Treating labour as a trauma does not help new mothers.
‘One in 20 new mothers may suffer post traumatic stress disorder’, revealed an article in the UK Guardian on 27 May 2003 (1). It reported the claims made by Dawn Bailham and Stephen Joseph, the authors of a paper published in the journal Psychology, Health and Medicine (2), that childbirth not only has psychological effects, but can lead to new mothers developing an actual psychiatric disorder – PTSD.
Papers such as this tell us much more about the mindset of those who write them, and the policymakers they are trying to appeal to, than they do about the mindset of new mothers. Above all, they show the extent to which our culture has developed an inexorable tendency to medicalise experience – a tendency that needs to be interrogated and confronted.
These claims about childbirth trauma take place within a context where any difficult or challenging life event can be defined as a potential ‘stressor’ capable of leading to PTSD. They also happen at a time when there is an obsession with ‘parenting problems’. But what is the basis of such claims?
Life redefined as stress
It is not just childbirth that has recently been discovered to be a cause of PTSD. Indeed, therapist Frank Parkinson, the author of one book on the subject, describes its possible causes as follows:
‘[I]n childhood, separation anxiety, going to school, puberty, making and breaking relationships, leaving school and home, starting work, unemployment and redundancy, falling in love, marriage, pregnancy, miscarriage and abortion, having new children in a relationship, separation and divorce, moving home, a hysterectomy, the menopause, retirement and adjusting to old age, the death of a spouse and the inevitability of one’s own death….’ (3)
‘All of these’, argues Parkinson, ‘involve reactions of grief and post-trauma stress’. This approach shows how definitions of PTSD have come a long way, from the point at which it was first ‘named’ as a specific kind of psychiatric illness in 1980. This was the year in which the American Psychiatric Association first included the category PTSD in its Diagnostic and Statistical Manual of Mental Disorders (the DSM).
The story of PTSD’s definition as a specific form of mental illness is a controversial and interesting one. It came out of a battle over how to understand the effects of war upon the psyche of soldiers, specifically those who fought in Vietnam. (This aspect of PTSD has lost none of its significance: as evidenced by the recent case in the UK High Court, in which former members of the British military sued the Ministry of Defence for compensation for the trauma they claimed to suffer by their involvement in war (4).)
The important point, however, is that in the first place PTSD was considered to be a disorder that may affect a minority of soldiers involved in bloody conflicts. Now, it has been has turned into a ‘risk factor’ of everyday life.
Today, as Frank Parkinson’s quote suggests, PTSD-inducing ‘stressors’ have multiplied significantly. Some may quibble that the approach taken by Parkinson is not characteristic of psychiatry and psychology. But look at just about any book on the subject, and you will find a consensus has emerged that it is better to adopt a broad, not narrow, approach to the definition of events that can cause PTSD.
The propensity to define trauma in an ever-broader fashion has no single cause. But at its centre is the emergence of a tendency, certainly in Anglo-American culture, to view the recognition of psychological suffering as positive and important. The way we show we care for other people, and have concern for them, has come to be through taking seriously – indeed positively searching for – their traumatic experience.
Most compelling studies suggest that the emergence of this way of relating to other people is connected to a shift in the way that personhood has come to be conceptualised. Derek Summerfield, a psychiatrist and critic of the concept PTSD, explains that in the past, the culturally dominant expectation of personhood construed the ‘normal’ to include such psychological states as resilience and composure.
Today, however, the conception of the ‘normal’ has shifted: ‘When a psychiatrist or psychologist attests that an unpleasant but scarcely extraordinary experience has caused objective damage to a psyche with effects that may be long lasting, a rather different version of personhood is being posited.’ (5)
The expectation is no longer that people will be able to cope, but that they will find it difficult, perhaps impossible, to do so. Thus if we are to show that we take their experience seriously, we have to relate to their difficulties in coping, and their sense of psychic vulnerability. Appreciating others’ emotional pain and experience of feeling damaged has become a culturally dominant means of connecting with other people.
Some accounts suggest that this redefinition of personhood has emerged as a result of loss of purchase of other meaning systems; systems that once provided people with ways of relating to each other that gave them a sense of personal strength, not weakness. Psychologist Peter Cotton argues that the rise of PTSD can be explained this way: it represents the emergence of a ‘precarious self’, he contends, in a context where traditional cultural, religious and familial frames of reference have receded, leaving the individual apparently isolated. In consequence, the idea of psychological fragility and vulnerability of the self has become the dominant cultural point of reference (6).
It is also worth noting, however, that in any arena one cares to look at, one will find that the definition of the self as ‘precarious’ has become formalised. Being alert to the problems of ‘mental ill health’ has become a part of the ethos of all institutions, from the military, to the University to the media. There is a growing trend in society to view people as constantly at risk of suffering from mental ill health.
In psychiatry this trend is expressed through the official acceptance of more and more specific categories of mental illness. (As Stuart A Kirk and Herb Kutchins, the North American writers on the subject, explain, whilst descriptions of madness and its subtypes have been around since the ancient Greeks, by 1994 ‘the count [in the DSM] had grown to over 300 categories, and the number appears to be rising’. This number of official categories, they argue, should be compared to the handful of unofficial, broad categories that ‘appeared to be sufficient until the last half of the twentieth century’ (7)).
The expansion of the definition of mental ill-health is also evident in the redefinition of existing categories, for example PTSD. ‘It would be hard for the Vietnam veterans and psychiatrist allies who fought for recognition of the syndrome to recognize the diagnosis as it is presently formulated’, state Kirk and Kutchins (8). They make this point in order to draw attention to process through which both ‘stressor’ causes of PTSD, and the ‘symptoms’ of PTSD, have become defined in increasingly broader ways by psychiatry itself.
In 1980, when PTSD first entered the DSM, the definition of the kind of event that could be considered of the quality to lead to PTSD was as follows:
‘The essential feature of this disorder is the development of characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience (ie, outside the range of such common experiences as simple bereavement, chronic illness, business losses, and marital conflict). The stressor producing this syndrome would be markedly distressing to almost anyone.’ [My emphasis.]
In 1994, criterion A for the disorder – that noted above, which states that the ‘stressor’ has to be ‘outside the range of usual human experience’- was removed. This suggests that it had come to be considered acceptable and possible for many life events to be viewed as sufficiently traumatic to lead to PTSD, so long as the event was viewed in that way by the putative ‘victim’. This approach has had important consequences.
As two authorities on the subject point out, ‘If criterion A is loosely defined and over inclusive, then the prevalence of PTSD is likely to increase, whereas a restrictive definition will reduce its prevalence’ (9). The definition that had emerged by 1994 had an unsurprising effect; it increased the number of potential candidates for a diagnosis of PTSD (10).
One British article in a journal for nurses thus claimed in 2000 that ‘Research in America suggests that 75 per cent of the US general population has been exposed to a traumatic event which is significant enough to cause PTSD’, and states that one study found 89.6 per cent has been exposed to such an event, and were therefore at risk of developing the disorder (11).
Childbirth as trauma
The redefinition of PTSD to include an ever-broader range of life experiences is the context in which Bailham and Joseph have developed their case about the psychological effects of childbirth. They note:
‘…it is only comparatively recently that difficult childbirth has been recognized as en event that can lead to the development of PTSD. This is because of the changes in the 1994 edition of the Diagnostic and Statistical Manual (DSM IV) in the definition of what constitutes a traumatic event…..through a culmination of research documenting PTSD symptoms following a range of events that were not viewed as outside the range of usual human experience, it became necessary to amend the definition of what constitutes a traumatic event to include subjective perceptions.’ (12)
The authors continue: ‘The revision of criterion A meant those women who experienced difficult childbirth could now fully meet the criteria for diagnosis of PTSD.’ Hey presto! Because the definition has changed, it is now possible to define women who were once considered ‘normal’ as mentally ill.
Bailham and Joseph’s accounts of the psychological effects of childbirth also reflect the way in which the ‘symptoms’ of PTSD have become more broadly defined. The DSM tried originally to make the criteria strict, but over time it is clear that more and more experiences have come to be viewed as symptomatic of the disorder.
One PTSD sufferer the provides the following list:
‘[N]ervousness, anxiety, fatigue, fragility, sleep problems, flashbacks and replays, trauma, tearfulness, anger, irritability, headaches and frequent illness, skin problems, poor concentration and memory, sweating, palpitations, obsessiveness, hypervigilance, exaggerated startle response, isolation, embarrassment and guilt, low self-esteem, loss of self-worth and “etc”.’ (13)
It might be argued that not all psychiatrists and psychologists would adopt this approach to what constitutes a traumatic event. But there is no doubt that it has become commonplace for broadness of definition to reign – as Bailham and Joseph demonstrate nicely. ‘We discuss the clinical presentation of PTSD in women who undergo childbirth’, they state, and continue: ‘sexual avoidance and parenting problems may be features particular to women who experience difficult and traumatic childbirth’ (14).
Of course neither of these ‘symptoms’ are included in the DSM. But, it seems, those who wish to ‘uncover’ PTSD can turn just about any emotionally taxing experience into ‘symptoms’ of this illness.
So, to exemplify their case that ‘sexual avoidance’ constitutes a symptom of post-childbirth PTSD, Bailham and Joseph give the example of ‘Mrs T’. This is a 40-year-old woman, who found that ‘during the first year following delivery she could not have a sexual relationship with her partner’. When she did have sex, she was ‘extremely anxious about accidentally conceiving despite the use of contraception’. Her ‘sexual difficulties and intrusions did resolve markedly following the surgical procedure tubal ligation [sterilisation] to prevent further pregnancies’, however.
The conclusion that the authors draw is that the behaviour she demonstrated towards her partner (not wanting to have sex) ‘was consistent with DSM-IV criteria of avoidance of stimuli associated with the trauma’. So, according to this view, she had a psychiatric illness.
How about this explanation instead? Mrs T found that she was much happier about having sex when she could be sure she would not get pregnant again. From this point on, she was fine. Her experience of childbirth was very difficult – more difficult than most – but was eventually resolved satisfactorily.
Yet this approach, it seems, will just not do. It is viewed as far preferable to give such experiences a medical label – in the words of Kutchins and Kirk, to ‘make us crazy’. Indeed, it seems that even PTSD will not do; another medical label must be made up, to allow an even more specific diagnosis of mental illness in mothers to be made.
Therefore, Bailham and Joseph argue that ‘Tokophobia is now recognised as an unreasoning dread of childbirth’. This phenomenon, of women who are so terrified of childbirth that they request abortion if they get pregnant, is, they suggest, yet another disease afflicting women, and should be diagnosed accordingly.
On one level, claims that childbirth causes PTSD are typical of the general propensity to medicalise human experience. But where childbirth is concerned, there is a particular dynamic that encourages medicalisation. The recognition of childbirth trauma is informed by a tendency to represent parents as a ‘risk factor’ in their children’s lives: in particular, during the very early stages.
The notion that ‘the first year of life is the most important’ has emerged as a dogma of our age, and it carries with it the insistence that anything that prevents parents from doing the ‘right thing’ (whatever that is) during this time must be tackled through a ‘supportive intervention’ of some kind.
In itself, this perception of the problem of parenting reflects the way in which our culture has come to view personality. Just as PTSD constitutes a metaphor for a perception of people in which they are viewed as fragile and ‘at risk’, so too does the notion that we will be ‘damaged for life’ if anything somehow goes wrong in the first year of our existence.
This preoccupation is very clear in Bailham and Joseph’s article. In their view, it is the issues of ‘mother-infant attachment’ and ‘parenting problems’ that constitute the reason why we should be so worried about PTSD.
These issues, they argue ‘would also seem to constitute another possible idiosyncratic feature in the presentation of PTSD’. They concede that the evidence for attachment problems in women who have PTSD ‘remains sparse’. But this does not prevent them making the assertion that it is ‘possible that PTSD symptoms could have a detrimental effect on the early relationship between a woman and her baby’. ‘In extreme cases’, they continue, ‘this could lead to maternal neglect and could raise concern for the need for child protection intervention’.
Never let the lack of evidence get in the way of raising the spectre of child abuse! And never pass up any opportunity to argue that parents generally benefit from increased ‘support’ for (aka surveillance of) their parenting capabilities.
The unhealthy outcome of medicalisation
It is one thing to say that a difficult labour can leave women with troublesome memories and bad feelings. But it is quite another to say that this means they are mentally ill. Moving from one to the other is a big step to take, and it has consequences. What does it mean to people, to understand and define their experience in medical terms?
Defining women’s experience of childbirth as somehow pathological first makes it harder for us to understand what, if anything, has changed about women’s experience of becoming mothers. If it really is the case that significant numbers of women are absolutely terrified of becoming mothers, and if it really is the case that, despite the fact that childbirth is now medically safer than ever, women in unprecedented numbers are finding it an unbearable ordeal, then we need to work out why. Labelling such women as having a psychiatric illness is unlikely to help us to do so.
The ‘solution’ to the ‘problem’ (insofar as there is one) as it is currently presented may well also make things worse for those women designated as having PTSD. ‘Counselling’ has emerged as the catch-all cure for women ‘at risk’ of, or deemed to be suffering from, pregnancy-related mental ill-health. But there is just as much evidence to show that counselling (and certainly psychological debriefing for PTSD) makes people feel worse.
In these days of ‘evidence-based medicine’, it is surprising the extent to which ‘assessment’ of pregnant women’s and new mothers’ mental state, with ‘counselling’ as the preferred intervention for those deemed to be in trouble, is advocated as ‘a good thing’.
One reason why interventions of this kind may not help is because they rely on the attachment of this medical label to an experience. This has the effect of fixing the relationship between event and experience. Indeed, this is the whole point about PTSD: the ‘stressor’ causes the ‘symptoms’.
Those who believe in PTSD must think that fixing the relationship in this way is helpful. But its effect may be to trap those who are encouraged to understand their experience this way in the illness diagnosis, ensuring they become far less likely to ‘get over’ their experience. The simple fact that we have a society characterised by more and more PTSD diagnoses (together with diagnoses of many other mental illnesses), together with an ever-expanding number of chronically ill people who fail to get better, suggests this may be the case.
By contrast, leaving people to find their own way through their problems may have much better results.
My mother would have been a very likely candidate for being diagnosed with PTSD following the birth of my brother, had such a diagnosis been in vogue in the late 1960s. Her labour was extremely long and arduous. After many hours, the baby was eventually delivered with forceps, leaving my mother badly torn as well as exhausted and demoralized, with a battered and bruised baby to show for her ordeal.
Without doubt this experience affected her very significantly for the following year or so. She had bad dreams, she did not feel close to my father, and it took her months to come to really love her baby (who, by the way, has turned out to be a well-rounded and very pleasant individual). But it is also interesting that she want on to have a further child (a birth that she always describes as a ‘great relief’). ‘All my worries disappeared the minute the baby was born’, she recounts.
And, while her bad memories have never left her – she can describe her childbirth trauma blow-by-blow to this day – this does not mean she has failed to ‘cope’. Indeed this description would be entirely untrue.
My mother is not a particularly stoic woman. She just did what most women can, which is to find her own way to cope, and to do so very successfully. It does not seem at all clear to me that she would have benefited from a psychiatric diagnosis and trauma counselling; indeed this may have made her less able to ‘come to terms with’ her experience than she has shown herself able to do.
This discussion of childbirth trauma draws to attention to worrying aspects of today’s culture. The fact that experiences like childbirth have come to be to be viewed as causes of psychiatric disease should be troubling for anyone that aspires to live in a society that can find ways of giving meaning to human experience, without recourse to medical labels.
Ellie Lee is coordinator of the Pro-Choice Forum, and a research fellow in the Department of Sociology and Social Policy at the University of Southampton. She is the author of Abortion, Motherhood, and Mental Health: Medicalising Reproduction in the United States and Great Britain, Walter de Gruyter, 2004 (buy this book from Amazon (UK) or Amazon (USA)). She is also the editor of Abortion: Whose Right?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)); Designer Babies: Where Should We Draw the Line?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)); and Abortion Law and Politics Today, Palgrave Macmillan, 1998 (buy this book from Amazon (UK) or Amazon (USA)).
Treating soldiers as victims, by Ellie Lee
The invention of PTSD, by Ellie Lee
(1) ‘One in 20 new mothers may suffer post traumatic stress disorder’, Guardian, 27 May 2003
(2) ‘Post-traumatic stress following childbirth: a review of the emerging literature and directions for research and practice’, D Bailham and S Joseph, Psychology, Health and Medicine, Vol. 8, No 2, 2003
(3) Post-Trauma Stress, Frank Parkinson, London: Sheldon Press, 1995
(4) Treating soldiers as victims, by Ellie Lee
(5) ‘The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category’, Derek Summerfield, British Medical Journal 322: 95-98, 2001
(6) ‘The Precarious Self, The Rise of Post-traumatic Stress Disorder’, Peter Cotton, Arena Magazine, October/November 1996
(7) Herb Kutchins and Stuart A. Kirk. Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York: The Free Press, 1997
(8) Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders, Herb Kutchins and Stuart A Kirk, New York: The Free Press, 1997
(9) Diagnostic issues in posttraumatic stress disorder: Considerations for DSM IV’, JRT Davidson and EB Foa, Journal of Abnormal Psychology 100, 1991
(10) Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders, Herb Kutchins and Stuart A Kirk, New York: The Free Press, 1997
(11) ‘Post-traumatic stress disorder’, Paul Rogers and Sheena Liness, Nursing Standard 14(22), 2000
(12) ‘Post-traumatic stress following childbirth: a review of the emerging literature and directions for research and practice’, D Bailham and S Joseph, Psychology, Health and Medicine, Vol 8, No 2, 2003
(13) Post Traumatic Stress Disorder, The Invisible Injury, David Kinchin, Oxon: Success Unlimited, 1998
(14) ‘Post-traumatic stress following childbirth: a review of the emerging literature and directions for research and practice’, D Bailham and S Joseph, Psychology, Health and Medicine, Vol 8, No 2, 2003
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