1 INTRODUCTION

The perinatal period is associated with an increase in levels of Obsessive-Compulsive Disorder (OCD), and a category has been developed to reflect the particular subtype of OCD arising during this time termed Perinatal Obsessive-Compulsive Disorder (POCD, Holingue et al., 2021). Research has estimated the prevalence of POCD to be 1.45 times higher in perinatal women than in the general female population (Russell et al., 2013). Recent estimates indicate that POCD impacts 3% of mothers during pregnancy (Visvasam et al., 2019), while postnatally POCD has been shown to affect as many as 9% of mothers (Fairbrother et al., 2021; Zambaldi et al., 2009).

OCD is a condition that is characterized by persistent unwanted thoughts, ideas, and obsessions that evoke anxiety; and urges to respond to obsessional anxiety with overt and/or covert ritualistic behavior known as compulsions (American Psychiatric Association, 2013). Research suggests that frequencies of obsessions and compulsions are similar in POCD and OCD in other life stages. However, contamination obsessions are thought to more common in pregnancy (Abramowitz & Fairbrother, 2008), while obsessions about accidental harm to the infant and other infant-focused obsessions; checking compulsions, self-reassurance and seeking reassurance from others; as well as aggressive obsessions are much more common postnatally (Collardeau et al., 2019; Maina et al., 1999; Starcevic et al., 2020). These types of symptoms are reportedly experienced by mothers with existing OCD in the perinatal period (Burton, 2020), and those who experience new onset POCD (Chaudron & Nirodi, 2010).

While there is no body of psychoanalytic literature relating to POCD specifically, due largely to its only recent appearance as a distinct category, there has been for over a century commentary and discussion on what is taking place in OCD, corresponding to the category of obsessional neurosis. S. Freud (1909) originally conceptualized OCD as obsessional neurosis. He suggested it was a condition that affected many but was often concealed. Early psychoanalytic theories proposed that OCD arose when the ego was faced with an experience, idea or feeling that aroused such distress the person tried to forget about it, resulting in defensive efforts to suppress the thought (Stein & Stone, 1997). Following a distressing experience, idea or feeling, the individual tries to defend against the suffering and separate it from its affect, which attaches itself to other ideas that then turn into obsessional thoughts. Theorists have proposed that repetitions take place largely because sense has not been made of the original distressing experience, and compulsive rituals emerge, representing a process of seeking repair (O'Connor et al., 2010). However, psychoanalytic thinking on OCD has been somewhat patchy. The psychoanalytic understanding of this condition has not been helped by a merging of interest in obsessional personality and OCD.

Freud's early enthusiasm that psychoanalysis would effectively treat OCD (S. Freud, 1909) quickly waned (Freud, 1926); what was being reckoned with was far more complex than he had initially thought; after Anna Freud's paper of 1966, following the Congress of the previous year (A. Freud, 1966), in which she sounded a clear note of caution around a dynamic understanding of this presentation, very little about this subject has appeared in psychoanalytic publications. There are a small number of notable contributions within psychoanalysis over the last 50 years (e.g., Meares, 1994, 2001). We are perhaps today in a position where there is an acceptance that psychoanalytic approaches alone may not be helpful in the case of OCD (e.g., Esman, 2001). It has been highlighted that our understanding of OCD from a psychoanalytic perspective has not developed greatly since Freud (e.g., Esman, 2001). The idea of repressed aggression expressed in the obsessional thought appears to be the most enduring part of this contribution (e.g., O'Connor, 2007) and one that transcends psycho-analytic paradigms into cognitive behavioral theories (e.g. Rachman, 1993).

Within repressed aggression, it is proposed that hostility or aggression towards other people that is not openly expressed manifests in fantasies, or in disguised form which is not always consciously available. Theorists have proposed that the hyper-morality seen in OCD is partly the result of reaction formation against latent aggressive impulses (S. Freud, 1909; Kempke & Luyten, 2007). Research has suggested that anger experience but not anger expression is enhanced in OCD, with individuals with OCD more likely to suppress or internalize anger (Moritz et al., 2011), with the translation of aggressive impulses into overt action suggested to be counter-acted by high moral standards in individuals with OCD. For individuals with OCD the suppression of anger has been associated with the tendency to believe that bad thoughts have moral significance or increase the risk of harm (Whiteside & Abramowitz, 2005). However, the exact nature of the relationship between latent aggression and OCD symptoms remains somewhat ambiguous, and it is unclear whether aggressive attitudes precede the formation of OCD symptoms or are its consequence (Cludius et al., 2017; Moritz et al., 2011).

In recent years, the experience of motherhood has become a focal point in psychoanalytic thinking, as researchers explored the distinctiveness of maternal experience (e.g., Spigel, 2010). Becoming a mother represents a unique transitional period in a woman's life (Erikson, 1959), and a psychic reorganization has been proposed to underlie the transition to motherhood (von Mohr et al., 2017). Theorists suggest that the perinatal period allows for an adjustment to occur, that facilitates a mother to identify with her infant and sensitively respond to their needs (Pines, 1972; Winnicott, 1953). This time of adaptation promotes mothers' investment of energy in their baby and is thought to enable a period of unity and encourage bonding between mother and infant (Pines, 1972; Winnicott, 1953). While early theorists, such as Winnicott, have highlighted the importance of the mother-baby connection, this work could only partly acknowledge the internal world of the mother. For example, Winnicott (1975) proposed a period of initial maternal pre-occupation, where it was suggested that there is no such thing as mother, but only a mother-baby-unit which is then followed by the emergence of mother and baby as separate entities. This idea charts a trajectory in development that comes with many possible versions for new mothers.

For some, that development could involve the emergence of unwanted intrusive thoughts. Research has suggested that many new mothers experience unwanted, intrusive thoughts, and neutralizing strategies during pregnancy and after the birth of their child (Fairbrother et al., 2021; Miller & O'Hara, 2019). For instance, Fairbrother and Woody (2008) found that, for their participants, postpartum intrusive thoughts of accidental harm to new-borns were universal. In addition, almost half of participants reported unwanted thoughts of intentionally harming their infant. However, this is an area that remains somewhat taboo (Murray & Finn, 2011). While accidental harm thoughts have been indicated to be more frequent and time consuming (Fairbrother & Woody, 2008), infant related harm thoughts (IRHTs) are thought to be more distressing (Collardeau et al., 2019; Fairbrother & Woody, 2008). Mothers may experience guilt, self-blame, or depressed mood in response to these aggressive intrusive thoughts (Collardeau et al., 2019).

Despite the high prevalence of POCD (Fairbrother et al., 2021), there is less than a handful of papers that examine mothers' experience of obsessive-compulsive symptoms during the perinatal period (Boyd & Gannon, 2019; Burton, 2020; Murray & Finn, 2011). A qualitative study involving six mothers who experienced IRHTs reported that participants described how they feared they would somehow damage their baby by having destructive thoughts. It was noted that participants' concern appeared to be exacerbated by the innocence and vulnerability of the infant who required its mother's protection (Murray & Finn, 2011). Participants described how IRHTs created an internal conflict for them, and they indicated a perceived pressure to be relaxed and happy, to be “the good mother.” However, internally participants referenced feeling worried, depressed, fearful, or even contaminating. Qualitative papers indicate that IRHTs are extremely distressing for participants, and participants can fear disclosing their symptoms due to the stigma associated with them (Boyd & Gannon, 2019). Given the idealized notion of the “good mother,” it is perhaps unsurprising that research suggests individuals may try to conceal the true content of their obsessions (Starcevic et al., 2020).

Current conceptualizations and treatments for OCD draw on largely cognitive behavioral models of OCD (e.g., Rachman, 1993, 1997; Salkovskis, 1985), perhaps due to a lack of development of psycho-analytic theories (Stein & Stone, 1997). More recently however, psycho-analytic literature has considered how it may contribute to our knowledge of OCD. OCD is a condition that fluctuates in its severity, and a psycho-dynamic understanding may assist in managing the condition (Gabbard, 2001). Current psychoanalytic theories of OCD derive from object relations theory and focus on the development of a fragmented or ambivalent self (Chlebowski & Gregory, 2009). Psychoanalytic paradigms for OCD have also pointed to the adaptive aspects of symptoms as a way to resolve intrapsychic conflict (Chlebowski & Gregory, 2009). In their qualitative study, Murray and Finn (2011) found some mothers spoke about adopting a more inclusive perspective of IRHTs and explained their thoughts of intentional harm as enhancing their protective impulses as a mother rather than bringing them into question. These mothers were relating to their thoughts as an aspect of how they came to productively recognize themselves as mothers. A psychoanalytic understanding of the condition may offer a way of thinking about OCD as it occurs within the self, which includes unconscious conflict, deficits and distortions of intrapsychic structures, and internal object relations (Gabbard, 2001).

Literature concerning the lived experience of mothers with POCD is limited. To date the study of the condition has focused on the use of questionnaire methods and structured interviews focusing on prevalence and phenomenology; and case series from the researchers' perspective reflecting on treatment protocols. Qualitative studies have used single interviews to explore mothers' experience of IRHTs (Boyd & Gannon, 2019; Murray & Finn, 2011), and mothers' accounts of an exacerbation of OCD during pregnancy and the post-partum (Burton, 2020). Of these qualitative papers only Burton (2020) involved a group of participants with a diagnosis of POCD. Given the scarcity of qualitative studies of mothers' experience of POCD, this research aims to add to what is known about mothers' experience of POCD, presenting findings and exploring the theoretical and clinical implications of these. This is an inductive research approach informed by a psycho-analytic method. The psychoanalytically informed method has been used with mothers who presented with post-natal depression (Hesse Tyson et al., 2020), individuals with OCD (Mulhall et al., 2019), people who hoard objects (Byrne et al., 2019), and people experiencing somatic symptom disorder (Byrne et al., 2019). The aim of this study was to provide sufficient space for mothers to explore what was meaningful to them in their journey with POCD, with a view to expanding our understanding of the nature of mothers' lived experience.

2 METHOD 2.1 Design

A qualitative research design was used. This drew in part from an emerging body of qualitative research methodology employing the use of a psychoanalytical interview (e.g., Cartwright, 2004; Clarke, 2002; Hollway & Jefferson, 2000; Holmes, 2013; Kvale, 1999). This approach allows for consideration of intrapsychic and relational processes (Kvale, 1999). Three in-depth interviews were completed using an open mode of interviewing that is free and non-directive. This type of psychoanalytic interview process creates a space for meaningful material to arise (Cartwright, 2004; Clarke, 2002; Hesse Tyson et al., 2020; Kvale, 1999; Mulhall et al., 2019). Close observation of changes in the researcher's feeling state, associations, and bodily reactions, facilitates an important source of reflexivity (Clarke, 2002; Holmes, 2013); the researchers' emotional responses are tied up with the participants communication throughout the interview process (Gemignani, 2011; Jervis, 2009). A psychoanalytically informed approach underpins all stages of the research interviews, transcription, and data analysis.

2.2 Ethics

Ethical approval was granted by the ethics committees representing the academic institution, the Community Mental Health Service, and permission to recruit participants through an on-line support group for mothers with POCD was also provided. Participants had access to support from a Senior Clinical Psychologist who acted as Clinical Advisor to the study. Participants recruited through the perinatal mental health group had access to the on-going bi-monthly group, and an additional telephone support service. Three participants were linked with additional mental health services at the time of the study. Two participants had completed a period of psychological intervention.

2.3 Participants

A sample of five participants, with a diagnosis of Perinatal OCD, were recruited on a voluntary basis via a community mental health service and an online group providing support to mothers with POCD. Participants met criteria that they were (a) aged 18 years or over, (b) were not currently at risk of suicide, (c) had no condition which limited their ability to give informed consent. Two participants were recruited through a Community Mental Health Psychology service. Three participants were recruited through an on-line perinatal OCD support group. Exclusion criteria for the study were (1) a diagnosis of bipolar disorder, schizophrenia or related psychotic disorders, (2) current reported alcohol or substance misuse, (3) significant on-going medical complications or needs of infant or mother that would contra-indicate partaking. All participants expressed written and verbal consent to complete three interviews over an online platform. The participants are introduced here via their pseudonyms: Sarah, Olivia, Ella, Lucy, and Rose.

2.3.1 Participant characteristics

Participants ranged in age from 27 to 35 years. All participants presented with POCD with onset in pregnancy or after the birth of their first child. Children were aged 1 to 4 years at the time of the study. One participant was pregnant at the time of the interviews, and two participants were trying to conceive. Participants reported a history of anxiety or low mood prior to onset of POCD.

Trajectory of symptoms

One participant had an existing diagnosis of OCD prior to pregnancy. Two participants experienced subclinical levels of OCD prior to conception, with worsening of symptoms to clinical levels during pregnancy and postnatally. One participant reported onset of POCD during the first trimester of pregnancy. One participant reported initial onset of POCD postnatally.

2.4 Procedure

The interviews were conducted via a secure approved online platform, recorded, and then transcribed. The interviewer was a psychologist in the final year of a Doctoral Program in Clinical Psychology. At the outset of the interview, the researcher explained the nature of the interview and the overarching goal: to provide an open space that allowed for an exploration of material relevant to each participants' personal experience of POCD. Participants were encouraged to discuss their experience in a free-flowing format and were invited to begin with information that was most tangible to them.

2.4.1 Researchers position as interviewer

Throughout the process the researcher listened attentively, with prompts provided as required to facilitate participants' comfort with the interview process, and to support in eliciting their story. Careful attention was played to participants' ordering and phrasing and these were reflected-back at intervals that were appropriate to the interview (Cartwright, 2004; Clarke, 2002; Hollway & Jefferson, 2000). The third interview provided opportunity to explore further earlier details arising in participants' narrative account, and opportunity to address any gaps in what was known (Hesse Tyson et al., 2020). Key areas of interest were influenced by the interviewer's position as a researcher. Knowledge of extant research relating to POCD provided an indication of areas which may emerge in participants' accounts, including the nature of POCD, pregnancy, labor, the post-natal period, relationships, and parenting. However, exploration of participants' journey unfolded in a natural free flowing way. During the interview, the interviewer was required to pay close attention to feeling states as they occurred within themselves and the interviewee.

2.5 Data analysis

Analysis and interpretation of the interviews involved multiple steps. The analysis process aimed to facilitate contextual and holistic analysis of the data in which certain key themes may point toward a shared experience while reflecting the individual experience of participants (Clarke, 2002). (1) Following completion of the interviews the verbal content was transcribed using strict verbatim transcription with nonverbal responses, pauses, and emotional expressions (laughter, crying) transcribed; attention was given to semantic content and tone of the interview. Transcription immersed the interviewer in the data collected from the interview process; (2) Each transcript was read and re-read individually with key elements highlighted by the author; an inductive approach was used and key-points of the narrative that represented participants experiences were documented; (3) Key identifications and object relations within dominant interview narratives were tracked (Cartwright, 2004); (4) The interviewer's internal responses were noted and initial transference-countertransference impressions were noted alongside key-points; and emerging themes arising from the data were recorded; (5) Transcripts were examined both within and across participants, there was repeated movement between the search for core narratives within the interview transcripts and themes were developed as a reflection of what was shared within participants' narrative; (6) The principal investigator met with the second researcher to aid meaning making of the content and felt experience of the interview process from a relational psycho-analytic perspective. Anonymized information was discussed with the research supervisor and the emerging themes were reviewed to ensure coherence of themes, a fit of themes with the data, and to evaluate whether alternative themes could be drawn from the data.

3 RESULTS

Three major themes emerged from the interviews conducted: a difficult road to motherhood; protector/aggressor; mothers' loss. These appeared to form a core part of participants' narratives during interviews and stood out as significant when the content was revisited during analysis, both individually and when participant accounts were considered in totality. In relation to the approach of participants to the interviews, the interviewer observed that participants were keen to present the right content to the interviewer. For all participants, transitioning to motherhood was something they had looked forward to. There was a sense of vulnerability in speaking with an unknown person about their experiences juxtaposed with a drive to share their experience and prevent harm occurring to others through POCD. Participants tended to begin speaking rapidly and often disclosed their most feared intrusion within the first encounter. The content of intrusive thoughts included fears of contamination, fear of accidental harm coming to the child, fear of their child being kidnapped, or killed while in the care of another person, fear of harming the child themselves through ineffective parenting, abandonment or physical acts of harm directed toward the child. Thoughts of sexual harm were also described, these tended to center around mothers' fear of being perceived as pedophilic while caring for their infants, for instance when changing nappies and applying creams.

During the interview exchange participants' narratives were punctuated by a strong sense of psychic pain. The intensity of participants' pain was observed by the interviewer. The interviewer witnessed participants becoming upset, tearful, engage in in-congruent laughter, become silent; and move between accounts of the present, the recent past and their earlier years. This movement sometimes brought participants to apologize for jumping around or to wonder whether the content was what the interviewer needed. During interviews, participants used a mix of second-person narrative, and first-person statements with these occurring in close succession within their accounts. The anxiety participants described was palpable and felt very live to the interviewer. The content and emotional tone of the interviews stayed with the interviewer and was reflected upon at length. Sometimes reflection felt ruminative, and the interviewer felt stuck in what felt like a mirroring response, while at other times it felt as if the interviewer had assimilated part of the participants' pain. Participants described finding talking about their experience more difficult than they had anticipated. However, by the third interview participants noted the process as restorative.

Most participants consciously noted a relationship between experiences in early life and adolescence, and the content of intrusive thoughts. In terms of their own childhood experiences participants described instances of trauma in childhood and adolescence, including physical and emotional bullying by peers, illness, unresponsive or invalidating parental responses to emotional difficulties, and instances of emotional abuse. Participants described intrusive thoughts that related to exposure, in adolescence and early adulthood, to media stories and historical accounts of kidnapping, abuse, and pedophilia. They noted a protective response of tending to avoid this type of media content in adulthood. Most participants described previous difficulty accessing support in terms of appropriate counseling to assist them to integrate or make sense of their challenging experiences. For some, attempts to enlist support were met with a lack of responsiveness by parents or professionals, others faced an absence of available services.

As adults, most participants described the occurrence of some less-than-optimal interactions with professionals. These interactions were noted to prompt the participants to push their thoughts away and continue with their day-to-day lives. However, successful therapeutic interactions with professionals were also described. These were noted to be invaluable, particularly where participants reported a strong therapeutic alliance with their clinician or clinical team. It impressed that the participants were involved in an ongoing state of meaning making regarding their experience of POCD. Participants explained having made therapeutic progress with their symptoms; however, despite these advances, the intrusions and integral emotional turmoil were sustained. Intrusive thoughts were described as clinging to whatever participants were doing; therefore as their children reached expected developmental milestones, intrusive thoughts shifted to the next possible source of harm.

Participants continued progression and management of symptoms involved continued focus on self-care including meditation, exercise, medication, ensuring good sleep, and enlisting supportive others. Participants described strategies that aligned with Cognitive Behavior Therapy, Acceptance Commitment Therapy, and Compassion Focused Therapy helpful. Participants described that they needed tools to respond to the OCD. Exposure and response prevention (ERP) alone, or “talk therapy” alone, were not described to be as effective as ERP that was embedded within aspects of “talk therapy.” Participants reported a desire to develop their self-awareness and understanding of their POCD, and appeared wary of the implications living with OCD could have for their child. They highlighted a drive to shield their children from OCD. For all mothers this was highlighted as a driving force behind accessing therapy and addressing symptoms.

3.1 Theme 1: A difficult road to motherhood

The first theme relates to participants' struggle on their journey to motherhood. Olivia described a loss of control in the timing of conception, having conceived very quickly contrary to her initial expectations: “I just didn't expect to get pregnant so fast.” There was a sense of being swept up by the process and the transition to motherhood, while still feeling unprepared. Conflicting emotions were experienced to a very powerful degree, including shock and excitement. Ella noted that when she became pregnant, she worried how OCD would “take its toll.” Sarah, Ella and Rose experienced miscarriage immediately prior to the conception of their child. Sarah described this as “a dark time definitely for the two of us” …. “I remember feeling really guilty.” The pain of miscarriage was evident with Sarah having felt that pregnancy had provided her with “a purpose in life now.” Sarah, Ella, and Rose described feelings of happiness at learning they conceived again. Falling pregnant in close succession to pregnancy loss was regarded as healing, however, this happiness was experienced alongside a heightened fear of miscarriage. Rose noted: “Obviously I was delighted but also really, really quite terrified and convinced that I was going to miscarry again.”

A sense of turmoil and a weighty responsibility pervaded participants' accounts of pregnancy: “I felt like it was all in my hands to keep her safe and healthy inside” [Sarah]. Rose described terror: “My OCD was very much contamination OCD. I was convinced I was going to kill him in some way.” Participants' experienced great concern for their unborn child, and showed difficulty trusting their own body and their instincts for how their baby was growing and moving within them. Rose described her deep yearning for a child: “It's all I want in the world…I've been desperate to have a baby, I'm you know I'm not going to be able to carry this baby to term. I'm going to kill it somehow.” There was a sense of counting down the days of pregnancy and a feeling of relief each time they reached the next milestone in fetal development. Lucy described thinking: “I just need to get to 12 weeks or I just need to get to 20 weeks…so I'd always be like kind of just waiting for the next thing to be…we're a bit closer to being ok.”

Participants described attending the hospital for additional scans, with concern regarding whether their baby was moving or could be in distress. For instance, Sarah described how her baby “didn't move at all while I was pregnant.” Descriptions of these events were accompanied by a sense of frustration that they required assistance, almost as if the later arrival of their baby cast doubt on the validity of their worry. Mothers found it difficult to discern what was a function of POCD and what was a routine part of pregnancy. There was conflict at times between accepting their emotional experience of pregnancy as a valid part of their journey, or as an experience driven solely by POCD. Partners were described as drawn into the POCD. Rose noted: “I just completely dragged him into it like made him part of my OCD.” Participants recalled feeling guilt and sadness at how their mental health impacted the course of their pregnancy: “I look back now and I was doing mad things…. I vividly remember my husband gardening once, and my being like you have to take off your shoes by the door and then anything that you touch you have to disinfect after….cause I was convinced like soil was going to come into my house and somehow end up in my mouth and end up killing my baby”[Rose].

Labor emerged as a traumatic experience for participants. Sarah noted “I would have said I had a traumatic birth”; Olivia said “I found it really traumatic, …. [he] was all bruised.” Participants had focused on the safe arrival of their baby into the world, but also described hopes for gentle and natural births. Participants held expectations that labor was “the most natural thing in the world” and felt in some ways unprepared for the reality of childbirth: “no one tells you how horrific it is” [Lucy]. What transpired for all participants was a pattern of prolonged labors with strands of risk, including lack of fetal movement and risk to participants themselves. Lucy recalled, “it was just not a great experience and she had the cord wrapped around her neck, so her heart rate kept dropping….” Participants described feeling panicked during labor. Sarah recalled how her delivery suite flooded with people, and her consultant comforted her: “We have this now. You're safe now, and I was like (tearful), when were we not safe?”, highlighting her absolute vulnerability during labor.

Participants reported hazy memories of giving birth. For Lucy, this was a cause of great concern creating doubt in her mind as to what may have happened during labor, in some way feeding her OCD and eliciting panic about what might have occurred when she blacked-out. For Sarah, Olivia and Lucy, feelings of failure clouded their experience of childbirth: “I remember for a long time feeling like I failed her because I've had this section. I was like I failed at the first hurdle. I couldn't even get her out myself” [Sarah]. Participants described their labor experience as being antithetical to their expectations, and internalizing this…“that's the basic thing you should be able to do” [Sarah], “everyone else does this, why am I doing it so badly” [Lucy].

Lucy and Olivia described feeling disregarded and spoken to poorly: “you're just not handling the pain well” [Lucy]; “I just remember fear and feeling so vulnerable” [Olivia]. Olivia described reliving her birth experience night after night, struggling to sleep as she relived her labor trying to make sense of what could have gone wrong: “I just kind of felt like that was kind of the beginning of all the horrible things that happened,” “I felt consumed by guilt constantly” [Olivia]. There was a sense of anger, frustration, and sadness in mothers' experiences of labor, and some mothers noted an absence of an available support to help them process these feelings. Olivia commented: “when I didn't have anyone else to blame….the only person I could blame was myself.” Participants also noted a positive side to their birth experience. Ella and Rose described a sense of being looked after and this appeared restorative. Sarah noted: “if anything was wrong the doctors had her now that it wasn't on me that I could kinda take a step back.”

3.2 Theme 2: Participants identity as mothers: Protector or aggressor?

The second theme related to participants' relationship to themselves as mothers. Participants experienced great conflict between their role as their child's protector, while also experiencing themselves as the aggressor or object of harm. Feelings of love and adoration were described by all participants at the birth of their baby, Rose commented: “when he came out, I was just so delighted he was there.” However, these were followed rapidly by forceful worries: “this is your responsibility now to keep this baby alive…and you have no experience, you have no qualifications” [Sarah]. Participants' journeys were additionally marred by struggles breastfeeding, and an absence of support to manage this, particularly for Sarah, Olivia, and Lucy. Participants described how these struggles added feelings of guilt and frustration, about what they had expected to be a very natural process. Rose described how for her breastfeeding came quite instantly, and she noted this was soothing following a “miserable” pregnancy.

With the approaching transition to motherhood, Ella recalled feeling that, “you know you can't really hide……there's a lot that comes out with being a mother.” Participants described an impending sense of danger, an unpredictability with what the OCD might do or how they might be impacted. While their experience of OCD prior to pregnancy was in some ways tolerable or less intense, the prospect of becoming a mother seemed to alter the impact of OCD. Sarah noted it was very different to experience intrusive thoughts of abuse about her own child: “It's very different, listening to stories of abuse to somebody else….it's a totally different kettle of fish when it's your own child, and you're having these thoughts about your own baby.” Intrusive thoughts emerged as powerful, a “beast,” a “bully.” Participants worried that the presence of intrusive thoughts meant they were an evil or immoral person; for example, Sarah noted: “I genuinely thought, you're a monster, like you are a murderous pedophile who just wants to harm people.” Ella described, “my worst fear with the OCD thing…was that I was evil.”

Participants reported extreme concern about how their thoughts would be perceived by others. Lucy recalled how “all of these things were just going crazy in my head. And then I had some more CBT, which helped. But I was also getting intrusive thoughts at this point, and I didn't want to tell my CBT therapist because I was so scared of like what I was having the thoughts about, and I thought she's going to get taken away from me.” A fear of separation from their babies was evident for all participants. Olivia reported feeling compelled to “act like a new mom, who had it all together.” Participants described a fear of being perceived as a bad mother resulting in participants' feeling frightened and alone: “I would just be constantly like thinking like I'm not, like I'm a really bad mum, like they're going to take her away from me” [Lucy]. It was the overwhelming nature of thoughts that prompted mothers to share their difficulties. Ella described leaving her baby for the first time: “the whole way through the movie, I had this awful, terrible feeling that I was going to go home and kill my child. And I just cried all the way home. And I just was like, this is just, it's just too much.”

The vulnerability of infants was explored, and participants described how babies were viewed as entirely defenseless. Ella commented: “it's their vulnerability that scares me,” and this image contrasted starkly with mothers' view of themselves as evil and/or harmful. Participants were tormented by their thoughts: “I would wash my hands before I changed her nappy, like I would be constantly washing my hands because I just felt like she was so like fragile. If I didn't wash my hands before touching her…something bad would happen” [Lucy]. Participants described a conflict between their desire to protect their infant and their fear of causing them harm. Ella noted: “I would do anything to protect him, but at the same time I was terrified that I was going to kill him myself.” Intrusive thoughts were described as constant and overpowering: “I would never act on them, but…where is it coming from?” [Olivia].

Apprehension that someone else would harm their child also pervaded participants' minds. Sarah noted “I was so bad when she was born, I didn't trust anybody.” Participants described how they felt that they needed to stay close to their child, noting difficulty allowing others to hold their baby, or to help with caring for them. Participants recalled feeling hypervigilant: “I was just so so petrified of something happening to her. I hated people holding her. I wanted to be in the room with her all the time” [Lucy]. This often impacted on participants' sleep as they lay awake watching their baby. For some participants, the period after the birth of their child was described as a very dark time: “I'm drowning here” [Olivia]. Conflict emerged in mothers' experiences: “the only reason I didn't hurt myself is I didn't trust anyone enough to mind (child) when I was gone” [Olivia]. Therefore, participants' sense of identity was conflicted; with images of themselves as potential assailant while also being the ultimate protective force.

3.3 Theme 3: Feelings of loss

The third theme refers to participants' sadness and loss having experienced POCD: “I mean there are elements of it like I find really upsetting to think about, like the fact that I didn't, I, I've never enjoyed a pregnancy” [Rose]. There is a sense of mothers feeling stuck with their thoughts: “I feel like I missed out a bit on (child) because I was so in my head and fretting and worrying, thoughts racing all the time” [Sarah]. There emerged a need to separate from the difficulty of their experience, Rose noted “there's so many things that I've forgotten, to be honest in terms of ….the stuff that I did because probably it's been easier to forget”; suggesting the weight of the emotion is too great to bear. For some, there was a struggle to make sense of their experience, and to take responsibility for the loss. Sarah noted: “I may have had a romanticized idea of what maternity would be.” Lucy commented: “when I look back, I honestly would call myself delusional (laughs), at…what I thought it was going to be and then what it was.”

Intrusive thoughts emerged as insidious elements that creep in, infiltrating the mind, and clinging to participants' consciousness, almost creating an alternate reality: “It kinda works alongside your conscious brain” [Ella]. POCD permeated the very core of mother's being, creating an environment of doubt, questioning the validity of mothers love, “do I have a bond with her, or do I love her enough? …what is this love meant to be like? What? What do people mean?” [Sarah]; “does this mean, do I not love my child?” [Olivia]; “I'd kind of look at him earlier on and go….do I actually love you? I might just be pretending?” [Ella]. Intrusive thoughts and compulsions appeared effortful, and grueling, “it's just, it's it's just exhausting” [Ella]. Intrusive thoughts were accompanied by feelings of guilt and shame, which compounded participants' sense of loss. For instance, Rose commented, “I had so much guilt in pregnancy, like I had created this really unsafe home for him.” Olivia described a sense of anger, and frustration at feeling unprepared for motherhood, labor and its impact on her mental health: “I suppose I wish someone had maybe warned me, you know that that could happen.”

Participants noted a strong desire to be in control, Lucy commented: “I hate the feeling of not being in control.” Rose noted, “maybe that's what I find so exhausting that I can't just relinquish control.” Intrusive thoughts and compulsions were regarded partly as a way of maintaining a sense of control, Ella commented: “I do have a habit of thinking bad scenarios so that if they come, then I'm somehow prepared.” Participants described how compulsions provided a way of getting rid of an intrusive thought before it could become too powerful. At times intrusive thoughts were regarded as comforting, Ella noted: “having intrusive thoughts is a bit like having an itch that you have to scratch. Just like it's…easy to go there, and it's comforting” [Ella]. Compulsions were described as occurring both consciously, for instance where participants chose to engage in a compulsion to access a sense of control or relief, and unconsciously, for example where participants noticed themselves engaging in behaviors when the action had already begun without conscious awareness. Participants described feeling a deep sense of shame when they were “caught” engaging in compulsions, and the drive to complete them was noted to create a tension in relationships. Rose described how her POCD impacted her husband: “I know he finds it in some ways more exhausting than me.”

Accounts of participants' own childhood experience intertwined across their personal accounts with a strand emerging that suggested instances of anxiety had been regarded as “silly” or “dramatic,” while some participants described a complete absence of emotional support. Participants highlighted their own desire to parent in a responsive way, to create an environment where their children could be vulnerable and supported. Children were experienced with a sense of idealization and awe. Participants described their children in wholly positive terms: “he's a complete ray of sunshine” [Rose]. They were regarded as a sustaining life force against the backdrop of pain related to intrusive thoughts and compulsive behaviors: “she's just so patient…like on days where I haven't felt good enough, or there's days where I thought you'd be better off without me…But then she reaches out and comes up for a cuddle and gives you a smile” [Sarah]. A strong “maternal instinct” emerged with participants displaying urges to care and protect their babies. However, participants' sadness at the difficulty of living with POCD was clear to the interviewer. Sarah commented: “I just wish it had been a bit more smooth sailing.” While Ella noted: “I'm just a little bit sad for me.” Rose commented: “having had OCD in pregnancy has basically given me…basically left me with OCD, that like if there's any stress in my life that I just have a flare up.” Ultimately, there was a sense of frustration and loss that having POCD during the perinatal period had robbed participants of a greatly anticipated time in their life, and that this had implications beyond the perinatal period alone.

4 DISCUSSION

The present study used a qualitative psycho-dynamically informed series of three interviews to explore participants' experience of POCD. Following analysis, three prominent themes developed. The first theme, a difficult road to motherhood, related to participants' struggle on their journey to motherhood. The second theme, protector/aggressor, described participants' conflict between their role as their child's protector, while also experiencing themselves as the aggressor or object of harm. The third theme, mothers' loss, refers to mothers' sadness and loss having experienced POCD.

In the present study, all participants described a tumultuous path to motherhood. This was distressing for participants as they had all identified strong urges to become mothers. This finding may be understood considering Raphael-Leff's (1986) proposed theory that the adjustment to motherhood is impacted by mothering orientation. It is suggested that “facilitators” interpret pregnancy and motherhood as an ultimate fulfillment of their identity. This appears fitting here as participants identified becoming a mother as a long-term aspiration. The transition to parenthood is one of the most important stages of life, and mothers have expectations for this time (Mihelic et al., 2016), including what childbirth will entail, how breastfeeding will be and what the day-to-day aspects of infant care and mothering will involve. However, there was a stark contrast between participants' hopes, from the time of conception, through pregnancy and delivery.

Participants noted idealized aspirations for the start of their parenting experiences. These expectations were violated at multiple points for the participants, for instance, timing of conception, miscarriage, pregnancy experience, labor and after delivery. The impact of these violations appeared to be negatively affected by participants' expectations of what becoming a parent would involve. In the present study, participants' aspirations were frustrated by instances of miscarriage which then increased participants' fear of pregnancy loss. Miscarriage has been related to women's pregnancy-specific anxiety (Tsartsara & Johnson, 2006). One participant noted the onset of POCD following her miscarriage and described POCD as a possible way of defending against this distressing experience, suggesting an alignment with early psycho-analytic theories of OCD (Stein & Stone, 1997).

Idealized expectations of pregnancy and delivery permeated participants' accounts. Participants noted idealized images of easy pregnancies; narratives created connotations of mothers who float effortlessly through, delivering the baby without the need for pain relief or assistance, followed by a calm transition to breastfeeding; the most natural thing in the world. Mothers' expectations have been shown to be strongly influenced by a romanticized expectation of an ideal motherhood (Boyd & Gannon, 2019; Murray & Finn, 2011). Participants' accounts suggested that they believed that this idealized image of motherhood is synonymous with reality, and when their expectations were disrupted, this impacted their sense of selves as mothers. Mauthner (2002) indicated that women often go to great lengths to protect the cultural ideology of motherhood by hiding their vulnerabilities and difficulties from other mothers. In the present study, participant narratives suggested that a tendency to portray an idealized image of motherhood may have negatively impacted participants' sense of self-efficacy, as participants lacked a framework within which to understand the difficulty of their experiences.

Participants identified a sense of having failed as mothers from early on, for instance, when they experienced miscarriage, were stressed in pregnancy, during harrowing labor experience, and during the early weeks. Participants worried their elevated stress in pregnancy had increased their cortisone levels thereby impacting the fetal environment. Participants also feared they had managed labor incorrectly, thereby failing to give their child an idealized natural birth experience. For participants, breastfeeding appeared to be associated with good parenting, and participants described ongoing guilt when their breastfeeding journey was frustrated. Early insults had lasting implications for participants, particularly in the case where the system was experienced as unresponsive or acted to invalidate their difficulties. Conversely, participants who noted accounts of feeling held and supported by the system, appeared to have experienced opportunity for repair. This seemed to be associated with a state of ambivalence, a sense that labor had been difficult but there were moments of restoration. Conversely, the absence of an available container to support mothers to process their distressing experiences, appeared to lead participants to repress their emotional experience and direct their frustration inward towards themselves, negatively impacting participants' sense of self-efficacy as a mother. This is significant, as research indicates that when actual experiences do not meet prenatal expectations, mothers have lower levels of self-esteem and higher levels of depression, anxiety, and stress postnatally (Lazarus & Roussow, 2015).

The second theme related to participants' sense of themselves as their infants' protector, while also experiencing themselves as the potential assailant of harm. Participants were conflicted by an assault of emotions. Feelings of love, adoration, and awe were tinged with the reality of their child's vulnerability. Winnicott (1975) described the primary maternal pre-occupation, a state of heightened sensitivity in the mother, which is thought to support the mother in attuning to the needs of their infant. For participants in the present study, this maternal preoccupation appeared to operate in over-drive, resulting in states of hypervigilance. Par