The impact of postpartum psychosis on partners

The study was given ethical approval from Cardiff University (EC.14.11.11.3914R2A). Participants were recruited through the UK based charity Action on Postpartum Psychosis (APP www.​app-network.​org). Permission to recruit through APP was obtained from the charity’s director and leadership team. An advertisement for the current research, featuring a brief description of the study and call for participants, was posted on the APP forum website, Facebook page, and Twitter feed. The advertisement included a link to more information regarding the study, a consent form, and access to an online questionnaire for partners to complete and to register if they wished to be contacted with more information regarding an interview. To be eligible for the interview the episode of PP was to have occurred more than 6 months ago but less than 10 years ago, to try and limit emotional distress and for recollection purposes. A further consent form was completed in writing immediately prior to an interview about their experiences of PP.

A sample size between 4 to10 is deemed adequate for the completion of IPA [24]. A total of nine partners completed the online questionnaire and agreed to be contacted for an interview, of which eight completed the interview. The ninth partner opted to withdraw from the research prior to an interview being arranged due to their other commitments. The questionnaire data from the ninth participant was subsequently excluded from analysis. All partners who volunteered were male, although the study was open to all couples. The most common age bracket for partners was between 30- to 34-years-old (n = 4), although ages ranged from 30- to 49-years-old. Most partners were married (n = 7), and all noted they were still with the mother (N = 8). The partners’ highest level of educational attainment varied, but the majority had either a master’s degree qualification (n = 4), or an undergraduate degree (n = 3), with only one partner noting no qualifications. All partners were in full-time work (N = 8). In terms of the episode of PP experienced, most involved the admission of the mother to either a psychiatric ward or a MBU (n = 5). The onset of each episode was typically within the first 2 weeks of childbirth (n = 7), with partners reporting the duration of the episode varying between 1 and 3 months to over 1 year.

All of the interviews were completed by the first author (NH) between April and June 2015. Partners were interviewed in their homes (n = 1), via SKYPE (n = 3), or on the telephone (n = 4), based on the participant’s preference. Only one of the eight partners interviewed opted for a face-to-face interview, with most noting that it was easier, and felt more private, for them to complete an interview via a video link or on the telephone. A semi-structured interview design was adopted (Additional file 1). At the start of each interview, the partner was invited to describe their experiences of PP. The subsequent interview schedule was led by the participant, but covered topics relating to partner relationships with the mother and infant, role, decision regarding future pregnancies, and coping and support.

All interviews were audio recorded and subsequently transcribed with all potential identifiers removed. Audio recordings of completed interviews were destroyed once transcription was completed. All data associated with the interviews was stored using awarded pseudonyms.

All interviews were transcribed by NH to help full immersion in the data. A step-by-step procedure for completing IPA outlined by Smith et al. [21] on the lined, numbered interview transcripts was followed (see Table 1).

Respecting the ethos of IPA, analysis of the interview data focused on developing an understanding of the meaning that each partner made of their experience of PP. Both Yardley’s [25] and Elliott, Fischer, and Rennie’s [26] criteria for assessing quality in qualitative research were considered throughout to ensure IPA was completed to a high standard. Yardley’s criteria included exploring: sensitivity to the context, commitment and rigour, transparency and coherence, and the impact and importance of the research. Similarly Elliott et al.’s criteria involved: considering one’s own perspective, situating the sample, providing credibility checks, establishing coherence, accomplishing general and specific research tasks, and ensuring the research resonates with readers. Due to the subjective nature of interpretation, the researcher held an awareness of the different hermeneutic levels involved. The researcher kept a reflexive diary of their experiences at each stage of the research, and any personal or prior experiences that they felt were relevant to reflect upon and bracket during the research process. During the analysis stage the researcher separately noted and bracketed any personal thoughts in order to concentrate on the partner’s own interpretation. After all transcripts had been separately analysed, similarities or differences in themes communicated across partners were identified. The researcher formed an overarching summary depicting a list of superordinate themes across partners. To test coherence and plausibility of the emergent theme structure, the researcher arranged separate meetings with the other research team members, and the charity APP, to discuss the identified themes.

Loss was strongly communicated by partners: from a loss of what was expected in having a child to loss of the couple relationship; physical loss or separation due to hospital admissions; and a feeling that life stops.

You would think that the first time after having a baby you go round obviously showing her off to everybody, and we couldn’t do that purely because [the mother] wasn’t there. (James)

At a lot of times, we would go up to [MBU] in the car and I’d go “who is she”[the mother], and I suppose those were the most difficult times. (Mark)

Essentially, I had gained a child on one day and lost my partner on the next day. (Henry)

…during it all there was no husband and wife relationship, which we had been having you know a week or so before [infant] was born. (Peter)

Partners used quite visceral language to refer to their experience of loss, which emphasised the physical and emotional pain felt due to being separated from the mother and infant.

You can’t get a cuddle, that sort of closeness is ripped apart…I felt I had lost not only my wife but my little one, he was in the MBU. (Ben)

A subordinate theme of trauma emerged due to the perceived threatened loss of the mother through PP. Partners described PP as a traumatic experience, stressing their feelings of loss for both the mother and infant. The grief and sense of abandonment experienced by partners is manifest by the frequent use of the word ‘lost’ across the interviews.

I didn’t recognise her at all… it just wasn’t her, but it was almost like she was kind of possessed. I was just terrified really that she... that I had lost her really. (David)

There were times there where we felt, I felt, that we had lost all of our family, that I wasn’t going to have [the mother]. (Ben)

Partners noted a sense of powerlessness, encompassing a general lack of control and uncertainty stemming from the birth and ongoing throughout the mother’s PP episode. There was a sense of partners not knowing what was wrong, or how to help the mother, or whether the mother would get better.

But I had no control on the situation, no input into it. I was just holding the sick bowl. (Henry)

I didn’t quite know what was going to happen next really. I think even with my mum and dad, because we just didn’t know what was going on. We didn’t know how to treat it. (Ben)

The language that partners used to describe their experiences highlighted their feelings of being overwhelmed, excluded, and the perceived gravity and enormity of their experience.

I don’t think I could have coped much longer… I honestly don’t think I could have survived much longer [without MBU]. (Ben)

Well it was pretty terrifying really. (David)

Most partners described the unexpected and sudden onset of PP, with the mother having had positive pregnancy experiences up until that point. The language used by partners stressed the severity and swift escalation of PP.

…very rapidly. I mean, thinking back at it, it happened within an hour, or hour and half, of [son] being born. (Stuart)

So, it was all a bit… exploding all of a sudden. (John)

Partners also emphasised their sense of exclusion and not being heard by healthcare professionals, further contributing to their feelings of powerlessness.

…as a partner, I wasn’t allowed to know what was happening…(Henry)

Different coping styles were adopted; some partners clearly communicated a unified approach to coping as a couple, whereas for others, coping occurred as a separate and dividing process between the partner and the mother.

…we thought something was wrong but we didn’t know what. (John)

[To the mother] “Look, you have to snap out of things, and if you don’t I’m out of here because I can’t cope with this”. (Henry)

A variety of individualised coping strategies were identified by partners. Some partners focused on practicalities (such as care routines), or pursuing normality, or taking an approach of planning one day at a time. Others had to learn to talk about their emotions, to speak as a couple; and some found dry humour to be helpful. Some partners reported needing their own space (so took the dog for a walk), or found it useful to vent to friends. For others, partners needed to seek out other people who had experienced PP, or search for information on PP. Utilising familiar work-stress management strategies were adopted by some, as was attributing blame (for example, believing that the mother’s birth plan choices resulted in the episode). All partners questioned their ability to cope and sought support, even if that was anonymised support through an online forum. Partners noted it was ‘impossible’ (David) to comprehend how they would have coped without familial support.

The thought of being a father was going to be tough and then you have that on top of it. Your world comes crashing down all around you. Looking back now you kind of think I don’t know how I got through that. (Mark)

Coping often involved partners having to become a ‘specialist’ (Mark) in PP in order to understand what was happening to the mother, and answer questions that healthcare professionals had failed to address. The word ‘specialist’ demonstrated the need to self-educate about the nature and development of PP, to become expert in order for partners to better cope and understand the experience. Furthermore, it implied a lack of communication and information from healthcare professionals, which motivated partners to commence a process of information seeking and assimilation, in order to generate answers to partners’ outstanding queries regarding PP. Partners often referred to needing to research PP but the language that Mark used captured the extent to which partners can adopt information gathering as a means to better cope with their experience.

I’m now a specialist in postpartum psychosis medication involved, because I am one of those people who will research in terms of Google and APP networks and what not. I guess that had been my idea of finding out what is actually going on. (Mark)

Issues that partners highlighted encountering when trying to cope included: having to compromise their values; having no opportunity to vent their emotions and to prioritise the mother’s needs; and continuing to question the mother’s behaviour (including her humour or signs of energy) after recovery for fear the mother was becoming unwell again.

She had to stop breastfeeding which she didn’t want to do… (Ben)

…I analyse our conversations more than I should really. (James)

Partners although praising the support provided by families, also reported the difficulties in setting boundaries for extended family involvement in providing care.

I think it strained… because the in-laws came and lived over at the house for a bit and helped out quite a bit. Which was good but hard to tell them to back off. (John)

Partners noted that generally they were not offered any support from healthcare professionals, and when it was offered struggled to understand the nature of the support and failed to believe any reassurances given.

I didn’t know what sort of support I needed. In fact I would say they didn’t help… I was completely lost as to what a social worker does and what benefit it was to me. (Henry)

…I thought she [nurse] was trying to comfort me rather than it actually being true…it was pretty hard, impossible to believe really at the time. (David)

Partners typically developed a specific theory about what they felt may have triggered the mother’s episode of PP. These hypothesised triggers differed across partners and included postnatal difficulties such as poor sleep, exhaustion, pressures or problems breastfeeding, and pressures relating to feeling unable to following a child rearing book. Other hypothesised triggers related to the birthing experience, such as, experiencing a difficult labour, unexpected changes to the birth plan, and or developing a sense of loss of control during the birthing process. Physiological changes due to labour were also considered by partners to be potential triggers, such as hormonal changes and anaemia.

Finally, delays in appropriate treatment were considered as significant in the further development of symptoms, for example, delayed access to appropriate perinatal mental health services and mothers being prescribed antidepressant medication which appeared to worsen symptoms. The benefit of reflection was remarked upon, especially as a couple, in making sense of their experiences. James reflected upon their infant as ‘this little person’, highlighting the sense of reality, responsibility and vulnerability faced by partners in trying to adequately meet their infants’ care needs in the context of also trying to care for the mother.

…we feel that the sleeplessness was very much a big thing… we have actually got this little person to look after…. (James)

Partners also communicated feelings of guilt and regret, often commenting on things they felt they ‘should have’ done.

…there is a huge amount of guilt I felt that I had pushed her into going out and things like that… because I’d been told to. But actually that didn’t help her at all and I felt masses amount of guilt. (Ben)

I suppose just feeling negative… that I let [the mother] down, when I should have been…[partner paused]. (Stuart)

…I probably felt if anything guilty that I wasn’t there in the Unit. (David)

A final regret reported by partners was that of not being provided with information to make an informed decision as to whether to have a second child, and thus opting not to.

…it would have changed my mind, having read other stories, evidence and stuff, I think we would have been in a better position to do that [decision to not have a second child]. (Ben)

Partners identified barriers to accessing care for the mother. These included healthcare professionals failing to accurately identify what was wrong with the mother due to poor understanding, the lack of empathy from primary care services, and the lack of consistency in care and communication between healthcare professionals.

…[GP] just told [the mother] to go and have a bath, try and chill out for a bit, and take some natural sleeping remedies and you’ll be fine…that’s another day or two down the line and we tried that and she just got worse and worse and worse. (James)

…people in the healthcare profession, they could have helped more, and got to get us support sooner, that is at the centre of everything. (Stuart)

…the locum at the end was “you’ll have to try harder than that to kill yourself”, and I could have disappeared I was so angry. (Ben)

Partners described not being heard, either individually or as a couple, by healthcare professionals, and if they were listened to then it was only after the mother had reached crisis point. For most partners, no enquiry was made by healthcare professionals to the partner’s own needs and no support offered.

…when the medical teams would be coming around and I would be talking to them, and thinking back, ignoring every single word I said…From the typical bloke perspective it was just kind of assumed by everyone that everything would be okay. There was never much discussion, even from family, but certainly not from any of the medical services, as to how I was, what concerns did I have. I was very much left to feel that you have got to cope… [this interview] …is probably the first time I actually had the opportunity to express it because going right back to day one no one ever really asks. (Peter)

Partners advocated that some changes need to happen, for instance: increasing the number of local MBUs, having noted them to be a ‘lifesaver’ (Mark); raising awareness of PP among primary care staff; educating partners about PP and increasing the support offered to them; and helping couples to be aware of PP and feel prepared for it, as this had helped some partners following later pregnancies.

The whole MBU staff was fantastic because they know it, and I think, at that point that was the first thing I’d heard of postpartum psychosis. (Ben)

…those places [MBU] are a lifesaver, because if you are not in that specialism no one else can really understand. (Mark)

Partners commented on the conflict between their many new roles and meeting the care needs of their family, particularly in the context of trying to maintain a job. In order to manage, partners would typically prioritise the mother’s, or infant’s, needs above their own, and would often then have to prioritise whether to care for the mother or their infant.

…I still had to work, there was no one who could cover my job, and look after a newborn, not getting much sleep, my wife is potentially on suicide watch, and being watched 24/7…There wasn’t really time to stop and think how am I feeling because there was no choice but to deal with everything. (Peter)

…I felt I struggled to sleep, because I wanted to make sure that she was sleeping and that put me on edge and I felt very agitated myself. (James)

Partners noted a shift in their couple relationship. David’s quote signified a shift in the partner's role within the couple relationship, from one of mutual supporter to that of protector and carer. The perceived vulnerability of the mothers by partners altered the relationship dynamic, and for some resulted in adopting a modified, non-egalitarian and paternalistic communication style.

…it was almost like speaking to a child I guess in a way… (David)

The majority of partners detailed a number of personal positive changes that had occurred due to PP, including increasing partners’ own empathy and understanding towards mental health issues in general.

…it gave us an empathy, not even with PP… people going through depression… I was probably being a bloke’s bloke beforehand in terms of thinking about people with depression. “Just snap out of it” type, sort of thing. (Ben)

I think I am far more aware of how [the mother], or how I perceive [the mother] to be feeling, so even without her saying anything I will find myself second-guessing how I think she is feeling… (Peter)

Furthermore, there was recognition for MBUs assistance in establishing a care routine for their infant.

…If there was any silver lining to be had out of this whole story, it was that the Mother and Baby Unit taught you how to look after a little one. (Ben)

Positive changes to the couple relationship were also noted by some partners. Following the episode of PP, some couple relationships had reportedly strengthened and became more supportive. Moreover, partners had experienced more time to bond with their infant, and had concentrated on redressing their work-life priorities.

I’ve always said that it has got better. It’s got stronger, that sounds really odd… I always say that we are actually stronger for it. These things make you feel stronger, I guess…My focus used to be very different. I used to be quite career driven… whereas now I’m like it’s just get through the day, get home. I use to work 90% of this time. Whereas now I’m out the door at one minute past five. (Mark)

…we are both very supportive of each other in life… when one seems exhausted and drained then we give each other a break, but then we kind of more sympathetic than before. (David)