Letter to Midwifery Matters on Mental Health

Dear Midwifery Matters,

I would like to respond to the issue on mental health. I am writing as a retired midwife and psychotherapist. What follows is not scientific in the traditional sense, but is based on clinical experience. It is scientific in the sense that testable hypotheses could be developed.

I believe that the baby blues are entirely hormonal. When the baby is born and the placenta detaches there is a sudden, massive alteration to a hormonal balance which has taken approximately 40 weeks to develop. In my experience women often do not feel distress or a low mood and are often surprised to find themselves weepy. The baby blues should have blown over within the first week. If they haven't, it might be an indication that something more serious may develop.

I think the situation with postnatal depression is completely different. It is far more multifarious and individual. As an MSc student of psychopathology in the mid-70s we didn't consider either postnatal depression or puerperal psychosis. This omission has only just struck me. As a midwifery student in the late 70s we were taught that postnatal depression was unequivocally hormonal. I do not believe this. I think that postnatal depression has social, psychological and political aspects.

Socially when a woman becomes a mother she is often comparatively isolated. Certainly if she is a mother for the first time she has undergone a profound and irrevocable change in her circumstances. Subsequent babies alter the family dynamics. All changes involve loss and it is well known that certain welcome changes such as promotion or moving house can precipitate depression. The isolation of mothers is a political factor; motherhood is considered less valuable than paid work although it could be argued that it is the most important work there is since how a child is mothered plays an important part in his or her subsequent physical and mental health.

My practice as a psychotherapist was informed by psychodynamic principles and I believe that motherhood can evoke past trauma. This is obviously individual.

I have no personal experience of cognitive behavioural therapy. It is politically in good favour at the moment largely because it is considered evidence-based: in other words it offers data which is capable of quantitative analysis. I believe that human experience is very seldom capable of being broken down into units which are amenable to such analysis. I also believe that science is not as objective as scientists would like to believe. Theoretical preferences may reflect factors other than the rational. CBT is also popular because it is cheap.

I was quite shocked by some of the language in the article by Dr Caroline Hollins Martin. The phrase such as 'faulty thinking' implies that there is such a thing as right thinking. I believe that if people are deeply immured in psychological distress correcting their thinking will not address the depth of the problem. I think that CBT relates well to the kind of tick box culture which predominates at the moment and which has caused damage in other aspects of health care and education.

With regard to psychosis I was taught as a master's student that psychosis was found in similar proportions across all cultures. Yet in this society young black men are diagnosed with schizophrenia at disproportionately high rates. Either this diagnosis reflects institutionalised racism or psychosis is amenable to social factors. My personal belief with regard to puerperal psychosis is that it shares the same causative factors as postnatal depression but is more severe. In other words, the difference is one of depth rather than nature.

Yours, Meg Taylor