Introduction to Maternal (or Perinatal) Mental Health

Rebekah Shallcross @mamafeminologist
👂🏼 Clinical Psychologist & Researcher
Talking all things Women’s Mental Health
Mum to Arfie
Lover of second hand bargains, leopard print and cake 🍰

If you ever visit a Clinical Psychologist, one of the first tasks you may do together is develop a ‘formulation’ of ‘the thing’ you are struggling with.  This ‘thing’ might be ‘I feel sad all the time’ or ‘I have thoughts about harming my baby’.  Often there are lots of different factors that have contributed to ‘the thing’ you are experiencing, and the role of a Clinical Psychologist (with the help of  formulation) is to help you unravel all of those factors, and begin understanding the nature of ‘the thing’ and to begin to see where making changes might help.

So for my first article about perinatal mental health (the perinatal (peri = ‘around’, natal = birth), I thought it might be helpful to run through a formulation, to help you to see, why a perinatal mental health problem might develop, what it might look like, what factors might be contributing to it, and what can be done to help.

It’s important to stress that no formulation is the same, it will be different for everybody.  What contributes to mental health difficulties will be different for everybody.  Its complex, and not as simple as mainstream media will have you believe (i.e. you were born with a mental health illness or you weren’t).  Rather, what I hope to do here, is to get you thinking about some of the things that might be hindering your mental health, and some of the things that might be helping, and to try and increase the things that help, and lessen the things that hinder.  Of course, we can’t always completely get rid of the things that hinder, but the aim is, that by developing an understanding of what helps and hinders, we can try and tip the balance towards helping our mental health where we can.  And this really applies to the whole spectrum of mental health experiences, not just for those who are struggling, or who are experiencing severe difficulties, but also for those who are struggling a little bit, and of course, for those who might want to think about what things they can put in place now, before having a baby, that might help to tip that scale in the right direction before giving birth. And I hope by the end of this article you will have an idea of what things you can be doing, but also what help is out there for you as well.

In this article, I’ll aim to give you an overview, and in later articles, we will go into more detail on some of the points.  So please do get in touch if there are particular points that you would like me to expand on in more detail.

What is Perinatal Mental Health, What Causes it, What helps: A Formulation

There are many types of formulation that a psychologist might use.  The one that I will use here to illustrate perinatal/maternal mental health, is The 5P’s Model (sexy name right?!).  You’ll see where the name comes from shortly. It covers:

1. The Presenting Difficulty (We’ll call it – ‘What’s up?’)
2. The Predisposing Factors (We’ll call it – ‘The History of You’)
3. The Precipitating Factors (we’ll call it – ‘What’s been going on for you lately?’)
4. The Perpetuating Factors (we’ll call it – ‘What’s maintaining the difficulty?’)
5. The Protective Factors (we’ll call it – ‘what are your strengths and what is helping?’)

So let’s look at each one in more detail, and what are some of the things, particularly when it comes to perinatal mental health, that come up in each area.

1. The Presenting Difficulty: What’s up?

What is the difficulty that has made you seek help.  This is often something like ‘I have started having panic attacks’ or ‘I have thoughts about harming myself’

What is it? Mental health difficulties can ‘look like’, lots of different things, including (but not limited to):

• difficult emotions (sadness, emptiness, anger, worry, nervousness, panic, anxiety, grief, guilt, irritation), 
• difficult thoughts (I’m worried I’m going to drop the baby, people think I’m a bad mother, no-body likes me),
• Difficult physical symptoms (aches and pains, trouble sleeping, exhaustion, fatigue, palpitations etc.)
• Difficult beliefs about yourself, others and the world (I am not good enough, I am unlovable, I am unworthy, people are not trust worthy, the world is a dangerous place)

Sometimes, mental health difficulties can also look like hallucinations (seeing, feeling, or hearing things other people don’t seem to see, hear or feel) or Delusions (believing things that other people don’t generally seem to believe (e.g. I am not the mother of this child).   It may also involve thoughts, plans or intentions around harming yourself or taking your own life.

How common is it?

Mental health is something that affects everyone.  We all have emotions that vary daily.  No-one feels ‘happy’ all the time – it is normal for emotion and mental health to fluctuate.  That being said, not everyone struggles with mental health (although, I would hasten to guess that most people have to a greater or lesser extent at some point in their lives).  So for me, the most important thing to stress is that the period around becoming a mother, the perinatal period,(normally described as pregnancy and up to the first 1-2 years post birth) is a time where mental health difficulties can thrive for all the reasons I’m going to touch on below.  It is estimated that around 10-20% of new mothers will receive a diagnosis such as postnatal depression, obsessive compulsive disorder, post-traumatic stress disorder (PTSD) or postpartum psychosis. but that doesn’t capture the many more who will struggle but will remain silent about it and/or not receive a diagnosis. 

Who can be affected? Anyone. Literally.

2. The Predisposing Factors: The History of You

Predisposing factors refers to things about our environment growing up that have shaped who we are, and how we experience ourselves, the world, and others, and made it more likely to experience mental health problems.  For our generation, a classic example is not having our emotional needs met as children (for example, being met with anger, shaming or indifference when we were scared, upset, or had other big emotions that our adult caregivers found intolerable to manage for us in a kind, competent and compassionate way, often because they also didn’t have parents that were able to do this for them as children).

Mental health difficulties can affect anyone.  However, there will be some people who are more at risk at developing difficulties that others.  Some other things that happen in our lives can also contribute to mental health difficulties, including (but not limited to):

• • Lack of a Support system
  • existing mental health difficulties that are unsupported
  • Your own experience of being parented (often unconscious)
  • Previous loss of a baby
  • Previous or current experience of abuse, deprivation, neglect (emotional or physical) and/or trauma, oppression

3. Precipitating Factors: What’s been going on for you lately?

There are lots of things that contribute to our mental health, but becoming a new mother is such a seismic shift emotional, psychically, physically, mentally that it is no wonder that this is often a time that women are most likely to develop difficulties with their mental health.  So in its simplest terms one of the things that has gone on for you lately, that makes it more likely than any other time in your life that you will experience mental health problems is the fact that YOU JUST HAD A BABY!

The experience of birth, the physical recovery from birth, the sleep deprivation, the 24/7 care of a new-born, the hormones, the visitors, yet the loneliness, the adjustment to motherhood, the change in identity, the responsibility of keeping someone else alive, the changes to your body and going from just the two of you to a family of 3 or more and the permanency of it all, can all lead to feelings of overwhelm and impact upon our mental health.

4. Perpetuating Factors: We’ll call it – What’s maintaining the difficulty?

So along with the fact that a lot of the precipitating factors are ongoing, there are other things that help mental health difficulties to thrive.  I have grouped these into: 

1. Things about our society that keep mental health difficulties thriving, such as the lack of value placed on mothering, the lack of ‘a village’ to support new mums, the lack of honouring the transition to motherhood
2. Things that others do that keep mental health difficulties thriving – such as not supporting new mums,  having unrealistic expectations of new mothers, dishing our uninvited parenting advice, visiting the baby (when really we should be visiting and caring for the new mum), not providing practical help such as bringing food, doing laundry, looking after other children

• Things that we might do that keep mental health difficulties thriving – such as indulging our inner critic, not stating and maintain boundaries with others, believing our thoughts and feelings as truth, striving for perfectionism, the belief that we don’t have the power or capacity to change, not seeking help
• Things about our environment or situation that keep mental health difficulties thriving – such as ongoing symptoms of birth trauma, sleep deprivation common in the post-natal period, the reality of life with an infant, feeding difficulties, physical injuries from birth

5. Protective Factors: We’ll call it – What are my strengths and what is helping?

MAKE (clap) A (clap) LIST (clap)

Write it down now!

Everyone has strengths – and one thing we can be particularly bad at, is recognising what are strengths are. So think about, what are your strengths?  For example; I might write: I am a good mum, I take opportunities that come my way, I am empathetic, I am open to learning, growth and change. Then think about what previous experiences have you gotten through? For example, I might write: I have birthed a baby, I have survived & thrived through a divorce, I continue to live through sleep deprivation.  And then finally, think about what people/resources/networks do you have around you that you find helpful? For example, I might write: I have a husband who shares the load, I have playgroup where people are kind and listen and give me a cuppa tea, I have breastfeeding support café that I can pop into, I have a friends who are supportive and loving

So that my friends, is the basis of a formulation.  But a formulation is just the beginning…it’s developing an understanding of how ‘the thing’ developed and is maintained.  Hopefully, it might give you some prompts to think about your own mental health, what’s been going on for, and what strengths you have in managing it. 

How do I know if I need further support?

So you might then wonder, how you know if you have a ‘mental health difficulty’, rather than say ‘the baby blues’…?  Well mental health difficulties might play out differently for everyone.  Mental health is a spectrum.  There isn’t a clear cut line between ‘baby blues’ and ‘mental health difficulties’…generally postpartum mental health disorders are thought of as things that are more sever ‘not being able to look after yourself or your baby, or having thoughts of harming yourself’, and more enduring (they last longer).  But the truth is everyone will vary in the depth or severity of their experience, and everyone will vary in the length of time they have those experiences.  But what’s really important to know is that if you feel you need support (whether a lot or a little) don’t wait because you feel that you don’t meet someone else’s definition of what a ‘difficulty’ is – seek support.  It is better to go to your doctor, have a chat and feel better, than it is to not go, not feel better, not be provided with the right support and your mental health to get worse.

Where can I get further support?

There are numerous places you can get further support. 

1. Your GP
   The GP may be able to provide you with the level of support you need, or they may refer you to other services for support (such as specialist mental health services).  Your GP is a free service that is available to you.  Their purpose is to provide you with care.  You are never ‘wasting time’.  If you feel you don’t get the support you need from your GP, remember you can always request to see another GP.
2. Self-refer for Psychological Therapy
   You can self-refer for talking therapy here: https://www.nhs.uk/service-search/find-a-psychological-therapies-service/
   Or, if you can afford it, you can pay privately to see a therapist
3. Self-help materials
   There is a wealth of self-help materials in the form of online courses, podcasts, books, audiobooks and more!  It can be overwhelming to choose, but the good thing about self-help resources is they are often free, meaning you can try different ones to see which ones work best for you.
   A good starting point is: https://maternalmentalhealthalliance.org/