is interesting about this list is that we are led to believe that all symptoms stem from being depressed rather than looking at the causes from a different angle. It could and should be argued that tiredness alone can be the cause of the rest of the symptoms and therefore depression can be a result of loss of sleep. Concerns relating to coping and nurturing whilst coupled with broken sleep can bring a parent to a level of exhaustion and anxiety previously unrecognised. Add isolation, feelings of inadequacy and a test of confidence into the mix and the result can be PND.1-5,7,8,11,13,15 Up to 15 per cent of women develop a form of depression after giving birth.1,7,14 Approximately two per cent will have hormonal PND, which is a treatable thyroid imbalance.7,8,10 Approximately 12 per cent will have situational PND, which, with the right therapeutic support, can be addressed.3,7,8,11,13,14

Peurperal psychosis

For less than one per cent of women this may become a psychotic illness, known as puerperal psychosis or post-partum psychosis, which can put both mother and baby’s life at risk. The onset of this condition is usually sudden and typically within two to three weeks of birth, although sometimes up to three months post birth. Common delusions and hallucinations include a belief that the new baby is evil or ‘the devil’. This minority of women initially require specialist psychiatric care in order to recover.1,8,9 It is thought to affect as few as one or two women in 1,000 (maybe more as it’s sometimes misdiagnosed, but certainly less than one per cent of women). Treatment usually involves anti-psychotic medication and a stay in a mother and baby unit until severe delusions and hallucinations have passed. At this stage it is thought that counselling and/or group support can be very effective, so you may encounter clients in private practice who have been diagnosed with this condition. The medical world hasn’t established an understanding of why some women develop postnatal psychosis, but the causes are commonly believed to be both hormonal and situational; the same as PND, but the condition tends to occur in women who have had a history of psychosis or severe mental health concerns prior to pregnancy.

‘Baby Blues’ isn’t, and shouldn’t be, categorised as PND. This is when a woman becomes emotional and tearful a few days post birth. This is hormone induced but passes within a few days.1 It is a result of the sudden withdrawal of high pregnancy levels of oestrogen, progesterone and endorphins. There is also a condition termed ‘Baby Pinks’ that refers to the intense ‘high’ that some women experience post birth.

PND and birth trauma: recognising the differences

As therapists we need to be aware of the difference between depression in the postnatal period and birth trauma. Although the triggers are similar, birth trauma is a form of acute post-traumatic stress disorder (PTSD) and should be treated as such.1,18

A woman should suspect that she has birth trauma as opposed to PND when she:

  • experiences an event perceived by her to be traumatic 
  • experiences flashbacks of the event, with vivid and sudden memories 
  • has nightmares of the event 
  • is unable to recall an important aspect of the event 
  • has an exaggerated startle response and is hypervigilant 
  • notices herself avoiding all reminders of the traumatic event 
  • experiences intense psychological stress at exposure to events that resemble or remind her of the trauma 
  • has physiological reactivity on exposure to events resembling the traumatic event, such as panic attacks, sweating, palpitations 
  • is plagued by fantasies of retaliation 
  • finds herself to be uncharacteristically experiencing cynicism and distrust of authority figures and public institutions
  • may be hypersensitive to injustice.

As with PTSD of any origin, when birth trauma goes untreated or persists, one or more of the following cover-up symptoms may develop:

  • alcohol and drug abuse 
  • eating distress: bulimia nervosa, anorexia nervosa, compulsive eating 
  • compulsive gambling or spending 
  • psychosomatic problems 
  • homicidal or suicidal behaviour 
  • self-harm 
  • phobias and panic disorders 
  • depression or depressive symptoms 
  • dissociation symptoms
  • fainting spells.

In the UK birth trauma is not currently included in the standard postnatal screening programme for mood/emotional disturbances following the birth of a new baby and is often misdiagnosed as PND. The likelihood is high, therefore, that some women currently diagnosed with PND may actually be exhibiting a traumatic response to their birthing experience.1,18 It is important to remember that it is the woman’s perspective on what constitutes trauma that is most relevant. It is easy for birth professionals to focus on the ‘positive outcome’ of the delivery of a healthy child and a mother who appears physically fit. However, we have experience of supporting women whose birth experiences were nonetheless traumatic, despite no apparent lasting health complications for mum or baby. If there are health difficulties or the loss of a child following a traumatic birth, then birth trauma might be more readily acknowledged. But we must not overlook the less obvious cases.

Sometimes women are encouraged by the medical profession to focus on the happy outcome rather than their anxiety, fear and possible anger about their birth experience. Following a very difficult pregnancy where she developed a dangerous condition called obstetric cholestasis and a resultant emergency delivery, Susan Utting-Simon recalls being told by her consultant that she should ‘remember how lucky you are – most women in such severe cases have a stillborn baby!’ She comments, ‘I can sincerely say that this did not serve to reduce my anxiety. Instead, like many other women, I felt guilty for feeling the way I did, and unable to voice my ongoing concern for my health and that of my baby.

‘My anxiety was heightened by the loss of my first child during birth many years previously and the lack of sensitivity to this fact added to my feelings of trauma, and triggered old traumatic memories too. I experienced flashbacks and auditory hallucinations of the moments surrounding both my birth experiences for many months. This could undoubtedly have been alleviated if someone had been prepared to listen to my concerns and help me process the events that occurred. As it was, it took me many months before admitting to my therapist that I felt traumatised by my birth experience, despite the fact that I had finally been blessed with a healthy baby.’

If you are supporting a woman with birth trauma it is useful to be aware that a specific trauma therapy could be more beneficial. Counselling alone may do little to alleviate severe PTSD symptoms and a referral or recommendation to a therapist who specialises in EFT, EMDR, the Human Givens rewind technique or other trauma treatments may support your client better.1,2,5,7,8,10,11,13,14,16 This does not mean that other forms of therapy are not useful, and some clients may benefit from a period of accessing a specific trauma-related therapy and then return to counselling to look at other aspects of their situation in the postnatal period.

Situational versus hormonal PND

PND is often incorrectly assumed to be a biological/hormonal condition. Surprising as it may be, however, there is no evidence that the majority of PND is due to hormonal imbalance.2-3,5,7-9,11,13,14,16 Less than two per cent of women suffer PND where the trigger is a hormonal disorder in which the body produces antibodies against the thyroid gland. About 10 per cent of women generally are thought to make thyroid antibodies and approximately two per cent of women are at particularly high risk of hormonal PND as well as damage to the thyroid gland. After delivery some women experience an enlargement of the thyroid as a result of producing thyroid antibodies, and this leads to swings in over- and under-activity of the gland. Over-activity causes anxiety, increased heart rate and palpitations, whereas under-activity causes autoimmune deficiency and excessive tiredness. These can be mistaken for ‘mood swings’ and are sometimes misdiagnosed as bipolar disorder. For women who have tested positive for thyroid antibodies, treatment with thyroxin after the birth may prevent the development of thyroid-imbalanced PND. If you are working with a woman and either of you suspect PND that isn’t situational, ask if a thyroid test has been considered.2-5,7,8,10

Situational PND is caused by the added pressure put upon a woman post-partum when her existing situation isn’t supportive or conducive to coping with the pressure of birth or parenting. This is called situational PND because the triggers relate to the woman’s life situation (physically, emotionally, environmentally, spiritually) and are not a hormone imbalance. Once you start to consider the challenges faced by most women when having a baby, it is easy to understand how situational PND can develop. For example, with the increasing number of women giving birth later in life, after establishing a career or personal life that might feel satisfying, we are certainly seeing women who are struggling with the life changes they experience when a baby arrives and throws all their planning and ability to ‘manage’ or control situations into chaos.

Some examples of situational PND

One client had worked for many years as a manager within a professional environment. She was competent in her field and enjoyed regular feedback regarding her success. Her pregnancy was planned and maternity leave appealed to her as an opportunity to bond with her new baby and step out of the high-pressure environment she worked in. However, several months after her baby was born she came to therapy exhausted and distressed. Her new baby simply wasn’t doing what she expected. She’d read all the popular guides about how to get baby to sleep through the night and feed at regular intervals, but baby simply wasn’t playing ball. On the one hand she said that she knew babies are all different and she needed to be flexible, but on the other she simply couldn’t accept that she couldn’t ‘get this right’.

The work focused on what it felt like to not be in control of the situation, and finding ways to respect and accept her baby’s routine, whilst also putting in strategies to help her get some sleep. Over time this client was able to acknowledge that her feelings of depression and difficulty in bonding with her baby were in part due to feelings of anger she felt towards this little human being who ‘simply would not be managed!’ and resentment that this new ‘job’ she had didn’t give her the
positive feedback she rightly felt she deserved.

Often women move away from family through accessing higher education or employment, so may not have a support network nearby. This may not have been an issue before becoming a parent, but the sudden awareness of needing more support than is available can be frightening, especially if a woman’s self-concept incorporates independence and little need for support. Alongside such women, there are women who through age or social circumstances find they are isolated or unsupported in real terms, even if on the surface they appear to have a large network around them. For example, very young mums may feel judged by mainstream maternity services and feel unable to acknowledge or even identify their needs.

Challenging assumptions

Susan Utting-Simon has had many clients in their teens who have voiced fears about being judged, or who have experienced birth professionals making assumptions. One young woman came to a point of almost giving up her baby for adoption because she couldn’t cope with raising a child on her own, but statutory services had assumed she was well supported because she lived at home with her mum. In reality, this client’s mum had a difficult and unsupportive relationship with her daughter and regularly put her down for ‘making the same mistake I did’, ie having a baby in her teens.

In a parallel example from her own personal experience, Utting-Simon found that her health visitor’s first visit post birth was equally unsupportive: ‘I lived in a deprived area and there were some very challenging family situations on the estate. When the health visitor arrived at my house she was barely in the door five minutes before casting an eye around my clean, well-maintained home and announcing that I clearly didn’t need her help, certainly not as much as “the women out there!” She declared that as “a mature mum” I was “obviously quite sensible” and capable of looking after myself, and she hurried off up the path advising me to “pop into the health centre” if I had any problems. I was feeling quite traumatised by my birth experience, had concerns about my baby’s health, and live several hundred miles from my nearest family members, so in fact felt isolated and vulnerable. I was very fortunate to have some excellent friends who stepped in and supported me, but that might not have been the case, and these examples simply highlight the importance of not making assumptions about anyone’s situation.’

Women from minority ethnic communities

Many minority ethnic communities have managed to maintain the extensive support that has traditionally been offered when a baby is born, but equally, many women from these communities find themselves alone and disadvantaged, particularly if language or culture is an additional barrier to accessing support. Women who might have been provided with a support network of women from their extended family can find it very difficult to access professional help, or ask for support from friends.

Utting-Simon worked for several months with a young woman of Asian origin who had moved to the UK to join her husband. She and her husband decided to start a family, but without having a network of family or friends she became depressed following the birth of her baby. Her husband had no living female relatives and so, for this client, her previous expectations of being ‘held’ and supported in emotional and practical terms by her female community members whilst she raised her child, vanished. 

‘She needed to feel part of a circle of women at this significant time in her life,’ says Utting-Simon, ‘and whilst my help was more emotional than practical, there were also times when I was able to signpost her to suitable services to help her fill in the gaps in her support network. Significant for this client was also my willingness to see her and her baby together. She had been told she was not allowed to bring her baby to therapy sessions by another private practitioner on the grounds that it would distract her from therapy, but of course this only heightened her sense of isolation.’

Women who arrive in the UK as refugees or asylum seekers will of course have the additional distress of whatever traumatic events have led them to flee their home country and concerns about waiting for their refugee/asylum status to be approved, alongside the challenges of a new baby, and potential language difficulties. The more of these emotional, physical, environmental and spiritual requirements that are missing from a woman’s life prior to pregnancy, the higher the chance of her developing PND.2-5,7,8,10

Treatments and why they can fail

Recent research states that antidepressants are no better than placebo when treating PND.15 SSRIs are designed to affect levels of serotonin in the brain, but only five per cent of serotonin is found in the brain.16,17 As stated previously, we know from research that PND isn’t usually a hormonal illness and, even if it is, the hormones affected are thyroid based and not a result of imbalance in serotonin.2-4,6-8,15 Yet clients are still routinely prescribed antidepressants which can alter how they engage in therapy. We will generally work with clients regardless of the medication they are on, and should not ethically advise against medication, but hopefully it can be possible to work with clients who are taking antidepressants to improve their lives so that they may feel that medication is unnecessary as their situation improves.

For PND sufferers counselling can provide a nurturing respite. If we study the list of PND symptoms we can see that a client may present in a real emotional and physical ‘state’ and, for the therapist supporting someone with PND, this can be daunting. But don’t panic! If your client is exhausted, without support, without nurture, low on cash, unable to heat her home, without family or close friends, with an absent partner, or has lost her support network or sense of self through no longer being in a working environment, then spend time finding out the root causes of her distress and help her to identify goals to address these. She is depressed because of her situation not because of her hormones. You will often find that something wasn’t quite right before she even became pregnant.

This is why it is important to understand that although the birth of a child can be a trigger, it isn’t always the cause of the depression. Help the woman to understand that it may not be her hormones as she was previously led to believe but that it’s about making lifestyle changes and gathering the appropriate support. It’s about working on confidence, empowering with access to appropriate information, supporting her to remember who she is, and reassuring her that feelings of exhaustion will pass. Counselling alone may not be enough and there are times when we may need to signpost clients to information and additional support. Leave your ego at the door and don’t be afraid to mention the possible benefits of bodywork, exercise (both yoga and Pilates can help women feel more in control of their post-partum bodies) or specialist trauma therapies.

As with any presenting issue, we cannot operate a one-size-fits-all approach when dealing with clients experiencing PND. Whether you are an integrative therapist or work from a purist theoretical perspective, it might be appropriate to offer your client information, or encourage her to seek additional kinds of support alongside the work you are doing together. Depending on the client’s ‘learning style’ there may be particular approaches/additional support that would be effective.

Men and PND

Generally, sufferers of PND benefit from a friendly, warm and non-hierarchical therapy, an environment where they can explore for themselves what their issues are, and be given the opportunity to work through them in a nurturing space, without fear of judgment. Clearly a male as well as a female therapist can provide this environment. Indeed, some women may welcome a male therapist, believing he may be more accepting of their feelings. One of the challenges many women face after having a child is a fear that they are being judged and found wanting by other, more experienced mothers. We all know that there is no handbook for raising children, and that being female in itself does not give a woman an inherited ability to know what to do in difficult and challenging situations with a new baby. However, some women may fear their female therapist will judge them, especially if they assume or deduce that the therapist has children herself.

If we work in private practice at home it can be difficult to remove all traces of a child in our midst if we are parents. This is important to bear in mind as a female therapist. No matter how tempting it is to offer advice on dealing with the challenges of raising a child, be mindful of appearing to take an expert stance with your client, who may already be feeling that they are not a good enough mother, and may project onto you the idea that you are judging them for not coping/finding it easy. It may be that a woman does prefer a female therapist, but at least in private practice we can usually assume that the potential client has chosen to contact us on the basis of what they know about us from our marketing. If they have contacted you knowing you are a male therapist, trust their decision.

Another consideration is that men will also be affected by the situational causes of depression that cause PND. Of course, without the trigger of actually giving birth, they will not be diagnosed with PND, but the root causes are the same. Similarly, people of either gender who adopt or co-parent in any circumstances, can experience the same challenges to their confidence, excessive tiredness and lack of ready support. In simple terms, this is why it is important to understand PND as a form of depression that occurs following the introduction of a baby/small child into one’s life, rather than a specific type of depression for which you need specialist training to offer support. If we look at the client’s situation more holistically, we can offer appropriate therapy, whatever our theoretical training. PND is treatable if we work to support our clients appropriately.

Susan Utting-Simon MBACP is a senior accredited counsellor/psychotherapist and supervisor based in Leeds. She offers face-to-face, telephone and Skype counselling/psychotherapy and supervision of practitioners from a wide range of working
environments. 

Lori Fitzgerald (Lifeboost-UK) is a natal psychotherapist and birth coach and the founder of The Fertility and Birth Network. Based in Leeds, she offers support throughout the UK via Skype as well as connecting clients to a larger support network in the birth arena across the UK, including doulas, private midwives and birth trauma specialists. Lori is an Associate member of BACP. 

All casework examples are composites of several clients to protect confidentiality. Clients have also given their permission for use of their material.

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