Mothers' memories: an approach to maternal mental health

La memoria de las madres: una aproximación a la salud mental materna

Psychological distress in women who are mothers is a serious public health concern that greatly affects the physical, social, and emotional development of their babies. Often, mothers with mental health issues do not receive the care they require, not only because of the persistent social stigma associated with mental illness, but also due to a lack of resources.

From the perspective of our perinatal and child-rearing psychiatry practice, and based on the available literature, we reflect on the care received by those women, who are now mothers, during their own childhoods and its impact on how they currently experience motherhood.

Early attachments have a deep impact on both memory and behavior throughout our lifetimes. When they become mothers, women may update their own childcare experiences, a phenomenon known as “psychic transparency” and mobilize the lessons they received as infants about relationships, care, and emotional regulation. The anxiety and frustration faced by mothers today seem to arise, partially, from the conflict between the parenting style they want to offer their babies (warm and conscious) and the one they received at a time when prevailing theories discouraged breastfeeding and skin-to-skin contact.

Taking care of mothers’ emotional states and supporting their relationship with their babies is a necessary and urgent public health measure, which has intergenerational repercussions in mental health.

El malestar psicológico de las mujeres que son madres es un grave problema de salud pública que perjudica el desarrollo físico, social y emocional de sus bebés. Con frecuencia, las madres con problemas de salud mental no reciben la atención que necesitan, tanto por el estigma social que aún existe, como por la escasez de recursos.

Desde la experiencia de una consulta de psiquiatría perinatal y de apoyo a la crianza, y con base en la literatura científica, el presente trabajo reflexiona sobre los cuidados que las mujeres que ahora son madres recibieron en la infancia y su repercusión en sus experiencias en la maternidad.

Los primeros vínculos afectivos influyen decisivamente en la memoria y las conductas de cualquier individuo a lo largo de su vida. Al convertirse en madres, las mujeres pueden actualizar sus propias experiencias de cuidado infantil (fenómeno denominado “transparencia psíquica”) y movilizan los aprendizajes que recibieron cuando eran bebés sobre las relaciones, los cuidados y la regulación emocional. La ansiedad y la frustración de las madres de hoy parecen surgir, en parte, del conflicto entre el estilo de crianza que quieren ofrecer a sus bebés (cálido y consciente) y el que ellas recibieron en una época en la que las teorías predominantes desincentivaban la lactancia y el contacto piel con piel. Cuidar los estados emocionales de las madres de ahora y apoyar su relación con sus bebés es una medida de salud pública necesaria y urgente, con repercusiones intergeneracionales en salud mental.

reflection

Rocío Paricio-del Castillo1,2

1 Universidad Rey Juan Carlos - Doctoral School - Madrid - Spain.

2 Hospital Universitario Puerta de Hierro de Majadahonda - Child and Adolescent Psychiatry Unit - Madrid - Spain.

Open access

Received: 13/12/2022

Accepted: 14/09/2023

Corresponding author: Rocío Paricio del Castillo. Unidad de Psiquiatría Infanto-Juvenil, Hospital Universitario Puerta de Hierro de Majadahonda. Madrid. España. Email: rocio.paricio@salud.madrid.org.

Keywords: Mental Health; Perinatal Care; Child Rearing; Mother-Child Relations (MeSH).

Palabras clave: Salud mental; Atención perinatal; Crianza del niño; Relaciones madre-hijo (DeCS).

How to cite: Paricio-del Castillo R. The mother’s memories: an approximation to maternal mental health. Rev. Fac. Med. 2024;72(1):e106328. English. doi: https://doi.org/10.15446/revfacmed.v72n1.106328.

Cómo citar: Paricio-del Castillo R. [La memoria de las madres: una aproximación a la salud mental materna]. Rev. Fac. Med. 2024;72(1):e106328. English. doi: https://doi.org/10.15446/revfacmed.v72n1.106328.

Copyright: Copyright: ©2024 Universidad Nacional de Colombia. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, as long as the original author and source are credited.

Abstract

Resumen

Introduction: Why are mothers suffering?

Psychological distress in women who have become mothers is a serious public health concern. Several studies have confirmed the existence of significant symptoms of psychological distress and mental disorders during pregnancy, postpartum period, and early rearing.1-5 Likewise, there is scientific evidence indicating that the presence of anxiety and depression symptoms during pregnancy and the postpartum period negatively affects the mother-baby bonding process.6 Thus, psychological distress in mothers reduces their maternal sensitivity and can impair the establishment of a healthy bond with their babies, which is necessary for their physical, social, and emotional development.

There is now ample scientific evidence of the deleterious impact of maternal affective distress on child development.7-10 Therefore, interventions in perinatal mental health and during the child-rearing period have a double implication since they not only treat the mothers’ conditions, but also aim to prevent potential complications in the development of the children.11 In this regard, it has been established that care-based assistance to women in the processes of pregnancy, childbirth and postpartum, as well as parenting support, reduce the occurrence of psychological distress symptoms and contribute to better infant development.12

Mental healthcare for women during their reproductive processes and in their role as mothers is a right that health systems must guarantee.13 Consequently, voices questioning the social idealization of motherhood have increased, thus raising awareness of reactions such as grief, anxiety, sadness, anger and guilt that are inherent to the maternal experience. From this perspective, the greater frequency of use of mental health services by women going through the processes of pregnancy and child-rearing should be viewed positively, as this is considered a desirable consequence of this social awareness that is enabling mothers to break the taboo on the expression of their feelings of discomfort.14

However, mothers in need often lack support to alleviate their suffering during the postpartum period and throughout child-rearing, especially during early childhood, either because of the social difficulties involved in breaking with the ideal of a happy motherhood, or, in some countries, because of a lack of access to mental health resources.15,16 In Spain, for example, pregnant women and women in the immediate postpartum period are assisted by the public health system and have access to basic knowledge about healthy parenting, but this care does not routinely include the identification and intervention of mental health problems, nor does it continue throughout the upbringing of their children.17

This deficit in maternal mental healthcare has persisted even though the magnitude of maternal psychological distress at the population level is alarming, with an estimated 1 in 5 women worldwide experiencing a mental health condition during pregnancy or in the year following childbirth.18 Thus, mothers who have had their pregnancies and postpartum period monitored by healthcare systems, have received adequate information, and wish to opt for a parenting approach that considers their babies’ needs, such as breastfeeding and skin-to-skin contact, find that there are doubts, conflicting emotions, and anxieties that they had not contemplated and that cause them suffering when it comes to the relationship with their child.19 Given the circumstances, it is necessary to prioritize comprehensive maternal healthcare, as it is a key strategy recommended by the World Health Organization (WHO) to enhance early childhood development.20

Recent WHO recommendations stress that maternal mental health should not be addressed by specialized mental health services (except in severe cases), but through comprehensive care involving pediatric and maternity services.19,20 In order to achieve an accurate identification and intervention in maternal mental health, it is critical that health professionals who care for women who have become mothers or are involved in child-rearing receive training about the common psychological processes observed in these stages, as well as those that may be pathological.

An increasing amount of scientific evidence about the negative impact of maternal distress on child development is leading to a significant shift in the healthcare system, as not only are psychosocial interventions aimed at addressing the mother-baby relationship in their current interactions becoming more common, but the importance of adopting an intergenerational perspective is also becoming stronger, as it is recognized that the mother-baby interaction is a reflection of the mother’s early experiences with her caregivers.21

In this context, the objective of the present work was to reflect on the care that women who are now mothers received during their childhood and its impact on their current experiences in motherhood, in order to promote mental healthcare for women who are mothers, particularly first-time mothers. In this scenario, there is an opportunity to open a space for reflection in which the following questions can be discussed: what are the implicit learning and unconscious memories that mothers encounter upon the arrival of their babies; how were the women who are now mothers cared for; can anyone learn to take loving care of a baby by reading books and taking courses; and what can health professionals do to help mothers with the limited space and time available in the consultation room?

This reflection was carried out in the context of the care services provided in a perinatal psychiatry and parenting support practice, and based on the existing scientific literature, both in classic books by perinatal and maternal mental health theorists (such as Daniel Stern or Raphael-Leff), as well as WHO clinical guidelines and scientific publications on the subject narratively reviewed in Medline.

Development

The paradox of childhood amnesia and mothers’ memories

A fundamental question of human beings is their origin as a species and as individuals. If an adult asks their mother, or the people who raised them, about the first stage of their life, these people will quickly try to fill in the gaps with their own memories of that baby. But these memories are infused with their perceptions and will be far removed from the experiences that the baby actually had. These accounts will describe how they experienced their relationship with the baby: “you were a crybaby”, “you slept very little”, “you were a big eater”, but their subjective image of the baby who was the person who is now an adult will be alien to them, at least to some degree.

The narrative that caregivers tell about the baby is critical as it forms the basis for the development of self-image, as pointed out by Raphael-Leff,22 who suggests that the unconscious stories of the body are expressed during pregnancy and motherhood. The influence of these narratives is so long-lasting that it may even reach the offspring of that baby. A typical example encountered in the perinatal mental health consultation is the mother who feels overwhelmed by her baby’s demands and refers that it was to be expected from her child because “she herself, as a baby, also cried a lot and was never at ease”.

This message, conveyed by her own mother, is accepted as part of her biographical history and will also be transmitted to her baby, who will probably replicate this identity trait in adulthood (“I was a difficult baby, who cried a lot”) without questioning whether, perhaps, the imbalance was due to the social expectations about babies, or to the ability of mothers and fathers to tolerate and meet their children’s demands. As will be discussed below, this is not a minor issue because many of the difficulties we encounter in our relationship with our children were also experienced by our parents with us.

The personal answer to “where did I come from?” is lost due to infantile amnesia, because of the inability of human beings to remember their early childhood experiences. Scientific evidence shows that this period (of which we lack conscious memories) has a great repercussion throughout our lives since, as established by Li et al.,23 events in the early stages of childhood have a decisive impact on human behavior and on the risk of suffering physical, social, and emotional problems in adulthood. As a result, it is surprising how childhood experiences, which are quickly forgotten (or, rather, cannot be consolidated as long-term declarative memory) exert such a crucial and long-lasting influence. This influence of childhood experiences, which are not declaratively remembered but continue to affect a wide variety of behaviors throughout life, is referred to by some authors as “memory trace”.24,25

Although childhood amnesia is a universal phenomenon, the amount of conscious memories of early childhood that adults can access varies widely. In this regard, it has been stated that the attachment style established by the child is one of the most relevant factors that could influence these differences. Thus, while early childhood amnesia is universal, studies suggest that the quality of the bond between infants and their caregivers in the early stages of life is directly related to the earliness and amount of autobiographical memory (after the age of three) that can be consciously retrieved by these children in adulthood.26 It has also been reported that there may be differences in the bond established between the infant and its mother or father.25,27 These findings correlate with what has been reported in attachment studies, which have pointed out that securely attached adults have a greater number and variety of memories of their childhood.26,28,29

The mystery of infantile amnesia

Several theories have attempted to explain infantile amnesia, one of the most widely accepted being the biological theory of the immaturity of the central nervous system in infants, which states that memories cannot be stored and subsequently retrieved by the usual cognitive pathways. In turn, psychological theories, which are also based on developmental processes, argue that the ability to establish a declarative memory is related to the development of language and the theory of mind; therefore, there would be a direct relationship between language and memory, in such a way that children cannot encode experiences and access them in the form of specific episodic memories until they are able to conceptualize knowledge by means of words.28,30

The early affective bonds between caregivers and infants have a decisive influence on the establishment of the long-term memories that adults retain of their own childhood.26,29 Similarly, memory traces associated with adversity in family relationships have a deep impact on health-related outcomes later in life.30 Accordingly, there is evidence linking adverse childhood experiences to a wide range of mental and physical health problems across the lifespan.31

Retrieving information about previous experiences and the strategies that were used to cope with those experiences is one of the basic mechanisms of learning and survival. So, it is not surprising that, upon becoming mothers, women update their own caregiving experiences by mobilizing all the implicit learning they received, as infants, about presence, affection, and emotional regulation.

The retrieval of early childhood memories by pregnant women or new mothers is a frequently observed phenomenon in perinatal mental health practice. This motherly attribute has been called “psychic transparency” and refers to a specific mental state of pregnant women characterized by a high emotional sensitivity and in which the re-experiencing and reactivation of early childhood conflicts frequently occurs.32 In other words, the experiences that mothers had as infants will influence their own approach to motherhood and their performance as mothers. In this regard, in 1975, Fraiberg et al.33 published an article entitled Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships, in which they talked about undesirable “intruders” from the mothers’ past, understood as adverse early experiences, traumas or tragedies, that may make their appearance in the relationship with their children.

Memory, attachment, and mother-baby bond

As stated by Stern34 when explaining his model of the motherhood constellation, in the interaction with her child, the mother enters into a process of re-memorization and identification with her own parental figures. This occurs because adults tend to care for their infants in the same way they were cared for, promoting an intergenerational transmission of attachment.35 Therefore, the repertoire of responses that a mother has towards her child has repercussions on the primary attachment style that the child will develop, and this repertoire, in turn, will be modulated by the mother’s adult attachment style, which was initially built in her own primary relationship with her caregiving figures.

Maternal skills involved in parenting, which are modulated by the mother’s early experiences, include the ability to detect the infant’s nonverbal cues (crying, gestures, vocalizations, etc.), make an appropriate reading of them, and respond to them consistently. This has to be repeated over and over again throughout the day and continuously, since babies lack the capacity for self-regulation and require the constant presence of a caring figure who keeps an eye on their needs at all times. However, the complexity of parenting as such is even deeper if we consider the needs of mothers who are recovering physically and psychologically from the puerperium, adapting to their new role and, often, dealing with added social demands such as a quick return to work, the early removal of the traces of pregnancy from their bodies, or the multiple social judgments about individual parenting decisions.

In Spain, according to the National Institute of Statistics,36 in 2021 the average age of first-time mothers was 32 years and women who are currently having children were born in the 1980s and 1990s, when hospital protocols for childbirth care in the country were contrary to the current health recommendations proposed by the WHO. During that period, various practices were prevalent, including the separation of mothers and babies after birth, moving babies to designated rooms with cribs under the supervision of healthcare professionals while mothers were kept under routine postpartum hospital observation, promoting scheduled artificial breastfeeding, and even carrying out unreasonable actions on the babies’ bodies that would now be regarded as violent practices (such as “slapping” to stimulate breathing, inducing crying, or inserting probes through the nose and anus to assess permeability and remove secretions).37 Moreover, following the hospitalization, health guidelines strongly encouraged mothers and fathers to ignore their babies’ cries and emphasized the advantages of using formula milk.37

The experiences surrounding childbirth itself influence the emotional and behavioral responses of the mother during childbirth.38 Thus, women’s looking back at themselves as babies allows them to reinterpret their psychic discomfort and promotes sensitivity towards their own children. This introspection helps them to reflect on the origin of their emotional reactions to their babies’ needs and creates an opportunity for change that encourages the construction of a healthy bond with their children. This, as Lieberman et al.39 note, would aim to encourage “angels in the nursery” (in contrast to the “ghosts” described by Fraiberg et al.),33which means promoting nurturing and loving experiences between mothers and children in order to break the intergenerational transmission of traumatic experiences.

In addition to their preventive role in promoting infant health, interventions during the early stages of parenting have a significant therapeutic value for mothers, as the recurrence of early childhood traumas and conflicts, while painful, offers unexpected possibilities for processing and healing.40 Therefore, in the practice of perinatal mental healthcare and parenting support, it is common to see a rapid improvement in women with a high burden of suffering by re-signifying and validating their experiences.

Mother’s discomfort and infant care

A very common experience among mothers seeking care in perinatal psychiatry or parenting support clinics is the presence of ambivalence towards infant care. Specifically, breastfeeding is a frequent source of conflict.

Clinical experience allows us to hypothesize that mothers who were not breastfed as infants have more difficulties in initiating breastfeeding with their babies. Occasionally, mothers’ emotional distress manifests as severe breast pain or mastalgia without an inflammatory biological explanation. Thus, pediatric and gynecology staff should consider the need for providing psychological support to mothers experiencing breastfeeding difficulties who do not respond to conventional community interventions.

Mothers’ anxiety and frustration often arise amidst the conflict between idealized social expectations of how babies should be cared for and their actual needs. A primary factor contributing to the fatigue experienced by both parents and guardians during the first year of their children’s lives is the infants’ sleep pattern and the associated challenges it entails. The schedules and productivity of adults, particularly those who resume their work activity early, are not compatible with the sleep patterns of babies, which often involve recurrent awakenings.41 Apart from the negative effects of sleep deprivation, mothers are frequently faced with conflicting advice regarding strategies for getting their children to sleep.

Furthermore, the narrative review conducted for the preparation of this reflection also shows that today’s Spanish mothers were brought up with a significant social stigma surrounding breastfeeding on demand and co-sleeping.42,43 The behaviorist current known as the “Estivill method”, which gained notorious popularity in Spain during the 1990s, recommended systematically ignoring babies’ cries during the night in order to “teach” them to sleep.44 Therefore, these generations grew up with the belief that their childhood fears of solitude and obscurity were not only unworthy of attention, but should also not be expressed, since crying and seeking companionship were seen as an attempt to exert control over their own parents.

Therapeutic intervention on maternal distress

Based on our experience in the perinatal and child psychiatry practice, it is possible to state that, in the Spanish context, women who are currently mothers question the techniques described above. For example, although there are no official data, Gimeno-Navarro45 reports that over the last 15 years there has been a progressive increase in breastfeeding rates at 3 and 6 months of age, which indicates a change in mentality in this regard. However, mothers often find themselves dealing with doubts and criticisms related to the perceived risk of “spoiling” their babies when they choose to be present during their developmental stages. Interestingly, these doubts and judgments may come from their own mothers, who disapprove of their daughters’ choices in raising their grandchildren.

Women’s anger and irritation in these situations stem from the fact that they may feel that their new role as mothers is being discredited, as has been frequently highlighted. However, their frustration may also originate from their role as daughters connecting with the babies they once were, considering that the critiques made to their own mothers for the care they received —which are painful and partially unfair to women who trusted the advice given by the health authorities— is not usually verbalized, but permeates the tensions between different generations of women. This phenomenon is a result of the fact that as adults, we are impacted by the negative experiences of our childhood and usually we are not able to talk about them because they are in a place of memory devoid of words.46

On the other hand, based on our experience in perinatal psychiatry and early childhood care, it could be said that performing therapeutic interventions aimed at solving the conflicts of new mothers with their own mothers can open spaces for change and healing of painful wounds that, if left untreated, can affect their children. The attachment perspective approach can be a very useful tool in the psychotherapeutic process involving women who are mothers.47 In this sense, most women are able to retrieve memory traces of the first signs of affection that their caregiver figures gave them to the best of their capacities, relying on their acquired knowledge. In fact, modern motherhood provides a place of encounter where adult daughters can meet and reconnect with their maternal figures.48

It is possible to suggest that the present generation of parents may have experienced a lack of affectionate gestures such as hugs, kisses, breastfeeding, warmth, skin-to-skin contact, presence, and quality time in their childhoods, and it is also possible to question these actions without placing any blame on anybody. In fact, recognizing this allows us to look with empathy at those children who were brought up under certain circumstances and contexts and are now taking on the role of parents, giving them the chance to transform themselves in order to forge a stronger connection with their own children.

In conclusion: care for mothers is revolutionary

The question “where do we come from?” should also lead to the question “where are we going?” and to questioning the direction that parenting is expected to take in today’s societies. Caring for mothers and their relationship with their children is a revolutionary stance that has a lasting effect across generations. Therefore, fostering secure bonds with babies in the present day is the most effective way to ensure their overall welfare and optimal growth, protects them from potentially traumatic experiences, and serves as a health prevention measure with a high social impact. To this end, it is essential, firstly, to provide specialized training for psychologists and psychiatrists who focus on parenting, as well as other professionals who work with mothers and infants, and secondly, to ensure the availability of mental health resources within the healthcare services provided to women in the perinatal stage, in pediatric services, and in early childhood care. This would ensure that all mothers and children have access to these resources throughout the child-rearing period.

Understanding the early experiences of women who are now mothers helps to bring about cultural change in child-rearing. As a result, it is possible to promote intergenerational benefits by raising awareness about the importance of caring for people who are now babies, allowing most new mothers to reconnect with their own childhood and relive feelings of tenderness, warmth, and close attention, so that they can fully embrace their motherhood in the most fulfilling manner.

Conflicts of interests

None stated by the author.

Funding

None stated by the author.

Acknowledgments

To the head of the Psychiatry Department of the Hospital Universitario Puerta de Hierro, for promoting and defending the implementation of a specific program for perinatal mental healthcare.

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