In the ongoing support and counselling of those mothers who lost a child or children to adoption, PTSD is one of those elements of their suffering that may be amenable to improvement by available government provisions. The following refers generally to the Australian experience during the sixties and seventies when tens of thousands of babies were coercively taken for adoption in the middle decade of that period.

In May 2013 The American Psychiatric Association belatedly published the DSM V classification of psychiatric disorders. The section on PTSD is well set out and has taken into account the wide range of research that has developed in the 21st Century. While overall classification in DSMV has created much criticism and disagreement, such do not apply to this section. From our point of view it sets out in clear language many of the forms that mothers suffer and links these to the core themes of the disorder, and its value to us is to be highly respected.

The causative criteria not only are due to the mother"s own direct experience of a series of traumatic events, but there are deep seated preoccupations with the possible effects on their baby that continue indefinitely.

The more obvious causal instances are associated with the threat of serious injury while in the birth crisis; we also have some who were certain they faced death, and many who faced genital exposure and unexplained vaginal or anal procedures while unsupported, where sexual shame and anxiety became significant.

The purpose of this paper is to delineate the context, social milieu and particular circumstances that have sensitised these women to their traumas in order to assist those caring for them, as well as to alert assessors to matters they or the mother concerned may not realise are part of the post-traumatic syndrome.

THE SOCIAL SETTING OF THE PREGNANCY AND TRAUMATIC EVENTS DURING ITS COURSE.

These include:

being forced to secrecy because of a parent or partner"s expected response;

rage, rejection and control from a parent or partner who is totally unaccepting of what has happened;

fear of forced abortion or fear of abortion procedures;

intense brainwashing techniques about her own inadequacy; her "responsibility" to the baby; the stable of "wonderful parents" waiting to adopt; and her "duty to herself" "to start her life anew" as if her pregnancy had never happened;

and specific crises.

An example: the young woman who had serially "escaped" from a benign Salvation Army home to then be in a Presbyterian version: she had collected a variety of items for the baby and had gathered them in her room. On discovery of these a senior woman there had pulled them out and hostilely thrown them around - shouting that she would not be needing them.
The more common of these specific scenarios was rejection from the family home, often being sent to a different city or country town. A large number went into "Homes for expectant mothers" run by the same organisations that were run by the adoption agencies. It often meant a complete breakdown in their relationship with a parent or parents. Many of these said to me that it was often associated with the parents having been openly judgmental about other girls who had become pregnant. Culturally this was still very common in the sixties and seventies.

All these factors during pregnancy lead up to "the state of mind on admission"

It was often their first experience of a hospital, let alone a labour ward. They have felt the fluttering first movements, wondered about the sex of the baby, got to know their baby"s habits, experienced times of vigorous motion during the swimming-pool stage, have been kicked in the bladder and latterly kneed in the ribs. Most girls have long-held fantasies of what their first born child will be like, and how it might be to have a real baby. This is it!
Some have surrendered to "the machine that takes babies", this is just another step; others are plotting scenarios about getting away with the baby, yet others are planning assertively with assistance to resist any attempt to take their baby. But they all have preoccupation with the baby"s position in this; they care intensely and they want to know.

THE LABOUR WARD

- "I want my Mum, Nanna , my boyfriend, my Aunty Julie, my sister or my friend Cindy".

Keeping them separate from any close person during labour was the usual tactic to prevent sudden support to keep the baby. The other was to avoid scrutiny.
To a sick person or a woman in labour their close people are, at the surface, comfort, succour, attachment - but at a deeper level they are protection. The baby takers were worried about the "agency" factor, particularly an agency with power, even a solicitor. The mother"s problem wasn"t the law itself: it was that it had no power, no policepersons. The hospital staff would follow the BFA on the file (or UB "ve) ie baby for adoption; unmarried: baby subtract (looks like a blood group)

Hundreds of women have related to me directly that the staff called her "Dear", but remained emotionally distant knowing the events that would happen. It was mostly all anonymous.
This isolation from protection, amplifies the fear/trauma/shock factors many times. What might be tolerable to a woman whose husband, friends and relatives take turns to comfort her during labour, might terrify a woman on her own having "artificial rupture of the membranes", or a PV or PR examination to determine the status of the baby"s head.

The immediate perception of trauma is what sets off the brain"s basal nuclei to leave permanent changes to their hippocampus and amygdala with their connections.. It is enhanced and fixed by the humiliation factor. There were many facets to humiliation. "How can I let them do this to me" To have myself exposed to others like this is unthinkable. Nobody cares a jot. Is there a real world out there" Do any of my family or friends know what they are doing to me"

In many smaller hospitals, particularly in the country, there were often personal acts of kindness, such as sneaking them to look at the baby in the next couple of days or one nurse staying with her until the end of her shift. What is being described above and below was exemplified by The Crown St Women"s Hospital Sydney.

Mothers were thus in this state, highly influenced by the work up they have been getting from the Agency (institution " mother"s home) who is managing them. The irony is that this is all happening to them while numerous breaches of "acting without informed consent", contrary to common-law, or even assault, such as injecting them with milk-suppressing synthetic hormones immediately after birth are being done to them; they are even using "The Wellfare threat" against her ""You don"t know how to look after a baby. You have no money to look after a baby; you couldn"t be capable of coping with a baby. We will just bring in The Welfare if you try to keep the baby." I can remember cringing with irony when I heard that was used in South Australia on an unwed mother who was employed as a neonatal intensive care nurse. This threat of Child Protection Acts was common, particularly if they had been primed in this way during pregnancy.

Similarly brainwashing was used extensively. Most in Catholic care had been taught what to think, how their role was to proceed and how to perceive themselves. Most of this was done kindly, but consistently with little or no effort to find out what the young woman was thinking or feeling.

Decades later, in such a state of mind, a woman suffering from PTSD and Pathological Grief still has the brainwashing imprinted upon her in doctrinal fashion during a time of entrapment and heightened crisis. It continues indefinitely with intrusive symptoms, irresolvable grief, and distorted personality, shaped by thoughts of keeping her shame a secret and attempts to mitigate her guilt.

In many women I have seen a secondary trauma when they eventually find out the lies told about the four weeks The Act provided for them to change their mind. The fobbing off, such as "ring me if you change your mind" then, "You can"t do that to your baby dear.", accompanied by various strings of fabricated pseudo-story about the baby"s current circumstances. In NSW they could go to the office of the Supreme Court building and change their mind during the first month, a secret that was tightly kept and never got out. This could hit them as an acute emotional shock. Many would have still not been able to do this because of their fear of The Welfare or from having sources of financial support hidden from them as well.

Labour wards in those days were Spartan. The smells were strange and various. Smells associated with doctors and hospitals are a frequent trigger for previous frightening circumstances, particularly when the mysterious pains of a primigravid labour are upon her already. The back pain of first labour is often both unexpected and mysterious. In a young woman"s predicament how does she ask about this, how does she seek relief or even the knowledge that this is usual" The whole experience is set up to amplify every aspect of trauma that might develop. How does she ask if the baby will be "alright" when the nurses will be defended against being close to her" She is surrounded by strangers.

Add to all this, the "induced labour" and drips generally. Often there might be unexpected injections, changing into a hospital gown, being put up in stirrups for examination, or being catheterized. People coming and going: who are they" What are they doing"

As labour progresses there may be brief words exchanged between staff. It there is hurry or sudden concern shown she thinks "is there something wrong" Is the baby okay"" When there is a change of plan, new equipment, others called in, she is vulnerable. And, at the end of all that, there is the primal index event:

My awareness of this fundamental enormity was to be focused three years after I had been made aware of the deep seated damage to both parents as a result of such coercive loss.

In September 1969 I was at the Tavistock Clinic in London on a Thursday morning for the Community mental Health class to be taught by Dr John Bowlby. Early he created the scenario of early humans living on the African Savannah and asked what would happen to the human infant if separated from its mother. There was a long silence. A brash Australian ventured to give a theoretical answer. He responded loudly, "It would be eaten!" That opened the way to learn the fundamental evolutionary biology of the survival of our species and the important knowledge of the development and strength of a babies" specific attachment to the familiar very close protecting adults.

THE TAKING OF THE BABY.

SYSTEMATIC CONTROL BY A CO-ORDINATED TEAM IN RESPONSE TO THE B F A OR UB-ve WRITTEN ON THE FILE

These people had a deliberate plan to prevent the young woman "bonding" to their baby. I know that this sentence sounds ridiculous and has been thought up by men, but these are nearly all women who are going to take the following three roles.
The delusional belief is that it is "easier" for the woman if she doesn"t "bond" to the baby. Much of this twaddle came out of research about ungulate animals and their calves. Research into primates was contradicting these notions. But there were many other rationalisations to mitigate their consciences.

Underneath it all, The Federal Act of 1965 to protect the mothers and babies from financial exploitation gave to religious organisations the responsibility to control most of it. Nobody was policing it.

The opportunity to halt the social changes developing in new directions after the Second World War was dropped in their lap. Most were not even going to read The Act, They knew what was best for society.

Hidden even from the sufferers, the chlamydia epidemic had started in the sixties. Effective contraception was available. There were new cultural influences particularly lyrics and major musicals. The sixties have been dubbed a time of sexual revolution. It added to the pressure to adopt from those who could not have their own children because of salpingitis.

The three roles of the team were:

THE CONTROLLER AT THE MOTHERS HEAD
THE ACCOUCHER
THE "WICKET KEEPER"

The accoucher properly gowned and gloved is delivering the baby. Instead of lifting the baby to the mother and sometimes resting the baby on the mother"s tummy with the cord still attached allowing blood from the placenta to return to the baby, she immediately puts two clamps on the cord and cuts it, then passes the baby with the clamp and cord to the "wicket keeper" who wraps the baby as she turns and walks out of the room with him. The baby may or may not have cried before this takes place.

While this is all being done, "the controller" is speaking firmly to the mother, keeping her lying down, obstructing her vision, and ready for the mother who will jump up to see her baby and in this crisis behave unpredictably.
This latter part of the baby taking would happen in rapid succession.

In those days, use of ergometrine sometimes left the placenta retained. Delivery of the placenta, even when properly separated, would usually done by pushing the contracted uterus downward and backwoods to push the placenta from the vagina. This is often totally unexpected and unexplained to a first mother in these circumstances. Sometimes the placenta would have to be removed manually under a general anaesthetic

In the Crown St Hospital this would be followed by the use of barbiturate sedatives as well as synthetic oestrogen injections to dry up milk. The hypnotic barbiturates used were pentobarbital (Nembutal orally), or pentobarbital sodium by injection, as well as their close relations Amytal and Sodium Amytal. Benzodiazepines and Chloral Hydrate were also used as adjuncts. Their aim would also be used (they said) to prevent her grief, but at Crown St it served the purpose of continuing until the fifth day when the mother would be able to request adoption. This was the form she had to sign.
But trauma and grief are aggravated by confusion and the inability to know what was going on, and later, served to build the anger at what was done while she was overwhelmed.

From past experience I am strongly aware that the style I am using might seem excessive and distressing of the reader; however when mother"s read my writings they say how much worse this time was for them, adding details and reasons, and then say that I have left out some of the most aggravating details that commonly occurred.. Accordingly I am trying to balance.

PTSD FROM THE FORCED ADOPTION PERSPECTIVE

There are many different modes and experiences of mothers, some of whom had obstetric complications, there were varying practices between hospitals and there were different mindsets among the mothers, but all had the feeling that the loss of the baby was so quick and so blurred by labour-ward drama and drugs, and eventually so total that it was impossible deal with: Helplessness, Shock, Disbelief.

They varied from the mother who had come from Melbourne with a wedding ring on her finger, to the younger girl who had accepted the repeated propaganda about being unable to keep her baby because she wouldn"t be able to afford it, or wouldn"t know how to care for him, and that he was going to a lovely home with a beautiful couple who couldn"t have their own baby. And if she did insist they would threaten to call in "The Wellfare" who would take her baby anyway.
Many were aware of the intense desire of all concerned to take their baby. One young woman teacher, whose twenty year old fianc‚ couldn"t get the permission signature from his mother to marry, was certain they would kill her to get her baby and was terrified for her own safety. She developed a PTSD with gross dissociation with derealisation and severe depression, to resolve much later to a multiple personality disorder where the damaged personality existed alternately with a militant one who led other mothers throughout the country to organise and ask for redress. This couple was married before the baby was even adopted, the mother found out many years later.

The thinking of the baby takers led by psychiatrist Dr Harry Bailey in NSW and by the obstetrician/gynaecologist Dr Lawson in Victoria was that heavy sedative drugging at the time would assist the mothers to " get over it" and allow them to start "a new life" without any problems. Most commonly used were Pentobarbital and Amylobarbitone, the injectable versions of which were Sodium Pentobarbital, and Sodium Amytal. They were sleep inducing drugs termed hypnotics, and pentobarbital is not to be confused with the longer acting sedative phenobarbital. Other hypnotic drugs such as chloral hydrate were used as were the benzodiazepines such as valium. The important issue for PTSD is that these drugs made the experiences surreal, confused, disorganized and inexplicable. They could not use their cognitive functions to get a reality view of their predicament. They precluded many of the healthy defenses against PTSD. The drugged experience made many of them much worse and probably more subject to the dissociative reactions that many experienced. But their direct effect made the women much more defenseless about losing their babies.

THE VARIED PRESENTATIONS OF PTSD

DISSOCIATIVE DISORDERS

What I was meeting in the seventies and eighties, was a variety of very severe dissociative disorders. There were mothers who were amnesic for the total experience of having a baby whilst living as a withdrawn inhibited machine complying with their relationships without initiative or good feelings. Sometimes over a decade later they would break though to their personality that existed before the trauma with sudden shock and dismay. Derealisation, numbness, negative schemata about themselves, pervasive experience of hopelessness, poor relationships chosen by others, and lack of positive affects was to be their lot. While such symptoms of these are very common among many of the mothers, when dissociation was a factor, these phenomena were "locked in".

DREAMs

Mother"s dreams many decades later are still invaded by babies, nurses, hospital corridors and trolleys. Some are as vague as their drugging, others are graphic nightmares.

INTRUSIVE IMAGES

However the invasion of their everyday consciousness with intrusive images of the hospital equipment, or their legs caught in stirrups, feet in the air waiting for something to happen was very common. Many times it was scenarios where they were being confronted so sign the consent form, or being bullied in the mother"s home. These would intrude like short video-tapes. One mother who had to have her membranes ruptured to induce labour had these many years later after her dissociation lifted.

AVOIDANCE

While many of these described above were associated with special circumstances, the one that was obvious across the broad range of mothers was observable in their avoidance behaviour. Triggers would bring back post-traumatic images similar to the ones experiencing intrusive images. The salient one is that 45% did not go one to have another child as they were supposed to do. The elaborate means that the others took to avoid any of the circumstances of their first labour was detailed and obsessive and even then the circumstances would trigger the horrors of their fears during the first labour. They would often have behaviour inexplicable in their anxiety and obsessive avoidances and resisting various procedures and even positions. Many had not disclosed to anybody they had a previous baby and it was a shamed secret which process itself destroyed their personality as I have described elsewhere.

But to avoid doctors, nurses and hospitals generally was so common that treatments for many urgent medical requirements were not done, not made, or disastrously delayed. This was seemingly inexplicable, unless you asked as I learned to do.

Some of the women did not tell me until many years of therapy that they avoided babies to extreme degrees. A friendship was ended or not begun because there was a baby or young child there. This would seem to be grief on the surface but when examined, there was a compulsive return to a wide series of post-traumatic issues that were being avoided. In a long therapy this was not able to be extinguished, but on the other hand the bleak life led by the patient lifted from self-deprecation, unhappy preoccupations, frank miseries, and left a better capacity to have fun.

RUMINATIVE PREOCCUPATION

Another post-traumatic consequence was going over and over the circumstances that led her to labour ward. These might be the circumstances of becoming pregnant that was often a one off event - totally unexpected. For a minority it was a traumatic rape as was the case in a patient who was raped by a policeman in a tunnel leading to the university. Sometimes it was about whether or not to have an abortion with accompanying guilt about even thinking this. At other times it was how she came to be so easily brain-washed to accept their view of what she should do.

I write this view of post-traumatic disorder as I will about the various forms of related depression with a strong sense of dismay about those who propose simplistic and brief therapy of these women with not the vaguest idea other than words by some author in a book about the extent of treatment those with PTSD and severe Depression require. I protested to the previous NSW premier in a letter about this and received a form letter that a friend had also received " grossly glib about how they had this all under control. The irony was that the funds were to go through an organisation all the mothers knew as a modern evolvement of a Baby Takers organisation of the sixties and seventies.
These women mostly need Psychiatrists with special training about their needs and the funding to do this without shortcuts.

TRIGGERS

We have discussed above their avoidance of triggers to do with hospitals, doctors, labour-wards and even having another baby. Triggers that are associated with humiliation and injustice deep within their damaged self can"t just be physically avoided.
Language itself is the common medium. They hear of relinquishing mothers as if they don"t know what the word "relinquishing" means. To them it is a blatant socio-cultural lie. Other words such as "chose" inflame them like the word "Chosen" sets of a lot of early teenage adoptees. "Decided" is another word that will provoke ironic laughter.
An offer had been made to The Leader of the Opposition Mr Tony Abbott to help him with this issue. It was not taken up. As a result terms such as "birth mother" were used and aroused cries of protest around the auditorium. Fortunately an aboriginal mother in the front row very close to him was able to communicate with him clearly early in the speech, and he was then heard in silence. He came up to her afterwards and warmly thanked her for her assistance.


THE MANAGEMENT OF PTSD FOR MOTHERS

There are many different forms of PTSD and there are a variety of
treatments most of which are quite effective.

However an early sharp focus on PTSD aspects of a mother"s distress can be a trap for inexperienced therapists. A wider view of their overall development, family of origin and its role in the loss of the baby, their level of adaptation to everyday living, the presence of functional close relationships, including employment, and their ability to cope socially with their immediate issue of getting to the therapist and accepting a professional relationship all need to be thought through carefully for issues that may be more urgent to them.

Thus my experience with a wide variation of mothers who have lost a baby to adoption is that the de-briefing assessment stage is long and needs to be detailed at the mother"s own pace. Even with a motivated mother and hour-long sessions I find I am finding new aspects of her PTSD or grief after many sessions as she becomes able to trust the therapeutic alliance and knows her feelings are received, contained and comprehended. It is important to say that this is difficult indeed to be with intense, unusual and alarming feelings that were new to a young man in his early thirties no matter what his experience in obstetrics was. I am indebted to the numerous mothers who serially taught me about these fearful occurrences and prepared me for the many I was to hear from then on. It was this learning the later ones would hear in response, and, above all, helped me to be oriented to the traumatic field behind it.

When there has been abrupt shock without support, followed by protracted fear it is important to be able to expose and share the feelings with the therapist. But the damage often leaves only a short intrusive picture, like a short video clip, sometimes it is a sound or a particular smell. The lead up and the actual scene and its happenings is often absent. In therapy one can"t help this without replacing it with a more everyday series of thoughts and memories to represent that circumstance whether they come back or are still amnesic.

This is sometimes done with systematic cognitive behaviour therapy which has been planned around the distressed memories and the confused thoughts and beliefs that have remained. Your build together new thoughts and memories around the traumatic
Event and it is as if you have found the damaged part of your hippocampus and are tidying it up together. At this stage mindfulness therapy can build a good platform for long-term benefit.

Other therapists use bilateral sensory therapy to help blocked brain function. Some of these are simple and inexpensive, some formal and very expensive. However they may not work, particularly when followed up in the longer term.

When there is dissociation of various degrees both aspects of the dissociation are brought together in the safety of the therapeutic alliance. This is easier said than done because the fear and anger of the memories defended against may be gargantuan, and the safety of everyday capable functioning is under jeopardy.
It is important to know that protracted grief and PTSD can both overwhelm the mother"s psyche, especially if they are together.
The word "decompensation" is used when the overwhelming brings about "breakdown". The overwhelming feelings are usually followed by depression. Sometimes depression of other types occur such as the depression of being alienated called "anomie", that is associated with bleak circumstances and loneliness. Sometimes there is a more acute depression because there is no really close other there. The decompensation depression when they don"t lift by themselves will mostly be helped by medications such as fluoxetine and sertraline in relatively small doses.
Follow up studies have often found however a huge amount of secondary disability when drugs are used to cover grief, or when the causes of the depression are multiple. Some depressions of hereditary origin sometimes need medication early. But in many instances there is treatment with benzodiazepines or major tranquillisers that produce secondary problems including addiction. Self-medication with recreational drugs and alcohol are responsible for many serious admissions to both types of hospital and are large in bad outcome statistics.

Family therapy is often indicated when an overview gives indications that their PTSD and grief are misunderstood by their immediate family. When a family member does not understand the strange nature of PTSD at times, and particularly that many of the features have become hard-wired into the nervous system from the beginning, their tolerance of living with it can be quite limited. The sufferer of PTSD has often been loath to burden their family with the details of what they experienced subjectively, and don"t realise that their family may be able to follow the therapists lead in
reshaping these experiences to take away the high emotional energy invested in them. There are some instances where the family is suitable where such enlisting family members in the therapy may short cut what is often a long individual work to a much shorter process.
This is not always possible and if mistakes about the "suitability" of the family for this are made; it can even backfire.

Above all in such treatment experience, kindness, and the development of a functional therapeutic relationship is what is required to advance healing where this is possible. And you don"t really know until you try it.

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