Why does the baby hate me?
A therapist specialising in perinatal mental health shares his experiences
Working with distressed new mothers and fathers can fill therapists with deep anxiety for the baby’s welfare, even though the client is the parent. There aren’t enough NHS perinatal psychotherapists to help the 20% of mothers and 10% of fathers who experience perinatal mental ill-health (Public Health England, 2015). So, in private practice, if a prospective or current client is distressed during pregnancy or postnatally, do we try to refer them elsewhere?
This article is an attempt to share some resources and experiences in the hope that these will be of use to other therapists doing perinatal work with adults.
Below I set out some common perinatal issues, some theoretical ideas that inform how I work, and six perinatal situations that help me think about clients’ needs and whether to refer on. There are also two clinical vignettes that are fictional composites of characteristics from many different clients.
Worrying with Mina
Despite her anxieties about Raju, her first baby, Mina seemed to want the role of special protected child herself, and I felt a corresponding parental pull and continually worried for her. Whatever the health visitor told her, Mina was sure Raju was underweight, but, after a few sessions, she told me feeding was getting easier. Then, right at the end of the session, she said: ‘Why don’t I love him?’
The next week she told me, with deep shame, that she didn’t wash Raju’s genitals. She said she didn’t even like to touch his bottom, in case she molested him. I welcomed her honesty and, over several sessions, we shared and eased our intense concern as we worked out together that she felt fear but not desire.
She soon reported finding intimate baby care easier. I said to Raju in his buggy: ‘Even though you’re still getting used to each other, it sounds like Mum’s really helping you.’
The next week, feeling more competent as a mother, Mina took Raju from the buggy and held him for some of the session. But she envied other mother-baby pairs who seemed closer. We explored her own early years – cared for by a childlike mother who, distressed by recent migration, seemed not to allow Mina to be a child. Now a mother herself, perhaps Mina was mourning the ideal childhood she never had, and part of her blamed Raju. I asked if her awareness of those mixed feelings could have planted the fear that she might want to do Raju harm. She was silent for a while, and then said: ‘It wasn’t easy for me or my mum, was it?’
In mourning her childhood and understanding her mother’s limitations, Mina began to forgive her own ambivalence about mothering and, no longer fearing she’d lose or hurt Raju, felt more able to risk loving him.
After 15 sessions Mina said she felt ‘more like a mum now’. Soon afterwards, she felt ready to end therapy.
The perinatal alien
A new parent may say that they feel like an alien, only half-recognisable as the person they were before, or that an alien has developed inside them.
They may be afraid of harming the baby or themselves, or traumatised by the birth, overwhelmed by baby-care responsibilities, panicky at the loss of self, drowned by sadness welling out of their own early experiences of neglect and abuse.
Distressing fantasies can crowd in: ‘The baby hates me’; ‘She is biting/crying deliberately to upset me and if I lose control, I will hurt her’; ‘She would be better off without me.’
Harmful coping methods may emerge, or re-emerge, to help manage the anxiety – OCD, eating disorders, drug use, self-isolation, refusal of parental responsibility. In rare cases, a parent’s ‘solution’ may be suicide, or, rarer still, harming the baby.
Sometimes a parent will spend our early sessions crying in exhaustion, despair and guilt. Or their affect is flat or inappropriate to the circumstances and the baby seems somehow not real in their mind, or not a person. Desperate displays of playing and nappy-changing may embody parental efforts to quieten their own ambivalence or prevent it being noticed.
Dr Amanda Jones, who supervised me in the perinatal service at Goodmayes Hospital, Essex, describes how mother and baby can each experience the other as impervious (Jones 2017). The mother tries to protect herself from a baby she experiences as persecutory, due to her own relational history. The baby tries to avoid the mother’s harsh gaze but consequently is left alone and in distress, simultaneously turning her head away from her mother yet desperate for some kind of contact.
Dr Jones describes a session in which the baby’s inconsolable screaming intensifies the mother’s need to defend herself, with the result that she avoids her baby even more and feels ever-more persecuted (Jones 2017). The mother blames Dr Jones for ‘making’ her continue to hold the screaming baby in the session. But the baby finally falls asleep in her mother’s arms, and subsequently the mother reports that she felt competent enough to stay with the screaming baby later that day at home, rather than shutting her in a room, as she did before.
If a parent can identify the tiniest element of goodness in themselves and the baby, they might be able to risk mutual gaze and connectedness.
Dr Jones taught me to talk to the baby in the parent’s presence. The baby can’t understand the verbal content and might be asleep, but what I say to him or her can help the parent feel understood and strengthen their sense of the baby as a person with whom a communicative, empathic, collaborative relationship is possible.
If a mother is very unforgiving of herself, I might say to the baby: ‘Your mum has had a very tough time, hasn’t she?’ If a father feels he’s failing the baby, I might say: ‘I think Dad is trying really hard to understand what you need.’ It may sound odd, but it can be very helpful for a parent who is able to hear it.
Attuning or rescuing?
‘Good enough’ caregivers mirror a baby’s emotion to show him that his state is understood, and to help him begin to build the security needed for later self-regulation by making it clear, through voice, expression and touch, that they can manage his difficult feelings together (Fonagy et al 2004). A baby can’t learn self-regulation from overwhelmed or intrusive caregivers and may end up relying on dissociation to manage affect. Parents then find it even harder to bond with their dissociated or very dysregulated infant.
Early intervention can prevent long-term harm if the baby can readapt neurobiologically to an improving relational environment. There is a danger that, aware of this and feeling desperate to save the mother and baby from each other, I might push into difficult material too fast and trigger a premature end to therapy. Equally, if I am too fearful of what a distressed parent might do to themselves or their baby between now and the next session, I might miss opportunities to open up the darkest material of hate and despair that the parent really needs to share.
However, if I attune sensitively to the parent’s own pace and emotion, she may internalise the experience and feel better able to offer attuned co-regulation to her baby.
Depending on the severity of the situation, my initial period of intense, usually shared anxiety may ease after two to three months, as the mother begins to trust her own capacity to be with her baby. My anxious awareness of the baby’s physical vulnerability may then be replaced by more positive parental feelings as the parent-infant dyad begins to focus on development rather than fear.
I often emphasise Winnicott’s concept of ‘good enough’ parenting and the value of psychological flexibility rather than rigid control, or expecting the baby, or the therapy, to meet desired developmental milestones ‘on time’ (Winnicott 1953).
About the body
From conception to birth to messy baby care, the body is a central concern in perinatal therapy.
Even if baby and parents are physically healthy, parents’ anxiety about the baby’s health can sometimes dominate. Insights from developmental science can help the therapist – such as Brazelton’s (2006) observation that brief periods of dysregulation may accompany the start of each new developmental stage because the baby is unused to its new self. However, I’m careful not to get pulled into a pseudo-medical role, and instead gently direct the client back to their GP, specialist or midwife for help on topics that are not within psychotherapy’s remit.
Psychologically, though, the body remains at the heart of the work.
Postnatally, all being well, the mother’s embodied psyche recovers a sense of wholeness and the baby’s body becomes – in feeding, washing, dressing, playing – the focus of affectionate collaboration between parent and baby.
But, consciously or unconsciously, parents can experience ambivalence about the baby – rage, fear, panic, fatigue or resentment (Public Health England, 2018; Winnicott, 1994).
Parents of either sex may then fear their power to abuse this helpless intruder, and fear it even more if they experienced abuse themselves. When this fear surfaces, the therapist might veer into active risk-prevention mode, triggering the client’s fear of their baby being taken away. The challenge is to keep the space emotionally safe enough for clarity to emerge. As with Mina, given time and trust, we may arrive at a shared realisation that the client is full of fear, not sexual intent, and the baby is safe.
The perinatal period may also be about a body that is absent. Parents whose first baby has died may struggle to attach to a subsequent child, fearing further catastrophic loss. To love the new baby wholeheartedly may feel like betraying the first child, whose baby clothes are still in the cupboard. So they look after the new baby with detached proficiency, focusing on physical care while emotionally constrained by unresolved grief.
They might need many months of voicing grief, anger and guilt before we can, together, start noticing signs of a more authentic joy in connecting with the new arrival, who is gradually allowed to emerge from her dead sibling’s shadow.
The body of the therapist is also in the room. Gender dynamics relating to the therapist, and to the baby, are specific to the client’s prior experience of being with, or being, male or female. The client has their own history-inflected reasons for choosing a male or female therapist and those reasons are likely to form part of the work.
Alex in control
Alex was newly pregnant at a crucial point in her career, when she was about to go abroad on secondment. She was trying to decide whether to have the baby and hadn’t told her employer she was pregnant.
Initially, in therapy, she talked about growing up in a prosperous, happy household, but she gradually revealed her dislike of her parents’ chaotic lifestyle, and then her father’s violent temper. She described how she used her husband, nannies and an online app to manage her previous baby like clockwork and confirmed my impression that she saw her primary parental role as providing security by routine.
After a few weeks of rationally discussing the pros and cons of a termination, she headed off on her secondment, undecided.
She contacted me again soon after a traumatic birth. Baby Paul (she referred to him only as ‘the baby’) was born with a breathing problem. The medical team had been ‘useless’. Now working from home, Alex couldn’t concentrate because ‘the baby’ needed extra care and frequent hospital appointments. The nanny was ‘feeble’ and husband John was ‘a spare part’. Second babies were ‘supposed to be easier’ and why wasn’t hers?
Initially, I felt like the ‘useless’ medical team – a therapist who was merely part of the problem. But, over time, Alex allowed me to see her vulnerability: the terrifying birth, the unfamiliar helplessness, the baby so ill. She returned often to the thought of abandoning Paul in a car park. She feared she was going mad.
It took a year of appreciating together a life spent protecting herself against vulnerability, against the chaos of her childhood, and gradually understanding how her exoskeleton of control had been shattered by the awfulness of the birth and the baby’s perilous early weeks. Eventually, Alex came to tolerate a messier schedule and shifted from brittle control to more flexible, communicative, ‘good enough’ parenting. She said Paul’s name aloud and showed me a photo of him. She realised that she didn’t want to return to work yet and negotiated a longer absence. I began to feel that she and Paul would be okay.
I use various theoretical lenses for thinking about a parent’s psychological response to the perinatal situation.
One is their historically rooted attachment style and its associated assumptions about self in relationship: contact-avoidant, anxiously contact-seeking, or a ‘disorganised’ mix of towards/away behaviours (Bowlby 1988; Meuti et al 2015). Another is Joan Raphael-Leff’s distinction between two defensive maternal modes: the detached, self-insulating, task-focused ‘Regulator’; and the self-denying ‘Facilitator’, who unrealistically idealises the perinatal experience (Raphael-Leff, 2015).
Parents default to these modes unconsciously to avoid or manage their own ambivalence about the baby and rely on compulsive thinking and overcompensating activity to ward off feelings of resentment, hate, panic, guilt and vulnerability. The baby adapts, with potentially lifelong consequences, to fit the resulting relational environment.
More psychobiologically, neuroscientist Jaak Panksepp proposed ‘affective balancing’ (2012). This aims to stimulate the positive affective systems such as Play, Care and Seeking in order to counterbalance over-sensitised negative systems, which he named Fear, Rage and Panic-Grief (separation anxiety and sadness). Play generates interpersonal joy in shared activity, Care rewards bonding, and the Seeking system rewards exploratory behaviour and discovery, so stimulating the baby’s development.
I add Winnicott’s (1971) and Marks-Tarlow’s (2012) broader concept of play, about the client allowing themselves to explore change, novelty and creativity, stepping outside their default patterns, increasing their psychological flexibility. The client can then allow the developing child more room to explore and interact.
I observe a positive feedback loop between these reward systems. For example, as they become less afraid of self and of their baby, a parent feels able to play with the baby; happy baby feedback then stimulates affection (Care), which helps the baby feel secure enough for exploratory developmental behaviour (Seeking), which may in turn stimulate parental joy and pride, and gradually parental fear can be replaced by confidence.
Some perinatal scenarios
The emotions in this work can easily distract us from a central question: ‘What is the basic psychological situation hindering this parent-infant bond?’ There may be multiple intersecting situations, but one or another tends to be foregrounded initially, and each one brings particular psychological tasks for the client. Here are six of them – I’ve given them names, but they’re not intended as diagnoses.
Unresolved – a parent’s still raw, or re-evoked, dynamics with their own parents, and other unprocessed psychological trauma from the past. Internal conflicts need to be worked through so that the parent can meet the baby for him or herself, not as a representation of the historic bad other, or as an annihilator of the parent’s own sense of self. The core task is to soften historically based relational patterns and fears so that the parent feels it is safe to love the baby. The sense of danger is primarily emotional.
Unrepaired – difficulty bonding with the baby after a traumatic birth. A core task is to recover a feeling of bodily wholeness, reducing the sense of physical peril or the need for dissociation. The birth may have re-evoked previous bodily intrusions, such as a traumatic accident or abuse. A very gentle, empathically relational approach to PTSD is needed, and perhaps some help with coping skills such as grounding and distraction. Alongside anxiety may be sadness or rage and panicky guilt or shame about being unable to bond. These feelings can discourage further conceptions or lead to different treatment of the child that is associated with the trauma.
Unmourned – delayed grieving of infant death, and consequences for subsequent babies. This may combine with aspects of ‘Unrepaired’ and often results in fragmentation of the couple relationship. This is dreadful for the parent, and sometimes complicated by formal medical and legal inquiries. It can be desolating for the therapist too, who may feel hopeless and useless.
Unmodelled – a parent with no experience of consistent empathic care themselves may struggle to relate to their own baby. This situation can feel chaotic and drifting for both client and therapist. The therapeutic relationship attempts to model an empathically contingent responsiveness and clients may be able to internalise this sufficiently to replicate aspects of it with the baby. Therapists can wonder aloud with the parent what the baby might need, or what the baby is trying to communicate. But much primary developmental work is required in the parent. Significant progress may take years and clients may quit therapy prematurely. Integrated multidisciplinary support may help parents provide a more consistent baby-care routine. But sometimes support is insufficient and, sadly, either the more stable partner or the local authority will be given custody of the child.
Unsettled – when current or recent physical conditions make the world feel like a very dangerous place to be caring for a baby (eg poverty, violence, eviction, migration, separation from partner or physical illness). This is a worrying and difficult situation for everyone. We may be liaising with multiple agencies, signposting clients to local sources of help, and communicating via psychologically untrained translators. While therapists can’t solve socio-economic problems or directly prevent violence, sometimes we can help relationally to contain anxiety and offer a protected space to think, feel and make decisions, if only for an hour a week.
Unmoored – clear psychotic behaviour. This is, to me at least, good reason to refer a client to a mother and baby unit (although places are scarce) or other secondary/inpatient care. Far more wrap-around containment is needed than a therapist alone can provide.
Risk and referring on
In private practice, I feel I am working within my competence and safety limits to help with the Unresolved, Unrepaired and Unmourned, although even here there may be higher-risk exceptions where I might refer. The Unmoored, and sometimes the Unmodelled and Unsettled, are situations where I would want NHS or other services to be involved, either instead of me or in addition. There are also various national and local organisations who provide perinatal support and knowledge (for example www.rcgp.org.uk/clinical-and-research/resources/toolkits/perinatal-mental-health-toolkit.aspx).
Severe and enduring mental illness tends to be picked up and actively managed by the GP, existing psychiatrist, midwife, social worker or health visitor. But sudden onset without a known history is possible. Referral options, preferably either initiated by the client or with their consent, depend on the specifics and the level of urgency, and include the GP, local perinatal service, mother and baby unit, A&E liaison psychiatry, 999 and social services.
My assessment process begins with an initial telephone conversation, followed by a 50-minute getting-to-know-you session, during which I’m thinking, and sometimes asking, how this relating feels. Then, there is a 90-minute history-taking session, particularly noting long-term relational patterns. We explore risk, and I specifically ask about, and we reflect together on, any psychiatric history, suicidal ideation, self-harm, addictions, phobias and experience of violence or abuse.
Often the parent prefers to leave the baby with another caregiver during sessions, either to protect the baby or themselves, but psychologically the baby is always in the room, whether before or after the birth. I’ll discuss those protective feelings with the client, and the pros and cons for them of having the baby present. At any age much over six months, a very active baby in the room may make this kind of adult-centred work impractical.
The basic questions I ask myself during non-perinatal adult client assessments in private practice apply equally to perinatal work, but with a slightly wider field of view to include the whole of the baby’s environment. Does this client’s history and presentation suggest that they need more wrap-around or specialist support than I can offer them? Are they able to relate to the baby as a person, or only as a ‘thing’ or a threat? What are the risk factors in the client’s lifestyle or household? Does the client say, if asked, that they feel able to keep self and baby safe? In private practice, I’d tend immediately to refer onwards a perinatal client who reported prior diagnosis of, or presented with, marked indications of psychosis, schizophrenia, bipolar disorder, significant recent self-harm, severe eating disorder, or current substance addiction or domestic violence.
If a prospective perinatal client mentions having had a personality disorder diagnosis, I tend to refer on, although there may be exceptions. Personality disorder diagnoses are contentious but whatever behaviour contributed to the diagnosis is likely also to have consequences for the baby and I’d rather not be trying to manage that risk in private practice. I know not all therapists will feel the same about this, particularly if meagre perinatal service provision in their area means onward referral might not guarantee better care.
Due to space constraints, there are many issues I have not explored here – for example, fertility and assisted conception, adoption, and babies born with disabilities. I might do an assessment for such work, but there are also organisations and therapists who specialise in these areas.
Parents’ ways of managing their own distress can affect their capacity to connect with and care for their baby. Perinatal psychotherapy may help them process historic experiences of intrusion or neglect, so that they can feel safe enough to love and tolerate both self and baby. In lower-risk situations, where the parenting environment is sufficiently stable, a generalist therapist can be, in a pragmatic Winnicottian way, ‘good enough’.
However, unless all parents can access psychotherapeutic care during pregnancy and in the early months after the birth, we will continue to see high numbers of adults coming for therapy to deal with harmful patterns of relating shaped by their own first year of life with distressed parents.
This article originally appeared in the December 2019 issue of Therapy Today published by the British Association for Counselling Psychotherapy.©
Jeremy Carne is an integrative psychotherapist in private practice. He has a longstanding interest in the psychological impact of perinatal distress on parents and babies, and their subsequent relational patterns. He trained at Metanoia Institute. His practice is in West London but during the Covid-19 lockdown he is working online. www.psychotherapistwest.london
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