Let us be a source of support to each other and a model to our children:

As we all know couples are made-up of different personalities, characteristics and traits. To make it even more compound partners have different mental health predispositions. Some have the tendency to think negative, to point at that which is not working or not present, to engage in obsessive behaviours, to seek perfectionism, to want to control and plan if possible every single second, minute, hour of the day, who make mountains out of a molehill, who get anxious when there are no solutions at hand. Some others act passively or cool, as though nothing is happening or others who take on a very rational approach to what goes on. Now why am I sharing this?

Because it is important that we:

Recognize and acknowledge the type of partners, personalities and mental predispositions the couple-hood is made-up of

By acknowledging who we are in the relationship, we become aware of what we bring to one another in our interactions. We accept our partnerfor what s/he offers, that is how s/he usually reacts, for his/her strengths and weaknesses and the like. By having this awareness in our foreground we make ourselves possible to offer ‘empathy’.

For example, if I have a partner who gets anxious when s/he has to attend to multiple tasks. In the situation where my partner is finding him/herself at home, having to perform his/her daily working duties, possibly also to contribute to parenting tasks it makes sense to hypothesize that s/he is going to manifest more anxiety. Hence rather than reacting to her/his outbursts by saying “this is not helpful, you shouting at someone every minute of the day”. This usually generates more anger in the atmosphere. Instead, if I were to react by sharing, “I understand this is challenging for you because you are expected to work as usual and yet there is the assumption that we, parents, have to manage our kids at home plus attend to their schooling and act as though this is not happening. It is too much to take on and definitely not easy for either of us”.

Instead of judging and/or blaming, we offer understanding. Like this, we immediately send the message to one another that we are on the same boat, we are in it together and there is no “YOU” being pointed at. Hence, it does not provoke any defensive attack but rather the message “I am here for/with you and you are here for/with me.”We will be looking out for each other in this way and we give the message that we are working together side by side.

Acknowledge that this is a novel situation for both and that it provokes uncertainty

Once we acknowledge who we are as individuals in the couple and we respond empathically to one another, we remind ourselves that this Covid-19 circumstance is new for both of us. Living with social isolation/ distancing, working from indoors, being within the parameters of our homes twenty-four seven not only with each other but also possibly with our children is novel to both (not to mention for all, I mean kids too).

The realization of the newness of this situation brings to our awareness that whereas before we might possibly have had answers, this time we do not. We are both learning to go through it, to work with it or to all affects fight it. Hence, the assumption that “I” or “you” have the answer does not hold. The new assumption is “together, let’s find what works for us”.

There is no point in looking at him or her and ask, “What are you going to do? Or “did you think about …?” Instead what would be helpful is for us to sit together and generate conversations around “ok, how are we going to create the possibility at home that all of us find space for oneself, so we make sure everyone goes on with his and her life activities (be it work, cooking, housecleaning, kids, monitoring kids’ educations, couple/family leisure, etc.). Let us brainstorm the most important aspects of our day! What are our priorities for each day? How are we going to set them in a way that allows us to support each other with every activity? Let’s allocate time to review.” Conversations like these are allowing us to bring together our ideas, opinions and expertise. This is teamwork and in our teamwork, weare paving the way for a (daily) routine.

A situation like this where novel and uncertainty prevails might be a huge challenge for our partners who want to have ready and fast answers, who do not sit nicely with the unknown, who want to plan and control as much as they can or who are super worried because there are the children’s needs or working concerns. Once again, the importance of acknowledging the uncertainty and working with it becomes ever significant.“ Yes I know it can be hard on you because you are used to doing things in a certain way, you usually want to have the answers but this is new for us both so we both need to figure out how to make it work for both of us and the children” The positive side of this is that again, it highlights (a) we, both partners, are not on our own and (b) we have the freedom to choose what makes sense to us. We are setting the pattern, our routine in operation. (It is helpful to see what other people out there are doing and just as important to attend to what works BEST for us.)

Recognize and acknowledgethat we are learning about ourselvesin this context by trial and error

As we go along living together at home, as days go by, we are learning through experimenting. This by default implies that there will be days where we succeed in meeting the tasks, objective and/or goals we set for ourselves, for our couple-hood and/or the children and there will be other days where we feel that it was less so. Perhaps it was less so for oneself on this day and more for the other or the other way round on a different day, or worse of all, a day were nothing gets done the way we planned it. Chaos rules the day. Understanding the element of learning by trial and error relieves us from the fear of failing. It normalizes the reality that certain days will be worse than others and vice versa.

Working in this way together has the psychological effect of increasing the ‘relationship-cohesion’ as we seek to build inter-relational trust. This experience will free us from carrying the ‘failure feeling’ or ‘successful feeling’ that would have most probably accompanied us when functioning within the normal circumstances (pre-Covid-19). Rather punctuating our doings as a trail and error learning helps us to stay in the process.

Experiments carry an element of risk. In this case, we, partners, are taking a risk in working our day/s together at home, in sending the message “we believe that this, in this way, makes sense to us ”even though it might fail.

Again I would like us to remind ourselves that when we or our partners who have issues of trust or of letting go or we feel our partners emotionally disconnected to us, we going to find such a way of working as very challenging. In this scenario the assumption we, as partners, function on is, “I am better off thinking for myself, by myself”. When this is the case, it does not mean that we do not have what is necessary to operate together but rather it highlights the importance, the significance and the essentiality of practicing step 1 and step 2. Ultimately believing that we both have the same intention for the couple that is, to survive this situation, to learn something from it and to come out stronger.

New situations whether by choice or forced, whether liked or not,challenge us to learn something more. It is constructive to share that this ‘Corona reality’ is literally taking everyone out of their comfort zone and compelling each and every one to accept it, face it, work with it to overcome it. We as a couple need to understand that this is a fight, we need and want to fight together. The enemy is out there and not between us. ACT TOGETHER is key.

Compliment, praise and giving each other positive strokes

Humans need encouragement,stimulation and motivation. It is not the time to criticize, to put my partner down or to be sarcastic. It is the time to compliment and praise as well as to build on each other’s strengths. When I have the tendency to do the former, it is better to stop and take a minute to reframe it into something positive. Caressing is possible not only physical but also verbally. Let us give each other positive strokes. In layman terms this is the feeling of ‘a pat on the shoulder’. When in movies we see buddies working together and having fun we also smile and have a sense of good feeling inside us. In our relationship our partner is our buddy. Let us look after him/her in this way.

And let me just add that humour is the best medicine. Social media is having a huge impact on everyone of us more than ever before. We share video clips, funny episodes or captions because we recognize we need and want to laugh. In times like nowadays, humour and laughter are essential surviving tools. We, as couples need to generate an atmosphere where this is possible in the privacy of our own homes. After all laughter is a constructive way of releasing stress and anxiety and transforming negative energy into positive one.

Let me end by nicely referring to the inevitable reality that our children are looking up to us parents in dealing with new situations. These tips also provide a constructive way of modelling to them useful ways of managing novelty, dealing with uncertainty and confusion as well as diffusing tension and anxiety……..and more importantly modelling how a couple (grown ups) does that together.

Ultimately by relating to one another in the above ways understanding, compassion and kindness prevail.

Reactions to change in families:

As a rule, one can argue that families do not look forward to change and strive to maintain homeostasis as much as possible. However when the family system is about to introduce some ‘newness’, in the context of the pandemic coming from the outside environment, this automatically exerts a force on the family system (conscious or unconscious) and puts pressure on the system to react.

When this happens, the family can react in different ways:

1 To ignore it and continue not to recognise the need for change.

2. To become aware of it but continue to refuse change.

3. To become aware of it and respond to it.

In the first two options, there is a huge risk involved as outside forces continue to exert pressure on the system. The risk is that the family system, unconsciously, might develop symptoms on a cognitive, behavioural and psychological functioning and family members would often fail to identify what is set in motion. Symptoms, such as highly expressed emotions between family members, emotional distancing, conflicts, increased levels of anxiety, mood swings as well as risks of collapsing or developing severe mental health issues may unfold. During the webinar, one of the questions asked was if adults, in particular women, are addressing ‘the sharing of load’. This could be a potential conflict trigger within the family system if families fail to acknowledge the increased load at home as one of the effects of Covid-19.

On the other hand, the families who stop to attend to the outside signals impinging on the system are usually the ones who go for option three.

Characteristics of responsive families:

Families who are open to change are usually those who engage with their environment. They do not look at themselves as an entity on their own but they position themselves as part of a bigger (societal) context.

In addition, these families have clear permeable boundaries. They know who they are; where they start and finish; and allow for the possibility of being influenced by society. Their system is able to regulate how much they are able to take in to respond effectively as well as appreciate that in return their contribution influences their environment too.

Families who have previously experienced unpredicted forced change, such as the sudden death of a loved one, facing a sudden chronic illness, loss of work or a traumatic experience and have successfully worked through it may all contribute in making their systems more resilient. These families have acquired internal resources-both intra-and inter-personal ones-that help them deal with new challenges.

Process of ‘change’:

So, we can safely say that change starts with awareness. Families accumulate stimuli from their surroundings that indicate something is happening. They listen and read news and stories. As they do so, a feeling of shock or disbelief might result, especially because they lack understanding around what is evolving. The unknown instigated by Covid-19 triggered some people to formulate conspiracy theories around the virus and its origin. This is a way of dealing with the uncertainty and fear around the unknown. Whilst doing so, these families still denied the possible impact the virus may have on their country, let alone conceptualize the idea that it can affect them personally. However, the more they assembled facts and reliable data the more they appreciated that this pandemic is happening around them and even if it is far, it may eventually hit them too-sooner rather than later. At this point, is important for family members to recognize negative emotions, such as anger and anxiety. These are justified feelings at times of change.

“...irrespective of what they recommend I’m not going to rely on anyone to tell me what to do…..”

Once the family system builds a comprehensive cognitive idea of what is happening out there – knowledge on Covid-19 virus, its symptoms, its spread and its fatality rates- the family recognizes that there is a risk. Hence, it is time to take further actions. The quicker family systems are in assimilating the knowledge (on the virus as well as on possible stresses and demands) gained,the quicker they are to use it to their own advantage in moving towards embracing change.When one member of a family brings home something new about the virus situation, whether it is the mother, the father or a child and the family systemis ready to take this on, even if at this point in time not all members are in a position to react, they are however offering the possibility to work with it. Families develop a predisposition to take up the new cues sent from the environment and rather than reacting antagonistically to the proposed recommendations announced by government and relevant authorities, they related to them as protective tools -ways of preserving their family system. A new meaning emerges, that of contributing to society-at-large, in this case by lowering the infected/ death curves.

“….we follow the necessary measures in order to flatten the curve whilst keeping ourselves and others safe….”

At this point families are in a process of active engagement, as they are letting go of rituals and developing new ones. Here, conversations between the family members of a system as well those beyond are the medium through which continued responsiveness is guaranteed. Also, by doing so families find ways of letting go of old behaviours and acquiring new ones. They are acknowledging the outside forces in relation to the consideration of the family life cycle they are in.

“In many ways the added emotional burden has been the most challenging and the most exhausting…….one good thing is that he has taken on the role as a home educator and I have stepped back and left him to it.”

During this pandemic, families cut off most physical exchanges outside of the home. Rather, they made space for more opportunities to be together in the same household as well as found ways of exploiting the current social media to ensure social connectedness. Parents, who are usually travelling around the globe or who contribute to the workforce, are bound within the parameters of their homes, possibly benefitting from quality time with their children. Fathers/Partners who usually carry less of the parenting responsibilities are witnessing what is happening at home, being offered the opportunity to appreciate more mother- children interactions, discovering the motivation to get involved.

“ I’m just loving seeing how a brain’s child is doing one plus one and seeing it developing…I am loving this.”

“ I now have an understanding of what really goes on whilst I am away…..oh gosh the way she does it is unbelievable…..I now hope that I won’t travel as much so I keep my contribution going.”

Mothers/Partners who usually carry more of the parenting responsibilities envy their space and time away from family duties, at the same time feeling less stressed to abide to tight schedules,enjoying their children more freely.

“….my kids and husband were ecstatic to be at home indefinitely…well, as for me. it was the opposite” “I suddenly realised that my freedom had dissipated and that this man and these two little people have invaded my space! The house was my space during the day and now there was not a single room with a door, which I could close and create a peaceful space for myself…….. I did panic a little……”

For those families who did not necessarily value the input of social media in their children’s life, they had to install the right technology in place to make sure their children have access to online schooling as well as be able to remain in touch with friends and extended families, such as grandparents. Hence, these parents/families may be grieving their once held beliefs.

Special challenge of Covid-19: Fathers and mothers who are dual earners, are challenged to think about their work-family life balance and possibly address their respective inputs as parents. Let us acknowledge that Covid-19 pandemic forced most families to juggle with the new reality of working from home while attending to the family needs and demands. Perhaps it presented women with a pronounced reality check-the inequality they suffer as they go on-being socially expected (within the family as well as from society) to carry more of the parental responsibilities. Hence, the changes being experienced are not only in terms of behaviours and interactions but also with regards to core gender beliefs.

Stability versus change:

Whilst learning to embrace these losses and gains family systems are monitoring the changes, to continue adjusting and adapting to make sure they find their ‘new grounding’, the ‘new stability’.

“…I did realize that we all needed to fall into a semblance of a routine and new normality before the tweaking was done…..I quit my role as an LSA and asked the school to have my son’s LSA better organised……….

I introduced a fresh routine of an early alarm for my kids….I talked with my husband and insisted that every day, after his work, we go for a walk as his lack of presence in our relationship was what bothered me the most……….

by week three of lockdown I started to realize how privileged me and my treasured family life are….my kids are still following school, we are safe, extremely blessed…….my perspective shifted and I felt lighter and had bursts of positivity within………Me and my husband noticed that our son is a generally happier…hardly any signs of stress related to learning…..”

They find a new balance of functioning and want to stay with it. They want to enjoy the product of their efforts. So now anxiety, once again, revisits as the ‘easing of lockdown’ threatens the new status quo and they wonder how it is going to be when a certain degree of ‘normality’ starts taking shape.

” I have experienced various adaptations in life, some harder than others. I’m quite seasoned to big changes…. This time it was quite different. Now I’m not sure I’d like it to change.”

Moving beyond:

Many countries, such as Switzerland are experiencing some degree of socialization whether it is school, work, shopping, going for appointments at the hairdresser or to doctor’s appointment or meeting up with friends. There is the interplay of anxiety and relief, especially because the threat is still out there. Families have to learn to live with the ambivalence of such feelings, of wanting to move forward and learn to adjust to the new normality and at the same time wanting to be sure that they are not putting their family system at risk.This kind of awareness will help them to keep on processing the further changes that might come their way.

Families in mid-2020 are really testing their resilience. Resilience is about falling, having the ability to get up again and incorporating the suffering and move forward. At the time being, families face moving beyond Covid-19 crisis as well as maintaining existence of new dynamics. Whether they like it or not, families are challenged to continue working with change. Upon listening to the webinar, many families’ reactions I received was amazement about the process of change described as they identified themselves with the shared, could acknowledge the hard work it entailed and instilled a sense of courage. This way of understanding the family in response to change offers asystemic perspective of how families develop over time as they interact between themselves and with their environment. It is a constructive way of thinking about families.

Take home message:

As much as tendency to react to something unpredictable happening out there is usually “stay away”, “this could be dangerous”, “why should we change? family systems do need to acknowledge the initial reactions, recognize the feelings and emotions it provokes and whilst picking up further cues learn to attend to these feelings as slowly they are the source of momentum for further adjustments as they transform to more constructive emotions that allow for further growth.

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Post-Partum Mental Health

By Ruth L. Formosa Ventura, Systemic Psychotherapist and Couple & Familly Therapist, member of the WBP Executive Committee

Fact: Did you know that 1 in 10 women suffer with postnatal depression? Prevalence varies from 4.5 % to 28 % in onset, duration, and severity of symptoms mainly because of the range of measurement scales used, timing of intervention and follow-up.

Some support and solutions exist. These range from talking therapies to courses, self-help groups, yoga, meditation, and even some pharmaceutical treatments.

In this article – published today in honor of Maternal Mental Health Awareness Week, the focus is to facilitate a conversation on post-partum depression in the hope of making it easier for women to talk about such experiences. It brings into awareness women’s symptoms and challenges as well as provides alternative treatments and ways forward.

Postnatal Depression can happen to anyone

Symptoms: The most common symptoms of postnatal depression include a general lack of enthusiasm, sustained crying and intensive sadness, continuous self-doubt and guilt around not being able to show love to ones’ baby, anxiety about coping with this new role, lethargy, lack of sleep and loss of appetite, and a general sense that life is not worth living.

Postnatal mental health difficulties range from the manifestation of a variety of the above symptoms to depression, anxiety, psychosis and post-traumatic stress disorder. Postnatal anxiety and postnatal depression often co-exist. The average prevalence rate of postpartum depression is of 13%. Psychotic disorders during the postnatal period may be associated with previously experienced mental health issues.

Suffering in silence. Many mothers are unable to talk about the reality they are facing. Some are not even aware of what is happening, as it is something that invades them without any notice. Others are aware that something is changing, yet they find it extremely difficult to put words to their thoughts and feelings as they are supposedly experiencing a time where joy and happiness abounds. This is what women are socially constructed to believe: everyone expects them to be happy and to embrace the new life they created.

“I love my baby. My fear is that I do not have what it takes to show him that.”

In their review of qualitative studies with mothers experiencing postpartum depression, Knudson-Martin and Silverstein found that the feeling of failing to be a “good mother” was a central experience reported in all studies.

“People think I do not love her. That is not true, I love her… I am afraid that I am going to harm her.”

Mothers who are already suffering from depression and anxiety tend to experience an increased intensity of symptoms, which is not necessarily detectable, and puts their mental health at higher risks.

Relating to their pain. Women walking out of hospitals or baby clinics with their new-born do so as mothers. This marks the beginning of a new phase. Mothers need help to take on this role and to grow into it. No course certifies an adequate parent. Parenting requires conscious effort and practice.

New mothers have to look after a baby whilst constantly doubting themselves and their actions. Everything they knew about themselves is changing fast. They cannot eat when they want to. They cannot rest when they want to, or be on their own if they feel it. A little creature depends on them day and night.

The baby becomes more important to them than looking after themselves. They do not realize they can take a time out or ask for help, partly because they believe they should be able to cope on their own. They feel overwhelmed with the constant fear and anxiety they carry around. Some mothers describe this as ‘a feeling of suffocation’.

To make it worse, they need to adjust to parents, relatives, and friends visiting, implying that they need to have energy for them too. Feelings of guilt, of not being able to feel or show gratitude for these people, might haunt them. The perfect, often unrealistic images of mothers with their babies in the media may add to the pressure they feel.

For women already parenting other children, the ´looking after oneself´ will be even more challenging.

How easy is it for mothers to ask for help?

Women feeling mentally vulnerable during and after pregnancy need to be listened to and given the relevant guidance and encouragement. Most women are not aware that they are going through low cycles of mood swings or that they have signs and symptoms of postpartum depression.

Mothers often share that they were given the opportunity to receive help and support, but they declined it. They felt they were already struggling to deal with “too much”. The idea that they have to find room to receive therapy or counselling sounds overwhelming.

We must inform and educate mothers about the possibility of mood swings, depressive tendencies, the overwhelming feeling that might accompany the arrival of a new-born at home, the self-doubt, and insecurity. Information about postpartum depression should be available for the whole family, especially partners and other close family members who may be the ones to identify the first signs of postpartum depression and encourage the new mother to get the support she needs.

This should come hand in hand with normalizing the act of reaching out for help or receiving counselling as part of the postpartum adjustment. Challenging the stigma related to postpartum depression will enable mothers to access support a bit more willingly when the need arises.

Who can help?

Midwives, perinatal nurses, consultant perinatal psychiatrists, midwife counsellors, doulas, psychotherapists, and family therapists as well as supportive partners, family, and friends are essential to the mother’s proper transition into this new lifecycle. In other words, we need a systemic approach to address postpartum mental health. Such a model understands and treats mother´s mental health in its totality – through the biological, physiological, psychological, and social components.

In their recommended approach to treatment decision making for postpartum depression Sit and Wisner conclude: “Effective decision making for the treatment of postpartum depression ideally occurs in a context that values a woman’s life experiences and her psychosocial environment, and must be a collaborative process between each patient and provider to be as successful as possible.”

Courses and self-help groups are also available, bringing mothers together to share their common experiences, offering guidance and tips on how to manage daily challenges. Other people’s stories about their own struggles are powerful human tools to access resources as well as in communicating understanding and compassion.

Today, mothers report finding yoga classes and meditation such as mindfulness practices very beneficial. These should not be underestimated, especially when we know that body and mind are interconnected.

There is actually a drug for postpartum depression. The story of its clinical development is an eye-opener, as they came up with a drug that works in women* just by studying the biology behind postpartum depression (which is sex specific) and its hormonal changes. As with other forms of depression, it is not a silver bullet, but it can help get a patient back on track.

Addressing pre-existing mental illness during and after pregnancy

Some mothers are already suffering from some kind of mental illness before they get pregnant. What happens when they have to stop medication because of pregnancy? What if they already struggle with self-confidence, self-efficacy, and adjusting to change? This puts an extra strain on their mental health. These risks need to be tended to and considered in their maternity adjustment plan.

Gynaecologists must work with the patient’s psychiatrists/psychologist/psychotherapist to jointly devise a treatment plan that caters both for the monitoring of the biological changes in the baby and mother as well as the psychological/therapeutic interventions needed to keep the mother, as much as possible, in a stable mental state.

Further research is needed

Postnatal health continues to be a relatively neglected as a topic for research and study. A survey conducted by the UK’s National Childbirth Trust showed that only half of the mothers thought they received adequate support and one quarter of the women reported no emotional support at all.

We must acknowledge the gap between evidence, policy, and practice if we want the care offered to pregnant women and new mothers to enhance their health and well-being.

WBP recognises that this topic is of major significance to women’s mental health. At their upcoming International Forum on Women´s Brain and Mental Health, a panel will be dedicated to this topic and will address different aspects of perinatal mental health including postnatal depression.

“I am a mother and I am vulnerable but I am capable
And I am doing the best that I can…”

*Comment by WBP: This drug was discovered because doctors focused on women and their specific biology during pregnancy. They noticed that a certain hormone (allopregnanolone) would be super-high in the last week of pregnancy, but drop dramatically after birth. Then they saw that the levels of this hormone inversely correlated with depression scores, and that mothers who got postpartum depression had the lowest levels. So, they manufactured a drug that mimics the action of this hormone to “rebalance” its levels. And it works (though it isn’t an absolute solution). It’s a wonderful example of how taking into consideration the exquisite female biology can result in sex specific drugs.