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The concept of normality as a component of help
seeking and adaptation in couples with experience of
postnatal depression:
A grounded theory study
By
Marlis A Bunyan
A thesis submitted in partial fulfilment of the requirements of the University of
Abertay Dundee for the Degree of Doctor of Philosophy
Volume 2 Chapter eight, appendices and references
Contents
Abstract.................................................................................................................iiAcknowledgments............................................................................................... iiiContents..............................................................................................................ivList of figures..................................................................................................... viiiList of tables........................................................................................................ ixVolume 1 Chapters one to seven....................................................................... xChapter 1 Introduction........................................................................................ 1
1.1 Background.............................................. 11.2 The area of study................................................................................... 31.3 Justification for the research................................................................ 41.4 The thesis as a developmental journey............................................... 5
1.4.1 Triggers......................................................................................... 71.4.2 Other drivers..................................................................................81.4.3 The theoretical framework............................................................ 91.4.4 Fitting it all together..................................................................... 11
1.5 Thesis overview..................................................................................121.6 Summary of the findings.....................................................................131.7 Conclusion.......................................................................................... 14
Chapter 2 Initial review of the literature............................................................162.1 Introduction......................................................................................... 162.2 Defining postnatal depression...........................................................172.3 Management and treatment...............................................................272.4 Context of care...................................................................................322.5 Gender roles.......................................................................................362.6 Social support.....................................................................................382.7 Conclusion..........................................................................................41
Chapter 3 The principles of analysis and their operationalisation...................433.1 Introduction............................................... 433.2 Defining the framework of qualitative enquiry.................................. 433.3 The issue of reflexivity...... ................................................................ 483.4 Grounded theory..................... 49
3.4.1 Philosophical considerations..................................................... 503.4.2 The tools of grounded theory..................................................... 53
3.4.2.1 Theoretical sampling........................................................... 533.4.2.2 Coding...................................................................................613.4.2.3 The constant comparison of the data................................. 713.4.2.4 Saturation of the data......................................................... 74
3.4.3 Interpreting grounded theory..................................................... 763.5 Thesis specific methodological issues..............................................80
3.5.1 Sampling through stakeholders.................................................803.5.2 Joint interviewing........................................................................ 823.5.3 Mapping the couples’ support networks................................... 863.5.4 Respondent validation................................................................87
3.6 Conclusion.......................................................................................... 88Chapter 4 Reflexivity......................................................................................... 90
IV
4.1 Introduction......................................................................................... 904.2 Taken for granted interests................................................................914.3 Personal value systems..................................................................... 944.4 Areas of potential conflict...................................................................954.5 Gatekeepers’ interests..................................................................... 1004.6 Potential lack of neutrality................................................................1034.7 New or surprising elements.............................................................1054.8 Methodological problems or opportunities......................................1064.9 The write up...................................................................................... 1074.10 Support for the analysis.................................................................... 1084.11 Conclusion........................................................................................ 110
Chapter 5 Findings stage 1: Seven early themes.......................................... 1115.1 Introduction....................................................................................... 1115.2 Respondents’ voices....................... ............................................... 1125.3 The identification of category networks.......................................... 116
5.3.1 Causality.................................................................................... 1195.3.1.1 External factors..................................................................1205.3.1.2 Internal factors....................................................................1215.3.1.3 Responsibility.....................................................................123
5.3.2 Emotional health....................................................................... 1275.3.2.1 Influences........................................................................... 1285.3.2.2 Response........................................................................... 1325.3.2.3 Background........................................................................ 1355.3.2.4 Maintenance....................................................................... 140
5.3.3 Access factors...........................................................................1455.3.3.1 Representation...................................................................1465.3.3.2 Personal background........................................................ 1495.3.3.3 Resources.......................................................................... 151
5.3.4 Roles and gender..................................................................... 1555.3.4.1 Family roles........................................................................ 1565.3.4.2 Personal background........................................................ 1645.3.4.3 Partner’s response.............................................................165
5.3.5 Professionals.............................................................................1695.3.5.1 Activities..................................... 1705.3.5.2 Medication.......................................................................... 1735.3.5.3 Influences on function....................................................... 178
5.3.6 Solutions.................................................................................... 1845.3.6.1 Personal resources........................................................... 1855.3.6.2 Services.............................................................................. 1885.3.6.3 Helper’s attitude.................................................................1925.3.6.4 Strategies........................................................................... 195
5.3.7 Help seeking............................................................................. 2005.3.7.1 Relationships......................................................................2015.3.7.2 Considerations.................................................................. 2045.3.7.3 Access................................................................................2065.3.7.4 Services.............................................................................. 210
5.3.8 Summary of respondent narratives........................................ 2155.4 Conclusion........................................................................................217
Chapter 6 Findings stage 2: Category frameworks........................................ 2196.1 Introduction........................................................................................ 219
v
6.2 Early themes and their development..............................................2216.3 Framework 1: The experience of postnatal depression................ 222
6.3.1 Speculation about causality..................................................... 2256.3.2 Coping strategies...................................................................... 2286.3.3 Strive to achieve normality...................................................... 2316.3.4 Strength of the relationship...................................................... 235
6.4 Framework 2: Support issues......................................................... 2406.4.1 Format of support..................................................................... 2416.4.2 People providing support......................................................... 2446.4.3 Characteristics of support........................................................ 2496.4.4 Outcome....................................................................................2546.4.5 Conditions for access to support.............................................2606.4.6 Support networks...................................................................... 264
6.5 Summary and conclusion................................................................267Chapter 7 Findings stage 3: The core category and its related processes 269
7.1 Introduction..................................... 2697.2 Defining ‘normality’ .......................................................................... 270
7.2.1 Interaction with the baby...........................................................2727.2.2 As a parent................................................................................2737.2.3 Interaction with the partner...................................................... 2747.2.4 Social interaction with others................................................... 2757.2.5 Characterising the normal person............................................2767.2.6 Comparison with other markers...............................................279
7.3 Linking the core category to its related processes.........................2837.4 Process to seek help....................................................................... 284
7.4.1 The internal system..................................................................2847.4.1.1 Unease and symptom check.............................................2847.4.1.2 Difficult to admit..................................................................2857.4.1.3 Effect on the relationship................................................... 285
7.4.2 The external system.................................................................2877.4.2.1 Hand over control.............................................................. 2877.4.2.2 Relief mixed with guilt........................................................ 2877.4.2.3 Stigma of diagnosis........................................................... 289
7.4.3 Summary...................................................................................2897.5 Process of adaptation to a new normality.......................................291
7.5.1 Considerations.................................. 2917.5.1.1 Representation of postnatal depression...........................2917.5.1.2 Existing coping mechanisms.............................................2927.5.1.3 Anticipated timeframe........................................................2937.5.1.4 Feelings.............................................................................. 295
7.5.2 Support......................................................................................2987.5.2.1 Helpers and their attitudes.................................................2987.5.2.2 Conditions..........................................................................2997.5.2.3 Treatment...........................................................................300
7.5.3 Outcome for the couple relationship........................................3017.6 Summary and conclusion................................................................304
Volume 2 Chapter eight, appendices and references.................................306Chapter 8 The application of the findings to the literature and healthcare. 307
8.1 Introduction.......................................................................................3078.2 The research question revisited...................................................... 308
VI
8.2.1 Experiencing postnatal depression..........................................3088.2.2 Supporting and being supported.............................................317
8.2.2.1 Format of support..............................................................3178.2.2.2 Access................................................................................3208.2.2.3 Characteristics and conditions........................................... 323
8.3 The concept of ‘normality’ ................................................................3278.3.1 The process to seek help........................................................ 3308.3.2 Adaptation to a new normality................................................. 332
8.4 Potential limitations.......................................................................... 3358.4.1 Retrospective accounts............................................................3358.4.2 Chronic mental health problems..............................................338
8.5 Summary of findings........................................................................ 3388.6 Service implications......................................................................... 340
8.6.1 Empowerment.......... ............................................................... 3418.6.2 Information sharing................................................................... 3428.6.3 Client centred care planning.................................................... 3448.6.4 Flexible care for different needs.... ......................................... 3468.6.5 Partners in care........................................................................ 348
8.7 Recommendations for future research............................................. 3528.8 Trustworthiness and authenticity.................................................... 3548.9 Conclusion........................................................................................ 357
Appendices and list of references..................................................................361Appendix 1 Diagnostic criteria for postnatal depression.............................362Appendix 2 Couple summaries...................................................................... 363Appendix 3 Example of couple interview guide........................................... 374Appendix 4 Table illustrating the stages of analysis.................................... 378Appendix 5 Thematic codes condensed under thematic headings............379Appendix 6 Mind maps of the stages of the analysis..................................382Appendix 7 Stage 1 categories and their link to stage 2 frameworks........ 384Appendix 8 The components of the category framework ‘support issues’ . 387Appendix 9 Examples of couple support networks........................................396Appendix 10 Descriptions of normality...........................................................397References.......................................................................................................403
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Figure 1 The thesis as a developmental journey..............................................6Figure 2 Example of conceptual map...............................................................69Figure 3 The iterative process of analysis....................................................... 72Figure 4 Order of interviews and related datasets..........................................79Figure 5 Network: causality.............................................................................119Figure 6 Network: emotional health...............................................................127Figure 7 Network: access...............................................................................146Figure 8 Network: roles and gender...............................................................156Figure 9 Network: professionals..................................................................... 169Figure 10 Network: solutions.......................................................................... 185Figure 11 Network: help seeking....................................................................201Figure 12 Category framework 1: experience of postnatal depression..... 225Figure 13 Category framework 2: support issues......................................... 241Figure 14 Sample support network................................................................266Figure 15 Core category and its related processes...................................... 270Figure 16 Defining parenting normality: analysis stage 1 to stage 2 ...........271Figure 17 Process to seek help......................................................................290Figure 18 Process of adaptation to a new normality.................................... 304
List of figures
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Table 1 Respondent characteristics............................................................... 59Table 2 Professional terminology informing early codes...............................63Table 3 Lay terminology informing early codes............................................. 64Table 4 Emergence of tentative categories and subcategories...................65Table 5 Combining early codes into summary codes....................................66Table 6 In vivo codes generated by respondents.......................................... 66Table 7 Example of micro analysis..................................................................67Table 8 Example of micro analysis memo...................................................... 68Table 9 Example of application of the flip- flop technique..............................70Table 10 Reasons for non participation.......................................................... 84Table 11 Ahern's (1999) ten tips for reflexive bracketing..............................91Table 12 Terminology utilised for code generation..................................... 117Table 13 Patterning of responses for network: causality.............................. 126Table 14 Patterning of responses for network: emotional health................ 144Table 15 Patterning of responses for network: access................................ 154Table 16 Patterning of men's conflicting role demands................................ 159Table 17 Patterning of responses relating to the role of ‘good mother’ ..... 162Table 18 Distribution of men's responses to their partner's illness.............167Table 19 Patterning of responses for network: roles and gender...............168Table 20 Patterning of experience with professionals.................................177Table 21 Patterning of perceived availability of services.............................. 181Table 22 Patterning of responses for network: professionals......................183Table 23 Patterning of responses for network: solutions............................. 199Table 24 Patterning of responses for network: help seeking...................... 214Table 25 Linking stage 1 categories and stage 2 frameworks...................221Table 26 Patterning of responses to the framework: experience of postnataldepression.......................................................................................................239Table 27 Patterning of responses to the framework: support issues..........258Table 28 Conditions which facilitate and impede access.............................263Table 29 Comparisons to define normality.................................................... 281
List of tables
IX
Chapter 8 The application of the findings to the
literature and healthcare
8.1 Introduction
This chapter examines the findings from the thesis and discusses them in
relation to the literature on postnatal depression. It adds new material to that
published since the earlier review and suggests new perspectives on the
subject, which have emerged from this study. The study findings are
discussed in relation to the literature on the experience of postnatal
depression for women and some of the issues raised by the small amount of
work on men. It expands on this area in particular and adds the dimension of
the couple relationship to the body of work. A number of support issues are
identified. These describe the factors, which the respondents considered
when they assess the help available to them. These reflect recommendations
for practice proposed in the professional literature but also highlight gaps in
services. The core category ‘normality’ proposed by the study describes
some of the key concerns, which contribute to the respondents’
understanding of their experience. This chapter summarises the findings from
the study and relates these to the delivery of clinical service for families with
experience of postnatal depression. Recommendations for future research,
which arise from this study, are made. The study provides an insight into the
experience of postnatal depression for couples and their support needs. It
further adds to our understanding of the meaning of parenting for the
respondents and its influence on their decision to access help and chart their
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recovery from the illness. The findings illustrate the complexity of the
experience of postnatal depression and have implications for the delivery of
clinical services. Recommendations for future research are made. Men need
to be acknowledged as integral partners to the care of women with postnatal
depression but also as participants with specific needs of their own.
8.2 The research question revisited
The two areas of interest for this study were the couples’ experience of
postnatal depression and the related support issues. A number of factors
were of particular concern to the respondents: they speculated about the
causality of the illness, considered various coping strategies to manage the
illness and described how they aimed to achieve their ‘normality’. The
participants in this study explored these aspects based on a perception that
the couple relationship is valuable and should be preserved. They all had
considered ending their relationship at some point during the woman’s
illness, but had decided to remain with their respective partner. Their position
reflected a particular perspective which may be specific to this group of
respondents. In addition the format of support, the people providing it, their
characteristics and the outcomes of this support were important
considerations for the respondents to access potential help.
8.2.1 Experiencing postnatal depression
The findings reflect some of the factors identified in the literature, particularly
in relation to the experience of postnatal depression for women. Mauthner
(1999, 2002) and Nicolson (1988, 1990) highlight the effect of the illness on
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women and question the representation of postnatal depression as a medical
condition. Their work describes vividly how women experience postnatal
depression. They understand it as a debilitating condition brought about by
the demands of the care for the new baby and the need to maintain a
functioning image of competent motherhood. Beck (2002) summarises the
qualitative work undertaken in the field and proposes four perspectives.
These reflect the sense of incongruity between the expectations and the
reality of motherhood. Women experience a downward spiral towards
isolation and loneliness, which is characterised by feelings of guilt, pervasive
loss and contemplation of self harm. Gains are only made through a process
of surrender, reintegration and change.
The respondents in this study also talked about a similar sense of
incongruity. They felt that often their expectations did not fit with their actual
experience of motherhood. They expressed a frequent desire to maintain an
image of normality but found that this conflicted with their ability to access
help from those around them. Their experience added a new perspective to
that presented in Beck’s model (2002). They acknowledged similar feelings
of loss and guilt but also expressed their desire to actively strive to regain or
adapt what they perceived to be their former ‘normality’. While they
experienced the feelings of guilt and loss described by Beck (2002) they
appeared to engage more actively in the process of recovery. The women in
this study presented themselves not so much as victims of their illness but as
individuals with a desire to regain control over their lives. Social factors and
the demands of the care of the new baby were a recurrent theme for these
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women as Mauthner (1999, 2002) and Nicolson (1988, 1990) suggest.
However they also appeared to see their response to these changes less in
terms of passive acceptance and expressed a desire to play an active part in
their recovery. They adopted a position of realism and adjusted their
expectations accordingly. Whether this is necessarily desirable is
questionable since it potentially implies an acceptance of the status quo.
These women went through change towards recovery as indicated by Beck
(2002) but saw this less in terms of surrender than as an opportunity to
regain control over their lives. Although this process was challenging, it
provided the women in the study with a sense of empowerment and control.
The above authors suggest that the experience of postnatal depression is
gender specific and reflects the difficulties faced specifically by women. The
influence of the woman’s personality or her personal background is not
considered. Such a gendered perspective was less obvious in the current
study with differences in explanations less clearly delineated. The partners
placed a different emphasis on some aspects of the experience but also
shared similar concerns. For instance both partners speculated at length on
the causes of the woman’s illness to help them make sense of their
experience. The women used a range of physical explanations such as a
difficult birth experience, hormonal causes and the demands of a difficult
child. They also considered the role changes brought about by motherhood
and their effect on the women’s mental health. These women utilised the
same range of explanations of causality proposed by the literature but also
reflected the tension between physiological and social explanations apparent
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there (McIntosh 1993, Moore and Emanuel 2001, Nicolson 1990, Small et al.
1994). Edhborgh et al (2000) and Meredith and Noller (2003) specifically
identify the difficult child as a contributory factor. The latter suggest that
depressed mothers have a tendency to see their children as fussy and
difficult to manage. As the respondents in this study commented on the
potential impact of their difficult child, this may be a reflection of their
depression rather than their child’s objective problems. For other couples in
the study difficulties of childcare were not necessarily an issue. On the
contrary, they expressed puzzlement that they did feel depressed despite
having a ‘good baby’. They would have found it easier to understand, if their
depression had been caused by a difficult child. This aspect contrasts with
the literature since the respondents assessed their child’s behaviour more
favourably than some of the authors suggest. The women’s judgement of
their child’s temperament may have been less distorted than anticipated.
The concept of motherhood and the notion of a good mother and wife are
further key concerns for women with postnatal depression. Women judge
their own performance as good women based on their understanding that
they need to fulfil their domestic roles as carers. Prioritising their own needs
is perceived to be unnatural placing women in conflict with their social world
and creating tension in their personal identity (LaFrance and Stoppard 2006).
The need to be seen to function effectively and to fulfil the role of a ‘good
mother’ also informed the women’s understanding of their experience in the
current study. They compared their own experience with their peers, who
were perceived to fulfil this aspect of their role more effectively. They made
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these comparison based on their definition of ‘normal’ parenting. They also
talked about the need to take time out from their childcare duties and their
feelings of guilt when they expressed this desire. Like the women in
LaFrance and Stoppard’s study (2006), the women in the current study
demonstrated a similar need to reject the concept of the ‘good woman’ before
they were able to recover from their depression.
Some couples were more likely to attribute the causality of the illness to the
influence of hormonal factors and traumatic birth events, while others
stressed the social causes of their illness, the additional child care demands
and changes in family roles. While the emphasis was slightly different, both
partners commented on the same aspects of the experience with some
couples focussing more on physiological explanations while others attributed
the illness more to social causes. The literature on postnatal depression
identifies similar conflicts of interpretation but is moving towards an
interpretation which recognises both perspectives (Holden 1991, Huang and
Mathers 2001, Tennant 2002). These are recognised in the importance which
is placed on the need to consider both medical and psychological
approaches to treatment (Scottish Intercollegiate Guidelines Network 2002).
The respondents in this study tried to make sense of their experience and
used the explanations currently available to them. Contact with medical staff
and the easy availability of drug treatment might have reinforced particularly
the physiological explanations. In addition, the men favoured more tangible
explanations for their partners’ illness such as hormonal causes,
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complications of childbirth and exhaustion. Since men often can feel
frustration when they can not ‘fix the problem’ (Meighan et al. 1999), such an
attitude might have made a physiological explanation for their partner’s
depression more accessible to the men in the study. It could also explain the
men’s more positive attitude towards medication as a treatment, although
they expressed their concerns about the potential side effects of medication.
At the same time, these functional explanations were insufficient to explain all
aspects of the experience. Leventhal et al. (2003) suggest that individuals
develop their understanding of illness representations from a range of
sources of information which include biological changes, the observation of
others and information gathered from the wider social context. The
respondents in this study were aware of the ranges of explanations available
to them. Their selection appeared to be based less on gendered differences
than on their need to make sense of their experience over time and within
their social context.
In addition the respondents in this study engaged in significant emotion work
to manage the disruption which postnatal depression had caused in their
lifecourse. The women commented on their efforts to hide their feelings in an
attempt to maintain normal social interaction with those around them and
manage the perceived stigma of their diagnosis. The respondents saw their
experience as contrary to their personal and social expectations of
parenthood, a perception which challenged their self identity. Emotion work
allows individuals to conform to given, dominant expectations. People
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actively deal with their emotions to manage their experience for themselves
and for others (Frith and Kitzinger 1998). This requires skill and effort since it
involves handling not only personal emotions but also those of close others.
It is possible that this can create a potential tension between the needs of the
patient and significant others (Duncome and Marsden 1998). The
respondents in this study demonstrated such a conflict in their efforts to meet
not only their own emotional needs but also those of their partner. The
attempts of both the men and women in the study to protect the partner from
distress illustrated such efforts to manage conflicting emotions. Their emotion
work reflected their sense of care and protection towards the other partner.
While it is suggested that such care work is gendered and the domain of the
female (Frith and Kitzinger 1998), both partners displayed similar concerns.
A significant life event can disrupt not only daily life but also the expected
lifecourse. Emotion work can help the patient to feel better about the self but
also make others feel better in order to maintain an authentic self within a
perceived disrupted lifecourse (Exley and Letherby 2001).
Managing emotions in response to a significant life event, which is perceived
to disrupt the expected course of personal or family life, requires emotion
work from not only the patient but also the informal carer. Informal carers of
cancer patients for instance undertake emotion work to help the patient while
also trying to manage their own distress. The relationship can be
strengthened by a sense of shared responsibility to manage the complex
emotions generated by the diagnosis. At the same time a desire to provide
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reassurance and maintain a positive image for the patient can make
additional emotional demands on the carer (Thomas et al. 2002). The men in
the current study engaged in similar emotion work when they commented on
their efforts to provide reassurance to their partners, stressed the common
responsibility for the management of their partner’s depression but also
described their hidden, personal distress. This suggests that the carers
engaged in emotion work not only for themselves but also for their partner.
The complexity of this process and the considerable emotional effort involved
have been highlighted by other authors (Duncome and Marsden 1998, Exley
and Letherby 2001).
For both partners, the underlying strength of the couple relationship was of
concern and a recurrent theme throughout the interviews. The feelings of
isolation and confusion described in the literature were also significant for the
respondents in this study. In addition they conveyed a sense of commonality
and a desire to maintain the relationship. A number of authors focus on the
negative impact of the illness on the relationship. They identify feelings of
isolation, frustration and a fear of not being able to cope with the partner’s
depression (Aiken and Kingsley 2000, Beck 2002, Davey et al. 2006).
Demands of childcare and sexual difficulties are additional stressors for the
relationship (Edhborg et al. 2000). The couples in the current study also
commented on their feelings of isolation from each other and their inability to
share their feelings of distress. Both partners felt a sense of distance, often
withholding important information in an attempt to protect the other partner
from distress. The men often felt frustrated that they were unable to help their
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partner effectively and could not always understand what was expected of
them. They expressed a desire to obtain information about their partner’s
illness to help them understand the conflicting demands made on them.
These findings reiterate the points made by other authors (Aiken and
Kingsley 2000, Davey et al. 2006), but add a further positive perspective to
this presentation. The respondents commented that their relationship had
also matured as a result of their experience. As they moved towards
recovery, they felt that they had developed as people and gained in
understanding.
The more the partners were able to communicate with each other, the more
they had felt that their relationship had developed positively. This need to
communicate with the partner to facilitate the relationship and to actively
seek help from others has been identified previously (George 1996). Even if
the women are supported effectively there is the possibility that they continue
to feel troubled in their relationship. Often the marital relationship is portrayed
as the primary source of support. Such a position can detract from the role
other forms of support play particularly for women (Mauthner and Doucet
1998). The women in this study also valued additional sources of support
such as family members, friends and professional helpers. While the men in
the study often perceived themselves to be more emotionally self sufficient,
they also described their need for additional support to help them manage
their partner’s illness. Both partners experienced postnatal depression in
similar terms. Although they had considered leaving the relationship at some
time during the course of the illness, they remained together based on the
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value both partners placed on the relationship. It is possible that the men
stayed in the relationship because they were more likely to draw emotional
support from their partner and had fewer support networks. Since this study
sought to explore the perspectives of parents who had negotiated postnatal
depression as a couple it could be argued that this represents an inherent
bias in the sample. While acknowledging this limitation to the study findings,
it could be argued that their perspective is as relevant as that of couples who
have separated. The experience of the respondents in this study has the
potential to provide valuable insights which might be of benefit to couples at a
crossroads in their relationship.
8.2.2 Supporting and being supported
The experience of postnatal depression described by the participants in this
study highlighted more similarities between the partners than suggested by
the literature. This was also the case for the support issues identified by the
respondents in terms of the format of the help available and discussed in
more detail below. In addition the study provided an insight into the various
considerations, which influenced the respondents’ help seeking decisions.
8.2.2.1 Format of supportMedication and physical exercise have been identified by users of mental
health services as important elements of support (Faulkner and Layzell
2000). Other helpful strategies include the need to change personal attitudes
and recognise the importance of relationships with others. The SIGN
guidelines for postnatal depression (2002) further stress the need for
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combined medical and psychosocial interventions. Of particular interest to
the couples in this study was the social support available to them. Social
support is defined in terms of instrumental, informational and emotional
support by a number of authors (Dunbar et al. 1993, Kendall - Tackett and
Kantor 1993, Reid et al. 2002, Wills 1985). The respondents in this study
commented on the various aspects of support. Examples of practical support
were given such as help with household chores, baby care and time out from
childcare. Emotional support was valued in the form of listening,
understanding and relationship advice. These examples contribute to our
understanding of the issues which were of concern to the participants and
help to contextualise the abstract concepts identified by others. The
respondents were not passive recipients of this help but judged its
effectiveness against their own expectations. For some couples unfulfilled
expectations led to feelings of rejection, which affected future requests for
help.
While the partner is often cited as the main source of instrumental and
emotional support (Besser et al. 2002, Leathers et al. 1997), some of the
men in this study expressed the need to be supported themselves. A number
of the men gave examples of having tried to seek help from other members
of the family network, friends and professionals. This suggested a tension in
the expectations of the men. They stated that they were inclined to manage
any difficulties independently but also described their efforts to seek out
others for emotional support. Particularly the support provided by the
partners for each other can contribute to a sense of satisfaction with the
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relationship (Knauth 2000). Furthermore men are more likely to be affected
by their partner’s difficulties and the state of the marital relationship (Dudley
et al. 2001). This suggests that it is important to address the emotional needs
of both partners, but contrasts with the findings from this study. The maps of
the couples’ support networks consistently demonstrated an imbalance in the
support available to the two partners. The men identified themselves and
were seen by their partners as the women’s main support but only some
received support from their partner during her illness. They commented on
this loss of a previously supportive relationship but felt able to manage this by
treating the difficulties as a temporary problem. The men in this study had to
manage an increased emotional burden at a time when their main source of
help was unable to provide it. It has been suggested that it is important to
consider the quality of the relationship and the mood of both partners during
the transition to parenthood to reduce the development of depression (Morse
et al. 2000). This, together with the recognition that men are more likely to be
affected by their partner’s problems (Dudley et al. 2001), has implications for
the emotional health of both partners.
Men provide both emotional and practical support for their partners,
managing their partner’s negative emotions due to a more robust self esteem
(Morgan et al. 1997). While the respondents in this study expressed a stoic
acceptance of their partner’s difficulties, they asked for information and
suggestions to support their partner more effectively. The opportunity to
explore these issues was welcomed by at least some of the men. As men are
increasingly included in the provision of support programmes, their need for
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information and desire to feel less isolated is gradually being recognised
(Morgan et al. 1997, Riecher- Roessler and Hofecker Fallahpour 2003,
Roberts and Kowalski 2000). However, most of these interventions relate to
the provision of various forms of group support. In contrast, the respondents
in this study expressed at least some reservations with this format of support.
They preferred informal contact and informational support in order to ‘fix’ their
partner’s problems. This desire to manage the disruption caused by the
illness and the need to ‘fix’ their partner has been identified previously by
Meighan et al. (1999) but was also expressed by the women in this study.
8.2.2.2 AccessAccess to support was a further issue of concern to the respondents. They
indicated that help seeking was a complex process and subject to a number
of considerations. For instance different individuals were likely to prefer
different interventions. They based their choice on their prior knowledge of
the helpers and their expected ability to deliver this support. This use of
background information, which might lead to a decision to reject the help,
suggested a new perspective on the provision of support. Both partners
described instances, which led them to exclude particular helpers based on
their prior experience in other situations of need.
This is an issue identified by Brugha et al. (1998), who suggest that the
perceived level of support can act as an early indicator for depression. A
perception that social support is poor is more significant than the actual size
of the support network. Overall, a relationship is judged to be satisfactory if it
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matches existing expectations. For women, in particular, this is more
important than the tangible support received. For the fathers concrete
support is more important than their expectations (Coffman et al. 1994). The
respondents in the current study reported similar considerations but did not
demonstrate the gender differences noted by the above authors. Both
partners described a clear decision making process, which was informed by
their previous experience of the potential helper. This in turn could lead to the
exclusion of that person from their expectations and a revised support plan.
This finding was unexpected. The literature focuses on the support activities
rather than the expectations of the recipients of that help. This study
highlighted the need for any helping activity to include a clear process of
negotiation. It was important to the respondents that the help offered actually
met their expectations and appeared to explain variations in the uptake of
some provisions.
In addition, the men and women in this study preferred different forms of
support activities. For instance the women commented favourably on the
benefits of group support in various forms, but found timing to be crucial.
This was in contrast to other studies, which note that women attend these
groups erratically and do not necessarily benefit from this intervention (Reid
et al. 2002, Stamp et al. 1995). These studies suggest that little economic or
health benefits could be gained by attendance at such groups. Since
attendance in particular can be variable, the viability of such groups has been
called into question (Reid et al. 2002). Nevertheless the findings from this
study suggested that the women did value group support but often were not
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able to attend when they were unwell. At such times they felt vulnerable and
exposed to unfavourable criticism from their peers. At other times they were
able to benefit from attendance by gaining positive support from others
outside their immediate family circle. They accessed groups as they felt well
enough to attend but also valued individual contact with sympathetic helpers.
For the men, group support was more contentious and appropriate only if it
was available for both partners. They felt that they would attend a group to
help their partner but had reservations about the potential benefits for
themselves. The male participants in a study by Webster (2002) also
expressed these attitudes. They had reservations about attendance at a
men’s group but were more receptive to a group in support of their female
partners. In contrast, work done more recently by Davey et al. (2006)
suggests that men do value support from their peers to reduce feelings of
frustration and isolation. It is possible that this difference in perspectives
could be attributed to the difference of context between these studies. For
instance the Davey et al. study (2006) reported on the findings of a postnatal
support group for fathers while Webster (2002) and the current study asked
men about their perceived attitudes without an actual experience of such
groups.
Most men in the current study expressed a need for more information about
their partner’s illness and strategies to support her. While they managed their
partners’ distress often unsupported, they provided practical as well as
emotional support. While men are more likely to support their partners
through practical tasks (Webster 2002), they do not necessarily need to
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undertake traditional female tasks to be perceived as supportive (Mauthner
2002). However the men in the current study described both practical and
emotional support activities. This suggests that they took a broader
perspective to their partners’ support needs than previously indicated.
8.2.2.3 Characteristics and conditionsAn attitude of warmth and unconditional regard were important helper
characteristics identified by the respondents. These attributes have been
described at length in the large body of literature on counselling relationships
(McLeod 1998) and specifically Rogers’ (1961) work on the basic qualities of
the effective helper. Effective counsellors should be able to demonstrate a
range of interpersonal skills including the ability to listen with empathy, be
aware of non- verbal communication and be sensitive to the expression of
emotion from a position of concern for others (McLeod 1998). Rogers (1961)
suggests that those who are being helped need to be able to trust the helper
and feel understood. The helper should show a warm interest for the person
without being too emotionally involved. The attitude of the helper is
consistently more important than a specific theoretical orientation. In fact,
there is little evidence that support from one type of individual is more
effective than that from another (Ray and Hodnett 2001). The respondents in
this study recognised and valued similar characteristics in the helper but went
further by suggesting that these were more important to them than a
recognised qualification. Both partners in this study appreciated an attitude of
encouragement, shared decision making and acceptance. These are
characteristic of the qualities of a close confidante described in the literature,
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who provides active, consistent and sensitive support (Armstrong 1995, Davy
1998, Dickinson 1990). In addition the couples found it unhelpful, when a
helper was dismissive and perceived to be too busy to listen. As expected,
being able to listen sensitively to their needs and communicate effectively
was appreciated as helpful.
A further significant aspect of support in this study was the outcome of the
helping activity. It related to the goals of support and its impact on the
recipients. Other studies, which have specifically focussed on women
attending postnatal support groups, have identified the need to build self
esteem (Gutteridge 2001, Hall et al. 1996). For instance increased self
esteem can help women negotiate various social stressors more effectively
and improve the quality of the marital relationship (Hall et al. 1996). These
studies focussed specifically on the needs of women. At the same time men
also comment on their need to manage their family and work responsibilities,
often feeling unable to cope and left out (Aiken and Kingsley 2000).
Interventions, which are aimed at women and their partners, challenge
negative thinking patterns and are promoted to address this concern. These
can provide opportunities for the partners to access their joint resources and
move beyond feelings of rejection towards a reappraisal of the help available
in preparation for a future pregnancy (Peden et al. 2005, Riecher- Roessler
and Hofecker Fallahpour 2003). Both partners in the current study expressed
similar concerns and talked about the negative emotions generated by their
experience and unmet expectations. They found it difficult to express their
need for help to each other and to others. A fear of the consequences, which
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a diagnosis of mental illness would bring with it in terms of stigma, was a
recurrent theme. How such a fear can act as a barrier to help seeking has
been recognised by various authors (Riecher- Roessler and Hofecker
Fallahpour 2003, Rogers and Pilgrim 1996). The fear of stigma for instance
has been implicated as one of the reasons why women often delay their
requests for help. This, together with a failure to accurately diagnose the
condition, suggests the need for specific psychotherapeutic interventions for
this client group (Riecher- Roessler and Hofecker Fallahpour 2003). In
addition, Rogers and Pilgrim (1996) highlight the conflict generally
experienced by individuals suffering from mental health problems. Their
desire to share their difficulties with others can interfere with their need to
present a positive image of themselves to others. This is a sentiment
expressed by the women in the current study, who described the tension
between their wish to meet other mothers and the feelings of failure, which
such contact generated for them.
Finally, the respondents identified a number of conditions, which helped them
access support. These related to their need for adequate information about
postnatal depression and its management. Help giving was interpreted as a
reciprocal obligation, based on an understanding that help received in the
past should be returned. This aspect of the couple relationship contains
elements of social exchange theory first proposed by Homans (1961) and
Blau (1964). It suggests that individuals act towards others based on mutual
rewards, which influence their relationships over time (Cropanzano and
Mitchell 2005). While social exchange theory is often related to the intricacies
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of economic exchanges, Widegren (1983) relates it specifically to intimate
relationships. In this context, the interaction between individuals is guided not
by economic considerations but concern for the other person’s well being.
Reciprocity becomes an indicator of the level of positive regard for the other
person. It contributes to the creation of increasingly positive attitudes
between the partners and nurtures the relationship (Widegren 1983). The
men’s perception of the reciprocity of support reflects Widegren’s (1983)
premise and an expression of their concern for the wellbeing of their
partners.
The respondents suggested that postnatal depression should be managed as
a joint problem to facilitate access to help and support. The men were often
unaware of the level of severity of their partner’s distress and could only offer
effective support, once they had understood this better. In addition both the
woman and her partner needed to be ready to accept the help on offer from
lay and professional helpers. While the need for relevant information has
been recognised by other writers (Roberts and Kowalski 2000, Davey et al.
2006), the other elements identified by the couples have not been described
in this detail. Williams et al. (2004) stress the need to ensure that any
definition of support is informed by, and explored within, the context of the
specific situation of the individuals affected. Definitions derived from other
contexts, which are then superimposed on that particular experience, are
unsuitable. Although the respondents in this study shared aspects of their
definition of support with others, their experience was also unique and
highlighted their specific support needs.
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8.3 The concept o f normality'
Throughout the interviews the respondents utilised the term ‘normal’ and
described their experience in these terms. They defined this ‘normality’ by
comparing it with a number of factors. Some of these were internal to the
couple while others were external. Although often aware of the idealised
nature of the images, which informed their definition, the couples utilised
them to assess their experience. Nicolson (1988, 1986) describes a similar
approach to the construction of meaning through which her respondents
attempt to understand postnatal depression. She suggests that this is a
process both conscious and unconscious, which evolves from the reflexivity
of the participants. Part of this process is unconscious and affects the
understanding of the experience of the individual. Symbolic interactionism
(Hewitt 1997, Klein and White 1996, Layder 1994, Meltzer et al. 1975)
suggests that such a reflective process is integral to the daily activity of
making sense of the social world. Language helps to understand the world
and allocate meaning to objects. I was aware that the language used by the
respondents in the current study, had a range of meaning not only to them
but also to me. For instance the use of language in terms of ‘nuts’, ‘off the
rocker’ and ‘mad’ had a range of possible interpretations, which differed
between layperson and professional. The interviewees utilised these terms to
compare ‘normality’ and ‘abnormality’, while I initially interpreted them in
terms of mental illness and psychosis. Their definition of ‘normality’ was a
constant theme for the respondents. It informed their decision making and
the assessment of their experience and progress. Consequently their
responses needed to be seen against this specific interpretative background.
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Family system theory provided a framework to explore the couples’
experience. The approach to families as systems is a useful concept to make
sense of a life-changing event such as postnatal depression. The theory
proposes that the various elements of the system interact with each other
and are in a constant state of flux as they react to events. Any incident
affects the individuals and the system as a whole (Allmond et al. 1979).
However caution should be exercised, not to confuse the model with the
reality of family interaction. This is an abstract model, which should be used
as a guide to understanding family interaction rather than as a blueprint for
family function (Broderick 1993). Klein (1996) suggests further that the
underlying constructivist epistemology of the approach ensures the use of the
model as an artificial construct to illustrate the interaction of the various
family members with each other and their social world. Although family
system theory adopts a constructivist perspective, Wright and Leahey (2000)
also acknowledge that meaning is created through the different
interpretations which both nurses and their clients bring to any interaction.
They stress the need for practitioners to be open and explore these different
perspectives in the therapeutic encounter. In this way their family
assessment model combines an understanding that reality and meaning are
constructed by the social actors with an implicit respect for the reality of the
world of experience of the participants. Their model understands human
participants as active agents in their world but also recognises that the world
of each family member is constructed within a wider social setting.
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The following definition of the family informs the work of family nurses: 'the
family is a self identified group of two or more individuals whose association
is characterised by special terms, who may or may not be related by
bloodlines or law, but who function in such a way that they consider
themselves to be a family' (Wegener and Alexander 1993, pg 4). In addition
families are made up of individual members who relate to each other and
form subsystems such as couple, sibling or parent-child groupings. The
family contains individual subsystems but also relates, as a whole, to other
systems outside the immediate family such as the wider community
represented by various social and political organisations (Wright and Leahey
2000). The current study focussed particularly on the parent dyad as a
subsystem of the family to explore the experience of the key partners in the
parenting relationship. In addition it acknowledged that the respondents were
embedded in the wider context of their family and its social and
environmental background (Broderick 1993).
Changes in the system occur as a result of the influences of the environment
or individual members on the family. The current study was based on the
premise that postnatal depression triggered such a change in the family
system. The couples’ desire to achieve ‘normality’ was an example of the
goal seeking behaviour proposed by the model. As an adaptive system, the
family is in a constant state of flux, influenced by a range of interpersonal as
well as external factors. The analogy of a mobile with interlinking,
interdependent parts illustrates the interaction of the different members of the
family system (Allmond et al. 1979). The family is able to respond to the
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different forces, which impact on it, and achieve a balance between change
and stability. The ‘process of adaptation to a new normality’ identified in the
current study illustrated the respondents’ attempts to establish a balance in
the system over time.
8.3.1 The process to seek help
Family systems nursing proposes that systems are able to regulate
themselves through a reflective process of assessment, which informs a
continuous feedback loop (Wright and Leahey 2000). This process was
apparent in the couples’ response to the challenge of postnatal depression.
They compared their experience against their definition of ‘normality’ and
their personal goals. When their experience did not meet their expectations,
this information was fed back to adjust their response. For instance the
couples reassessed their need to seek help based on the realisation that
their experience differs from that expected as part of the ‘normal’ transition to
parenthood. Feedback resulted in a review of the earlier interpretation, an
adjustment in response and disclosure.
The trajectory and time span of the ‘process to seek help’ proposed in this
study depended on a number of factors, which influenced the couples’
decision to request treatment and care. From the number of maternal barriers
to help seeking identified in the literature (Dennis and Chung-Lee 2006), of
particular interest was the suggestion that women attributed their symptoms
to causes other than postnatal depression. They also found it difficult to
disclose their problems to their partners and family, fearing the stigma of
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mental illness. It has been suggested that men and women have different
perspectives in their attribution of the causes of postnatal depression: women
focus on the social process of transition to motherhood; men see the physical
demands of childcare as central (Everingham et al. 2005). These different
perspectives hamper the process of communication between the partners but
also the couples’ ability to share their experience with others. Women need
to be reassured that their experience is valid and that they are ‘good mothers’
while the men try to fix the problem for their partners. When this fails, they in
turn become distressed and remove themselves from the relationship. They
withdraw to other activities such as work and hobbies, which make them feel
more comfortable (Everingham et al. 2005). However the respondents in the
current study did not demonstrate such clear divisions in their interpretation
and often expressed very similar concerns. Both partners considered various
reasons for the woman’s illness, attributing her symptoms to a range of
causes both physical and social. During the early stages of the process to
seek help, these different interpretations influenced the decision to disclose
any difficulties to others outwith the couple relationship. In addition both
partners talked about the stigma surrounding the diagnosis of mental illness
and took this into consideration when they sought help particularly from
external sources of support. Their responses contrasted with Goldstein’s
suggestion that only individuals, who attribute depression to psychological
causes, are more likely to express a fear of stigma and delay their help
seeking accordingly (Goldstein and Roselli 2003). Regardless of attribution,
the respondents in this study shared a concern of the stigma of a diagnosis
of depression.
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8.3.2 Adaptation to a new normality
Families evolve continually in response to changes in the family members
(Bateson 1979, Maturana and Valera 1992). Illness, as a major life event,
can prompt a major transformation in the family system. This leads to
changes in attitudes and behaviours. Change of the system is influenced by
previous experience and the interaction of the family members with the
external systems. The respondents in the current study described their
progression from early parenthood and postnatal depression to a new
understanding of the illness and their relationship. Systems theory describes
the various components of the self- regulating feedback loop in broad terms.
In contrast, the Leventhal et al. (2003, 1997) self regulation model of health
and illness focuses specifically on four distinct elements of health behaviour.
The model is informed by a problem solving approach. It suggests that
individuals identify goals, consider various inputs and outputs and evaluate
the effectiveness of interventions when they respond to an illness. Of
particular interest to the current study are the five domains of illness
representation proposed by the model: identity, cause, timeline,
consequences and cure. Individuals act as common sense scientists when
they attempt to assess a threat to their health (Leventhal et al. 2003). They
then utilise these representations to set goals for the management of the
illness, identify procedures to attain these goals and evaluate the
effectiveness of the response. In addition the individual continues to strive to
make sense of the illness experience as more information becomes available
(Leventhal et al. 2003).
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When the model was reviewed as part of a meta- analysis of relevant
studies, its usefulness as an aid to our understanding of the response of
individuals to various physical illnesses was confirmed (Hagger and Orbell
2003). In contrast, the current study focused on the experience of postnatal
depression, a mental illness. The ‘process to seek help’ proposed by this
work met the criteria for the five domains of the Leventhal et al. (2003) self
regulation model. Respondents described how their experience deviated
from their understanding of ‘normality’ (identity), speculated about the
reasons for these symptoms (cause) and determined a time period (timeline)
within which they assessed the symptoms to reflect the ‘normal’ early
recovery from childbirth. They were further prompted to act by concerns of
the potential consequences of poor parenting and the effect of the illness on
the couple relationship (consequences) and the available treatment options
(cure).
The Leventhal et al. (2003) model further suggests that an individual’s
emotional response to a health threat affects their practical management of
that threat. For instance a correlation exists between medication uptake and
depression in patients receiving treatment for a physical illness (DiMatteo et
al. 2000). When the illness is perceived to be time limited and controllable,
individuals are more likely to seek solutions to the problem and adapt to the
changes brought about by the illness (Hagger and Orbell 2003). The
respondents in this study emphasised specifically the anticipated timeline of
the woman’s depression. The men wanted to ‘fix’ their partner. The couples’
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expectation that the illness was time limited and curable influenced their
response and prompted their search for help.
The current study supports the Leventhal et al. (2003) model and relates it to
mental illness. It identifies a specific additional element: the identification of
an appropriate helper. The respondents based their decision to seek help on
their previous experience. The personal characteristics and the relationship
of the helper to the family were significant considerations in this process.
Leventhal et al. (2003) formulate a number of rules to explain how individuals
interpret their experience and seek to control illness. The current study
proposed an additional rule: a ‘helper knowledge- support access’ rule. A
potential helper was more likely to be approached if he or she was perceived
to have positive attributes. In such a case, the helper’s characteristics were
more important than their relationship to the family system or their
qualifications.
The outcome of the process of adaptation took on different forms. Some
couples noted a return of their relationship to pre- illness levels, adjusted to
include the new baby. Others described a new type of relationship,
strengthened by their experience of postnatal depression. Finally a few
couples adapted to respond to a more chronic depressive illness. When this
adaptation was successful, the couples experienced a sense of
developmental growth characterised by the reaffirmation of their relationship.
Andresen et al (2003) propose a model of recovery for patients suffering from
serious mental illness. The individual’s ability to re-establish previous goals
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or formulate new ones is an important aspect of this process, which is
characterised by personal growth and a positive sense of the self. The
individual should feel ‘that the experience has made them a better person
than they might otherwise have been’ (Andresen et al. 2003, pg 591). The
respondents in the current study experienced such a sense of personal
growth when they talked about achieving a ‘new normality’ at the end of their
journey through postnatal depression.
8.4 Potential limitations
Methodological considerations have been discussed in chapter 3 which
explored issues relating to the sample selection, access to respondents
through gatekeepers and issues arising from joint interviewing. The following
points should be considered as additional potential limitations for this study.
8.4.1 Retrospective accounts
The respondents talked about experiences and feelings, which they had had
some time previously (see chapter 3, table 1). The average time, which had
elapsed between the time of diagnosis and the first interview with the
respondents, was approximately two years and three months. The
professionals referring potential participants to the study were asked to
approach only couples well enough to participate. As the exploration of
difficult memories had the potential to challenge an already fragile situation,
the need to protect the participants from additional distress was a key
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concern. All respondents were therefore already somewhere on their path to
recovery when they participated in the study.
While some respondents were still relatively close to the initial diagnosis,
others recalled events from a number of years previously. Speaking to the
couples and reading their accounts highlighted the ongoing immediacy of
their experience for me. Evelyn, Frances, Rachel and their partners talked
about their experience five to seven years previously. Despite this distance in
time, they described their feelings and actions in great detail. In addition they
had reflected on their experience and added new interpretations to their
accounts. Other couples were closer in time to the illness. For some a new
pregnancy potentially challenged the relationship and the woman’s mental
health. The interviews were often the first opportunity for the couple to
explore their feelings together. All couples felt that helped them to revisit their
experience and allowed them to move forward as a couple.
It is important to ensure that the boundary between research- and therapeutic
interview is not overstepped. The research interview must not provide new
interpretations for the respondents but focus on their understanding of
themselves and their experience (Kvale 1996). As the participants in this
study talked about their experience they also tried to make sense of their
feelings and responses. It was often difficult to separate their accounts of
their experience from their subsequent interpretation of events. In addition
the partners often continued a conversation started during the interview after
I had left. They then brought these thoughts to our subsequent conversation.
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This posed a dilemma, which reflects the tension between Kvale’s (1996)
position and Holstein and Gubrium’s (1995), which recognises this active
process of interpretation constructed jointly by the interviewer and the
respondents. The couples developed further personal interpretations during
and after the interviews, over which I had little control and which illustrate the
additional complexity of the joint interview. It remains important to guard
against an infringement of the boundary between research interview and
therapeutic intervention by building appropriate support mechanisms into the
process (Dicicco-Bloom and Crabtree 2006). All couples were encouraged to
utilise their existing healthcare contacts to explore any new perspectives
further and ensure access to appropriate therapeutic interventions.
Silverman (2000) gives an example of a qualitative study, which reported the
retrospective interpretations of the respondents and claims that these
represent the subjects’ experience. He cautions that such a claim fails to
understand the complexity of the interview encounter. He suggests a social
constructionist approach to address this issue (Silverman 2001). The
researcher needs to recognise that the respondents’ own perspective is
informed by the wider social context of their experience. The participants in
this study for instance often use the conjunctive in their narratives. They
noted that they might have acted differently or that their interpretation did not
reflect more commonly held beliefs. They often commented that they ‘should’
or ‘ought’ to have acted in a particular manner. The respondents
differentiated between their reported actions and their desirable actions, their
interpretation of their experience and its socially acceptable context. This
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study reports the couples’ experience as it was informed by the social
construction of their world, their subsequent reflection on the events and the
specifics of the interview situation.
8.4.2 Chronic mental health problems
The majority of respondents had recovered or were on the path towards
recovery by the end of the study. For three women the initial diagnosis of
postnatal depression though had developed into a chronic depressive illness.
In addition two of the men were receiving treatment for a depressive illness.
This fact needs to be considered when assessing the findings of this study.
As depression is associated with expressions of intense feelings of
helplessness, hopelessness and worthlessness (American Psychiatric
Association 2000), some of their responses may have reflected these
emotions. Nevertheless their experience also illustrated one of many
representations and levels of severity of postnatal depression.
8.5 Summary o f findingsThe study explored the experience of postnatal depression for couples and
their support needs. Both partners shared significant aspects of this
experience but also placed different emphases on some aspects of their
experience. Respondents attributed postnatal depression to a range of
causes. They expressed a need for more clarification and specific advice
about the management of the illness. The couples conveyed a strong
commitment to their relationship, which allowed them to manage the
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challenges posed by the illness and recognise opportunities for personal
growth. Support was understood to be an integral part of any reciprocal
relationship and obliged the well partners to help the ill partner. Postnatal
depression was perceived to be a temporary difficulty, which was likely to
resolve within the foreseeable future.
The couples commented on various support activities including group
activities. The men expressed some reservations in relation group support
and highlighted the perceived mother-child focus of clinical services.
Potential helpers were valued if they demonstrated an attitude of acceptance,
strove to ensure that the expectations of the partners were explored and
involved both partners in clinical decisions. The men tried to support their
partner in practical and emotional terms. They did find it difficult to judge the
extent and severity of their partner’s illness though. The couples, and in
particular the men, expressed a need for information on postnatal depression
and specific strategies to respond to their personal experience. Effective
support therefore needs to be individualised, non judgemental and inclusive
of both partners.
Family system nursing (Wright and Leahey 2000) and the Leventhal et al.
(2003) self regulation model of health and illness provided the theoretical
background for the study. The core category ‘normality’ was the benchmark
against which the respondents assessed their experience of the illness,
sought help and charted their progress towards recovery. The respondents
considered similar issues to those described by Leventhal et al. (2003): the
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causality of the illness and its anticipated time line. The study provides
additional confirmation of this model and extents it into the field of mental
health. The respondents’ utilised their prior knowledge of the helper and
previous helping activities to decide whether to access a potential source for
help. This ‘helper knowledge- support access’ rule is proposed as an
additional rule for the Leventhal et al. (2003) model but requires further
exploration.
8.6 Service implicationsThe respondents identified a number of factors which are of interest to
healthcare professionals providing services for this group of clients and for
educators preparing clinical staff for work in this area. Considering the
implications of this study’s findings for healthcare professionals from a range
of backgrounds recognises the contribution of a multidisciplinary group of
practitioners to the care of families experiencing postnatal depression. It is
suggested that the findings might be of interest to medical personnel, nursing
staff and workers in the non-statutory sector. The themes for service
provision identified in this study reflect the current focus of care delivery
which stresses the need to involve clients actively in the decision making
process of their care (Faulkner and Layzell 2000). Self care is encouraged
based on access to appropriate information and tailored to the client’s
specific needs. Services should be flexible in response to identified client
needs. The redesign of community nursing services in Scotland currently in
progress emphasises the importance of a central contact person for clients to
access (Scottish Executive Health Department 2006). This has significant
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implications for mental health practitioners since it recognises the importance
of client centred care which is responsive to need through negotiated care
planning involving the whole family. Professionals should become allies in
recovery to help clients become able to reach out for help, take control and
become involved in their treatment (Mancini 2007). These issues should be
considered by the range of professionals who support families with postnatal
depression. It is important that these general principles also inform education
in the field in order to develop practitioners who work with their clients from a
perspective of inclusion and empowerment.
8.6.1 Empowerment
The need to be active participants in their recovery was identified clearly by
the respondents. Both partners expressed a desire to have control and share
in the decision making process. They wanted to be involved when decisions
about treatment were made and valued treatment decisions which took
account of their specific situation and the stage of the illness. Only when
clients feel that they are actively involved in this process does empowerment
become more than a rhetorical concept (Lloyd 2007). Service users have
highlighted the values which should underpin a service based on a
philosophy of empowerment. The keys for self help in this context are
information, the active participation of service users, providing participants
with the skills to be assertive and to express themselves. Services need to
ensure that clients feel that their experience is valued and encourage clients
to take control of the management of their condition (Lucock et al. 2007).
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Since managing the demands of postnatal depression involved both partners
in emotion work, this needs to be recognised by those providing services.
Often communication between the partners had broken down and was
recognised by the respondents as a contributory factor to mutual feelings of
isolation. Screening early for relationship problems and devising subsequent
interventions informed by the issues identified during this process as
proposed by Simons et al. (2001) may be useful in raising awareness of the
importance of the relationship and identify problems early. Providing care
which is aimed at inclusion can facilitate a sense of empowerment not only of
the person receiving care but also engage the carer in this process. Service
providers working with families with postnatal depression may consider a
couple counselling approach to work with families to provide more inclusive
care. For instance Dennis and Ross (2006) stressed the importance of
perceived social integration through encouraging the partners to
communicate their expectations of parenthood and child care in the prenatal
period. Such an approach recognises the potential contributory effect of the
men towards the development of postnatal depression in their partners. As a
result, service provider should facilitate discussions about the relationship as
part of routine postpartum care and include the male partners in such
conversations (Dennis and Ross 2006).
8.6.2 Information sharing
Information appropriate to the needs of clients is a recurrent theme in the
literature which identifies a lack of relevant information for women with
postnatal depression and their carers. For instance women can feel
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unprepared for the impact which postnatal depression has on their lives and
require detailed information about the causality of the illness and treatment
options (Ugarriza 2002). Men particularly appreciate the opportunity to gain
information about management strategies and practical information (Davey et
al. 2006). Although such information needs have been identified, there would
appear to be scope for service providers to review how information is made
available to clients. The comments by respondents in this study would
suggest that alternative approaches to information sharing may need to be
explored further. The partners, but in particular the men in the current study,
commented on the lack of relevant information regarding the condition. They
needed to be able to apply general knowledge about postnatal depression to
their specific situation and understand the severity of their partner’s illness.
Opportunities to discuss their personal experience with a trusted,
knowledgeable helper were welcomed by both partners. It was suggested
that these contacts should be available in various formats depending on the
specific needs of the couple. These ranged from a single information session
shortly after diagnosis to extended counselling interventions for one or both
partners. Certainly carers need to be included in any information provided
and not only ‘tagged on’ to the care of the main recipient of professional
services (Morris and Thomas 2002). The need for information about service
provision and treatment options identified in their study of carers of cancer
sufferers were also relevant concerns for the partners of the postnatally
depressed women in the current study. As a consequence service providers
should seek out early opportunities to explore which specific information
clients require and provide individualised support based on this assessment.
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When the respondents speculated about the causality of the illness, they
attempted to make sense of their experience and also understand the various
treatment options available to them. This suggests the need for service
providers to present information about the range of causes of postnatal
depression, the treatments available and their side effects in various formats.
The latter was of particular importance to the men in this study but was also a
concern for the women when their treatment resulted in unexpected side
effects. Information sharing has been recognised as an essential element in
the effort to encourage self care. The respondents expressed a desire to be
fully active in their care for which they needed to have relevant information. It
is important for service providers to be aware of this need and provide
information in a range of formats, specifically negotiated with all participants
(Lloyd and Carson 2005). Although previously identified specifically as
important for carers and patients with a severe and enduring mental illness,
the expressed desire of couples in this study highlights the need for service
providers to make similar information available to postnatally depressed
women and their partners.
8.6.3 Client centred care planning
The various aspects of both the experience of postnatal depression and the
support issues identified in the study reinforce the principles of current policy
initiatives for inclusion and the empowerment of service users and their
carers (Scottish Executive 1997, Scottish Executive 2003b, Scottish
Executive 2006a, Scottish Executive 2007). The respondents’ understanding
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of the concept of ‘normality’ and its related processes provided an insight into
the decision making of this group of clients, which can be used to review and
focus service delivery. Service providers could use this concept to explore
with their clients what they perceive to be the normal transitory process of
parenthood and how their own experience differs from this. Including such a
discussion in the assessment process can provide additional insights into the
clients’ experience and inform care planning. If care providers can facilitate a
process of reflection on these beliefs, this may help clients to examine their
expectations in the light of new information and make informed comparisons.
The process of adjustment to a new normality described in this study
highlighted that such a readjustment of beliefs was part of the recover for this
client group. In addition, respondents based their search for help on their
previous experience of the helpers available to them from their existing
support network of family, friends and professionals. This information is
relevant to care providers since it would allow them to clarify early the
specific support needs of their clients and what systems would be potentially
available to draw on for support. The recovery alliance theory proposed by
Shanley and Jubb-Shanley (2007) proposes that an approach to care
informed by the concept of recovery can facilitate the development of client
centred services. It is important for health professionals to explore and
understand their clients’ perspective, their previous coping mechanisms and
experiences. Using a problem solving approach the client is at the centre of
care planning and accepted as able to cope (Shanley and Jubb-Shanley
2007). Some of the respondents in this study commented specifically that
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they had excluded some family members and friends from their identified
network of helpers due to a perceived lack of interest or understanding. An
awareness of such existing issues would provide a useful background for
service providers who would need to adjust their care planning in the light of
the family’s particular circumstances. For instance professionals can not
assume that grandparents living locally will be available or acceptable to
provide the support required by the woman and her partner. In such
circumstances other sources of help would need to be explored and
mobilised. Professionals should try to understand what the couples
understand to be their concept of ‘normal’ parenting and what their support
expectations are in the light of their previous experience, their specific
situation and needs. Healthcare interventions for postnatally depressed
women which focus on needs identification certainly would appear to be
more effective than interventions based solely on education (Tezel and
Gozum 2006). The findings from this study suggest that such an approach
would be welcomed by clients and help professionals gain important
information to provide support contextualised to the circumstances of each
family.
8.6.4 Flexible care for different needs
The respondents’ experience highlighted that any decisions about the care
available should consider further that treatments are specific to the client’s
situation and the stage of the women’s illness. For instance, although the
women often commented favourably on the benefits of support from other
women accessed through mother and baby groups, they also had negative
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experiences if either the groups were not welcoming or the women were not
well enough to attend. In those circumstances attendance at a group was
detrimental to the women’s mental health and support on a more personal,
on- to- one basis was appreciated. This suggests that service providers
should negotiate the format of support with the woman and tailor it to her
ability to participate in groups. Although the women commented favourably
on the benefits of group support, they expressed a need that this should be
available in conjunction with individual support. Encouraging individuals to
share their experience with others can help to reduce the perceived stigma of
a diagnosis of mental illness and positively influence efforts to seek help from
others. This may lead to improvements in self esteem and a reduction in
distress. However, service providers should also be aware of the potentially
detrimental effects of social disapproval which disclosure may bring with it
(Ruesch et al. 2005). The sentiments expressed by the respondents in this
study highlighted this potential dilemma and the need to offer opportunities
for disclosure within an appropriate setting. When group support is provided,
this should be none threatening and available at the right time providing
flexible and accessible care for women.
In addition, the men and women in the study favoured different types of
support activities. The quality of the couple relationship, paternal-infant
attachment and the father’s emotional health should be recognised as
significant influencing factors in the transition process to parenthood (Condon
et al. 2004). Although the existence of postnatal depression in men has been
questioned (Condon et al. 2004), any depressive illness in the father during
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the early months of parenthood can be detrimental to the infant’s
development (Buist et al. 2003, Ramchandani et al. 2005). Since the father’s
attitude towards his partner’s illness can affect its outcome, health
professionals should be aware of the various stressors affecting the
relationship and provide interventions aimed at reducing their impact
(Condon 2006). One such intervention discussed in the current study was the
provision of group support to both partners. This was viewed less favourably
by the men than their partners and contrasted with the findings from previous
studies (Roberts and Kowalski 2000, Morgan et al. 1997). The men in this
study favoured individual support in preference to group support specifically
for men. Although it has been demonstrated that men can benefit from peer
support (Davey et al. 2006), the men in this study preferred to accompany
their partner in preference to attending a ‘men only’ group event. Service
providers should consider the different needs of men and women when
planning services for this client group. Healthcare professionals providing
support activities for men should take account that such services are likely to
be more acceptable if they are offered on an individual basis or publicised for
women accompanied by their partner.
8.6.5 Partners in care
The respondents valued a number of specific characteristics in the helper:
time to listen, a caring attitude and an acceptance of the decisions made by
the couple. Their desire to be involved in decision making and the importance
of a trusting relationship with their clinician highlights the need for
professionals to ensure that clients not only receive information but also feel
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that they are heard. Patients can feel more engaged with services if they trust
their clinician and have a choice of treatments (Laugharne and Priebe 2006).
Additional considerations were important when the respondents accessed
support. These included their need to feel in control over the support activity
but also their readiness to accept the help available. They expressed a need
to explore their support expectations with others to encourage active
participation in care and develop self esteem. Although such sentiments are
often expressed at organisational level, they are not always as apparent in
daily clinical practice (Laugharne and Priebe 2006). The experience of the
respondents in this study does suggest that there is scope for further
improvements in this area. Since the men often perceived themselves to be
positioned on the periphery of the care provided for their partners, their need
for support was often ignored by them and the professionals providing
services to the couples. As the men talked about the emotional and practical
demands which their efforts to support their partner generated, they often
had to manage the tension this created between their work and family
commitments. The impact of stress on the carer can be reduced through
social support (Gavois et al. 2006). In addition carers need to be recognised
as a source of knowledge to inform the care of the client. Open
communication and shared planning can support both the client and the carer
and allow them to respond to the challenges of the illness more effectively.
Within this context, the benefits of a therapeutic relationship between the
professional and the whole family have been recognised (Gavois et al. 2006).
Service providers need to continue to explore educational and staff
development opportunities to ensure that clients have access to
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professionals with relevant interpersonal skills to build mutually trusting
relationships with both parents.
The perceived stigma of healthcare providers can act as a barrier to access
to these services. The self stigmatising views by the woman and her fear that
the child may be taken into care are additional factors, which influence
service access (Edwards and Timmons 2005). Stigma was a recurrent theme
for the participants, who stressed the need to actively work towards raising
awareness of postnatal depression in order to facilitate early diagnosis and
access to appropriate services. Throughout the process of recovery, the
respondents valued ongoing contact with their helpers to monitor progress
and readjust to a ‘new normality’. The contribution of informal and
professional helpers was seen to be an integral element to facilitate this
developmental journey towards recovery. The respondents expressed a
desire to be actively involved in their care but also highlighted the importance
of access to relevant information from healthcare professionals. Individuals
need to be able to take control over and make decisions about their own lives
but should be supported in this by a public commitment to reduce stigma
through legislation and public awareness raising (Masterton and Owen
2006). Service providers should take these issues into account when they
seek to identify potential clients early and explore strategies to improve
access to support. Early access to services can be encouraged if service
providers support women in reducing the perceived stigma of a diagnosis of
postnatal depression. It has been suggested previously that this process
could be facilitated by contact between women newly diagnosed with
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postnatal depression and those recovering from the illness (Edwards and
Timmons 2005). It might be useful to consider the development of individual
peer support in addition to self help groups to achieve this. For instance close
contact with successfully breastfeeding peers can influence attitudes towards
breastfeeding (Hoddinott and Pill 1999) and may be a useful model to adapt
for the support of families experiencing postnatal depression. The complex
nature of the interaction between the potential helper and the recipient of that
help has been highlighted in this study. With this in mind healthcare
professionals should ensure that they establish a reciprocal relationship with
both partners and involve them in the decision making process as equal
participants. In addition, they should be aware of the impact of stigma in
terms of treatment and help seeking in their clients. They should further
examine their own attitudes and exert a positive influence on public attitudes
towards mental health (Pinto-Foltz and Logsdon 2008).
The study adds to the understanding of the underlying considerations and
processes, which informed the participants’ response to the illness. The
concept of ‘normality’ for instance highlighted both the internal and external
factors, which affected the participants’ response to the illness. Clinicians
might wish to explore this understanding to shape their support strategies
and gain an insight into their clients’ perspective. The ‘process to seek’ help
demonstrated the interplay between internal and external systems.
Practitioners can use this knowledge to explore opportunities for early
interventions and strategies to reduce some of the barriers to service access.
The respondents particularly highlighted the stigma of a diagnosis of mental
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illness and the need to differentiate normal and abnormal responses to
childbirth and parenting. The process ‘adaptation to a new normality’ outlined
in the study, illustrated the potential for personal growth and development of
the relationship as a positive outcome of postnatal depression, which service
providers can discuss when they provide information to individuals and
advise on suitable management strategies. This process can be facilitated by
a clear identification of goals and an acknowledgement that each partner has
specific support expectations. Overall, a range of support options should be
available, which are responsive to the couples’ needs at different times of the
illness and negotiated with all parties concerned.
8.7 Recommendations for future researchWhile these considerations should inform the delivery of care, it is important
that future research tests changes in such approaches to care in terms of
acceptability and efficiency. In particular approaches to involve male partners
in care decisions, while seen as favourable by the respondents in this study,
need to be explored more with a wider group of clients in diverse settings. As
policy drivers promote the importance of client empowerment and
involvement in decision making (Scottish Executive 2003b, Scottish
Executive 2007), it is important that these are subjected to robust evaluation.
For instance different approaches to information sharing with clients and how
families can be involved in care decisions need to be explored further. The
respondents in this study valued individualised information to help the men
specifically to support their partners. Although suggestions about how this
information could be conveyed were made by the respondents, the format
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and its most effective dissemination still require further investigation in
comparative studies with clients from different backgrounds. The use of
family health assessments has been promoted as one way to involve all
partners in client care (Scottish Executive 2006b) but this and other family
models of care still require detailed testing with families experiencing
postnatal depression.
Work undertaken in relation to peer support by lay helpers for breastfeeding
women have been related to positive outcomes (Hoddinott and Pill 1999,
Palda et al. 2003). Similar peer initiatives aimed at young people have also
been proposed but require further examination specifically in relation to the
most appropriate type of intervention (The Evidence for Policy and Practice
Information and Co-ordinating Centre (EPPI-Centre) 2001). The use of
people with similar experiences has been recommended as one possible
strategy to support young parents in particular (The Evidence for Policy and
Practice Information and Co-ordinating Centre (EPPI-Centre) 2006). Support
for women with postnatal depression and to a lesser extend for their partners
in peer groups has also been examined but with mixed results (Reid et al.
2002, Stamp et al. 1995). The value which the respondents in the current
study placed on the specific personal characteristics of their helpers suggests
that this is an area which would benefit from further study. Since it would
appear that the characteristics of the helper rather than the professional
qualifications of the helper were valued, exploring support initiatives which
utilise peers with experience of postnatal depression might be of benefit.
Such work should specifically examine issues of acceptability, empowerment
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and stigma reduction through different models of care delivered by lay and
professional helper.
8.8 Trustworthiness and authenticityConsiderable discussion surrounds the issue of trustworthiness of the
findings of qualitative research. A number of likely interpretations of the
findings are possible, which depend on the researcher's philosophical
perspective (Bryman 2001, Flick 2002). The main stances adopted range
from those informed by a positivist perspective to those, which have moved
to a post structural interpretation. The latter clearly define the criteria for
interpretation but set them apart from those applied to quantitative enquiry
(Denzin and Lincoln 2000). Positivism embraces the notion that all scientific
research needs to be able to meet the same standards of rigour and address
issues of validity, reliability and generalisability equally well. Post positivism
also recognises the need for such criteria. It argues that the naturalistic
context of qualitative research should be acknowledged and reflected in the
findings. Issues of scientific credibility, a theory grounded in the data, which
can be generalised to other settings and recognition of the impact of the
researcher and the setting on the findings, need to be clearly addressed.
In contrast, the interpretivist writers argue that these concepts should be
replaced by the two central dimensions of trustworthiness and authenticity
(Denzin and Lincoln 2000). This reflects the reality of qualitative research,
which does not claim to reflect a neutral, objective reality but present one of
many possible interpretations of a social reality (Lincoln and Guba 1985).
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Credibility is a key aim of the work. It needs to demonstrate that the given
account has been reached through a rigorous process and is acceptable to
the wider research community. Kvale (1996) in particular describes seven
criteria for the evaluation of scientific rigour in qualitative work. This extends
from the early design of the work through the actual process of interviewing
respondents to the analysis and the reporting of the final results of the
research. Finally, post-modern and poststructuralist approaches reject such
positivist scientific concepts altogether. They argue that the nature of
qualitative enquiry conflicts with this form of assessment and fails to
acknowledge the subjective and emotional elements of the research process.
This debate reflects the wider concerns about the differences between
qualitative and quantitative research. The positivist, quantitative researcher
searches for an objective reality through a clearly defined, systematic
process. Theory is tested to reach an objective, value free conclusion. This is
in contrast to the interpretivist perspective, which strives to seek out the
subjective meaning of any observed social action. Individuals differ from one
another, attribute meaning to their experience and cannot be interpreted as
inane objects of science. An understanding of the world is sought, which
sees through the eyes of the participants and seeks to represent their
interpretation of events. This approach is informed by the search for
'verstehen' (Weber 1947, Schwandt 1998) and symbolic interactionism
(Schwandt 1997, Bryman 2001). Bryman (2001) argues that most qualitative
researchers identify with a position in the middle between these two
perspectives. Respondents' narratives may represent one of many possible
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versions, but strategies need to be applied to ensure the trustworthiness and
authenticity of the accounts presented.
The current work is informed by both the desire to seek a rich description of
their experiences from respondents, but also to approach the process of
analysis in a systematic manner and with scientific rigour. An analytical
approach informed by grounded theory combined with a symbolic
interactionist perspective meets both the above requirements. The work is
positioned in a post positivist, interpretivist part of the spectrum of enquiry. It
addresses issues of trustworthiness and authenticity through a systematic
approach to enquiry, the constant comparison of the data and the search for
deviant cases (Silverman 2000).
While the exploration of specific contexts and experiences of respondents
provides a rich description and in depth analysis, the results of such an
approach are often met with criticism that they are not transferable to the
wider population due to the sample size and the specificity of the situation
explored. The researcher therefore aims to transfer the findings of the work
to the wider population through the application of criteria to relate the findings
to contexts outside the immediate area of investigation. It is suggested that
this process contains three distinctive steps: a decision of the degree of
generalisation aimed for, the integration of different cases and context
through careful sampling and finally the systematic comparison of the data
(Flick 2002). Thus the procedures employed in the sampling and the analysis
of the data becomes central to the degree of generalisation possible. It is the
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researcher's responsibility to present the case as concisely and clearly for
the reader to judge the degree of generalisability of the emerging theory
(Bryman 2001, Kvale 1996). Kvale (1996) compares this approach to the
judicial process, where the audience seeks out similar cases to that under
investigation and applies the findings to the case under discussion.
To make a judgement about the transferability of the study’s findings asks the
reader to utilise the data and their contextual background presented by the
researcher to assess whether they could be applicable to other settings. This
thesis has presented not only detailed information about the study population
and their characteristics but has also charted the various stages of the data
analysis in detail to provide an audit trail of the analytical process. In addition,
the findings have been related to the wider literature in the field. It is
suggested that this will allow the reader to make a decision about the
transferability of the findings and set the work within the broader context of
healthcare.
8.9 ConclusionFamily systems theory and the Leventhal et al. (2003) model of health and
illness provide the theoretical context of this study. The core category
‘normality’ is a central component of the feedback loop, which informs the
couples’ response to the illness. The self regulation model of health and
illness (Leventhal et al. 2003) contributes the more specific components of
this process. The current study adds an example of the mental health
perspective to the existing work on illness representation. The proposed
additional rule of “helper knowledge- support access” relates to the specific
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experience of the respondents in this study, which requires further
evaluation.
Methodological considerations have been highlighted which relate to the use
of two datasets and joint interviewing. The data generated by the study were
analysed in stages and utilised to confirm and refine the emerging findings.
This approach provides an additional tool to strengthen confidence in the
findings. The use of joint interviews has the potential to raise both
organisational and ethical problems which were overcome by combining joint
and individual interviews. This allowed each participant to be heard
separately but also provided opportunities for the couples to present their
joint narrative.
The reader of this study would wish to consider a number of issues when
reviewing the findings. These relate to the retrospective nature of the
responses, the use of respondent validation, the effect of chronic depressive
illness on some of the participants and the recruitment of the respondents
through gatekeepers. Participants constructed their responses during the
interviews based on a retrospective reflection on their experience and as a
result of the interview process itself. Respondent validation was utilised as a
source of additional data rather than to seek a confirmation of the “truth” of
the responses. The validity of the study’s findings should be judged on the
systematic approach to the analysis and rich description of the findings rather
than on respondent validation.
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Some respondents reflected on their experience not only from the
perspective of postnatal depression but also that of chronic depressive
illness. In this respect the study illustrates the range of experiences
associated with postnatal depression and its continuing impact on the mental
health of some individuals. Although some potential participants were
excluded from the study sample, the overriding need to protect potential
participants from harm and avoid exposure to distress was paramount. The
respondents included in the study were able to participate over a
considerable period of time and provide detailed insight into their experience.
This study has highlighted a number of areas of interest, which have
provided useful insights into the experience of postnatal depression and the
support needs of couples. The findings reflect a considerable amount of the
literature on postnatal depression and support for women. It adds the
perspective of the male partners to this knowledge but also some themes of
common interest to both partners. The couples’ definition of their ‘normality’
informed their decisions when they sought help and assessed their recovery.
This illustrates the complex interaction between the internal and external
forces, which affected the participants’ response to the illness. The Leventhal
et al. (2003) common sense model of health and illness provides a useful
framework for our understanding of these processes. This model is utilised
and extended to relate to people suffering from postnatal depression. The
additional rule of ‘helper knowledge- support expectation’ reflects the
couples’ assessment and expectations of the potential helper. The proposed
processes and their representation require further testing as do the
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suggested links to the Leventhal et al. model (2003). The study adds the
dimension of the couple experience to our understanding of postnatal
depression. It recognises that men, as fathers and partners in the couple
relationship, make a significant contribution to their families’ well being.
Research and clinical services have, in the past, focussed on the needs of
the women and children. It is important to recognise that men are active
participants in parenting work and that the successful outcome of postnatal
depression for the couples in this study is a joint achievement involving both
partners.
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Appendices and list of references
Appendix 1 Diagnostic criteria for postnatal depression
Psychiatric classification Criteria fo r postnatal depression
International Classification of Diseases Version 10, World Health Organization
Depressed mood for most of the day
Loss of interest or pleasure in normally pleasurable activities such as playing with the baby
Tiredness, decreased energy and fatigue
Additionally, any four of the following should be present:
Loss of confidence and self esteem
Feelings of guilt and blaming oneself
Recurrent thoughts of suicide or death, including that of the child
Difficulty in concentration
Agitation or lethargy
Sleep disturbance
Appetite disturbance
DSM IV - Postpartum onset specifier
O n s e t o f d e p re s s iv e e p is o d e m u s t b e w ithin 4 w e e k s p o s tp a rtu m
Symptoms do not differ from symptoms in non-postpartum mood episodes and may include:
Fluctuations in mood
Preoccupation with infant well being
Severe anxiety
Panic attacks
Fearfulness of being alone with infant
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Appendix 2 Couple summaries
The following short family summaries present background information about the couples and their circumstances. They are intended to give the reader an understanding of the couples’ perspective, which informs their presentation of their experience of postnatal depression.
Aileen and Alan- couple 1Aileen and Alan had been together for 6 years. Aileen had a daughter from a previous relationship to whom Alan had been a devoted father to from early childhood. They lived in a small flat in a rural village setting, where they moved before the birth of their second daughter. At the time of the first interview, Aileen still felt that she was a stranger in the village, experiencing a sense of isolation and distance from her family a distance away. Alan worked in the village and knew a number of people due to his involvement with the local golf club. Aileen was a very chatty and gregarious person who was keen to share her experience during the interview. Alan was the more taciturn and quiet partner of the couple, who was used to being self reliant and keeping his own counsel.
The couple welcomed me and made every effort to allow space and privacy for the interviews to take place in their home. For the individual partner interviews each partner ensured that interruptions were kept to a minimum, although due to space restriction, the baby was in the room throughout each session. Both engaged actively in the interviews and were open about their feelings. Aileen often became quite emotional but insistent that she would continue the sessions commenting that it was useful to revisit her experiences. Alan engaged in the sessions but often need a little more prompting to share his deeper feelings.
Both reported a close relationship with each other, although Alan appeared at times to have been somewhat distanced from Aileen’s emotional turmoil. Aileen commented that she preferred to talk to the professionals about her problems rather than burden Alan with her worries. He noted that he was always prepared to talk, but tended to protect Aileen from some of his own worries.
When I visited Aileen and Alan after 6 months for the return interview Aileen was well on the way to recovery, had started a new job locally and had made friends with a number of other women in the village.
Barbara and Bert- couple 2At the time of the first interview Barbara and Bert had been together for 4 years. They had left their respective partners for each other. Having left the village for some time they had decided to return there shortly before the birth of their second child. Barbara’s son from her previous marriage had been with the couple throughout. Initially the family had lived in a small cramped flat but had recently moved to a house located centrally in the village. Bert’s
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parents and extended family all lived in the village. Barbara’s family stayed a distance away but she felt that she could relate better to Bert’s parents than her own. The father of her older son also stayed in the village, which had caused some embarrassment in the past when they had met. This seemed to have been resolved prior to my involvement with the family.
Both were welcoming and participated fully in all interviews. Bert felt a little apprehensive at first but quickly relaxed into the conversations, sharing his experience freely. Both commented that this had been the first time they had had a chance to review their situation consciously and hear each other’s perspective. I was very conscious that my role was that of interviewer and not as a health professional, although Barbara and Bert were not the only couple who commented that they had felt that participation in the interviews had been beneficial to their relationship.
They had both been fully involved in the management of Barbara’s illness, with Bert regularly taking over childcare responsibilities on his return home from work. He felt that he had tried hard to support Barbara under some rather difficult circumstances. Both felt that early housing issues and emotional strain had contributed to Barbara’s illness. At the time of the interviews they felt more settled in their own house, were in regular contact with Bert’s family and had been accepted again by the wider village community. Bert’s mother had played a key role in helping the couple understand Barbara’s illness utilising her connections with the local surgery to obtain useful information on medication and treatment.
When I returned to visit the couple after a six months interval, Barbara had discontinued her antidepressant medication. Over the Christmas period she had felt a little low again but had not required further medication. Barbara had started to work on a part time basis in a local shop and felt more confident and positive since the initial set of interviews had been conducted.
Carla and Chris- couple 3Carla and Chris had been together for 5 years following the break-up of their respective previous relationships. Carla’s daughter and Chris’ son as well as their son from their relationship were living together in a small house in a rural village. Carla had had to take extended sick time from her work as a teacher due to her postnatal depression. Carla had previously been in an abusive relationship but felt happy and comfortable with Chris. Both were very outgoing people who obviously enjoyed each other’s company, sharing light banter throughout the interview sessions. Both Chris’ and Carla’s family lived in the village. Carla’s relationship particularly with Chris’ sister was positive and open. Although Chris was initially reluctant to participate in the interviews, he quickly became engaged and offered his views on Carla’s illness. Both had felt that their relationship had been put under significant stress due to Carla’s illness but felt it important to stay together to overcome their difficulties.
There were sometimes mixed messages from this couple. They appeared to be supportive of each other, while he seemed to be actively involved in the
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care of the children. At the same time he made no secret of his impatience with the situation and his feelings of frustration. Both seemed to work together to manage the situation. Carla had supported Chris in the past through stressful work problem. This seemed to lead to an understanding between the partners that there was an obligation for Chris to return the favour. Their mutual affection appeared to have helped the couple to work through their difficulties.
When I returned to interview them after six months, they had moved house to be closer to their friends and family, Carla was contemplating her return to work and they had explored the possibility of a further pregnancy. They had decided against adding to their family, with Chris feeling that they had enough responsibilities already, while Carla was afraid of a possible recurrence of postnatal depression.
Dana and David- couple 4When I first met Dana and David, Dana was heavily pregnant with their second child. They were alternately looking forward to the delivery and apprehensive in the light of their previous experience of postnatal depression. For most of their 7-year relationship they had been living away from their respective families. David’s work had also meant that they had been moving around and had not stayed long in a number of places. They presented a close relationship to their families and friends but had felt very isolated from each during the early stages of her illness. They had only gradually been able to share their feelings and fears.
When I interviewed the couple they had been able to resolve these difficulties and were both very open about sharing their feelings with me. David, in particular seemed to welcome the contact. Both commented that the interviews had given them the opportunity to revisit their experience and also plan for how they would manage a possible recurrence of postnatal depression after the expected birth of their second child.
Both seemed to have found it difficult to cope with postnatal depression. Dana had experienced a traumatic birth and had suffered considerable medical complications. Initially David had found it difficult to understand how Dana had been feeling. He had also been newly promoted to his post; he felt pressured at work and had been working away from home. The early months seemed to have been spent in isolation from each other. Gradually David was able to understand Dana’s feelings more as she was more able to ask for help, sharing her difficulties more and utilising medical treatment. David felt that his attitude changed as Dana started to feel better and he could see an improvement in her condition. David was mainly involved with the care of their young daughter, while Dana had found it difficult to relate to the child. Dana struggled with her feelings for the new baby, while David had been able to bond very quickly. This had been an additional strain to their relationship.
When I returned to interview the couple after six months, they were positive and felt able to enjoy their second daughter. The birth had been a much more positive experience, breastfeeding had been established and the new baby
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seemed to be a calmer, more settled baby. Their attitude was positive and optimistic. Their fears of a recurrence of postnatal depression had not been realised. Both felt that they had been able to share their feelings more openly with related benefits to their relationship.
Evelyn and Edward- couple 5Evelyn and Edward had been together for 9 years during which time they had experienced a number of significant challenges to their relationship such as financial difficulties, housing problems and job loss. Although Evelyn’s diagnosis of postnatal depression went back to the birth of the couple’s first son, 7 years previously, the couple recalled their feelings from that time vividly.
Both partners had suffered depressive illnesses since then, with Evelyn being treated for chronic depression to the present day. When I first met them, they were living in an upstairs flat on the outskirts of a small town. They had moved there from their home in another part of the country shortly after the birth of their son. Their three children were active and outgoing, frequently joining the interview sessions. Edward was working in the local hospital, while Evelyn looked after the children at home. Both were still in regular contact with local health professionals but felt that they had had difficulties accessing services after the birth of their son. Evelyn and Edward were able to explore their experience of postnatal depression but also to contrast this with their subsequent experience of chronic depression. Evelyn certainly felt that postnatal depression had been the more challenging illness due to the concurrent responsibilities for a new baby.
Edward appeared to have been Evelyn’s main practical and emotional support, despite trying to work through his own considerable personal difficulties. He had found it difficult to share his feelings with Evelyn, who was heavily reliant on his support during her illness. Both talked about the importance of their religious faith to their lives and their relationship.
When I returned to interview them after six months, they felt they had make progress in the intervening months. Evelyn had returned to work part-time, they were making plans for the future and felt positive about being able to manage their mental health.
Frances and Freddy- couple 6Frances and Freddy had been together for 13 years, when I first met them. The couple had been older when they started their family. Frances had given up a responsible job to stay at home and look after the couple’s two boys. Freddy often worked long, unsociable hours away from home. He also was actively involved with a local sports club, playing at competitive level. Frances had discovered a talent for writing poetry and used this extensively to express her feelings about personal experiences and family problems.
The couple were welcoming when I arrived to interview them, although Freddy tended to sit apart from the interview group and frequently expressed his view, that the situation was mainly Frances’ problem. Frances on her part
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commented on her feelings of frustration and loss of role since she had given up work to stay at home full time.
The couple appeared to have a number of unresolved relationship issues relating to role adjustment, responsibility for postnatal depression and different expectations of the support to be expected from the other partner. Freddy felt that he was able to deal with any problems himself, while Frances utilised local support groups to share her feelings and seek help. Frances felt that there were parallels in experience between postnatal depression and other taboo subjects such as infertility and continence.
When I returned to interview the couple after six months, Freddy had been promoted in his post and was working more irregular hours. Frances seemed to have resigned herself to this. She had become more involved with work for a local charity and was going out more often to meetings. She also felt that her poetry had helped her to express her feelings but also gain recognition and build her self-esteem.
Gina and George- couple 7Gina and George had been together for 9 years. Their two boys were active and outgoing, close to their mother and enjoying the company of their father. The couple had lost a baby four years previously, a loss still strongly felt by Gina in particular. They lived in a small village close to Gina’s parents. George was estranged from his mother and had lived most of his life with his father. He felt that he had a good relationship with Gina’s parents and encouraged her to have regular contact with them.
When I first met them, the couple were reticent to talk about their experience. Gina commented that she had felt uncomfortable talking about herself previously when health professionals had visited during her illness. George commented that talking was very much a part of his job, he felt inhibited when asked to talk about his own personal experiences. Both relaxed more as the interviews progressed, commenting that sharing their thoughts had been a new experience for both of them.
Gina and George seemed torn between a desire to be available for each other and feeling distant from the feelings of the other partner. At times they appeared to have withdrawn into their own private worlds, occasionally trying to reach out to the other partner. A sense of mutual isolation during Gina’s illness seemed to be the main theme of the couple’s experience. Both appeared to have stayed in the relationship for their own reasons. George in particular commented that he felt committed to his family and did not want his own children to experience the same difficulties he had had due to his own parents’ break-up.
When I returned to interview them after six months, both were much more relaxed with each other and with me. They were easy in each other’s company, exchanging light jokes and more able to talk about personal issues. Gina had felt more able to make social contact with other women in the village, had joined the local mother and toddler group, had supported
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another mother through postnatal depression and had attended a keep fit class on a regular basis.
Hannah and Harold- couple 8Hannah and Harold had been together for about 4 years. They had been living in the local village since the birth of their daughter, but Harold often had to be away from home for work commitments. Hannah’s parents had provided some practical child care help in his absence when Hannah had been unwell. Although useful, both partners had felt that this was intrusive and had made them feel that they were losing control. Harold had a difficult relationship with his parents and did not have any contact with them.
Both partners seemed to be supportive of each other. Harold had taken on the main burden of care for Hannah when she had been unwell. She expressed feelings of guilt that she had had to rely on him as much as she had needed. At the same time Harold’s support had been the most important to Hannah. Hannah and Harold appear to have relied mainly on each other throughout her illness. Harold’s frequent work absences made it difficult for Hannah to manage. This was a particular problem when she had not been well. Both try to keep in touch with each other when Harold is away but often need to encourage each other to share feelings of low mood.
On the return interview, the conversation centred mainly on Hannah’s pregnancy with her second child and how the couple were going to manage the possible recurrence of postnatal depression. Harold had re-established contact with his own family. Both felt that they would be able to ask them for help. Hannah had also decided that her expectations of help from her family would be more realistic. Both seemed to feel that their previous self-reliant approach had been the most effective. They had learned how to manage postnatal depression previously and felt more confident to do so should it recur.
Irene and Ian- couple 9Both had been together for approximately 8 years. Their twins, a boy and a girl, had been bom just over 2 years previously. Although Irene had suffered from depression before the birth of the children, she had become very unwell afterwards. She was still struggling with her illness and found the stress of childcare for two demanding toddlers almost unbearable. Ian was finding it difficult to understand Irene’s strong feelings, her recurrent tiredness and inability to tolerate the children. Both their families lived a significant distance away from the couple and had little contact with them. Both felt let down by their respective parents but also local professional services.
The relationship between the partners had been significantly affected since the birth of the children and Irene’s postnatal depression. Both commented how postnatal depression had affected their relationship and been causing stress for them individually and as a couple. Ian’s frequent work related moves and absences from home had added to these stresses. Both felt that Irene’s postnatal depression and chronic depression was a family problem and required both their input. They presented a number of mixed responses
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to interview questions, which made an understanding of their needs, and how professional workers responded to them, somewhat unclear.
When I returned after six months, the relationship had continued to be stressed and tense. Particularly Irene had felt that she was becoming distant from Ian, while he seemed to have lost his desire to try to understand her feelings. Despite these problems they had continued to stay together and felt that they would be able overcome their difficulties together.
Jane and Jason- couple 10Jane and Jason, the youngest of the couples, had only moved into their current home near Jane’s family one month before I visited them for the first interview. They had been together for 19 months and had moved house 4 times since the birth of their little son. Jane was happy to have moved to live closer to her family, but Jason felt isolated and without any local friends. Jason was not working and was spending his time at home to support Jane and look after the baby.
The couple had had a traumatic time since their son’s birth both socially and emotionally. They were trying to manage a number of financial and social problems but presented them as less significant than their concerns in relation to Jane’s mental health. Jason appeared to be suffering from low mood, while at the same time trying to support Jane to the best of his abilities. Jane felt that the postnatal depression was directly related to traumatic birth experience and isolation from her family. Since their move to the local area, she felt more able to share her feelings with her extended family.
When I returned to interview them after six months, both seemed to have mixed feelings about progress in the interim. Although Jane felt more positive, Jason had commenced on anti depressant medication himself and was still unsure about his future life in the locality, living a considerable distance away from his own family. Jason in particular felt that he was unable to meet Jane’s expectations of him, which appeared to add to his emotional stress.
Karen and Kurt- couple 11Karen and Kurt had been together for 5 years when I first met them. Although they had been together for some time before the birth of their daughter, they had faced the challenge of marriage, childbirth, moving to a new house and starting a new business all within the previous year. Kurt was working from home, often away for long hours and visiting prospective clients in the evening, while Karen stayed at home with the baby. The location of their home in the countryside made it difficult for Karen to meet other mothers and friends. Both their families lived a considerable distance away from home. Kurt’s father was unwell and required nursing care. These concerns appeared to add considerably to the couples’ difficulties and had left them both feeling stressed.
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They were open about their difficulties, which had affected their relationship in the early weeks after the birth of their daughter. Kurt commented that he had often used his work commitments as an excuse to escape the home situation. Only a conscious effort by him to bond with the baby eventually helped him to engage with his young family. There seemed to be a discrepancy in the needs of each partner. Kurt tended to stress the physical aspects of the relationship and his desire to avoid conflict. Karen for her part had felt left alone and isolated but had needed to be heard and share her feelings with somebody. Karen felt that she would have felt more able to do this with another woman like her mother rather than with a man since men: “don’t understand feelings and are more into action”.
When I returned to interview the couple six months later, they had made considerable progress and felt much more positive. Karen had passed her driving test, which had allowed her to be more independent and meet friends locally. She had stopped taking her anti depressant medication independently of her General Practitioner, which she had felt to have been a major step towards independence. Both had felt that they had adjusted to their new life but also been able to accept the limitations of their situation. They raised the issue of adjustment and acceptance of a new normality, which eventually developed into an analytical category.
Lena and Len- couple 12Lena and Len had been together for 6 years. Both presented as a successful couple with a large home and a busy working life for Len. Lena had held a responsible job managing her own business prior to the birth of their older son. She was now at home to look after their two boys and retraining as a childminder. Len was away from home on frequent business trips. When Lena became ill with postnatal depression, Len had been between jobs and had been under considerable work related stress.
Throughout the interviews, Lena in particular felt that she continued to adjust to a changed lifestyle. She commented that Len was mostly uninvolved in the care of their children. He was helping with childcare when he was available but this occurred on his terms. Both portrayed a positive picture of having managed postnatal depression effectively. This was in contrast to their recurrent references to feelings of frustration and helplessness. Neither had been able to share their feelings with each other or their families. Len felt that he was close to his parents but had been reluctant to burden them with his personal problems. Lena had tried to reach out to her family but had found little support since she was perceived to be a “coper”, able to manage independently.
When I interviewed them after six months, they reported to feel more relaxed and positive about their situation. Lena, in particular, felt that she had moved on considerably to the extent that she attributed her problems to lack of sleep rather than postnatal depression. She felt more in control and to have adjusted to her role of ‘stay at home mother’. Len felt that Lena had needed time for this adjustment. Since postnatal depression was very much Lena’s problem, she had to be given time to take control over her life.
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Maureen and Mike- couple 13When I first met Maureen and Mike, they had been together for 3 years. They had moved into the area only very recently and were still trying to settle into their new home. Mike was off work with depression. Both felt that they were struggling to overcome their own illnesses, support each other and look after their little girl. Maureen found it difficult to talk at times and Mike often apologised for not being able to express himself more clearly.
Mike had a history of depression and had been supported in the past by Maureen. When Maureen herself became ill with postnatal depression, Mike felt that he should support her in return. Although he had tried to do so, this had caused him significant stress and a relapse into depression. Both appeared to have tried very hard to work together to overcome their difficulties, trying to support each other, as they were able. Both were determined to reduce the impact of their problems on their little girl. They were making significant efforts to spend time with her and to hide their unhappiness from her. Maureen’s own background as an adopted child made her particularly sensitive to the need to be a “good mother”. Although some of the professional services had been helpful, the couple commented negatively on the lack of counselling services in the area.
When I returned to interview them after a six months interval, both were still unwell and receiving treatment for depression. Mike had recently returned to work, which had brought its own problems with it. Maureen had started to attend regular counselling sessions and had been able to explore some difficult personal issues. Their relationship appeared to have undergone a period of significant disharmony, which they were still trying to resolve when I visited.
Nancy and Norman- couple 14Nancy and Norman had been together for 6 years when I visited for the first interview. Nancy had been diagnosed with postnatal depression two months after the birth of their daughter. Although this had been two years previously, both were still clear in their recollection of events and the impact the illness had had on their relationship. Nancy had been diagnosed relatively quickly, but had been reluctant to accept treatment initially. She had eventually moved to stay with her parents a considerable distance away, received treatment there and returned eventually after an absence of a number of months. Norman had supported this move and visited his wife and young child regularly at weekends throughout this time. During this time Norman had experienced considerable work related problems, which he had only been able to share with Nancy long after her return to the family home.
Both partners had struggled with Nancy’s illness. There had been a significant time when they had not been able to share their feelings and had felt isolated from each other. Although Norman had visited at weekends, neither partner had felt these to have been successful, even contributing to the feelings of isolation and distance in the relationship. Both felt that this had
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been due to the medication Nancy was taking rather than due to an underlying problem in the relationship.Mutual friends appeared to have withdrawn from contact with the couple. Both stressed the lack of support available for Norman as the reason to participate in the study.
When I returned to interview the couple after an interval of six months, Nancy and Norma felt positive and announced that they were expecting their second child. They felt very positive about this event, having reflected on their previous experience. They had decided to be pro active in their approach, planning for the pregnancy and the possibility of a recurrence of Nancy’s postnatal depression. Norman showed a particular interest in the dissemination of the study’s finding, reiterating the need for men to be offered more support from professional services.
Olive and Oscar- couple 15Olive and Oscar had been together for 20 years when I first interviewed them. They lived in a semi-detached house in an urban area in close proximity to both their families. Their older daughter attended the local primary school and had been very excited about the arrival of the new baby eighth weeks previously.
Olive had experienced postnatal depression after the birth of both their children, and the partners were able to contrast these episodes clearly. Both commented that their attitudes and those of the professionals had changed, that the time to diagnose the condition and seek help had been shorter and that their family network had reacted very differently. Oscar admitted that he had found it difficult to accept Olive’s first illness, escaping into work to manage the situation at home. Both commented that they had been able to use their first experience to prepare themselves for a possible recurrence after the birth of their second daughter. This had allowed them to seek help early and also to enrol the help of their extended families more effectively. Both had been able to draw on an inner circle of friends and family who were aware of their difficulties. An outer circle of acquaintances was not aware of the couple’s problems.
When I returned after six months to interview them, Olive and Oscar reported positive progress. Olive had been able to negotiate an extension to her maternity leave to allow her more time to recover from her postnatal depression. Family support had been helpful, allowing Olive time to recover. Oscar had reduced his working hours and was able to spend more time with his family.
Pam and Paul- couple 16Pam and Paul had been together for 15 years when I first visited. They lived in a terraced house in a small town with access to local facilities and transport. Their teenage son had welcomed the arrival of his little sister, 11 years his junior. Although Pam had been diagnosed with postnatal depression approximately two months after the birth, she was unwell and continued to need medication when I visited two years later. Both had
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suffered considerable emotional difficulties during the previous two years. Paul was self employed and tried to support Pam, while worrying about his business.
Postnatal depression appeared to have had an impact on both the partners as well as their older son. Pam suffered from postnatal depression initially, which then became chronic depression after an episode of glandular fever. This made it difficult to distinguish between the impact of postnatal depression and the subsequent depression. Particularly Paul’s levels of tolerance towards Pam’s illness appeared to have changed as the condition became more chronic. Both partners appeared to have tried to protect each other from the more serious effects of their individual problems.
In the interval before my return after six months, Pam had been very unwell. She had had to be referred to the community psychiatric nursing service and was also attending the local psychiatric day hospital. The couple differed in their assessment of the benefits of this. Pam felt she had benefited from this contact, while Paul felt that Pam was becoming dependant on treatment.
Rachel and Richard- couple 17Rachel and Richard had been together for 20 years when I first met them. They were living in a detached house in a large urban area, where they had moved to shortly after the birth of their son. Rachel’s postnatal depression had been diagnosed and treated abroad, while Richard had been working for a large company.
They were able to contrast their experience of services there and in Britain. They commented in particular on the family focussed nature of services and the involvement of both partners in the Rachel’s care. They felt that Richard had been involved in Rachel’s care decisions at all stages of her illness, diagnosis, care and discharge. These included arrangements for childcare while Rachel was in hospital, time off work for Richard and joint as well as individual counselling sessions for both of them. They perceived the care provided to have been family focussed rather than individual focussed with a proactive approach to care, anticipating possibly problems and addressing them before they became an issue. Rachel’s postnatal depression had eventually developed into bipolar disorder, for which she continued to receive treatment.
When I returned to interview them after six months, they had continued to work together to manage Rachel’s illness, remained committed to their relationship and felt that they had been able to balance Rachel’s need for ongoing care with a satisfying family life.
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Appendix 3 Example of couple interview guideInterview 1- Joint interview with couple
Thank you for making time today for the interviewI am interested in your views about the care of families with experience of postnatal depression and in particular your views on their support needs The interview is fully confidential and will last about one hour
Introduction Who am I?ConsentConfidentialityHonesty/ non-judgementalBasic personal details and how interviews will happen
Today and over the next 2 interviews I would like to find out from you about your experience of postnatal depression and the support you have had from different people such as professionals, family, and friends How would you define ‘support?’What have you found helpful when trying to cope with postnatal depression? What has been less useful when trying to cope as a family with postnatal depression?What would have been an ideal solution to managing postnatal depression?
First of all could you tell me a little about you as a family who has experience of postnatal depression?Can you tell me how you first found out about postnatal depression?How were you referred?How were you diagnosed?What treatments were offered/ available?What information was given/ did you request?How often were you seen by professionals?What treatments did you receive?
Often the woman will have most contact with professional services What involvement did you as the partner have in your wife’s care?What was your role?What were your concerns as the male partner?What contact did you have with professionals?What were your information needs?What was your response to the diagnosis?
Postnatal depression can cause stress in a relationship- How did this affect you both?Could I just summarise what you were telling me, just to check that I have understood........
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Support is always quoted as one of the important factors to help women recover from postnatal depressionI am particularly interested in the kinds of support which have been helpful toyou bothWho?Where?What?Differences between woman and partner’s need Support that has not been helpful
How easily were you able to access these supports?What barriers were there to access?Can you think of anything that should be available but is not?
Is there anything that you can think of that we have not covered in this interview?Anything you would like to add?Many thanksCould I return if I need further help?
Interview 2- Individual interview with each partner- couple C7Thanks for seeing me today. This time I am particularly interested in your personal views and experiences.The last time we spoke together of postnatal depression and how this has been for you as a couple. Today I would like to look specifically at your own perspective.None of the information we’ll discuss today will be passed on to your partner. It is confidential within this study.
Relationship effect of postnatal depressionEffect of postnatal depression on relationship- can you tell me a little bit about how postnatal depression has affected the relationship between the two of you?Men, whose partners suffer from postnatal depression, often feel quite helpless, never being able to do the right thing.How did you feel you were able to meet X ’s expectations?Men are often expected to take on the shared responsibilities of looking after the children.How do you divide the chores in the house now?How is this different from the time when your partner was ill?
Support issues-Tell me about an example during postnatal depression when you felt supportedWhat was it about that situation that made all the difference?What kind of things made you feel less supported?What word or phrase would best describe the ideal kind of support that your partner could have given you?
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How about the support which you were able to give to your partner-Can you give me an example of a situation in which you felt that yousupported your partner well?How did it feel to give/ receive this support?Where do you/ did you get support when it is not from your partner?What help did you get from these people, which you did not get from your partner/ your relationship?How are things for you now?
C7-PM-Specific IssuesInformation needs- possible support groupContrast of coping with emotional issues at work vs. at home- putting things into boxes?Professional defenceWhat would have helped him/ would he have liked to have done- With hindsight, would he have done anything different?If HV had invited him to listening sessions- what would his reaction have been?Own childhood experiences and need to keep the family together- could he have walked out?Personal relationships- experience?Feelings of rejection during postnatal depression from wife- difficulty to admit thisWhat is not helpful?
C7-PF-Specific IssuesYour views on others have commented on: postnatal depression as a weakness/ embarrassment re seeing community psychiatric nurse Difficult to speak to people- what would have made it easier to do that?What questions would have helped her to open up?Hiding feelings/ didn’t talk in depth- how far was she able to open up/ what stopped her from going further?What are the barriers to help- to speaking?Is talking helpful? Are there other things also helpful?Did the Edinburgh postnatal depression scale ever get done? How did that feel? How honest?What is not helpful?
Is there anything which you would like to add, anything that is important and has not been covered?Thank you for your time and help with this interview
One piece of advice for other couples____________________________________
Interview 4- jo int return interview with coupleIdentify changes that have happened to the couple since the previous contact.Have they had any further thoughts on postnatal depression and support issues?
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Are there any relevant key points that they think are important when supporting families with postnatal depression?
Can you map your own support network for me?Where are you individually and together?Who is around you?How close are they to you in terms of support when you were not well?Use of different coloured post- its:Those important in giving support to him- green Those important in giving support to her- pink Those important in giving support to both- yellow
Feedback from study- narrativeHow does this compare to your own experience?_________________________
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Appendix 4 Table illustrating the stages of analysisStage Grounded Theory tool Action Content
1 - inductive Open coding Grouping concepts and early category development
Reduction of range of codes and formation into thematic groups
Early axial coding Categories and subcategories Networks of subcategories
Narratives Hypothesis development to integrate concepts
Develop narrative story for respondents- mother/ father/ couple
2- deductive Axial coding at category level informed by research questions
Categories arranged around: Relationship issues Support issuesMini frameworks to illustrate relationships between concepts
Components of final processes described:
1. Adaptation to new normality
2. Process to seek help3- inductive Selective coding Identification of core category
‘parenting normality’ and development of process theory
Description of process theories and their component categories
Appendix 5 Thematic codes condensed under thematic headings
THEMATIC CODE THEMATIC HEADINGBelieves Happy families RelationshipsConfidentiality Include the partnerCouple conflict Love and affectionCouple problem Not a bad personDistancing OutsiderFamily dynamics Partner’s interestFamily support ProtectGood dynamics Relationship stressGroup dynamics TrustFatherGender issues
W oman’s problem Gender issues
Judgemental Perseverance AttitudesKeeping up appearances RespectLife experience Own upbringing
Very young
Disempowering Voluntary groups Types of supportTalk What can 1 do to help?Good mum Professionals RolesGood wife ReassuranceMedical vs. layman Sick roleParenting responsibilities Permission to support
Worker role
THEMATIC CODE THEMATIC HEADINGAN factors Physical factors Illness processCausality PsychosisCrisis Readiness recoveryHelplessness SeverityImprovement SuicideLong term effect SymptomsCultural factors Non prescription drugs Psychosocial issuesEffect on carer Partner’s needsEffect on children ResentmentEmotional issues Social issuesFears Society factorsFix it TransportGeography UnemploymentGuilt and loss Work commitmentsIsolationAcceptability Fallen through the net TreatmentActivate own resources HunchAssessment LimitsBarriers ListeningCompliance Listening visitCounselling OptionsDiagnosis Options riskDoctor Taking tabletsEPDSInformation needs Parenting preparation Need for informationNeeds Public awareness
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THEMATIC CODE THEMATIC HEADINGPush things aside Self help Service access
SolutionsWavering off the truth
Coping
Informal network Practical support
Sharing experience Social contact
Sources of support
Baby effect Breastfeeding
Childcare Baby/ childcare related issues
Fallen through the net InputMaking a difference Mental vs. physical ModelNormal vs. ill Normalising Parenting reality
Postnatal depression vs. depression PoliciesProfessional developmentResourcesStigmaStories about Postnatal depression Unique circumstances
Other
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Appendix 6 Mind maps of the stages of the analysisStage 1 of the analysis________
Network-causality
Chapter 5, Section 5.2.1 Chapter 5, Section 5.2.2
Chapter 5, Section 5.2.3
Network- roles and gender
Chapter 5, Section 5.2.4
Network- professionals
Chapter 5, Section 5.2.5
Chapter 5, Section 5.2.7
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Stage 2 of the analysis
Experience of PND
Chapter 6, Section 6.3 Chapter 6, Section 6.4
Sample Support NetworkLena’s m other and sittings: Reliance or Lena for support
ten ’s parents: practical help with chidren and house
- 4^3
Lena’s local friends: gradual development, sharing
General Practitioner: fem ale, listening, tim e constraints
L a i's friends: not for sharing persona problems
I Support group: variO>te involvement
Chapter 6, Section 6.4.5
Stage 3 of the analysis
Defining parenting normality
Chapter 7, Section 7.2 Chapter 7, Section 7.2.7
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Appendix 7 Stage 1 categories and their link to stage 2 frameworks
Stage 2 analysisMini framework 1: experience of PND
Category from stage 1 analysis (1 of 7)
Stage 2 analysisMini framework 2: support issues
1. CAUSALITYSpeculation about causality External factors Outcomes
PeopleSpeculation about causality Internal factors Outcomes
PeopleResponsibility Outcomes
People2. EMOTIONAL HEALTH
Strive to return to lost normality Influences OutcomesPeople
Strive to return to lost normality Response OutcomesPeople
Strive to return to lost normality Background OutcomesFormat
Strength of relationship Maintenance Outcomes
3. ACCESSCoping strategies Representation OutcomesStrive to return to normality Personal background Characteristics
OutcomesCoping strategies Resources Characteristics
Mini framework 1- experience of PND Category from stage 1 analysis (1 of 7) Mini framework 2- support issues4. ROLES AND GENDER
Speculation about causality- Role changesEmotional challenges of new baby
Family roles PeopleFormat
Personal background PeopleStrength of relationship Partner's response People
FormatCharacteristics
5. PROFESSIONALS AND WORKERSActivities People
FormatCharacteristics
Medication PeopleFormatCharacteristics
Influences on function PeopleFormatCharacteristics
6. SOLUTIONSCoping strategies Personal resources CharacteristicsStrength of the relationship Helper’s attitudes CharacteristicsCoping strategies Services Format
CharacteristicsCoping strategies Strategies
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Mini framework 1- experience of PND Category from stage 1 analysis (1 of 7) Mini framework 2- support issues7. HELP SEEKING
Strength of the relationship Relationships OutcomesConsiderations Outcomes
Coping strategies Access CharacteristicsCoping strategies Services Characteristics
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Appendix 8 The components of the category framework ‘support issues’Category Subcategory Components/representations Subcomponents
v P ip p L i;; .: Individuals Family PartnerChildren/ babyParentsSiblingsExtended relations
Friends Close friendsExtended circle of friends
Professionals MidwivesHealth visitorGeneral PractitionerCommunity Psychiatric NurseCounsellorPsychiatrist/ Psychologist
Groups Formal groups M&T groupsBF support groupsPND groups
Informal groups Other mothers
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FORMAT PracticalEmotional
CHARACTERISTICS Helpful/ Effective HelperActivityRecipient
Unhelpful/ limitations/ barriers Helper
ActivityRecipient
CO NDITION S Under which help is given Level of awareness of severity of illnessPerspective of problem “us” vs. “me”Perceived reciprocity of obligation
Under which help is received Level of readiness to accept helpPerception that experience is internal to the individual and can not be alleviated by othersLevel of readiness to recovery
Perceived need to protect the helper
Perception that helper is too busy with own issues/ problemsExpectations of helper ability to provide
OUTCO M ES GoalImpact
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Support activitiesPractical approaches for effective support Emotional approaches for effective supportUndertake daily chores (house/ childcare) Reassurance of recovery/ normality/ time limit of conditionFacilitate access to transport Breastfeeding as a bonding activity with the baby (NB opposite
for some women i.e. BF as more stressful to PND)Have access to a network of family/ friends as a structured support framework
Utilisation of self discipline to persevere with daily tasks
Have structure to the day/ week Desire to be independent as a driver to persevereProvide financial security Talk (personal/ telephone/ general or counselling)Access to medication ListenRegular contact with helper/s Share experienceAdvice from helper/s Understanding of conditionJoint/ individual listening sessions Time to self- “release"Information from reliable source OpennessFacilitate access to medical appointments Mutual protection (specifically between partners)Consider work outside the home (part of process of recovery) Encouragement“Buddies” to facilitate attendance of groups and activities Raise awareness of the impact of PND: issues/ effect on child/
consequences of untreated illnessGet out of the house/ arrange outings Awareness of chanqes in the personReview of birth records CBTProvide space for individual/ couple Consultation to reach treatment decisions
Chart progress in diary
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Support characteristicsHelpful strategies/ mechanisms Unhelpful strategies/ barriers to effective supportHELPERS ACTIVITIES RECIPIENT HELPERS ACTIVITIES RECIPIENTConsistency/ Continuity Self generated Level of readiness
to accept helpService constraints/ staff changes
Lack of control Lack of control
Understanding Recovery not forced
Level of readiness to move towards recovery
Unrealisticdemands
Time limited Experience internal to the person
Availability F o c u s on the ind iv idual
Comfortable with helper/ values the helper
Lack of understanding
P e rc e iv e d lack o f re le v a n c e
Desire to protect the helper
Shared experience Adopts a family perspective
Openness/ prepared to disclose
Lack of availability/ distance/avoidance/ work commitments
Ad hoc nature ofcontact/disclosure
Level of receptivity to help
Familiarity Facilitates meeting other parents
Positive feelings towards the helper
inappropriatecomments
Expectations of group members
Unrealisticexpectations
Commitment Diversity of option/ activities
Desire to recover Conditional Raises false expectations
Level of preparedness to disclosure
Honesty Comfortable to the recipient
Honesty Geographic distance (telephone contact can be substituted for some couples)
Gender specific services
Perceived role obligations
390
Helpful strategies/ mechanisms Unhelpful strategies/ barriers to effective supportACTIVITIES RECIPIENT HELPERS ACTIVITIES RECIPIENT
Quality of the relationship
Appropriateformat
Trust in helper/ others
Too busy with own concerns
Wronginformation/advice
Ability to express need for help
Prepared to take the initiative
Unrelated to problem and childcare demands
Trust in helper Awareness of level of severity of illness
Type of relationship with helper
Perceptiveness/sensitivity
Timely Unhelpful/ dismissive advice
Frustration with helper due to their lack of understanding
Approachable Links to the experience of others
“Her/she”perspective
Perceived stigma of Postnatal depression/ embarrassment
Not judgmental May take on different meaning than that perceived e.g. weighing clinics
Dismissive attitude Perception of triviality of concerns
Not bearing a grudge Anonymity Lack of interest “Being a number”“Us” perspective Confidentiality Wants to help but
does not understand
Dread of attendance
Reciprocity of obligation Judgemental Level of perceived expertise of the helper
391
Helpful strateg ies/ m echanism s Unhelpful strategies/ barriers to effective supportACTIVITIES HELPERS ACTIVITIES HELPERS ACTIVITIES
Liked by the recipient of help
Diagnostic/prescriptive
Deceptive outward appearance
Show non-invasive interest
Helplessness Perceived derisory attitude of potential helper/ men
informal contact DistantPrepared to spend time Information given is
out of dateMutuality of relationship Assumptions about
knowledge due to familiarity
Leave recipient/ couple in control
Accept variation in moodAwareness for need for space for woman/ coupleDoes not panicPrepared to listenImpartialKnowledgeable/ relevant informationNot emotionally involved
392
Helpful s trateg ies/ m echanism s Unhelpful s tra teg ies /b arriers to effective supportHELPERS ACTIVITIES HELPERS ACTIVITIES HELPERSDemonstrates an interest in the couple/ the probleminclusive of the partner“Be themselves"Alleviate anxietiesGet to the pointAwareness of potential difficultiesOpen to suggestionsNo preconceptionsLow profile
393
Outcomes of supportGoal ImpactAchieve distance from problem Increased understanding of condition/ helping strategiesSeek help (often outside the immediate family system) Reduced guiltEarly access to help Improved mobilityTime to self/ break from childcare Perseverance/ keep goingRetain perspective/ proportionality Mixed outcome- practical/ not so practicalReduce pressure on PF vs. address underlying cause Choice of action/ freedom to chooseAchieve enjoyment/ anticipation Reassurance that partner is cared forEnjoy positive aspects of parenting Not feeling like a nuisanceAchieve a structure to the day/ weekAdjustment to the situation/ illnessReduce isolationReduce chance of deteriorationRecoveryIncrease confidence and self esteemIncrease mobilityIncrease opennessEncourage disclosureImprove understanding of PND and its causes
394
Goal ImpactIncrease coping strategies W HEN SUPPO RT IS NO T EFFECTIVE THE IMPACT CAN BE:Gain reassurance Disappointed expectationsManage problem vs. find solution to the problem Isolation“Offload” on others Dread of attendance becomes a barrier to supportSocial contact Varying levels of support for partnersRetain control Reduced self esteem/ reduced self worthSpecific feedback vs. general insight Informs the assessment of the degree of recoveryReduce deterioration Reassess potential approach to future supportRelaxation “let hair down”Progression (to recovery)Realistic advice Feeling pushed away
395
Appendix 9 Examples of couple support networks
Support network: Aileen and Alan Support network: Barbara and Bert
Support network: Carla and Chris Support network: Frances and Freddy
Support network: Nancy and Norman Support network: Hannah and Harold
Support network: Maureen and Mike Support network: Pam and Paul
396
Appendix 10 Descriptions of normalityDescriptions of normality extracted from data and grouped under the following categories:1. Interaction with baby2. As a parent3. Interaction with partner/ in the relationship4. Interaction with others- people/ family5. Characteristics of what a normal person is/ does6. Comparisons which inform the individuals definition of what is normal/ What was before
1. Interaction with baby Baby becomes part of the family Routine is established for the childNo change to the regular routine in the household or very limited changeNo adjustment to the household routineBeing able to leave the baby with othersBeing able to adjust to the baby as another member of the familyBeing able to enjoy and smile with the baby
NORMALBaby as part of the family Routine for baby Adjust to baby’s presence Able to leave baby with others Smile with baby
Parenting/ baby dimension NOT NORMAL No adjustment Tired and weepy UselessNo good with the baby
2. As a parent Childcare easier due to child’s growing independenceCompetence in childcareNot doubting parenting abilitiesNot blaming the child/childrenNot feeling negative towards the child/ children
397
Being a confident parent Having a natural birth Easy motherhood Being tired as a new parent Work at motherhood
NORMALEasy motherhoodEasy childcareCompetent in childcareConfident as a parentNatural birthTired as a new parent
Parenting dimension NOT NORMALWork at motherhoodDoubting one’s parenting abilitiesHaving negative feelings towards thechild/ childrenBlame the child/ children for the illness
3. Interaction w ith the partner/ the relationship Give best to the relationship Talk togetherBeing/ feeling empathetic to partnerGive inspiration to partnerAccept ups and downs of relationship/lifeHave fun together as a coupleShare eventsLove/ care for the partnerHave reasonable expectationsMaintain role distributions? Be accepting/ understanding of each others roleHaving a solid relationship Being in sync with each other Close relationship Not keeping things to seif
398
NORMALCareFunEmpathySharingReasonable expectations Solid
Relationship dimension NOT NORMAL Keep things to self Isolation from partner DistanceOut of sync with each other Unreasonable
4. Interaction with others- family/ people Attentive to peopleBeing part of people’s livesHave time for peopleSpeak to others, sit and chatMake an effort with familyTolerate crowded venues/ groups of peopleHaving family supportHelp othersHave contact with close friends
NORMAL Attentive to others Involved Interact Being tolerant Closeness(short talks on the phone)
Social interaction dimension NOT NORMAL Tied to the house Irrational IsolationDistance from friends (too long on the phone)
5. Characteristics of a normal personEmotions Strong
Moody. Grumpy/ have a temperLogicalPositiveIn control: plans activities/ feelings/ the environment/ simple
399
things and the bigger pictureIndependentIn chargeBe strongBe selfCaringMotivatedOutgoingEnjoy lifeHappy/ full of the joys of living
Touchy/feely Fiery/ have a short fuse Impulsive Bubbly
Activities Do simple chores/ keep up with the household choreHave a good night outCope admit to limitationsSay what 1 wantTrust own judgementDo anythingSocially active/ go out/ socialise/ enjoy holidays
Physiological Regular menstruation
400
DESIRABLE In control/ coping Independent StrongHappy/ bubbly Sociable Return to work Have a range of moods
Attributes/ characteristics dimension UNDESIRABLE Plastic person Rock bottom PanickingUptight/ not relaxed Extremes of moods
6. What was before: comparison to inform definition of normal
Go back to before the illness Accept change Calm rather than storm Less stress Hope of recovery No more laughing Minor adjustments Get on and do thingsPlanning activities rather than being spontaneous
401
NO REC OVERY Indicators of recovery or lack of recovery RECOVERYStorm Accept changeBeing spontaneous CalmnessNo more laughing Get on and do things
Plan activities (this can be an indicator of recovery or an acceptance that new coping mechanisms have had to be found)Get on and do things Hope of recovery Go back to what was before New normality
402
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