Thoughts on pollution, disassociation and risk assessment

I'm not sure how useful any of this may be. It's pretty free associational.

I first thought about the language of pollution. There is a book of writings by feminist theologians called Through the Devil's Gateway: the devil's gateway is of course the birth canal.I'm not sure who the editors are, I think one of them may be Jo Garcia.I seem to remember a number of the writings were looking at traditional Christian views of women which see them as both polluted and polluting.The vocabulary chosen by the community midwives in your research seems to imply an internalisation of similar values.I also think that the choice of such language indicates considerable anger and I suspect the anger is about the lack of resources which leads to the sense of being exploited.

I'm not sure of the situation in the real world of the NHS at the moment but I suspect that these midwives' feelings are quite legitimate.I re-read the chapter I submitted for your book on supervision of midwives and I noticed there that I mentioned how lack of resources exacerbates the tendency towards 'regressive' defences such as splitting and projection.It seems as though the clinical supervision was perceived as yet another burden rather than something which would increase their resources. This doesn't surprise me: Isabel Menzies- Lyth found that any intervention which brought NHS staff into a closer realisation of the emotional reality of their work and their clients' experiences increased stress levels.

I was talking with my friend Linda about how it is that psychotherapists and counsellors do not find their clients' emotional reality burdensome and we found ourselves talking about empathy. There is a definition of empathy (but I cannot give you any reference for this) which emphasises the 'as if' quality.In other words, I am open to my clients' emotional experience but I am not experiencing it as mine.The idea of structure seemed important for me here too.When I was practising psychotherapy the sessions were bounded and predictable.Midwifery can't be predictable in the same way.And the training for psychotherapists and counsellors places an emphasis on self-awareness in the way that midwives' training doesn't: the NCT must have some literature justifying their requirement that trainee antenatal teachers debrief their experience.This might be relevant.

To return to Isabel Menzies- Lyth, I re-read her research on children in long stay wards at the Royal National Orthopaedic Hospital.I re-read this because I remembered it concerned the staff, especially nursery nurses, being required to support mothers and children differently and I wondered whether there might be some parallels.In the event I found a number of parallels with midwifery which interested me but were not relevant.But she did accord serious attention to the nature of the change she was requiring staff to make -- on P 114 she used the word 'courageous' and I notice that the whole research took four years (P 153).In other words I think what was important was that the staff felt they were being asked to make a big change but that it was for a commensurately worthwhile cause.There was also some explicit education about the nature of emotion (P 184) although she does not describe in detail what form this education took.

On P 187 she wrote 'their (the nursery nurses) initial training and experience had not usually prepared them for such work, nor had they chosen a profession in which they would ordinarily be expected to do it.It is much to their credit, therefore, that they were willing to undertake it and became very competent in carrying it out.This work involved, as did that with the children, being in close touch with and working with distress without denial, false reassurance or evasions but with respect, understanding and tolerance.It required a good deal of wisdom and understanding of the complexities of feelings.'

This quotation appealed to me because I saw a parallel with midwives caring for women in labour, or in any case with childbearing women's intense feelings.The difference is that midwives are supposed to have been trained to deal with this.So why couldn't the community midwives in your study?I'm sorry to keep banging on but I don't think the work of the great Isabel has been superseded.I don't think midwives are trained to deal with this.There seems to be still the split between theory and practice and midwives, when confronted with the practice, either internalise the values implicit in it, leave, go into education, go independent or into one of the few case loading practices.

Community midwifery used to be particularly prestigious and accorded either sister status or a G. grade -- I get the impression this is not the case now.And yet, on the community, the institutional structures aren't there, so that might feel like being insufficiently resourced.

With reference to dissociation I think the first place to look would be a standard psychiatric textbook.What they have to say on post-traumatic stress disorder would be pretty apposite, I should think.There is an interesting individual case study ('Childhood Sexual Abuse, Sexuality, Pregnancy and Birthing' a life history study.Patricia Smith. PCCS Books, Manchester 1995.ISBN 1898059 10 1.) I don't know how easy this is to get hold of.I wrote to the author care of the publisher and got my letter returned.

With regard to risk assessment Garry and I have talked about this.He says that there are principles around this and hazard elimination which have been totally overlooked in the evolution of the medical model of childbirth. I think that his approach to risk assessment could offer an interesting basis for a critique of obstetrics.The trouble with all this though is that it is to do with money and insurance liability.