pediatrics
November 1998, VOLUME102 /ISSUE Supplement E1

Mothers' Emotional Needs

  1. Daniel Stern, MD

Abstract

In most families, mothers contribute substantially to the new infant's emotional environment and development. Because such mother–infant interaction is crucial, a mother's emotional context is very relevant to infant development. This article in New Perspectives in Early Emotional Development addresses the relationships that a mother requires to regulate her maternal or parental capacities, which enable the infant to develop appropriately.

  • infant development
  • mothers
  • holding environment
  • motherhood constellation
  • attachment

POSITIVE HOLDING ENVIRONMENT

An often-told story about a new mother in her first days of being a parent goes like this:She was asked, “What was the most psychologically supportive interaction you had during the hospital stay after the baby was born?” She replied, “Well, my answer's a little funny. The person who really mattered the most to me was the cleaning lady. She came in every morning at 7:15 and she would stop by my bed, really look at me and the baby and we'd talk. She was a grandmother. She was about 55 and she'd say, ‘Oh, how are you doing this morning? How’s the baby? Oh, the baby looks good. Well, how did it go last night?' Every day I looked forward to her visit.”

To this new mother, this visit by a kindly grandmother was the most psychologically supportive thing that happened for her. Of course, the visits by the doctors and nurses and her husband were essential, but if you asked her what was the high point in terms of establishing her new role in life, it was this grandmother.

This special kind of relationship is hard to define and difficult to name, so I use Donald Winnicott's old term, positive holding environment. It has to do with psychologically framing, holding, and contextualizing the mother in such a way that she feels validated, encouraged, supported. You don't have to teach her. You don't have to advise her. You do have to give her a benign regard. You have to create some kind of psychological holding condition so that she feels free to explore her own basic repertoire of maternal behavior and to try them out with a certain amount of confidence. It is like a psychological doula following birth, to complement Dr Klaus's doula during labor.

This observation is important for two major reasons. First, it points to a real need on the part of women that isn't being met. Second, although this may be perfectly obvious, there is a theoretic and research gap, and not enough research on it has been done.

APPROACHES TO PARENT AND INFANT PSYCHOTHERAPY

I've spent a lot of time in the last few years looking at different forms of parent–infant psychotherapy. It turns out that there is actually a great deal of convergence in what different schools of thought and training actually do (Fig 1).

Fig. 1.

Interactions involving the behaviors and representations among mother, father, infant, and therapist. BB is the infant's behavior; TB is the therapist's behavior; MBis the mother's behavior; and Fb is the father's behavior. BR is the infant's representation; TR is the therapist's representations; MR1 is the mother's representations before therapy; MR2 is the mother's representations during the therapeutic alliance; FR is the father's representations.

The mother has representations in mental sets or preconceptions about what's going on, as does the infant, the father, and the therapist. A different set of maternal representations (MR2) exists when she is in the therapeutic relationship. This means that the mother's representations, or conceptions, of who she is and who her infant is, may be different when she is in a therapeutic relationship than when she is alone.

Let's look at five different approaches.

  • The psychoanalytically oriented people address themselves to: MR2, what was problematic for the mother before, and which of her conflicts now are being played out with the infant.

  • For people who work in a more behavioral manner, the port of entry into the system is through the interaction and primarily the mother's behavior.

  • Others are interested in what they would call the representations that are permitted by virtue of the mother being in the corrective attachment experience with her own mother.

  • A developmental pediatric approach focuses on what the infant can do, and showing that to the parents.

  • Family systems theory approaches the mother, father, infant together.

All of these techniques are approximately equal in effectiveness. One of the reasons that they all work is that an enormous amount of time and effort are spent creating a positive therapeutic alliance. Positive is a very important part. The specificity of the approach is relatively unimportant compared with creating this positive context.

THE MOTHERHOOD CONSTELLATION

The question to me became, “What is it about this positive therapeutic holding environment that works?” Or stated another way, “What are mothers really concerned with? What are the things that constitute the necessary experiences or difficult areas in becoming a mother? What provides the context that permits her to become an adequate mother?”

Here's the picture that emerged. When a mother becomes pregnant and gives birth, she starts to form a new psychic or mental organization that I call the motherhood constellation. All of the primary organizing principles she had before are moved from center stage, and the motherhood constellation becomes preeminent. The constellation remains prominent for a variable period depending on the woman, the culture, and the home/work situation. Then very slowly, months or years after the infant's birth, the motherhood constellation progressively moves into the background, but it never goes away. It can be reactivated immediately if there's something wrong with the child and she has to become a mother again. For example, if a child who is 7 months or 7 years becomes sick, it then comes right into the center again. It doesn't disappear. It simply is relatively deactivated.

Protect the Newborn

What's in this constellation, and why is it important? The first thing that almost all mothers will tell is that their primary concern is the task of keeping the infant alive and protected. When they return from the hospital, it is the most organizing and preoccupying central theme of their lives. There is nothing that comes close to it. All mothers have a set of fears which, at least in our society, are totally characteristic. They're afraid that the infant may stop breathing, so they go to the infant's crib several times during the first couple of nights to check. If one tries to stop her, the mother's anxiety level becomes unbearably high. Similarly, she's afraid that when she's bathing the infant, he may slip through her soapy fingers and bang his head on the tub. When she changes the infant she fears he will fall off the changing table. These all are totally normal fears, yet we don't have a good theory for thinking about how to approach them.

I think that they're not only normal and necessary, they're also the price a mother pays both from biology and from culture that indicates the high value placed on infants. This creates a powerful theme to protect her infant that often leaves a mother exhausted and overworked. One of the reasons that she needs to be contextualized is most mothers do not know what to do with the fear and fatigue that are created by this survival theme during the newborn period. It's very hard to confront alone. It requires a good holding environment.

Love and Attachment

The second theme in this constellation is what I call love and attachment. Here, the mother asks, “Am I a competent human being? Can I love others? Will they love me? Will I be able to recognize that they love me? Will I be able to love my infant in a special way so that he will become my baby and not just any baby?” These are very tough questions because the entire process of being with an infant in those early interactions requires a lot of unusual elements. For the most part, the process is nonlinear, spontaneous, and dynamic. This requires that the mother feel quite competent in her spontaneity, her generosity, her ability to do all of these things; this is very difficult for her if she isn't appropriately “held” psychologically.

Because of this process, mothers spend a vast amount of time watching other mothers to see what they know that she doesn't know or what she can learn from them. The big question here is something like, “Am I a natural mother? And if not, what can I do to become one?” For professionals, this means that mothers know better than the professional what they don't do well. Mothers know deeply and fully the things that they do poorly or are incapable of doing. On the other hand, what they don't generally know is what they do well and how they can use those skills. This is one of the reasons that they require a positive holding environment. Criticizing the mom is counterproductive.

Creating the Maternal Matrix

The third theme is that a mother creates around herself something I call a maternal matrix. This is a kind of network of one or more experienced mothers or experienced parents. Someone who has been a successful parent is necessary to create the holding environment.

This entire process forms during pregnancy when a woman start to have thoughts and fantasies and recollections about their own mothers. There's a turning point when she becomes much less interested in men and much more interested in women. She becomes much more interested in her mother, not as a woman, a worker, or wife to her father, but as a mother. The relationship that a mother has with her own mother is extremely important to creating the new mother's psychological context.

Another piece of evidence comes from a study that we conducted in Boston, MA, along with Ed Tronick and Kathryn Weinberg. In a telephone interview with new mothers, we asked: “Who stayed at home with you after you came home from the hospital? Who phones you?” And so on. The data were very clear that this person was the new mother's mother. Relatively speaking, next in line were other experienced women on the mother's side of the family—sisters or aunts with children. After that were experienced mothers on the father's side, then the woman's female friends who already had children. Males friends tended to talk about the infant for 5 minutes then move on to what's going on at the office.

Now, when you add up all the contacts, what effectively happens is that most women create for themselves a matrix of experienced women with whom they have contact anywhere between 6 and 12 times a day for several months. So this business of a matrix is not something that's theoretic. It's something that most women actually create during this period.

The last reason I think a maternal holding context is important is that a woman is concerned with her experience with a mothering figure. For example, we know that the present context in which a memory is elicited is important because it determines the choice of memory fragments and how they are put together. The infant in its entirety—seeing, feeling, and hearing the infant—is a very powerful memory inducer that elicits neural circuits, some of which have not been used for a very long time, some going back to infancy or childhood. Thus, the presence of the infant elicits the experience that the woman has had with other maternal figures in her own life. The fantasy that most women have, at least in our culture, is that they would like to be surrounded by a benign grandmother. This is the nature of the desired relationship that they would most like to have for this positive holding environment.

CONCLUSIONS

A major practical implication of helping mothers to create a positive emotional environment is that intervention techniques alone will never be effective. Professionals need to establish a good relationship in which the intervention is performed. And not just anyone can get emotionally close to the mother—it must be someone special. If we're going to be training people to create the emotional environment so that interventions can take hold, these people have to be highly selected. Unfortunately we spend most of our time training people, not selecting them. There's no question that people who do this well have a highly specific set of characteristics, but there is no good, fast way to select them. We can teach the intervention techniques, but as far as establishing the positive holding environment is concerned, we need to select. This may be contrary to some of our current practices, but I think it's absolutely necessary to move to a new paradigm.

MR2 =
maternal representations