Diana Skibniewski-Woods appraises the evidence on how mothers can cope with perinatal mental health problems.
Diana Skibniewski-Woods, SCPHN health visitor, currently undertaking a research PhD in health science at Swansea University.
- This integrative literature review critically appraised 26 papers on the subject matter. Search terms were mothers; mothers and mental health; mothers mental health and coping; and defences of the ego.
- Fifteen papers were included in the review.
- The review concluded that the understanding of coping and resilience is multi-dimensional.
- Individuals directly interact within multiple settings: family, school, neighbour-hood; friends, work and local industry; and social, cultural and histori-cal influences.
- Life course perspectives of coping are important; personal experiences of sup-portive relationships plainly affect individuals´ ability to perceive offered support as constructive or helpful.
- Parenthood can bring with it strength, skills and social resources; the under-standing of parenthood as enabling, particularly in terms of mental health and recovery, is significant.
- The sense of normality that children can provide, together with the opportunity for loving and meaningful relationships, can give meaning and focus outside mental illness.
An integrative review was undertaken using systematic methodology into current research into coping as a phenomenon. This review highlights the multidimensional understanding of coping and resilience. Individuals are encased by multiple settings in which the individual directly interacts, including family, school, neighbourhood; friends, work, local industry; and social, cultural and historical influences. There is an importance in life course perspectives of coping; the personal experiences of supportive relationships plainly affect the ability of individuals to perceive support offered as constructive or helpful. There is potential for parenthood to bring with it strength, skills and social resources; the understanding of parenthood as enabling particularly in terms of mental health and recovery is significant. The prevalence of studies that are situationally specific and culturally based indicates a gap in the literature. There is a lack of literature on mothers and mental health and how they cope on an everyday basis, which supports the need for research in this area.
Keywords: motherhood, mental illness, coping, resilience, attachment.
This review is part of a wider research study into the coping mechanisms of mothers who have experienced mental health difficulties. A background review into motherhood and mental illness was carried out. Following this, an integrative review into the current litera-ture on coping as a phenomenon was carried out.
An integrative review of the literature was completed in order to locate, appraise and syn-thesise the available evidence on the research question: What is the current literature on coping as a phenomenon, with particular reference to mothering with a mental illness?
Systematic review methodology steps were followed in accordance with Boland et al (2017) – see Table 1. The data is presented using narrative integration, discussing the data rather than undertaking statistical analysis as there is heterogeneity between studies that precludes meta-analysis (Coughlan et al, 2013).
Becoming a mother
Many mothers may feel that they just muddle through, juggling a job, home and motherhood. A common complaint in our modern age is that women are expected to work as if they have no fami-ly commitments and parent as if they have no work commitments. A mother who has given up her morning shower and her lunch for her baby, when asked what she has done that day will probably say ‘nothing’; in reality, she has been devoting her time and energy to mothering her baby. Moth-ering is exacting – how mothers comfort their infants is an extremely complex skill involving high levels of emotional competence, but may be considered to be taken for granted in today’s society (Stadlen, 2004).
Motherhood and mental illness
There is an increased risk of mental ill health in the first year following the birth of a baby (see Ta-ble 2), amounting to 13% to 20% of women suffering from psychological problems during this pe-riod (Monteiro et al, 2018). However, this excludes pre-existing severe mental illness including bipolar disorder, schizophrenia, obsessive-compulsive disorder, eating disorders and personality disorders (Viveiros and Darling, 2018).
Parents with mental illness can experience particular stresses and strains, including stigma; inse-curity in the parenting role; concern over how to explain illness to children; difficulties managing the demands of parenting and mental illness; fear of losing friendship with children; and difficulties implementing boundaries and discipline (Shor et al, 2015).
Coping theory has evolved through much of the past century and the question of how coping as a phenomenon supports mental health is of interest and importance for practitioners who are supporting mothers and families. As individuals who experience stress, we engage in coping. Coping may not be able to terminate stress, but rather can often manage it by tolerating it or accepting the distress (Lazarus, 1999). Coping is a transactional process; it assesses the situation, appraises risk and determines behaviour (Folkman, 2011). Coping processes have the potential to sustain well-being, promote resilience and regulate distress (Folkman, 2011).
Heidegger (1953) explains the term ‘phenomenon’ as meaning ‘something that can be encountered’ or in a direct translation from the Greek ‘to show itself’ (p27). It was considered that examining coping as a phenomenon was valid and would be able to contextualise the literature for the examination of mothers’ coping in the face of mental illness. The link with coping and mental health was maintained throughout the search. Two searches of databases were carried out on 23 and 25 July 2019, with a follow-up search on 3 October 2019. Databases searched included Medline, PubMed, Embase, PsycInfo and CINAHL. Quantitative, qualitative, mixed methods and reviews were included in this literature review.
The main inclusion criteria were that the papers should be written or translated into English, within the past five years, with full text available online; however, older papers were included on the secondary search if they were felt to be important to the subject and able to be informative. Search terms were as follows: mothers; mothers and mental health; mothers mental health and coping. Studies may include data on diverse issues; for the purpose of this review the data extracted was specific to the phenomenon of coping, with some references to resilience when this concept was presented as interdependent. A separate search was conducted for the search term, defences of the ego, as this was identified as intricately linked to the term coping (see Table 3).
The 26 papers that were identified from reading of the abstracts were critically appraised for trustworthiness, results and relevance using the Critical Appraisal Skills Programme (CASP) checklists for case-controlled study; cohort study, qualitative research, and systematic review (2018a; b; c; d) as appropriate for each individual study. Critical appraisal facilitates the identification of the most relevant papers and can aid the distinguishing of evidence from opinion, assumptions and belief (Morrison, 2017). All studies were found to be acceptable from quality perspectives; the range of quality was high to medium. Nine studies were excluded because they had only limited relevance for inclusion, and one was excluded as it was a discussion paper. The remaining 15 papers were included in the review.
The included studies used a variety of methods including literature and data reviews, interviews, electronic surveys, questionnaires and validated assessment tools. Examples of the validated assessments tools used included the Ways of Coping Checklist (Vitaliano et al, 1985) and the COPE inventory, which has two main components, problem-focused coping and emotion-focused coping: the COPE was adapted by Carver (1997) into the brief COPE, which consists of 28 measures with participants using a score to rate frequency. Table 4 indicates the papers that were included in the review.
Results: Thematic integration of data findings
Lowe et al (2015) described coping participants as displaying an active approach that was able to secure and maintain resources and prevent their distress from escalating into more serious mental health difficulties. Women were identified as being more likely than men to use active coping such as self-distraction, emotional support and instrumental support (Ito and Matsushima, 2017). Ito and Matsushima (2017) identified age differ-ences in coping styles, with younger people tending towards seeking emotional support and older people being more likely to use emotional coping strategies, adding a life course development into the coping equation.
Adaptive coping skills, including reframing, positive comparing and taking positive action, were found to be protective by Lowe et al (2015), and Adams et al (2017) found those who adopted more positive coping strategies reported lower levels of depression. Schoenfeld and Cameron (2015) point out the positive effects of active coping on neuro-genesis; they found evidence to suggest that new neurons are important for mental health, the hippocampus being involved within the limbic system with the formation of new memories, learning and emotions. Neurogenesis was seen to occur particularly with the use of exercise as an active coping strategy (Schoenfeld and Cameron, 2015). Tada (2017) also found exercise linked with active coping and lower levels of psychological dis-tress.
Active-avoidance coping was linked with higher levels of anxiety, depression and negative affect (Tada, 2017; Adams et al, 2017; Lai et al, 2015). Ito and Matsushima (2017) specifically linked the negative coping strategy of self-blame with depression. Monteiro et al (2018) found that avoidance strategies negatively affected psychological adjustment in post-partum women; however, conversely, they found that acceptance-based coping and self-compassion could act in a protective way for anxiety and depression risk. Sharma et al (2017) in a study of war-affected youth, recognise coping as multidimensional and point out that different strategies may be more or less effective in different situations. Avoidance coping, which is mainly perceived negatively, may have a role in promoting self-preserving schema that are threatened in trauma experiences and may be effective in reducing anxiety and depression for stressors that are perceived as uncontrollable.
Strength from being a parent
Being a parent was found to bring strength by van der Ende et al (2015); the sense of responsibility that occurs with parenthood was enabling for parents, while dedication to the parenting role provided a focus, and the development of strengths and skills as a parent helped them find a balance between attending to their own lives and caring for their children. Parenting also provided a basis for social participation through school and the children’s friendships, and prompted parents to seek adequate sources of social sup-port (van der Ende et al, 2015). The study found that the coping strategies related to par-enting were fundamental to mental health and recovery from mental ill health, and rec-ommended a family-focused approach to help identify strengths and vulnerabilities, ad-dress challenges and build resilience (van der Ende et al, 2015).
The importance of family and community support was identified by several studies (Light et al, 2019; Sharma et al, 2017; Yanes et al, 2017; Reyes and Constantino, 2016; Cherewick et al, 2015; Lowe et al, 2015). However, attachment relationships and child-hood experiences of attachment figures were found to influence how people respond to the social support that is offered (Light et al, 2019; Cherewick et al, 2015). Lowe et al (2015) were also able to demonstrate a link between participants with increased distress and higher rates of strain in intimate partner relationships and higher recorded childhood trauma and adverse childhood experiences (ACEs).
A life course perspective was found to be important when trying to understand an individ-ual’s outcomes and links with the importance of positive attachment relationships. The study by Light et al (2019) with post-partum mothers identified that mothers who had ear-ly trauma experiences reported their support networks as less helpful and more upsetting and unpredictable than other mothers, leading them to seek support less often. The inse-cure attachment styles in the mothers tended to lead to more negative perceptions of so-cial support offered (Light et al, 2019). Mothers of fussy babies could also feel under-mined by support offered to them and lower nurturing self-efficacy was predicted by high-er baby fussiness (Light et al, 2019). Yanes et al (2017) specify affectionate support as widely reported to improve psychological outcomes, including individuals’ quality of life and stress responses, and suggest that encouraging people to find sources of love and affectionate support can facilitate the adaptive process in coping.
The study by Lai et al (2015) of parents of children with autism spectrum disorders rec-ognised that coping and psychological wellbeing were time- and context-dependent. Lowe et al (2015) describe resilient survivors of Hurricane Katrina as having a continuity of psychosocial and economic resources that are able to act in a way that promotes mental health. In this way, coping is dependent on changeable factors that can undermine or promote it. Reyes and Constantino (2016) also cite environmental factors that can sup-port resilience and coping, including perceived social support, physical and mental status, income, age and identity. Lower levels of resilience were found to be present where there was an absence of psychosocial resources and this was synonymous with an increased risk of mental health difficulties (Lowe et al, 2015).
Siriwardhana et al (2014) found that the interdependent dynamic associations between resilience and mental health are contextualised within a framework of supportive envi-ronments, which have sufficient resources that aid individuals or communities to over-come adversity. Their review highlights the dynamic, multi-level, multi-contextual nature of resilience, which follows individual and community trajectories (Siriwardhana et al, 2014). This approach considers the idea that resilience can be examined as a systems phenomenon, with a person’s resilience system being relatively stable over time, able to maintain its key characteristics and be resistant towards external factors (Reyes and Constantino, 2016).
Reyes and Constantino (2016) discuss the development of resilience through several episodes of stressful events, and conceptualise resilience as a coping strategy. The transmission of resilience is seen to occur by the observation of adults coping with stressors by children, who go on then to have a coping repertoire to help them deal with stressors in their futures, thus creating resilience as an enduring phenomenon. Sharma et al (2017) recommend a socio-ecological model of coping that encompasses factors that promote resilience across the nested social ecological levels of the individual, family, community, institutions and culture.
The conceptualisation of resilience as a coping strategy by Reyes and Constantino (2016) is of interest, as most authors seem to place it the other way round: that is, coping as part of resilience.
When looking at definitions of coping and resilience it is clear that they are intrinsically linked and may be viewed legitimately from both sides: coping forms part of resilience and resilience supports coping. Rutter (1999) describes resilience as the ability to overcome risk or substantial adversity. Coping can be defined as ‘managing or dealing with something successfully’ (Oxford Essential English Dictionary, 2011). However, concepts of coping have developed within mental healthcare provision to involve a set of cognitive and affective responses to stress and adversity (Linehan, 2015). It may be considered that coping may include responses that would not necessarily be envisaged in the understanding of resilience, for example maladaptive coping strategies such as self-harm or substance abuse. In this way effective coping can be viewed as an expression of resilience, but maladaptive coping may not.
However, Crittenden (2008), who developed the dynamic maturation model, creates an understanding of maladaptive coping strategies. These may be put in place as part of the human adaptation and survival drive, which can be difficult to understand from the perspective of coping. It is a reminder to us as practitioners of the danger of judging mechanisms for coping that we can come across in our work with patients and clients. It is nonetheless legitimate to assess coping stability, effectiveness and ineffectiveness; however, Lazarus and Folkman (1984) point out that it is questionable whether most people always know what they are doing to cope and what their coping strategies are.
Yanes et al (2017) propose that coping mediates the relationship between appraisal and adaptation. Appraisal of stressors in these papers is consistently of stressful circumstances, which include harm/loss threat and challenge (Lazarus and Folkman, 1984). In terms of stress and coping, many of these studies present extreme situational coping: Hurricane Katrina, war-affected youth, forced migration and so on. It is clear that stressors may be extreme, but how we perceive them is down to our appraisal of them. In terms of motherhood, an individual woman’s experience of pregnancy and caring for an infant may constitute the most extreme demands on her coping abilities that she has ever faced. Childbirth can be potentially life-threatening and the demands of motherhood on physical and emotional resources are great. The appraisal of potential stressors of motherhood in this way can be argued to be the same as the more extreme situational stressors for individual mothers.
A life course perspective (Light et al, 2019; Cherewick et al, 2015; Lowe et al, 2015) is really important for practitioners working with mothers with mental health difficulties. The personal experiences of supportive relationships plainly affect the ability of individuals to perceive support offered as constructive or helpful. The worse a person may feel, the harder it may be to support them when they have negative associations with supportive relationships. This is so challenging in health and social care practice: good intentions may be counterproductive and distinct individual differences need to be acknowledged for support offered to be accepted as helpful.
However, the potential for parenthood to bring with it strength, skills and social resources (van der Ende et al, 2015) may be encouraging for practitioners; the understanding of parenthood as enabling particularly in terms of mental health and recovery is significant. When working with parents it is valuable to remember the truly helpful motivations that parents have to provide the best possible care for their children that they can. The sense of normality that children can provide, together with the opportunity for loving and meaningful relationships, can give meaning and focus outside mental illness (Dolman et al, 2013).
Limitation in the review
The inclusion in this review of studies of diverse design means that integrative interpretation is potentially problematic, and it is not possible to present cross-applicable results. However, the phenomenon of coping in many of its forms is presented by these studies, which show a snapshot of the available research base on coping and mental health. The inability to separate the concepts of coping and resilience at times within the research has been challenging, but it is hoped that the value of the insights from the literature outweighs the problematic linguistic difficulties.
The prevalence of studies that are situationally specific and culturally based indicates a gap in the literature. There is an apparent lack of literature on mothers and mental health and how they cope on an everyday basis, the coping strategies they use and what makes them feel supported. This supports the need for research in this area. The majority of the studies in this review used questionnaires and validated assessment measures to gather the data. There is a place for in-depth interviews, which can allow us to think outside the box and potentially give insights from everyday experiences, which could be enlightening. What we do know, however, is that ordinary people have to cope with extraordinary things.
This review highlights the multidimensional understanding of coping and resilience. The socio-ecological model of coping recommended by Sharma et al (2017) resembles Bronfenbrenner’s (1979) matryoshka dolls model, which perceives the individual as encased within many layers of involvement and interactions like the layers in a Russian doll. The individual is encased in microsystems of settings in which they directly interact – for example, family, school, neighbourhood; surrounding these settings are exosystems of friends, work and local industry; and macrosystems of social, cultural and historical influences (Bronfenbrenner, 1979). In this model, there is also a mesosystem, which encompasses how all the systems relate to each other. Coping is not something that the individual does alone, without influence from all that is around them. An individual is born into a social world of family and peers, and even television can play a role in the socialisation process and the internalisation of the social world in the development of the personality and of coping skills (Lazarus and Folkman, 1984).
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