Motherinfant relationship disorders

Just as the emerging relationship with the fetus is an important prepartum psychological process, so the growth of the mother-infant relationship is a key psychological process in the puerperium. In popular parlance this is often called 'bonding'. The mother-infant and infant-mother relationships are two different things. The infant's attachment comes later, and is usually fully developed after 7 to 8 months. The mother-infant relationship consists essentially of ideas and emotions aroused by the infant, which find their expression in affectionate and protective behaviour. Its immense power is revealed in self-sacrifice, and the pains of separation. The mother's emotional response enables her to maintain a never-ending vigilance, and endure the exhausting toil of the nurture of the newborn.

To progress our understanding, we must define and measure this relationship. Relationships are specific, persistent, and affect-laden psychobehavioural phenomena, whose inner presence is betrayed by external signs—in this case, touching and fondling, kissing, cuddling and comforting, prolonged gazing and smiling, baby talk and cooing, recognizing signals, tolerating demands, and resisting separation. These behaviours are all ambiguous; none are essential. Maternal care is an insufficient criterion, because many mothers feed and care for their babies, while suffering from painful negative feelings. It is hard to select a single activity that lies at the core of the phenomenon. Particular behaviours wax and wane, but the relationship endures, even when the child is absent, even when it is gone for ever.

There is no 'critical period' in the development of the maternal response. Close proximity from the start ('rooming-in') confers confidence in mothering skills. The infant plays an important part in provoking the maternal response. At an early stage, the infant can discriminate speech, and reacts preferentially to the human voice and singing. The baby is programmed to respond to the human face, and can imitate facial expressions. Eye-to-eye contact mediates the interaction with the mother, and gazing becomes an absorbing activity on both sides. The baby's smile is another catalyst. Even before he can babble, videotape studies have shown how the infant contributes to a dialogue with his caregiver.

Sometimes the maternal response is immediate, primed by her prepartum affiliation, but sometimes there is a worrying delay. For the first 3 to 4 weeks many mothers feel bruised, tired, and insecure, and their babies seem strange and distanced. This phase may end when the baby begins to respond socially. Thereafter there is an incremental growth until, by the end of the third month, mothers feel pangs of conscience on leaving their babies.

The term 'mother-infant relationship (or bonding) disorders' covers a spectrum of clinical states, including the following.

• Lack of emotional response The mother experiences a disappointing absence of feelings for her infant, sometimes accompanied by a feeling of estrangement—the baby does not seem to be her own.

• Rejection of the infant The mother regrets the pregnancy and expresses hostility to the baby. She may try to persuade her own mother, or another relative to take over, may demand that the infant is fostered or adopted. Some mothers try to escape, leaving home for long periods or repeatedly. The most poignant manifestation is the secret wish that the baby 'disappear'—be stolen, or die.

• Pathological anger The infant's demands make the mother feel tense and angry, and provoke aggressive impulses, which may lead to avoidance, neglect, and assaults.

These disorders are common in mothers referred for psychiatric help, for example 22 per cent of postpartum referrals and 29 per cent of those presenting with 'postnatal depression'/34 Their treatment forms an important part of the work of peripartum mental health teams. It is these disorders, rather than uncomplicated depression, that are likely to have long-term effects on the child's behaviour, mood, and cognitive development. The mother experiences extreme guilt, and may be exposed to criticism. Family relationships deteriorate. Such situations can lead to severe, prolonged, and irreconcilable conflicts.

These disorders are usually accompanied by depression, which may be primary; indeed mothers may lose an established 'bond' for the duration of an intercurrent depression. In other cases, the bonding disorder seems primary, because it precedes the depression, is relatively severe, and the mother feels better, even normal, when separated from her infant. In these cases, successful treatment of the bonding disorder simultaneously cures the depression.

Diagnosis

To establish the diagnosis, an interview is often sufficient, but inpatient observation yields valuable information. Each member of the multidisciplinary team contributes: the psychiatrist assesses depression, morbid ideas, and aggressive impulses; the social worker assesses family and network support; the nursery nurse and/or paediatrician assesses the baby; psychiatric nurses make the crucial observations of maternal behaviour. It is useful to keep a shift-by-shift record of salient incidents, reporting the mother's statements about the baby, her competence and skill, her affectionate behaviour, and her response to crises. Structured home observations, audiotapes to analyse speech, videotapes to study mother-infant interaction and ethological techniques (timing and counting behaviours in the natural setting) have all been employed for research purposes.

Treatment

The treatment proceeds in stages.

• Where there is a delay in the maternal emotional response, an explanation and reassurance are often sufficient.

• When hostility and rejection are prominent, the primary decision is whether to attempt treatment at all. The mother must be given freedom of choice; it is dangerous for her to feel trapped in a tunnel of unwelcome motherhood. At the same time, the father has his rights. The option of relinquishing the infant must be openly acknowledged, and fully discussed with both parents.

• If it is decided to embark on treatment (as in most cases), depression should be treated with psychotherapy, drugs, or (occasionally) electroconvulsive therapy.

• The specific element of therapy is working on the dyadic relationship. This relationship does not differ radically from others, which grow through shared pleasure. The baby alone has the power to awaken its mother's feelings. Therefore the aim and essence of treatment is to create the circumstances in which mother and child can enjoy each other. It is a mistake to separate the mother and baby completely; this merely compounds the problem by adding an element of avoidance. If there is any hint of abuse or aggressive impulses, the mother must never be left alone with her infant. She must be relieved of irksome burdens of infant care. When mother and baby are both calm, she must be encouraged and helped to interact with him—to cuddle, talk to him, play, and bring out his smile and laughter. Participant play therapy and baby massage may assist.

• A panel of recovered mothers, who can instil hope in those still in trouble, is an important resource.

Treatment can take place in various settings. Home treatment can be successful, provided there is enough support to relieve the mother of night care and stressful duties. Sometimes, the maternal grandmother is able and willing to take on this role. An understanding husband, or a family group, can do the same. Day-hospital treatment can provide individual support and group discussion, as well as specific therapies. With the most severe and refractory cases, the proper setting is an inpatient mother-and-baby unit, where an experienced team of psychiatric and nursery nurses, available 24 h a day and 7 days a week, can provide full support. Even in the most severe cases, one can feel optimistic about a successful outcome. (For further information about child abuse see ChagteLQJJ...)

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