Who Contains the mother?

The Lindsay Clancy case has stayed with me. I find myself returning not only to the horror of what happened to her three children, but to the months before it happened.

She was suffering. She knew that something was wrong. She asked for help.

I keep coming back to that.

What does help mean?

Is help an evaluation? A diagnosis? A prescription? A hospitalization? Certainly, each of these may be necessary and, at times, lifesaving. But are they enough?

I believe the mental health system failed Lindsay Clancy.

I do not say this because I know precisely what was happening in her mind when she killed her children. I do not. That question has been fiercely debated by psychiatrists, psychologists, lawyers and, most recently, a jury that could not reach a unanimous verdict. Nor does trying to understand her mental illness diminish the unbearable reality of what happened to her children.

But something was terribly wrong long before that January afternoon.

Clancy sought psychiatric help. She was evaluated and hospitalized. She was prescribed multiple psychiatric medications. She struggled with depression, anxiety, insomnia and thoughts of suicide. Yet the clinicians treating her did not arrive at a diagnosis of postpartum psychosis before the deaths of her children.

What troubles me is the difference between receiving treatment and being helped.

What does it mean to ask for help when the person asking may be losing the very capacity to understand what kind of help she needs?

She could not possibly be expected to know that she needed help making meaning of thoughts and feelings that may themselves have become frightening, confusing or incomprehensible. She could tell people that something was wrong. She needed others to become curious about what that “something” was.

Medication may be essential. Hospitalization may be lifesaving. Diagnosis matters. But help also requires trying to understand a patient's state of mind. What is she experiencing? What can she still think about? What has become impossible to think? What is she frightened to tell us? What might she be communicating without yet having words for it?

When a person's capacity to make meaning of her own experience begins to fail, she needs another person to help her think. 

For me, this is where psychoanalytic thinking becomes essential. 

The Vulnerable Mother

For quite some time, I have been deeply influenced by the work of psychoanalyst Joan Raphael-Leff, particularly Spilt Milk: Perinatal Loss and Breakdown (2000), and by the tradition of infant observation in London. I have also been influenced by the work of Louise Emanuel at the Tavistock, whose writing about infants, young children and their parents has helped me understand how much can be communicated before it can be put into words.

Raphael-Leff asks us to enter the internal world of pregnancy, childbirth and early motherhood rather than simply looking at motherhood from the outside. In Spilt Milk, she and her contributors consider the experience of having a baby, pregnancy and the internal world, postpartum disturbance, and puerperal psychosis.

The birth of a baby is also, psychically, the birth of a mother.

A woman arrives at motherhood with her own infancy. Her own experience of being mothered. Her experiences of dependency, care, abandonment, safety and danger. She carries fantasies about the baby she will have and about the mother she imagines herself becoming.

And then the actual baby arrives.

The actual baby cries.

The actual baby does not sleep.

The actual baby needs and needs again.

The mother's body has changed. Sleep has changed. Her relationship with her partner has changed. Time itself may seem to have changed. Her sense of who she is may become unfamiliar.

There is love, certainly. But there may also be anger. Resentment. Terror. Envy. Helplessness. Ambivalence. At moments, even hatred.

Psychoanalysis does not regard the existence of these feelings as evidence that a woman is a bad mother. On the contrary, psychoanalytic thinking gives us a language for understanding that love and hate coexist in our most important relationships. The capacity to bear that ambivalence is part of psychological development.

But what happens when depression, anxiety, sleeplessness, trauma or psychosis overwhelms a mother’s capacity to think about what she is feeling?

Learning to Observe

Infant observation has been important to my own thinking because it teaches us to look differently. To wait, watch and wonder. To listen with our eyes, ears, heart and mind.

We pay attention to what happens between mother and baby, but also to what happens within ourselves as we sit with them. We listen to what is spoken and to what is communicated without words.

Louise Emanuel's work is particularly relevant here. In her 2006 paper, “Disruptive and Distressed Toddlers: The Impact of Undetected Maternal Depression on Infants and Young Children,” she describes clinical work in which difficulties in young children led retrospectively to the recognition that their mothers had suffered from undiagnosed postnatal depression.

The mother's state of mind does not exist in isolation. It enters the relationship with her infant. Something may be communicated between mother and baby long before either has words for it.

This kind of observation asks something different of the clinician.

Not simply, “What symptoms are present?”

But “What is happening here?”

Bion: Container and contained

Wilfred Bion gives us another way to think about what help means.

In Learning from Experience (1962), Bion describes the infant as having emotional experiences that cannot yet be understood or thought about. The infant needs another mind capable of receiving these overwhelming states, bearing them and transforming them into something more tolerable.

Bion conceptualized this relationship as container and contained.

Containment does not mean taking distress away. It means receiving another person's overwhelming emotional experience without becoming overwhelmed by it, thinking about what has been communicated, and helping return it in a form that can gradually be felt and thought about.

Closely related is Bion's concept of reverie. Reverie is the mother's receptive state of mind, her capacity to take in something of the infant's fear, distress or confusion before the infant can understand or put words to it. Through reverie, she lends the infant her capacity to think.

The infant needs containment.

But mothers need containment too.

Who contains the mother?

Who can receive her terror without immediately trying to make it disappear? Who can remain curious about it? Who can help her make meaning of experiences that have become unbearable or unthinkable?

And what happens when sleeplessness, depression, anxiety or psychosis begins to interfere with the mother's own capacity for thought and reverie?

This is why a prescription, although sometimes essential, cannot by itself constitute containment. A mother also needs to be known.

The Mother Does Not Exist Alone

Another aspect of Louise Emanuel's work that has been important to my thinking. In “Father ‘There and Not There’: The Concept of a ‘United Couple’ in Families with Unstable Partnerships,” Emanuel asks us to consider the psychological importance of a parental couple capable of creating a containing structure around the child.

The mother and infant do not exist alone. There is a third.

Most often, there is a partner, an actual father or another parental figure. There is also the mother's internal experience of a parental couple.

The capacity of the adults to function as a parental unit can provide an essential containing structure around both mother and baby.

This brings me back to Patrick Clancy and to a question that continues to trouble me.

Where was her husband during the months in which she was deteriorating?

I do not mean this as an accusation. Nor do I believe that a husband should be expected to diagnose postpartum depression or postpartum psychosis.

I mean it as a clinical question.

What did he see? What did he not see? What did he become accustomed to seeing?

What frightened him? What did he communicate to the professionals treating his wife?

And what did they ask him?

When a mother is becoming increasingly depressed, frightened, sleepless or psychically disorganized, the partner may be one of the few people able to observe the change over time.

He may see what cannot be seen during a psychiatric appointment. A woman may be composed for forty-five minutes and fall apart at home. She may minimize frightening thoughts because she is terrified that someone will take away her children. She may no longer recognize how profoundly her own thinking has changed.

The partner, too, may minimize what is happening. He may become accustomed to it. A family can gradually organize itself around illness without understanding how ill someone has become. This is why the couple must become part of our thinking about postpartum mental health. We cannot simply treat the mother and send her home.

What is happening between these parents? Can they think together about what is happening to the mother and the baby? And when they cannot, who is helping them?

Emanuel's idea of the “united couple” gives us a way of thinking about something larger than the marital relationship itself. It points toward a psychological function. A parental couple capable of creating a space around the infant in which vulnerability, dependency and fear can be recognized and thought about.

This takes Bion's question of containment one step further.

Who contains the mother? Who contains the baby? And who helps the couple remain a thinking couple when one parent is beginning to lose the capacity to think?

What does help look like?

There are programs that have tried to think differently about vulnerable mothers.

The SPRING Project is one example. It was developed to increase access to affordable, high-quality psychotherapy for mothers and families experiencing prenatal and postpartum anxiety and depression. Its network includes licensed mental health professionals with specialized training in perinatal mood disorders, and it explicitly seeks to create links between psychotherapists and the health care professionals who encounter new mothers and babies.

This matters.

We cannot tell mothers to “get help” and then leave them to navigate a fragmented mental health system while they are depressed, frightened, exhausted or unable to think clearly.

In New York City, The Motherhood Center represents another important model. It specializes in perinatal mental health and treats a range of conditions including depression, anxiety, OCD, bipolar disorder and postpartum psychosis. Its approach includes psychotherapy and psychiatric care while also recognizing babies, partners and families as part of the mother's world.

These models remind us that psychiatry and psychoanalysis do not have to be placed in opposition.

We need reproductive psychiatry. We need medication. We need hospitalization when a mother is psychotic or unsafe. We also need clinicians who understand infancy, unconscious life, maternal ambivalence, couples and families. We need infant observation and parent infant psychotherapy. We need continuity of care. We need communication among psychiatrists, psychotherapists, obstetricians, pediatricians and families.

We need somewhere for the mother's terror to go.

Who is Listening?

The lesson I take from this tragedy is not that women with postpartum depression are dangerous. They overwhelmingly are not. Nor should postpartum depression and postpartum psychosis be collapsed into one condition. They are not the same.

The lesson for me is about vulnerability and our capacity to recognize it.

A mother can deeply love her children and become profoundly mentally ill. She can ask for help without being able to communicate the magnitude of what is happening inside her. She can appear coherent while something much more primitive may be disintegrating. A partner can see that something is wrong without understanding what he is seeing. And a family can be surrounded by mental health professionals and still remain terribly alone.

Perhaps this is what Raphael-Leff, Emanuel and Bion each teach us in different ways. Raphael-Leff asks us to enter the internal world of the mother. Emanuel asks us to observe the mother, infant and parental couple. Bion asks us to think about containment, reverie and the capacity to think.

We must become interested not only in the symptom, but in the emotional world surrounding it.

Instead of asking only: “Are you depressed?” “Are you anxious?” “Are you thinking about hurting yourself or your baby?”

Perhaps we also need to ask:

What is it like to be you with this baby?

What frightens you?

What happens inside you when your baby cries and you cannot make the crying stop?

What happens when everyone expects you to be happy and you are not?

Who knows how frightened you are?

Who takes care of you when you no longer feel able to take care of everyone else?

And what is happening between you and your partner as you try to become parents together?

Perhaps most importantly:

Who is close enough to notice when a mother who is asking for help is beginning to disappear?

References

Bion, W. R. (1962). Learning from experience. Heinemann.

Bradley, E., & Emanuel, L. (Eds.). (2008). What can the matter be? Therapeutic interventions with parents, infants and young children. Karnac.

Emanuel, L. (2006). Disruptive and distressed toddlers: The impact of undetected maternal depression on infants and young children. Infant Observation, 9(3), 249–259.

Emanuel, L. (2008). Father “there and not there”: The concept of a “united couple” in families with unstable partnerships. In E. Bradley & L. Emanuel (Eds.), What can the matter be? Therapeutic interventions with parents, infants and young children. Karnac.

Raphael-Leff, J. (Ed.). (2000). Spilt milk: Perinatal loss and breakdown. Institute of Psychoanalysis.

Resources

The SPRING Project. Support and referral resources for pregnancy and postpartum mental health.

The Motherhood Center, New York City. Specialized treatment for perinatal mood and anxiety disorders and other postpartum mental health difficulties.

Vivian Eskin PhD