An interpretative phenomenological analysis
Name of Author: Dr Julie Hannan
Institutional affiliation; Middlesex University and Metanoia Institute. Doctor in Counselling Psychology and Psychotherapy by Professional Studies.
Author’s details: Clinical Director and Counselling Psychologist at Morency Therapy, The Mill, Radford Road, Alvechurch Birmingham B48 7LD. www.morency.co.uk Tel: 07530 854530 email: julie@morency.co.uk/morency-rooms.
Abstract
This study uses Interpretative Phenomenology Analysis (IPA) to explore the lived experience of postnatal depression (PND). The four participants, all aged 30 years or above at the birth of their first child, had never suffered from depression previously and were interviewed on two separate occasions about their PND experiences.
Six themes emerged from the interviews: striving to be a perfect mother; feeling a failure; being sucked dry; shame of the others gaze; feeling stuck and overwhelmed and becoming lost. Participants sacrificed themselves in the hopeless pursuit of their own expectations of being the perfect mother and fulfilling all their child’s needs. Not wanting to appear inadequate to others, and desperate to make sense of what was happening to them, they suffered in silence in a context of depleting resources, loss of their former life, wellbeing and sense of self.
The findings suggest that particular themes of PND exist within older mothers’ experiences suggesting a tailored treatment approach for these women.
In a situation where PND is the most common complication of childbearing in the UK, affecting between 10-15% of new mothers (Royal College of Psychiatrists, 2014) and where the birth rate for women aged 30+ is growing faster than for any other age group in the UK, research that furthers understanding of the experience of PND for mothers in this age group can help guide interventions and support.
The Study
Postnatal depression is under-diagnosed worldwide, with fewer than 40% of depressed mothers seeking help (Haynes, 2007). In the UK the most commonly used assessment tool for PND is the Edinburgh Postnatal Depression Scale (EPDS) a questionnaire-based quantitative tool.
Identification and treatment of PND is vital as infant development is particularly sensitive to the quality of the mother-child interaction in the first postpartum year (Logsdon et al., 2006).
Antidepressant medication is frequently used in the care and treatment of women suffering with PND (Misri et al, 2004) other treatments include Cognitive Behavioural Therapy (Chabrol et al, 2002); psychodynamic therapy (Cooper et al, 2003); and counselling, whether home, group or telephone supportive (Holden et al, 1989).
PND and delayed motherhood
In 2014 a report produced by the Office for National Statistics (ONS) found that over half (51%) of all live births in England and Wales were to mothers aged 30 and over.
With women within the age range of 30-34 years producing the largest amount of babies. The postponement of childbearing to later in life is a trend in most developed countries.
Research studies of PND have included women (both primiparous and multiparous) from across the fertility spectrum (17-48 years), with assisted or non-assisted reproduction technologies. The limited research into older mothering suggests that their approach and adaptation to motherhood is different and more intense with different personal expectations and higher levels of anxiety than other mothers. Few studies to date have concentrated solely on older mothers’ experiences of PND and so it remains unclear if the support needed by a single teenage mother with PND with an unplanned/unwanted baby is the same as that required by a 35-year-old professional woman in a stable, loving relationship who develops PND after the arrival of a longed for baby.
The growing number of older mothers with PND is likely to increase future demands on health care professionals, doctors and midwives. Research which improves understanding of the nature of PND needs for these mothers can benefit health services, improve the appropriateness and cost-effectiveness of treatment programmes and clinical interventions offered to them.
Criteria
The inclusion criteria specified that all participants would be women who had had their first child when they were aged 30 years or older. This child would have been born within the last 5 years and the mother would have to identify with feeling ‘down, with little interest or pleasure in doing things’ for a period of at least two weeks within 4 weeks of giving birth to their child and was now recovered.
History of depression is identified as a major risk factor for PND, so women without a previous history of depression were chosen to rule out any comparisons of previous depressive episodes. Primiparous mothers were chosen to capture a woman’s first experience of PND rather than a second or third experience, whose impact might have been lessened by knowledge and practice of coping strategies learned from previous PND experiences. By choosing women aged 30+ this study specifically targeted the fast growing category of mothers in England and Wales.
Participants: 4 women came forward for interview. Three were aged 30-34 years and one was aged 35 when they had their first child. All four women were white, middle-class, English-speaking, highly educated and married. Three were from the UK, where their first child was born, while the fourth and her child were from outside of the UK.
Data analysis: The participants were interviewed twice with a gap of 4-6 months between interviews. All interviews were transcribed in full and analysed using IPA (Smith, 1996). IPA is concerned with the detailed examination of human lived experience via in-depth interviews with a small number of participants.
A number of sub themes emerged from the participants’ interviews, which were then grouped together into six superordinate themes that appeared to resonate strongly with participants’ experience and are presented below.
Findings:
Striving to be a perfect mother
This theme highlights the participants’ intent to be the best mother they could possibly be. All had been looking forward to becoming mothers, were excited about having a baby and all held expectations, not only about the kind of mother they wanted (and were going) to be but also about how the experience of motherhood should be for them.
Rachael’s pre-delivery expectations of motherhood were clear:
I thought I wanted this (baby) for so long, I’ve been given this chance and it must be perfect, it must be amazing and I’ll never be able to do this again.
For some, being the ‘perfect’ mother meant giving the baby the ‘perfect’ start, for others it was about enjoying motherhood in an effortless way, projecting a perfect mother image to others, or having a baby that was soothed quickly.
Mary expected motherhood
would all just happen naturally and that I would be really good.
All four participants expected to adapt ‘naturally’ to motherhood and enjoy it, but over time they found the lived experience of being a mother very different from their expectations.
When the mothers found themselves falling well short of their own expectations, they experienced disillusionment, feeling perplexed and despondency.
All were used to coping and working successfully through any difficulties they encountered during their lives before motherhood. Not questioning the appropriateness or relevance of the standards they expected to achieve, only themselves, they began to believe they were somehow at fault or doing something wrong. Ultimately, all of them felt deskilled, with a deep sense of failure.
All of them knew quite soon after birth that something was wrong, but not all women identified their symptoms as PND.
Feeling a failure
Failing to live up to their own expectations of being the perfect mother was a scary ‘new’ experience for the mothers and one they feel ill-equipped for. The sense of failure has a self-punishing element to it as they turned on themselves for their perceived inadequacy.
Mary described her sense of failure thus:
I’m not very good when I can’t do something, when most things come to me quite easily…So I think part of me was that I had failed and that I had failed (my child).
This new world of ‘failure’ challenged their self-identity and unsettled them, blinkering them to the positive things that were happening for their children. In reality all the babies were thriving, reaching developmental milestones with no concerns about their progress being raised at the health clinics their mothers were attending.
Punishment for failing is never directed outwards towards the baby or others but is internalised. While one mother resorts to self-harm, others consider it in an attempt to cope with the feelings they are experiencing.
Judy described her attempts at self-harm:
Never was there a thought of breaking anything or harming anything, just…me…I was always thinking I was failing…I didn’t know what to do at all and once I was on a complete downwards, I would try and hurt myself.
Their unspoken worry about how different and inadequate they felt generates shame and concerns about not being understood by others. As Rachel put it:
I’ve never really failed at anything so people just don’t expect me to struggle with things or find things difficult, and I think when, when I did tell them they thought I was partly joking.
The diagnosis of PND seemed to increase their sense of failure rather than help clarify or explain it.
Rachael said:
I can’t suffer with that, there’s nothing wrong with me, I’m fine. It doesn’t affect people like me.
All four participants were capable, professional women who had rarely failed at anything in life. It was the mothers, not the babies, who were in danger. Their endless attempts to make the situation ‘better’ by providing baby with what they felt it deserved were being made at the expense of their own self-care. Caught in this unrelenting daily cycle, the mothers had problems eating and sleeping. They began losing their appetites, their personality, their energy, their desire for anything.
Shame of the other’s gaze
This theme shows how part of the experience of motherhood with PND involved shame: shame at being seen as deficient by others and also shame at feeling unable to ask for help. This led the mothers to withdraw from family, friends, other mothers, and health professionals. Participants were aware of the stigma attached to mothers with postnatal depression and had mixed feelings about letting other people know of their difficulties.
Sophie took pains to disguise her inner turmoil:
If I took Jonny into (his father’s) work, I had to make sure I put make-up on and done my hair and was looking like we were a happy family and be jealous of us because we’ve got it all going on…because I was so controlled and good at my job before I had him, I can’t seem that I’m failing…the myth, the image, you’ve got to keep that up!
The stigma of mental ill-health, and the fear and risk of being judged by others because of it, acts to silence the mothers.
When Rachael told her parents about her PND diagnosis, she found herself battling their incomprehension and prejudices. She said:
Mum was very upset and was very concerned that it was something she’d done …Dad didn’t want to talk about it at all.
Participants’ accounts also made it clear that sometimes health services also failed to provide them with a safe haven. Some health professionals did not seem to understand how disempowering and unfamiliar it was for new mothers to think they were being seen as deficient. The delicacy of the participants’ situation — their need for reassurance, their fear of judgement and their own fragility — was also reflected in their interactions with health professionals.
Sophie strove her best to keep up appearances,
Particularly to the health nurse, because she was there to judge me – that was her job! Really her job is to make sure that we’re ok and that our babes are ok, but I thought ‘she’s judging me…’
The PND thus swathes the mothers in shame. The shame is silencing and becomes entrapping for all the participants.
Feeling stuck and overwhelmed
Central to this aspect of their experience of PND was the mothers’ inability to ask for help: they felt they ‘should’ be able to sort out things for themselves. Anxious to understand what was going wrong, they could see only one ‘solution’: to try harder and ‘push on’ with their efforts while ‘pushing down’ their sense that all was not well. The cycle is one of hopelessness and entrapment.
Sophie described the nightmarish quality of this experience, which she likened to a ‘vortex’ that was sucking her in though she was desperately trying to get out.
The mothers hid their difficulties rather than ‘burden’ others with them and trying to protect their loved ones from worrying about them. This led them to disguise the full extent of their distress, so that the pain travelled inwards rather than outwards, creating another cycle of ‘stuckness’.
This downward spiral of emotional turmoil contained an embodied element: a splitting-off or dissociation which Rachael described as “just like an out of body experience”. In order to manage their emotional distress, the mothers not only had to disconnect physically from others but also experienced an internal emotional disconnect, as if to prevent them having to acknowledge the change in themselves and their circumstances.
Two months after having her baby, Judy knew she “wasn’t quite right”’ but didn’t want to go to her GP:
I knew she would just write a prescription and send me away…that wasn’t what I wanted’.
As the mothers struggled desperately to understand what was going on, they were conscious that something big and important was happening, something that needed to be understood so it would not happen again. None of them saw medication as offering that explanation.
Becoming lost
Having sacrificed their ‘old’ professional self, participants experienced themselves differently and this triggered identity issues.
Sophie recognised the difference between her new self and her old one:
Old me was professional in my job, my job was timelines and process and controlling…but all of a sudden I was responsible for someone else who didn’t fit my order…there was no turning off… I lost all sense of who I was. I lost me completely, because me didn’t exist…I just didn’t understand how I could completely lose my personality and there was no hope of that ever coming back.
Giving up responsibility for the child was not an option as this could potentially further damage their already fragile sense of self. As Judy said:
It never crossed my mind to leave her with anybody else…that’s the last thing I wanted…I wanted to keep looking after her even though I couldn’t really cope with it very well.
It seems the women become objectified as mothers and lose their own personhood and identity. The prioritising of the child overshadows the needs of the mother, who becomes lost in the process.
This invisibility is reinforced by the attitudes of health professionals. Rachael recalls that
They (health visitors) never asked about me, they only ever asked about breastfeeding and they seemed quite pleased that I was doing that, not for me though, but for the baby. They never asked me questions about how are you coping with that or that night feeding or anything, it was just about the practical implications for the baby, umm, but very little about me.
Mary recalled ”it made me think maybe I’d have been much better if I’d had more severe postnatal depression, then they’d have to take notice”.
What emerges from the mothers’ narratives is their yearning to be seen and acknowledged as a person, not just as a mother. To be ‘found’ appears to be connected to acceptance that the experience of motherhood has led to a changed existence. This is a frightening prospect. Mary describes this process of acknowledging and incorporating a changed self thus:
I guess maybe by accepting (a new me) it I guess you had to acknowledge that the experience had happened, really happened and it wasn’t something that was actually going to go away and it was something that was actually going to be part of me.
The participants describe losing their old identity and, for a while, not having a new identity into which they could step comfortably and confidently.
The process of being ‘found’ is however aided by counselling. Participants mention various reasons why counselling proves helpful. Firstly, it gives them the opportunity to speak to an independent person, someone unconnected to them who won’t be burdened by their worries. Secondly, it seems connected with feelings of not being judged. Thirdly, counselling is seen as removing the threat of someone stepping in and taking the child away by its promise of emotional support, help and understanding.
Mary describes her experience of counselling thus:
I think it’s also speaking to someone who has no experience of what I went through or vested interest in me or anything like that which makes it easier to have that conversation I think…not kind of worrying if I describe what’s happening you’re not going to feel, ‘Oh God, I could have been more supportive’…I think that’s what I’ve found helped with the counselling at the time; being able to have a conversation and not having to worry about the impact of what I was saying.
Judy says of her counselling:
It was just nice to open up and just tell somebody all the panics that I had got into…somebody who understood why you were saying it and somebody who was reminding you that it was an illness and not to feel guilty about it.
Discussion
Perhaps the most compelling findings from this study was that for the participants, the antidote to being lost was being found again. They embarked on a recovery journey of personal understanding and increased self-awareness, made possible through counselling.
What is clear from the current study is that even though at times the participants weren’t fully aware of what was wrong with them, they instinctively knew that medication alone would not be sufficient to make them well, release them from their emotional ‘vortex’ and ultimately satisfy their desperate need to understand what was happening to them and how to fight a possible recurrence of these difficulties in the future.
Participants’ need to talk about their experiences with a person for whose feelings and reactions they did not feel responsible is a prominent and unambiguous finding of the current study. This finding adds a fresh dimension to previous research. In the current research, most of the participants had social support and accessible family around them but felt that they couldn’t ‘burden’ their families with their problems, the more so because they were so used to dealing successfully with and feeling responsible for their own problems – can be factors that work against their wellness.
The reluctance of the participants in the current study to rely solely on medication as the means to overcome their PND, and their determination to get to the root of the problem, raises the possibility that such attitudes may be part of the PND experience of older, capable women used to overcoming problems and achieving success in their lives. Not wanting to ‘burden’ family members with their problems, emphasises the need for these women to be given the opportunity to explore and/or express feelings in a ‘safe’, non-judgmental environment, away from family and friends.
The gap between women’s expectations of motherhood and the reality they experience has been frequently noted in research containing women’s narratives (Antonis, 1981; Blum 2007). There is considerable scope for future research into how ideals of being the ‘perfect, natural mother’ are formed. The current study highlights the natural desire of each mother to provide for their child. This appears to spring not from a sense of duty but rather from a position of love for the child and a desire to take responsibility for the care of the child. Those participating in the current study did not seem to consciously deny their own needs; rather, their own needs just never seemed to enter the frame or occur to them, so all-consuming was the nature of their care for the child.
It seems the ideology surrounding motherhood as a happy and fulfilling experience (Ussher, 1990; Nicholson, 1993) continues to permeates contemporary society setting women up to develop a sense of failure when reality does not match expectations. The image projected is of women feeling fulfilled (Nicolson, 1990) in their new role as mother, happily attending to the needs of their child and adapting seamlessly to the tasks of motherhood (Sears, 1985).
The role played by the media in forming people’s ideals and reinforcing myths has been investigated to some degree (Choi et al, 2005; Hadfield et al, 2007). However, there would appear to be scope for further research into socially constructed, ‘idealistic’ media representations of perfect mothers and motherhood and the impact these may have on new mothers.
Beck (2001) lists some of the significant predictors that have been recognised as putting mothers at risk from PND; low self-esteem, childcare stress, prenatal anxiety, weak social support, poor marital relationships, history of previous depression, infant temperament, maternity blues, marital status, socio-economic status and unplanned/unwanted pregnancy. On the basis of this list, the participants in this study do not emerge as ‘obvious’ PND candidates given that they did not have many of the risk factors quoted.
The participants themselves seemed to know at varying points after giving birth that they felt ‘different’ or that something was ‘wrong’. Yet it took time for them to label symptoms as PND, despite them all being well read in mother-and-baby literature and aware of the existence of PND.
Whilst acknowledging that among some women there may be a resistance to being labelled with a PND diagnosis, these findings do question the accuracy of symptoms listed in the DSM and support other findings which challenge the appropriateness of the DSM diagnosis (O’Hara & Swain, 1996).
All participants were looking forward to becoming mothers. Feeling a failure was a new experience for them.The punishment for failing was directed inwards, not towards the baby, with one of the four participants going as far as to self-harm. Self-criticism was the order of the day; none of the mothers reported being openly criticised by anyone else.
Together with their sense of failure, the participants experienced a profound loss of optimism. They seemed to have no expectation that things might get better sending them “spiralling downwards” (Beck, 2002, p.453) into a vortex.
The participants in the current study attended meticulously to their babies’ needs; if anything, they ‘over-loved’ their offspring, to the detriment of their own wellbeing. Never in any danger, the babies were stimulated emotionally, socially and educationally by their postnatally depressed mothers. As they tended their new arrivals, the participants kept their suffering locked away from family members, other mothers, health professionals and close friends. They seemed imprisoned in the practice of self-silencing. The shame they experienced at not enjoying motherhood was thus kept hidden until they found the safety of the counselling room.
One aspect of this self-silencing, which does not feature in previous research studies and which may be of particular relevance to older mothers, is that many older mothers may have been trying for some time to have a baby, or may even have been told they were unlikely to have children. In the current study, Rachael was a case in point about to start IVF, she conceived naturally. She said of motherhood:
‘it came along and it was really grim and so I thought I really do want to complain now but I can’t because I’ve got this precious little gift miracle and he’s still hard work.
Perhaps the socially constructed view that older mothers ‘have it all’ — a strong long-term relationship, a high educational level, a professional background, sufficient financial resources to be a fulltime mother, and success in pushing biological boundaries to have a healthy baby – merits further investigation as a possible contributory factor to their experience of PND. Expectations around such women feeling ‘grateful’ for their situation may contribute to their inability to speak out.
Recommendations and implications for practice
There now appears to be a growing body of evidence from research studies that suggests that postnatal depression experiences are different for older mothers and those women of advanced maternal age (AMA) that is aged 35 years plus. This study recognises three areas that would benefit from attention to ensure that adequate and appropriate support is being provided for these women; (1) Antenatal care and education which addresses damaging ideological portrayals of motherhood within society and the media. (2) The identification of women postnatally with PND symptoms who perhaps haven’t recognised those symptoms as being PND. (3) The provision of relevant adequate support and treatment programmes appropriate to the difficulties older mothers experience. These three areas are considered further below.
With regards to antenatal care, the identification antenatally of women who may go on to suffer PND postnatally feels significant. The need for appropriate, age-sensitive antenatal education emerges clearly from the current study and the role for psychology and psychologists in the design of these workshops is essential. For example, workshops might be offered on the less positive aspects of motherhood, including its ability to feel like a conflicted space in which women’s expectations are not met and where they can feel disillusioned and cheated. These workshops may highlight the difficulties women have transferring competency skills from their work life to their new motherhood life as found in Carolan’s research (2003) and the feelings of failure and underperformance which may be associated with this. It is important that women are warned that, along with the excitement of having a wonderful new baby, they may also experience elements of loss relating to their role and life before motherhood. The difficulties highlighted in these workshops that many women experience in their transition to motherhood need to be reframed as part of an adjustment process, rather than as evidence of personal inadequacy and offer opportunities to recognise and challenge socially constructed images of happy, contented, perfect mothering.
Recognising that ‘intense mothering’ is targeted to middle-class women and that Rutledge’s (1991) research suggests that higher levels of education contribute negatively to the process of maternal adjustment, this is an area where midwives and other health professionals can be mindful of some of the challenges older pregnant women fitting that description face when attending clinics. The challenge of socially constructed images of the ‘type’ of woman who might suffer postnatally can also be addressed, particularly as this current research project dispels Beck’s (2001) ‘typical’ postnatally depressed woman, which might also limit feelings of shame. Asking for help should be encouraged at this stage antenatally; women need to know that feeling overwhelmed can lead to feelings of detachment and that, despite this, their babies are safe and well cared for. In common with other research, this study highlights the importance of optimism, self-soothing, and stress management for mothers seeking a way out of the emotional vortex of postnatal depression. However, women cannot be taught the value of hope if they are encouraged to approach motherhood with unrealistic expectations and remain ignorant of the challenges which lie ahead. Such a situation leaves them ill-prepared for difficulties and can add to their sense of being ‘cheated’ out of an enjoyable transition to motherhood.
The identification of women postnatally with PND symptoms who perhaps have not recognised those symptoms as being PND also appears to be an issue within postnatal care. In the UK the most commonly used assessment tool for PND is the Edinburgh Postnatal Depression Scale (EPDS) a questionnaire-based quantitative tool used for mothers of all ages. Yet in this study the majority of participants failed to recognise their symptoms as PND. There appears to be something in the identification of PND that plays out here alongside the non-recognition of symptoms. This is an area I believe there is scope for change which may help identification of women suffering with PND early on so they can access treatment programmes.
I believe there is an opportunity for a new assessment tool for PND to be developed for older mothers and those of AMA that is more relevant, suitable and better able to capture the PND experience of these women. The EPDS was developed in 1987, when the diagnostic and landscape of motherhood was very different to today. A new up to date assessment tool which reflects and acknowledges womens differing age categories and life experiences upon entering motherhood based on the growing body of evidence which supports the differing PND experiences of women at different points of their lives, could be a great help to identify women with PND.
For example the findings of the current study suggests that older mothers, particularly those within the 30-34 year old category may identify less with the current EPDS statement ‘I have been anxious and worried for no good reason’ and more with statements such as ‘I feel it is my responsibility to provide solely for my child’ or ‘I feel I can’t complain about motherhood because I chose it and should be grateful that I have a baby’ or ‘I’m upset that I’m not enjoying motherhood more’.
Likewise the gap between expectations of motherhood and reality which has been raised in numerous studies could also form part of this new PND assessment tool. Statements such as ‘I feel I should be doing a better job at being a mother’ ‘Motherhood is not as enjoyable as I expected’ requiring an answer. Once these women are identified, appropriate treatment and care programmes need to be based upon the growing body of research which captures older mothers experiences of PND.
It seems older mothers are reluctant to rely solely on medication as a means of overcoming their PND. This study has highlighted participants need for understanding the difficulties they are experiencing and the value they placed on an ‘independent’ person for them to share their difficulties with, whose feelings they did not feel responsible for. Perhaps befriending and counselling services should be encouraged on a national scale. Further research into the positive aspects encouraging recovery from PND would help support this. A poignant finding within this project for health professionals and midwives is that despite the mothers in this project having social and family support, their feelings of responsibility, shame and inadequacy prevented them from accessing that support. There should not be an assumption that women who have access to their families and a network of friends will be adequately provided for emotionally.
Mothers with PND require increased opportunities to create their own cultural practices and to alter the way they are conceptualised by others, whether health professionals, family and friends, or other mothers. I encountered difficulties in locating just four women who fitted the criteria for this study and were prepared to take part, there appears to be a reluctance on the part of women to come forward. Perhaps this reflects a more general reluctance to ‘speak up’ about PND. If such is the case, I hope that this study contributes to an opening up of discussion and stimulates further research into women’s lived experience of postnatal depression which encourages the provision of relevant treatment containing practical parenting skills, educational workshops, appropriate assessment tools and emotional support from informed health professionals, both antenatally and postnatally for older mothers to help boost their confidence and generate optimism.