PERSPECTIVES

Systemic Perspectives on Perinatal Mental Health: Six Major Changes for Parents

 

Amy* was sitting slumped on a couch in my office for her initial appointment. She appeared a little nervous but was trying to hold it together. After pleasantries were exchanged, she stated she had her son four months ago, and since then, things had changed a lot around the house and with the family, especially with her in-laws. She explained she was feeling anxious, was short of breath, had overwhelming worries, and was irritable for the last couple of months.


“These symptoms are gradually getting worse lately,” she said. She now has arguments with her husband daily and has difficulty focusing on her work. She returned to her work as a middle manager after maternity leave one month ago. Her husband was determined that these symptoms were because of a previous miscarriage she had. She stated the miscarriage was a difficult experience, but it was not the concern at this time. Her concern is about the relationship with her in-laws and her husband.

She described that the relationship with her in-laws was distant, and they had infrequent, short visits before their son’s birth. However, after her son was born, her in-laws want to have a weekly family get-together, give overwhelming, unsolicited advice, and cautionary tales. Her husband is going along with whatever his parents want, allowing the visits, gatherings, etc. She added that her son is the first grandchild for her in-laws. She stated she was already feeling guilty, anxious, and stressed about going back to work after maternity leave and being unsure of parenting for the first time before these interactions escalated. Feelings of anxiety were getting worse. She felt more overwhelmed, judged, on the edge, had difficulty breathing and relaxing, and had guilt about how she was as a mother now.

Amy’s story is not unique, on various levels. Many new mothers face numerous intricately interwoven changes in their lives. By incorporating a systemic perspective into work with people facing postpartum challenges, we can enable dynamic and systemic changes; changes that the individual and family see as useful and sustainable. In this article, I will explore postpartum mental health through a systemic perspective, hoping to improve family therapists’ work with women and men. I will also address the role the system plays in postpartum difficulties, which can hopefully lead to societal changes.

I use phrases such as ‘becoming a parent’ and ‘bringing a baby home,’ instead of pregnancy and delivery, because there are numerous ways to become a parent, such as fostering, adoption, and surrogacy. Even though it is often called perinatal mental health, studies show that male parents, adoptive parents, and same-sex couples experience biological changes during the perinatal period and postpartum depression and anxiety, as well. Therefore, I describe ‘parents and partners,’ instead of mothers and husbands in this article.

What is perinatal mental health?

Perinatal mental health describes the mental health of people during pregnancy, delivery, and postpartum. Postpartum is the time between the birth of a baby and one year after birth (American College of Obstetricians and Gynecologists, 2022). The word postpartum does not inherently point only to mental health concerns and mental health diagnosis. The term perinatal mental health includes non-clinical mental health changes and distress as well as clinically diagnosed mental illnesses. Matrescence means the process of becoming a mother (Cambridge Dictionary, 2022), and perinatal mental health is part of matrescence—naturally occurring mental health changes and adjustments. In Amy’s case, she is in postpartum, and her main concerns apply to perinatal mental health. To diagnose her with postpartum mood and anxiety disorders, the therapist needs to conduct a further diagnostic interview.

What happens to a person when they become a parent? Six major changes

Through working with parents in postpartum, I found that there appear to be six major categories of changes that a person experiences while becoming a parent: physical and physiological changes, psychological changes, identity changes, relationship changes, logistical changes, and social status changes. Physical change and psychological emotional changes intertwine heavily and directly during pregnancy and in postpartum. These changes are interwoven in a person’s system and affect and change various parts of the system.

Physical and physiological changes are discussed with parents in classes and are often monitored by healthcare professionals. Contrary to the common belief that postpartum recovery takes six weeks (Gjerdingen, Froberg, Chaloner, & McGovern, 1993), some physical recovery continues for six months to one year after the birth of a child, depending upon health, pregnancy, and birth complications (Woolhouse, Perlen, Gartland, & Brown, 2012). One notable, physical change that often happens after one year after birth is hormonal changes that come with weaning of breastfeeding (Canul-Medina & Fernandez-Mejia, 2019). The body continues to heal for about one year, which requires systemic changes in terms of increased support from a partner and support systems to delegate daily tasks and chores, such as setting boundaries to secure physical rest, and to reset others’ expectations of each other in the system. In Amy’s story, her physical tiredness is related to the physical changes and healing that she is going through.

Psychological changes can include increases in sensitivity to emotions, expectation changes, confidence, efficacy, and changes in sense of self, to name a few. As Amy described, many parents say they feel guilty, feel sad frequently, and anxious. As many as 80% report experiencing baby blues, which can include sadness, general overwhelming feelings, worry, fatigue, and guilt within the first two weeks postpartum, even if their symptoms do not meet clinical diagnosis criteria (O’Hara, 2014). Due to hormonal changes, sleep deprivation, and physical fatigue, many going through postpartum experience amplified feelings. For example, they may feel outraged about something that previously would only cause irritation. The same is true for positive emotion. They may feel overjoyed during a small, happy moment. Experiencing opposite feelings is common with perinatal parents, which often causes friction with people around them or micro aggressive comments from others, including professionals. A person may think, “I am supposed to be happy, but I feel sad, anxious, and even resentful. I must be a bad parent and a bad person or broken,” which causes shame and guilt. It also influences the interactions within the system surrounding the parents.

Identity change affects all the areas of one’s life. Becoming parents includes different expectations from society and from themselves, such as being an idealized figure, dealing with external expectations, and navigating the history of relationships with their own parents and caregivers. Some parents report that their sense of parenthood grew soon after realization of conception and throughout pregnancy. Others report they noticed the sense of feeling like a parent grew long after the birth of a baby. There is no uniform timeline of this change regardless of whether the person gave birth or is a partner. Identity reductionism often happens, where parents make a statement such as “Now I’m a mother; my needs come last.”

Change in social relationship is inevitable as a person becomes a parent along with changes in personal relationship to their cultural background or religion. The boundaries and rules of relationship and communication change. In partnership, it grows from dyad to triad, which increases interaction points and paths. Often, parents sadly report that they lost friendships with their long-time friends because they are all single and do not have a child and don’t know what to do with the new parent. Or, as in Amy’s case, increased social interaction and change of quality of family relationship happened among family members after becoming a parent and new identities emerged among family members, such as “first time grandparent.” When a couple is married but does not yet have children, they may not be involved much in cultural activities, nor with their families. However, they often re-engage in their cultural traditions or religious activities once they have their children to preserve traditional values.

Becoming a parent demands changes in logistics. However, homeostasis often brings opposite reactions in parents. They attempt to keep the same expectations, same routine, and same efficiency and productivity of a person who does not have an infant, even after bringing a baby home, which cause negative experiences and negative self-image as parents. Expecting parents and new parents often report that they are surprised by how much time and effort small, daily tasks take now. Many parents say that it takes three times longer to get out of the house after a baby joins the family. Some mothers say they cannot take a shower more than a few minutes before others start knocking on the door or they hear their baby crying. I remember I became a super-fast eater, where I would gobble down a good-sized dinner in under 5 minutes and not remember the taste or exactly what I ate. Coordinating different appointments, other family demands, and work and life balance often affect the emotional state of new parents and interactions between the couple. In Amy’s story, coordinating new family gatherings, having people over, and negotiating parenting styles can be exhausting and stressful.

Social status change is often overlooked and has significant impact, especially for those who worked before pregnancy, and must now shift to stay home temporarily or permanently. Because we live in a capitalistic society, where money and productivity play a great part of building identity, stripping our work identity, halting our career growth, and losing income affects parents’ identity and mental health in regard to self-worth, self-efficacy, and self-image. It also affects dynamics in the couple’s relationship. This often comes up as common phrases in the session, or in support groups: “My partner is working the same way as pre-pregnancy, but my life changed so much becoming a stay-at-home mom. I am so jealous.” Or “My working partner cannot do anything right around our baby.” Elly Taylor, author of Becoming Us (2014), says that often the stay-at-home parent becomes critical of the working partner’s child raising skills, and states “I am the only one who can do this right,” for the purpose of regaining power and the status that they lost by giving up work.

Why is the systemic perspective useful in working with perinatal clients?

As we saw in Amy’s situation, and the six changes above, looking at perinatal changes through a systemic perspective has numerous benefits. By using a systemic lens, clinicians can conceptualize clients and their situation to identify opportunities for interventions for useful changes. By understanding rules and boundaries, homeostasis, patterns, and feedback loops, we can see what is going on in the clients’ system and serve them holistically.

What family therapists can do outside of the therapy room

Because people in postpartum impact society, and society impacts people in postpartum, what can family therapists do outside the therapy room to influence clients and their postpartum lives as well? Supporting and advocating for organizations which support perinatal mental health nationally or locally, such as Postpartum Support International, Merce Society, special task forces in the Department of Public Health, and local service organizations for people in the perinatal period, can support the recognition and importance of perinatal mental health.

Continuing education, increasing numbers of articles, presentations, and workshops on perinatal mental health and postpartum endorsed by major therapy professional associations can be helpful in reducing the stigma of perinatal mental health, increase the number of therapists who specialize in working with families in postpartum, and improve access and treatment quality for clients. 

It is my hope that perinatal mental health becomes a major specialization in academia, where more educational institutions will have standalone courses focused on perinatal mental health widely available, that many clinicians will be competent in treating clients in the perinatal period, so that clients have an easier time finding a therapist, and that clients will receive quality care from therapists who have a deep understanding of postpartum and perinatal mental health.

By using a systemic lens, clinicians can conceptualize clients and their situation to identify opportunities for interventions for useful changes.

Keiko Yoneyama-Sims, MS, is a Colorado and California licensed marriage and family therapist and an AAMFT Professional Member holding the Clinical Fellow and Approved Supervisor designations. She has a private practice, Small Steps Count Counseling, in Denver, Colorado, where she works with clients with Medicaid. She supervises graduate students at Maria Droste Counseling Center and Center for Resilience Strategies and teaches at University of Denver.

*Amy is a fictional client with many clients’ stories combined to illustrate the points in this article.


REFERENCES

American College of Obstetricians and Gynecologists. (2022). Perinatal mental health. Retrieved from https://www.acog.org/en/programs/perinatal-mental-health

Cambridge Dictionary. (2022). Matrescence. Retrieved from https://dictionary.cambridge.org/us/dictionary/english/matrescence

Canul-Medina, G., & Fernandez-Mejia, C. (2019). Morphological, hormonal, and molecular changes in different maternal tissues during lactation and post-lactation. The Journal of Physiological Sciences, 69(6), 825-835. https://doi.org/10.1007/s12576-019-00714-4
Gjerdingen, D. K., Froberg, D. G., Chaloner, K. M., & McGovern, P. M. (1993). Changes in women’s physical health during the first postpartum year. Archives of Family Medicine, 2(3), 277–283. https://doi.org/10.1001/archfami.2.3.277

O’Hara, M. W. (2014). Perinatal mental illness: Definition, description and aetiology. Best Practice, 10.

Taylor, E. (2014). Becoming us. Three Turtles Press.

Woolhouse, H., Perlen, S., Gartland, D., & Brown, S. J. (2012). Physical health and recovery in the first 18 months postpartum: Does cesarean section reduce long-term morbidity? Birth, 39(3), 221-229. https://doi.org/10.1111/j.1523-536X.2012.00551.x

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