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Grieving for my former self: a phenomenological hermeneutical study of women’s lived experience of postnatal depression

27 January, 2009

Grieving for my former self: a phenomenological hermeneutical study of women’s lived experience of postnatal depression

The this study provides a deeper insight into the life world of women who have lived through postnatal depression (PND).

EBM: Dec 2003


Denise Lawler1 MSc, BSc, RNT, RM, RN. Marlene Sinclair2 PhD, MEd, BSc, DASE, RNT, RM, RN.
1 Midwife Teacher, Coombe Women’s Hospital, Dublin 8 Ireland.
Email: dlawler@coombe.ie
2 Senior Lecturer in Midwifery and Course Director Advanced Nursing/Midwifery, University of Ulster at Jordanstown, Newtonabbey BT37 0QB Northern Ireland.
Email: m.sinclair1@ulster.ac.uk



Abstract

Aim. The aim of this study was to provide a deeper insight into the life world of women who have lived through postnatal depression (PND).
Objectives. Gain insight into women’s lived experiences’ of PND and describe the meaning of the illness from the perspective of the people who have had experience of the illness.
Method. A phenomenological, hermeneutical approach was used to describe women’s experiences of PND. A purposeful sample of seven women agreed to participate in the study. In-depth unstructured interviews were audiotaped and transcribed verbatim with consent from the participants. Transcriptions were processed using the hermeneutic circle: dialogue, fusions of horizons and metaphors to understand the meaning of the experience adapted from Dicklemann et al, (1989) and the participants confirmed the transcript interpretations.
Findings/results. The findings were presented under the four existential lifeworlds – lived space, lived body, lived relations and lived time (Van Manen, 1990). All of the women experienced a loss of their former self after they went through a process of being a known person in a known world to an unknown person in an unknown world (Rubin, 1984). The women vividly described their brokenness and sorrow as they struggled to come to terms with their new image and their new role as a mother. It was after they had experienced a cycle of grief that they were able to accept their new self and new role as a mother. These women came to accept their experiences as normal. They felt they had to experience death of their former self before giving birth to their new persona.
Implications. This perception of normal experience challenges midwives and mental health workers to redefine the meaning of normal and to review the consequences of labelling women as suffering from PND. The study calls for a review of current antenatal preparation for parenthood and challenges midwives to review commonly accepted beliefs that almost every woman naturally adjusts to the role of motherhood when their baby is born. New approaches are required in order to prepare women for the possible event of experiencing this sometimes ‘natural’ metamorphic state after giving birth.


Key words: Hermeneutical phenomenology, grief, rebirth, postnatal depression, midwifery, women


Introduction

PND is categorised as a mental illness, defined according to biological, biomedical or behavioural perspectives (Baker et al, 1997; Baker, 2001). Traditional research
into PND has used objective methodologies that contribute to an epistemological understanding of the illness, but there is little research that focuses on the woman’s actual experience. Therefore, this study used a qualitative hermeneutical approach that subscribes to the basic tenets of interpretative and descriptive phenomenology to provide women who have survived PND with a platform to discuss, describe and disclose their personal experiences.


Aim of the study

The aim of this study was to investigate women’s subjective experiences of living through PND. The study was based on the belief that essential truths about reality are grounded in an individual’s lived experience.


Objectives

The objectives of this study were to:

- Gain an insight into women’s lived experiences of PND
- Describe the meaning of PND from the perspective of those who experienced it.


Methodology

A phenomenological hermeneutical approach was used to conduct the study. As a method of inquiry, phenomenology cuts across philosophical, sociological and psychological disciplines. As a science, its purpose is to describe the essence of a particular phenomena as the lived experience. This search resulted in the identification of the essence of PND and its accurate description through everyday lived experience (Rose, 1995). As a research approach, phenomenology links the phenomenon PND and the human being in an inseparable way, because the phenomenon is there only when there is asubject who experiences that phenomenon (Sadala and Adorno, 2002). The research design was influenced by the hermeneutical philosophy that contends that a hermeneutical inquiry is not to develop a procedure of understanding, but to clarify the conditions in which understanding takes place. By using hermeneutics as a basis for this study, it was possible to combine the tenets of descriptive and interpretive phenomenology.

The four steps associated with descriptive phenomenology – bracketing, intuiting, analysing and describing were incorporated into the study. Within this hermeneutical inquiry, research participants presented the self-interpretation constructions of their situations resulting in many constructions or multiple realities including the researcher’s own constructions. Indeed, this hermeneutical inquiry focused on the existential-ontological questions of how people came to understand. Ontological-existential phenomenology has two essential convictions, which are inextricably intertwined – historicality of understanding and the hermeneutic circle. The key philosophical constructs of Heidegger’s existential hermeneutics are the application of the hermeneutic circle, dialogue and the fusion of horizons as metaphors for understanding in interpretive work (Koch, 1996).


Sampling and recruitment

Purposeful sampling of women who were attending a self-help PND group was used to identify women who had managed to live through the illness. The sample size of seven (five primigravidas and multiparous women) was reached when no new themes emerged from the data analysis.

 
Pilot study


A pilot study was conducted to provide an opportunity to explore the research method and to test the recording equipment.

 
Ethical approval

Ethical approval was sought and granted from the local ethics committee. The committee was satisfied that the potential for harm to these women was minimised by the fact they had lived through PND and were attending a self-help group.


Confidentiality and anonymity

To ensure anonymity and confidentiality, each participant was assigned a pseudo-name and code number that appeared on all the transcribed data. Informed consent to
conduct and to tape the interview was obtained from participants at the outset of each interview. The interview schedule was versatile and flexible and the interviewer’s role was a passive, interpretative one. A prompt guide devised after the pilot interview ensured that the same topics were addressed in each interview. This prompt guide was only used if there was a difficulty in disclosure.


Sensitive research

PND is both an emotive and sensitive topic. The research interview may provide informants with the opportunity to discuss the topic openly and frankly. The researcher should therefore endeavour throughout each interview to empathise with the informants state of mind and to tailor the progress of the interview to limit any discomfort to them. By being empathic any possible harm to the informant will be minimised. However collaboration and subjectivity may make the researcher vulnerable. Human rights must always be protected, but qualitative research brings with it a new set of ethical considerations. Informants must not be harmed thereby supporting the principle of nonmaleficence. If the researcher senses that the interview is causing discomfort, which may result in serious consequences, the informant’s welfare must be protected perhaps by ending the interview or providing follow up counselling or referral. Informed consent must be obtained and informant participation must be voluntary, supporting the principle of autonomy. Additionally according to the principles of beneficence and justice,
researchers must assure informants that confidentiality and anonymity will be upheld and that they will be treated with dignity and respect. Adherence to ethical principles may ensure that informants and researchers are not placed in vulnerable positions.

 
Data collection

With the women’s permission, in-depth unstructured interviews were conducted and tape-recorded. The interviews were conducted in participants’ homes and ranged
from 60 to 90 minutes. Some time was spent before the interview in establishing a rapport with the participant and this facilitated disclosure. After each interview there was time set aside for debriefing.


Data analysis

Data analysis and data collection occurred simultaneously. As each interview was completed, the data were transcribed verbatim and read and re-read as many times as
was necessary to gain a feel for the content and to achieve a sense of the whole as well as an understanding of the participant’s use of language. Editing and line-by- line coding took place, freeing the text temporarily from its context and allowing it to be seen as a whole and as parts simultaneously. Themes that unified all the texts and employed a creative, linguistic and intuitive process to transform participants’ experiences into psychological language using metaphors or images were identified and categorised under Van Manen’s (1990) loose framework that consists of four existential life worlds – lived space, lived time, lived body and lived relations. The intuitive process of a hermeneutical inquiry required imagination to vary the data until a common understanding about the phenomenon emerged.


Confirmability and trustworthiness

After the analytic process, the interpretative transcrip- tions were returned to the informants to confirm the descriptions that emerged from the study. The nature of
the experiences encountered by individual women was unique and therefore there was no single reality. However, by using the hermeneutical approach, it was possible to gain an understanding of what the participants’ particular reality actually meant to them (Koch, 1996).

Table 1. Labour/delivery outcomes











Findings


The findings will be presented under a profile of the women and under the four existential lifeworlds: spatiality (lived space), corporeality (lived body), relationality (lived relations) and temporality (lived time).


Profile of the women

Seven women gave informed consent to participate in the study. Of these, five were first-time mothers and the other two had several children. Six out of the seven pregnancies were planned. Five of the women were aged between 21 and 30 years and the other two were between 31 and 40 years. All of the women were married and held down demanding jobs with four being in the profession of midwifery/nursing and three working as business managers. Three of the women suffered from pre-eclamp- sia, one had an antepartum haemorrhage and another had gestational diabetes. In addition, these women all chose consultant-led care and four received totally private care. The vaginal birth rate was under 50% (n=3) (see table 1).


Spatiality

Spatiality (lived space) refers to the changing and movement of time and the physical world surrounding individual experiences. Women within the study described PND as a spontaneous, insidious process, which occurred over time reaching its ultimate form in a downward trajectory towards ‘rock bottom’ and, arguably, oblivion. All the women felt ill-prepared for the psychological adjustment required in the postnatal period and all identified that there was little to no antenatal discussion on this topic during antenatal classes. Physical and psychological complications were experienced by six of the seven women. Physical complications included pre-eclampsia, antepartum haemorrhage and diabetes. As a result of these complications women discussed how their level of stress was heightened during the antenatal period.

Additionally, the key concept to emerge within this life-world was that of detachment. Words like ‘aloof’, ‘unconcerned’, ‘indifferent’ and ‘remote’ were used to describe this concept. Detachment was discussed in relation to physical detachment from family, community and society, but also the detachment from reality as perceived by the woman. The women identified that their experiences of detachment from their babies were initiated immediately post delivery where the midwife failed to give them their baby – opting instead to give the baby to their partner or placing the baby in an incubator because of birth complications. Three of the babies were admitted to the neonatal intensive care unit and this compounded feelings of detachment even further.

Detachment from family members and friends occurred mainly because of the women’s inability to socialise and the perceived social isolation that emanated from the experience of PND. A lack of trust existed in all women’s interpersonal relationships and when the women were asked to clarify this, they disclosed their distrust of everybody including their partner. It appeared that not trusting anybody and doubting everybody allowed women to cope with the uncertainties of their lifeworld. Women explained that their ‘detachment’ from the real world with its overwhelming responsibility for a new baby helped them to avoid facing the responsibility. Although these women clearly articulated their planning for the birth, such planning stopped at the birth. They had not made any plans for life after the birth. They had all idealised motherhood and had high expectations of themselves coping competently with their new role as a mother. On reflection it was evident that they now realised that their expectations of themselves were unrealistic.

All seven women expressed a deep sense of being in control, a high sense of self-awareness and self-esteem before the birth and went on to describe how this rapidly disintegrated after the birth. They knew they were changed by the event and they were no longer in control of their lifeworld. One woman described herself as ‘spiralling deeper and deeper into a state of detachment and social isolation’.


Corporeality

Essentially the women described their experiences of PND in relation to lived body as a process of suffering deep psychological, spiritual and physical pain. Suffering
was described by the women as being something totally encapsulating affecting their complete being. Definitional words such as ‘undergo’, ‘experience’, ‘sustain’,
‘encounter’ and ‘endure’ are used in the literature to define suffering and all emerged in the study.

For some women the experiences of PND were not manifested as physical pain, but there was an alteration in their psychosocial being, which resulted in the development of unpleasant experiences and lead to a disturbance in cognitive and behavioural function. Some women yearned to have their former self back again, that is the self that was there before the birth of their baby. However, all of the women expressed an overwhelming sense of responsibility towards their baby and a desire for everything to be ‘rosy in the garden’. They described feeling a sense of being ‘cheated by life’, being ‘denied the joys of motherhood’. Outwardly the women appeared calm, but inwardly they described feeling ‘empty’, ‘detached’ and ‘intolerant’.

Women experienced some escape from their corporeal existence when they sought and accepted help and treatment from professionals and began to attend the self-help
group.

 
Relationality

Relationality refers to lived relationships with others inside shared lifeworlds (mostly women, their partners and their babies). In these lifeworld’s women’s self-confidence and self-esteem were continually threatened by recurring shame and associated guilt. Shame arose out of women’s inability to cope with their new role, as well as the stigma of being labelled ‘suffering from PND’. Relationships suffered and the most profoundly effected was the relationship between the women and their partners. Several women described their partners as being ‘brilliant’, ‘fantastic’, ‘their only link to the real world’, while others refused to have intimate relations and moved out of the bedroom or even their home.
Descriptive words like ‘despised’, and ‘disliked’ ‘distrusted’, ‘forced him to sleep in the spare bedroom’, ‘it was all his fault’ typify their perceptions.


Family relations

Family, especially parents, were a major source of security for some women. Two of the women moved back to their parental home in an attempt to regain the security they felt in their own childhood. In addition women described how some family members had no insight into their experiences and for one woman some of her immediate family distanced themselves when she was diagnosed with PND.


Professional relations


One woman described how she felt ‘safe and secure in hospital’, however the other women within the study did not experience such support and security. Negativity
towards health professionals was illustrated when the women used words like ‘rude’, ‘unsupportive’, ‘judgemental’ and ‘constantly questioning my ability to be a good mother’.

Temporality

‘Lived time’ refers to subjective time, which has the temporal dimensions of past, present and future associat- ed with it. For the majority of women within the study, PND was viewed as an insidious process, creeping up on the individual over time. All women experienced feelings and behaviours, which were described as their lowest ebb or ‘rock bottom’. This rock bottom was experienced physically, socially, psychologically and spiritually. Significantly it was this experience of rock bottom that became the turning point for the women and once experienced, women sought help and a diagnosis, which
placed them on the path to recovery. Meeting other sufferers of PND or generic forms of depression were cited as a turning point, as was being diagnosed with PND. On reaching rock bottom, women identified how the associated hopelessness and total despair caused them to seek help and treatment in alternative forms. Once treatment started, feelings of loneliness and isolation abated and panic attacks ceased. Surprisingly, all women indicated that their experience with PND was a learning curve and all agreed that as an illness, it is an enigma with long-term effects. Essentially, PND was a part of the women’s life and living with the illness was difficult. Ironically as a result of their lived experiences of the illness, women generally gained a new perspective on life and viewed life from a more positive domain. Their experiences facilitated recognition and realisation of what happiness really is.


Discussion

The study set out to explore women’s experiences of PND. For the women in this study the birth of their baby was a major life-changing event, which brought about a new pattern of life for the whole family. New mothers all over the world are influenced by public expectations, prescribed roles, social, political, economic, cultural constraints and circumstances (Murphy-Lawless and Kennedy, 2002). Parallel to these influences, women have to cope with private, biological, emotional, physical and psychological experiences of pregnancy, childbirth, motherhood and general life events.

The themes from this research represent the inner dialogue that each woman experienced as a result of her transition to the uncertain world of motherhood.
Suffering, adapting to and living with the sense of loss and the uncertainty of the unknown outcome became everyday life experiences for these women. Motherhood brought a loss of their former self that resulted in these women experiencing a deep grief reaction, exhibited by their emotions and behaviours experienced by these women.


Self-conceptualisation

Self is conceptualised as a culturally and socially constructed entity (Forrest, 1993; Fry and Nguyen, 1996; Markus and Kitayama, 2001,). In western society, self is constructed culturally and emphasis is placed on assertiveness, self-actualisation, personal rights and freedom, autonomy and independence. Self is construed as independent and is regarded as a higher-order construct. In contrast as a social construct, reflective appraisals of others define self to the self (Forrest, 1993). Such appraisals are based on internalised and culturally determined values, norms and expectations, which constitute an individual’s frame of reference for living (Fry and Nguyen, 1996). Self-concept has two elements: self-esteem and self-image. Self-image has an influence on and affects an individual’s social role. The loss of formal self experienced by women in this study was not monolithic. Women experienced loss of self in their interaction with the physical and social environment, as well as in their interpretation of their past and future. More importantly, the study identified three types of loss in relation to self that women are likely to experience postpartum –loss of clear knowledge, loss of self by comparison and loss of self in the eyes of others.

 
Factors inflencing self
 
When a person’s individual identity or one’s self concept is threatened or lost, they experience many feelings and emotions – fear, anger and denial being the strongest.
Searching, anger, guilt, fear and anxiety were key emotions that emerged in this study. A sequel to such emotions was that of loneliness, despair, helplessness and powerlessness. This threat to self-concept contributed further to these women’s sense of loss, resulting in self-loathing, decreased self-esteem andself-confidence.


Loss and grief

Rubin (1984) indicated that over time a transformation evolves in the maternal self during pregnancy, childbirth and into the puerperium. Childbirth requires a change of a known self in a known world for an unknown self in an unknown world (Rubin, 1984). It is postulated that as a result of this experience of loss of former self and subsequent loss of self-concept and self-esteem the women in this study experienced a process of grieving. As a result, grief became the subconscious response evoked by the women. Grief is a normal reaction to overwhelming loss, albeit a reaction in which normal functioning no longer holds (Parkes and Weiss, 1985). Equated to separation anxiety, grief occurs when the severity of a relationship is lost leaving a frightening incomprehensible void (Bowlby, 1979). The process of mourning is not rigid or linear and some authors (Kubler-Ross, 1978; Parkes, 1985; Jones, 1989; Mander, 1994; Keane, 1995; Walsh, 1995) discuss grief in terms of stages or phases indicating that individuals go blithely from one stage or phase to another. All women of the study seemed to experience the five stages of grief as described by Kubler-Ross (1978) denial and isolation, anger, depression and acceptance.


Adapting to grief
 
Grief became the subconscious response evoked by the women. When grieving, a person progresses through two phases – initially there is recognition and psychological
acceptance, which is followed by psychological healing.


Immediate reaction

Immediate reaction is a temporary defence mechanism consisting essentially of delaying tactics, which serve to insulate the suffering person from the unacceptable
reality (Engel, 1961). All women experienced the denial phase. This denial surfaced unconsciously at the very early stages of women’s experiences. This denial functioned as a buffer and allowed the women to collect themselves and with time mobilise other less radical defences (Kubler-Ross, 1978). Denial afforded the women protection from their awful reality and was manifested in a sense of numbness and a state of shock. The women recuperated gradually from this state of being and as the phase of denial disappeared, it was replaced by a growing acceptance of their new lifeworld.


Developing awareness

Awareness gradually manifested and with this came powerful emotions: guilt, anger, rage and resentment.Women questioned this phase: ‘Why me?’ ‘What happened to me?’. They were very angry because their life experiences was so painful.


Realisation
 
Depression is one of the commonest defective disorders, which accompany full realisation (Kubler-Ross, 1978; Parkes, 1985; Jones, 1989). Evidently this sequel became a very real and vivid experience for the women in this study. Depression did not occur as a result of past lost, rather it occurred as a result of loss of one’s former self and a loss of control. Depression brought with it physical and psychological changes such as panic attacks, poor concentration and insomnia. Feelings of incompleteness and great emptiness also accompanied such changes.


Resolution

Resolution or acceptance was the fourth theme to emerge and was illustrated in lived time. This lifeworld was almost void of emotion as the women described their
hopefulness and intentions to make a full recovery from PND. Personal growth and self-development increased the women’s ability to cope. The reconstructed self
allowed individuals to maximise their ability to live, work and socialise. All the women were on a journey of recovery, self-enhancement and self-discovery.


Hope

Davidson and Strauss (1992) suggested that interventions to enhance a person’s sense of self should instil hope and foster positive and realistic appraisals of self and encourage women to build on their existing strengths. In essence for these women recovery only occurred once diagnosis was made and treatment commenced. This resulted in the pain becoming less, negative thoughts abated, self-awareness, self-confidence, self-esteem increased and the women found they could discuss their experiences without experiencing the disabling pain and sadness that had consumed their lives for so long.


Recommendations

This study calls for a review of current antenatal preparation for parenthood and challenges midwives and other health professionals to review commonly accepted beliefs that most women naturally adjust to motherhood.

Comprehensive evidence-based information on PND needs to be given to every mother. This should include a directory of relevant PND services, including consumer and professional support groups.

The harm caused by being labelled, as ‘suffering from PND’ requires serious consideration as it can lead to a delay in women seeking help. The removal of the word ‘depression’ seems to be the key and the following suggestions for new titles are posed:

- ‘Problems in adjusting to motherhood’ (PAM)
- ‘Delayed transition to motherhood’ (DTM).

The authors strongly recommend that the women who have suffered PND be brought together to decide on a new name.


Conclusion
Can this be normal?

The women in this study considered their personal journey through PND to have been ‘a normal birthing experience for them’ as they ‘had to say goodbye to their former self and accept their new self… in the very real lifeworld of motherhood’.

Perhaps giving birth is a metamorphic state?

‘Our babies
Are our immortality, right here
And now. They are also the best
Personal growth experience
available. Anybody who wants to
tread a spiritual pathway that
will hold up a mirror to the
person he or she truly is, need
search no further than having a baby.’

(Chilton, 1946)


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