Perinatal and Infant Mental Health in Ireland
Guest blog by Barbara Western
Perinatal and Infant Mental Health in Ireland attracts a growing body of research. It is wonderful to see the attention moving towards infants and young children, a cohort who until the last 20 years, or so, have been seen as having little to no agency or as ‘tabula rasa’ – blank slates upon whom adults can impart knowledge and the proper way to conduct oneself. Sometimes, however, the focus can get skewed and researchers can often neglect that the individuals who are conceiving, carrying and birthing these babies are living, breathing humans as well. These are people who have contributed immensely to their communities. Individuals who have changed their lives and who have made sacrifices in relation to what they eat, what they drink, how they work and how they feel in order to ensure a healthy start for their offspring. There is an abundance of research on attachment theory (different from attachment parenting) that strongly supports the nurturing of a secure and healthy emotional bond between infants and their caregivers. The evidence for this theory is particularly poignant and hopeful for families where there has been a disruption in infant-caregiver bonding, for example if a mother or parent has experienced illness, complications or trauma during pregnancy, labour or birth.
Birth Trauma and perinatal infant and mental health
Thus, when an article purporting to be scientific research on birth trauma healing opens with a line like: “Research has proven that babies born without trauma enjoy an intact capacity to love and trust”, there is some serious cause for critical analysis. Anyone reading an alleged scientific article on any subject should hear alarm bells when the phrase ‘research has proven’ is used to make a claim. Scientific rigour and the most robust research can not ensure the proof of anything. All the scientific research method can do is analyse well constructed hypotheses and carefully collated data to show support that the variables being studied are evidence of a claim, or not. Any science that declares ‘this is proof’ is not good science. Any method that is applied with the claim of being the only one that is right or the only one that works is most likely marketing, and not science.
The onus on articles, like the one above on birth trauma, is to highlight the science that supports a theory or method and to omit emotive opinions and pseudoscientific claims. Women who have recently given birth can often be vulnerable and sleep deprived and may find it more difficult to discern the scientific authenticity of an article or method from the pseudoscientific claims the author(s) are making. Claims such as ‘babies are conscious from conception’ or that any separation of a baby from its mother after birth is perceived by the baby as ‘abandonment’ are categorically false and run the risk of causing increased distress to those who are already traumatised by birth. What is equally distressing is that the article above cites no references for these claims. The only links at the bottom of the article are to sources directly related to the author(s) and to a book by Dr Arthur Janov, the creator of ‘primal scream therapy’, a method that has virtually no rigorous scientific research to support its effectiveness.
Upon further reading, the article continues with questionable statements about ‘optimal birth’, such as “The mother works with the baby to help him be born successfully…Such a child will have a life script of ‘I can succeed’”. Another claim about ‘life scripts’ declares that “babies born by elective caesarean section (sometimes necessary) may have some of the following life scripts: ‘Life is something that happens to me’ or ‘I don’t like things happening suddenly when I am not ready’. These babies have also missed out on the important stimulation of the birth contractions.” While these life scripts may be tenuously linked with cognitive psychology and schema therapy, there is no scientific basis given for any of the above assumptions. While some people may connect with these claims on an intuitive level, it can be extremely dangerous for others to read them and to internalise self-blame or guilt for experiences that were outside of their control. Particularly when these claims are egregious and false.
The rest of the article goes on to promote the work of two doctors. It appears their areas of specialty are psychotherapy and developmental psychology. This is where things can get confusing. When a person refers to themselves as a ‘doctor’ or uses any professional title, we expect them to be an expert in the field in which they are qualified. We expect certain competencies, knowledge and skills in their qualified discipline. In the last decade, there has been an agreement between various psychotherapeutic and psychological associations & societies on the international standardisation of the accreditation and registration of psychotherapists and psychologists. This is important work that addresses the vulnerability of the clients involved as well as the power dynamic and the role of mental health professionals in the assessment, treatment and diagnosis of the individuals with whom they work. For too many years, psychology and psychotherapy have suffered from the prevalence of unqualified practitioners who are often more interested in marketing a toolkit they have developed or a book they have written than in providing an ethical and professional service.
Scientifically proved versus “opinion” in pregnancy and postpartum marketing
It is hard for someone marketing a theory or product to admit that it may not work, that it requires updating or that it may not be suitable for everyone. Years may have been invested in writing, training and selling their product(s). This is where marketing veers sharply away from the scientific method. A person who is selling a self-designed birth tool or service has to believe strongly that they are offering something that no one else can offer. They have to develop a marketing language that makes their product or service appear to be more effective than the competition. The problem with this is that the language to sell a product can appear to use scientific language and terms when the theories or concepts being discussed are pseudoscience. In the above article the words: cellular, hormones, brain and nervous system appear by the second paragraph with absolutely no references to explain how these biological terms or processes relate to birth or birth trauma. This is a powerful, and sometimes disingenuous, use of language to convince people that they need something that may be entirely unnecessary or even ineffective. Current research supports the theory that using terms like ‘brain’ and ‘neuro’ in marketing or health & social sciences literature appeals to the reader so that the reader will believe what the literature says, even if it is irrelevant pseudoscience. This verges on the unethical when individuals are expected to part with money for a service or product that appears to have scientific support but when critically analysed offers no more evidence than opinions and anecdotes, which are notoriously unreliable and biased.
Treating birth trauma
Going back to the content of the above article, the ideas relating to ‘re-patterning’ (defined as “creating the birth that should have happened”) and encouraging a baby to relive their birth trauma with the alleged effect of healing are highly questionable, at best, and unethical, at worst, due to the lack of evidence to support this practice. Robust and scientifically sound therapeutic approaches to healing birth trauma will draw from the most reliable and valid psychological research and not from unsupported claims in relation to an esoteric practice such as rebirthing. In fact, the most recent research on treatment of trauma is a 3 phase approach that takes the individual being treated into account. Some will gain benefits from re-living and reprocessing a traumatic event while others will not find it helpful or may even find it harmful. If the trauma is more complex or ongoing, then different approaches will be more appropriate (http://psychcentral.com/lib/ treatment-of-ptsd/). The key here being that anyone undergoing therapeutic intervention should be assessed individually by a trained and qualified mental health professional and a treatment plan should be designed accordingly, ideally in collaboration between the individual and the professional. There is an additional ethical consideration in that the babies undergoing the interventions described in the article are not able to give their consent. This means their parents – who may be sleep deprived or suffering from PTSD – are being expected to give consent for an intervention that is based on little to no empirical evidence.
Partners in healing rather than treatment from an “expert”
In Perinatal and Infant Mental Health in Ireland, there are a plethora of therapeutic tools and treatments where the person imparting the therapy or intervention implies that they are ‘the expert’ and the one being treated is the passive recipient of the intervention. This is not authentic therapy, where the quality of the therapeutic alliance is one of the biggest determinants of efficacy and the individual in therapy is facilitated to adopt healthier coping styles and to feel empowered and more confident in their ability to face life’s stressors. In the above article, one has to question: where is the facilitated care for the mother? The baby appears to have been given an intervention that the creators of the therapy claim will heal trauma for the infant. But what about the trauma affecting the mother and wider family? It is implied that once the baby is relieved of trauma then the parents can go back to parenting and a normal life, without the interference of the baby’s cries. This is far too simplistic and ignores the numerous other factors at play when it comes to birth trauma. Significant factors like: maternal morbidity, family history, prior birth trauma, socio-economic status, mental health history, expectations of childbirth, adjustment to the role of parent, and many more aspects can influence the way in which a woman and her family integrate and heal from a traumatic birth.
There is an anecdote in the above article that depicts a 15 to 20 minute intervention whereby one of the doctors cited in the article invites a woman to bring up her ‘niggling’ baby to the front of the room. It is established that the baby has been fed and wasn’t hungry but that he had endured a protracted second stage of labour. The alleged expert holds the baby’s head and then pushes on his feet until he ceases crying and this is seen as evidence that the baby has somehow re-experienced or re-patterned his birth. The idea that one single aspect of birth (long 2nd stage) is deemed the causal variable in the baby’s current discomfort and that one expert can change the trajectory of the infant-parent relationship simply by holding a baby for a few moments completely undermines the entire discipline of perinatal and infant mental health research. In addition, it reduces the role of the mother to passive participant in the care and nurturing of her child. While the power of touch has some robust evidence behind it as a way of deepening bonds and expressing and eliciting compassion, it would be far more effective to empower a mother and to encourage her to hold her own baby to facilitate and deepen the bond between them.
Promoting parental competence and confidence in parents who have experienced birth trauma
This therapeutic method neglects situations where a baby may have spent spent time in NICU or when a mother or her baby have experienced interventions or complications during pregnancy, labour and birth. Complications during birth can occur for myriad reasons and can affect the mother, the baby and the extended family to varying degrees. The methods of dealing with birth trauma in this article ignore the scientifically supported therapeutic tenets of early individualised family-based interventions – particularly those that promote parental competence and confidence – that reduce maternal stress and depression and increase maternal self-esteem, leading to more positive early parent-infant interactions. Assessment and treatment of an infant’s mental health involves much more than one therapist holding the baby for a few moments in the hopes of ‘re-patterning’ the baby’s birth experience. It involves the mother or caregiver, the infant and the support of an entire team.
Infant Mental Health
As an emerging discipline, Perinatal and Infant Mental Health in Ireland embraces the most current empirical research on infant-child development and its intrinsic relationship with parents and caregivers, in the early years of life. Contrary to the idea that the mother is totally separate from the infant, a recent Infant Mental Health Group Networks Evaluation (2015) document, states that a quality infant mental health model will draw on the skills and knowledge of a “network of professionals involved in providing services and support to caregivers, families and children age 0-3” (p. 5). This group will then work closely with the wider community to support primary caregivers, infants and families to achieve optimum mental health and wellbeing across the perinatal period. This requires that consideration not only be given to the physical needs but also to the psychological, social, cultural and geographical issues facing women, men, infants and families during this time.
Birth trauma does not lead to the irrevocable disruption of bonding between parent and child
In reality, if there is a disruption to the infant-parent bond due to trauma of any kind then overwhelming evidence suggests that the bond will not be irrevocably disrupted. In fact, even in cases where there has been prolonged difficulties or separation, interdisciplinary professional mental health support will take time but it will have a much more significant long term beneficial effect for the infant-parent/caregiver relationship than biased and pseudoscientific therapies. A mother, parent or caregiver should be encouraged and supported to take an active part, if they are able, in nurturing and protecting the bond with their child. If there is trauma involved, families should find great comfort in the robust evidence that in time and with evidence based support, mothers and infants can, and do, heal and go on to thrive in their relationships.