The Nursery: A Raw Portrait of Intrusive Thoughts and New Motherhood
A book for all psychiatrists with woman patients and for all parents.
The Nursery by Szilvia Molnar
BOOK REVIEW
By Szilvia Molnar; Penguin Random House, 2023
208 pages; $18 (paperback)
Reviewed by Susan Hatters Friedman, MD, MSt; Nina Ross, MD
In The Nursery, Szilvia Molnar’s debut novel, new motherhood is laid bare. From the second sentence, we reproductive psychiatrists were drawn in: “The baby I hold in my arms is a leech, let’s call her Button. Button is crying.”
Meg, the book’s protagonist, is a new postpartum mother and in charge of meeting every need of her vulnerable Button. The nickname Button perhaps signifies the neutral features of a newborn who has yet to develop a personality in her own right. Meg has taken some time away from her job as a translator, and her husband has returned to work soon after the delivery. While Meg’s husband John plays a role, as does an elderly upstairs neighbour, Meg and Button are the main characters.
Time is an important aspect of the story. Pre-pregnancy, pregnancy, and postpartum vignettes are woven together in a fluid and at times confusing way, perhaps to mimic the endless and blurry postpartum days running into each other. In some instances, time is an amorphous, shifting, abstract, and almost meaningless entity; “today, like yesterday, so let’s call it tomorrow” (p 74). In other moments, time is an objective truth that moves forward and clearly delineates distinct eras, such as before and after motherhood. Certainly, the narrator’s sleeplessness, an inevitability of the newborn period, contributes to the reader’s sense that time is an important but hard to grasp concept.
It is in this setting of endless days and sleepless nights—stresses of new mothering—that Meg experiences intrusive, almost obsessive-compulsive-like thoughts. Intrusive thoughts are featured prominently throughout the novel. Meg thinks about Button coming to harm in a multitude of ways, including both purposefully and accidentally, by her and others. Such thoughts include Button being suffocated by a pillow, wrung like a washcloth, crushed by a foot, sliced like a chicken by a knife, or her baby-body slipping through John’s fingers in the bath. One single poignant paragraph goes through many questions Meg has: “…What if, in my postpartum delirium, I accidentally place her down on her stomach in the bassinet and she dies? What if I one day step on her? What if I do anything to her with intention? What if I let her sleep for too long and she dies smothered by my embrace? What if there is a day when she simply stops breathing?” (p 76) She has a dream of killing Button.
Like many of our patients, Meg is disturbed by these thoughts. These thoughts frighten her, and she wonders about the likelihood of acting on these thoughts. She worries what others will think of her if she tells them about the thoughts. She turns to google, asking how common it is to have infanticidal thoughts and why mothers have these thoughts.
The Nursery raises important questions about the challenges of psychiatric diagnoses, particularly during a time of stress. Even a normal, uncomplicated pregnancy and postpartum period is filled with stressors, including recovery from childbirth, hormonal shifts, changing roles and identities, and the steep learning curve of regarding caring for a newborn. The Nursery exposes the at times blurry distinctions between a reaction to common stressors in the postpartum, baby blues, and postpartum obsessive-compulsive disorder (OCD). Baby blues is a normative experience, as more than half of new mothers experience it.1 A mother with baby blues may have mild irritability or anxiety, with symptoms resolving within 2 weeks. Intrusive thoughts are extremely common in the postpartum period, even in the absence of psychiatric illness, including thoughts of accidental or purposeful harm towards one’s child, which may be seen in over half of new mothers and which alone are not associated with actual behaviours to harm the infant.2 There are various theories as to why intrusive thoughts are so common, including that these thoughts are the result of hormonal changes or a stress response to a new situation. Intrusive thoughts may also be a symptom of psychiatric illness, such as postpartum OCD, which may affect more than 5% of postpartum women.3
Distressing obsessions regarding violence are common in OCD and may lead to concerns about infanticide risk among psychiatrists.4 However, intrusive thoughts that are ego-dystonic have not been associated with elevated risk of harm to the infant, in the absence of other factors4—although the distress from the thoughts themselves may lead to, for example, compulsive behaviours such as avoidance that could inadvertently lead to infant harm. Harm could also occur when these thoughts are shared with others including psychiatrists, who are unfamiliar with this phenomenon and may not realize that unwanted, ego-dystonic intrusive thoughts about harming an infant are very different from the ego-syntonic thoughts and perhaps delusions of harming an infant that may occur in severe postpartum depression and postpartum psychosis. There is a very real risk of misdiagnosis of postpartum OCD with postpartum psychosis, and with this misdiagnosis, potentially inappropriate psychiatric hospitalization and medications for the medical emergency that is postpartum psychosis.1
In The Nursery, Meg’s intrusive thoughts remind the reader about the stress that mothers—even those lucky enough to have well-meaning partners like John—face. First-time mothers have gone from being single or married women living for themselves, to having another person’s very life depend on them. Caring for a newborn is a steep learning curve even for the most prepared. There may be a disconnect between the intentions of supportive partners and the support that is actually needed, which can prompt friction and resentment. Intrusive thoughts may be disturbing, particularly if one is not aware of what or how common they are. Childbirth and early mothering are hard—physically and mentally—and painful. Vivid descriptions are given by Molnar of postpartum healing, pads, and breasts leaking—that most mother-readers will recall intensely— but will not recall reading about in fiction. New mothering inherently brings with it existential questions of identity shifts and loss amidst sleepless nights of feeding. Honestly acknowledging and processing these challenges becomes even more complex when society demands a façade of perfection.
The Nursery is an unglamorous and honest look at the postpartum experience which includes things that are, at first glance, terrifying—but may be quite common and certainly should be discussed. In reading this novel, we were immediately reminded of Charlotte Perkins Gilman’s The Yellow Wallpaper, an important semi-fictional novella in reproductive psychiatry. The Yellow Wallpaper, which was written in the 1890s, describes a new mother’s psychosis and the patriarchal cure of putting her away in a room with wallpaper that becomes a focus of her psychotic thinking. Not since The Yellow Wallpaper has there been a book that so vividly describes a situation within motherhood as does The Nursery. Matrescence—or the process of becoming a mother—even in the absence of any complications, could be thought of as a hero’s journey: a time of challenge, stress, growth, and ultimately transformation. We highly recommend this book to all psychiatrists who see women in their practices. And to all parents.
Dr Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; a professor of psychiatry, reproductive biology, and pediatrics; and an adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the GAP volume Family Murder: Pathologies of Love and Hate, which won the Manfred Guttmacher award. Dr Ross is a reproductive and forensic psychiatrist.
References
1. Friedman SH, Prakash C, Nagle-Yang S. Postpartum psychosis: protecting mother and infant. Current Psychiatry. 2019;18(4):12-21.
2. Fairbrother N, Woody SR. New mothers’ thoughts of harm related to the newborn. Arch Womens Ment Health. 2008;11(3):221-229.
3. Fawcett EJ, Fairbrother N, Cox ML, et al. The prevalence of anxiety disorders during pregnancy and the postpartum period: a multivariate Bayesian meta-analysis. J Clin Psychiatry. 2019;80(4):18r12527.
4. Booth BD, Friedman SH, Curry S, et al. Obsessions of child murder: underrecognized manifestations of obsessive-compulsive disorder. J Am Acad Psychiatry Law. 2014;42(1):66-74.
