Reported prevalence of postpartum posttraumatic stress disorder (PTSD) in community samples was 3.1% and in at-risk samples was 15.9% in Grekin and O'Hara's (2014) meta-analysis. In a United States national survey conducted by Childbirth Connection, 9% of the sample of 1,573 women screened positive for meeting diagnostic criteria for PTSD after childbirth (Beck, Gable, Sakala, & Declercq, 2011). Mental health disorders have provided fruitful areas for researchers to conduct metaphor analyses. Examples of these frequently researched disorders include depression (Charteris-Black, 2012; Fullagar & O'Brien, 2012) and anorexia (Bates, 2015; Knapton, 2013). No studies, however, were located that examined how metaphors shape the experience of PTSD in the general population let alone, more specifically, in PTSD due to traumatic childbirth.

Figure. No caption available.

Why are metaphor analyses so helpful to clinicians? "The reason is that metaphor plays a role in human thought, understanding, and reasoning and, beyond that, in the creation of our social, cultural, and psychological reality. Trying to understand metaphor, then, means attempting to understand a vital part of who we are and what kind of world we live in" (Kovecses, 2010, pp. xii-xiii). Individuals suffering with mental health disorders may draw on various metaphorical expressions to articulate their everyday experiences of these illnesses and to communicate more effectively with their nurses and other clinicians. The overall purpose of this metaphor analysis was to examine the language used by mothers experiencing PTSD due to traumatic childbirth for metaphors as a rich source of insight into this mental health disorder.

Posttraumatic Stress Following Traumatic Childbirth

Diagnostic criteria for PTSD according to the Diagnostic and statistical manual of mental disorders- 5th Edition (DSM-V) (American Psychiatric Association [APA], 2013) are based on exposure to actual or threatened death, serious injury, or sexual violence. The four major symptom categories identified in the DSM-V include recurring intrusive thoughts or dreams related to the traumatic event, persistent avoidance of reminders of the trauma, marked negative changes in thoughts and mood, and marked alterations in arousal and reactivity, such as, irritable behavior, angry outbursts, or disruption of sleep.

Although the DSM-V does not specifically identify childbirth as an example of a traumatic stressor, childbirth certainly can qualify as a traumatic event (Beck, 2004a; Grekin & O'Hara, 2014). There was one difference, however, in the diagnostic criteria for PTSD that Beck (2004a) found in her phenomenological study of traumatic childbirth. The DSM-V criterion that a person be exposed to actual or threatened death, serious injury, or sexual violence was not applicable to some of the women in Beck's research. For some of the women it was not that they were exposed to actual or threatened death of either themselves or their unborn infants, but instead, it was that they were stripped of their dignity during childbirth. Beck's variation in the definition of PTSD was used in this metaphorical analysis.

Traumatic childbirth and its resulting PTSD can have long-term chronic effects on mothers, their families, and clinicians. Traumatic birth can have an impact on breastfeeding (Beck & Watson, 2008), the anniversary of traumatic childbirth (Beck, 2006), subsequent childbirth (Beck & Watson, 2010), fathers (Beck, Driscoll, & Watson, 2013), and clinicians present during the traumatic birth (Beck, 2015). With such chronic negative effects of traumatic childbirth, identification and management of PTSD and its symptoms need to be in the forefront of care for these struggling mothers and their families. An international group of clinicians and researchers met to assess the current issues and recommendations regarding PTSD following childbirth (McKenzie-McHarg et al., 2015). They concluded that at present there is relatively little research into assessment of PTSD in mothers after birth trauma. A metaphor analysis of how women describe their experiences of PTSD following childbirth can provide a unique approach to helping in the identification and assessment of mothers who are suffering with this trauma and stressor-related disorder.

Metaphor

A metaphor principally is "a way of conceiving of one thing in terms of another, and its primary function is understanding abstract, emotional or other experiences" (Lakoff & Johnson, 1980, p. 36). A metaphor is more than just words. Only when a metaphor is linked to its experiential basis can that metaphor increase our understanding. Lakoff and Johnson developed the cognitive linguistic view of metaphor. Cognitive linguists define metaphor as understanding a conceptual domain in terms of another conceptual domain (Kovecses, 2010). These two domains of a conceptual metaphor have special names: source and target domains. The source domain is the conceptual domain where the metaphorical expressions come from to help understand the target domain. The formula of A IS B can be used to characterize a metaphor. The target domain is A, whereas the source domain is B. A is understood in term of B.

There are different types of metaphors. Some types of metaphors include structural metaphors, container metaphors, and personification metaphors. In structural metaphors, the source domain provides more specific rich, concrete structure for the target concept. In container metaphors as Lakoff and Johnson (1980) explain "even when there is no physical boundary that can be viewed as defining a container, we impose boundaries-marking off territory so that it has an inside and a bounding surface-whether a wall, a fence, or an abstract line or plane" (p. 29). Personification is yet another type of metaphor where we see something that is nonhuman as human. In this type of metaphor physical objects are specified as being a person. These metaphors help us make sense of an experience in terms that we can understand and in turn provide valuable guidance for clinicians in providing evidence-based practice.

Study Design and Methods

Qualitative Secondary Analysis: The Corpus

Secondary qualitative data analysis involves using an existing data set to answer a research question that differs from the original research question in the primary study. A unit of analysis in this secondary analysis, metaphors, differed from that in the primary study. The primary research was a phenomenological study of PTSD due to traumatic childbirth (Beck, 2004b). Its purpose was to describe the essence of mothers' experiences of PTSD. Women were asked to describe in depth their experiences of PTSD following childbirth and sent their descriptions to the researcher on attachment. Approval to conduct the study had been obtained from the university's Institutional Review Board. The Internet sample, recruited from Trauma and Birth Stress (http://www.tabs.org.nz), consisted of 38 mothers from four countries: United States, United Kingdom, New Zealand, and Australia. Informed consent was emailed by attachment to interested participants. Women electronically signed it and returned it to the researcher by attachment. Diagnosis of PTSD was made by the mother's self-report that this disorder had been diagnosed by a healthcare professional. Women were not asked if they had comorbid disorders of PTSD and postpartum depression. These are limitations of the sample. Examples of the types of traumatic childbirth that the participants described included stillbirth/infant death, forceps/vacuum extractions, emergency cesarean birth, fear of epidural, inadequate pain relief, postpartum hemorrhage, preterm birth, severe toxemia, and degrading experiences.

In this Internet sample from the primary study, 21 mothers (55%) had vaginal births and 17 women (45%) had cesarean births. Twelve women (32%) were primiparas and 26 women (68%) were multiparas. Regarding marital status 34 mothers (90%) were married, 2 women (5%) were single, and 2 mothers (5%) were divorced. Of the 17 women who shared their education level, 15 had at least a college degree. The mean age of the mothers was 33 years. When the women participated in the study the range of time from when they had given birth was from 6 weeks to 14 years.

Data saturation was reached earlier than the final sample size of 38. Nine of the 38 women who had participated in the study validated the study's findings. The researcher had the opportunity to meet with these 9 mothers while speaking at a conference on traumatic birth in New Zealand. All 38 mothers' data were included in this secondary analysis. Using Colaizzi's (1978) phenomenological method, analysis of women's descriptions of their experiences of PTSD following birth trauma revealed five themes: (1) Going to the movies: Please don't make me go; (2) A shadow of myself: Too numb to try and change; (3) Seeking to have questions answered and wanting to talk, talk, talk; (4) The dangerous trio of anger, anxiety, and depression: Spiraling downward; and (5) Isolation from the world of motherhood: Dreams shattered.

The corpus for this metaphorical analysis consisted of 124 typed pages from the primary study. A corpus consists of a large collection of texts that come from natural language use and not from texts that were developed specially for the illustration of a point about language (Charteris-Black, 2004). Both quantitative and qualitative approaches can be used in corpus-based analysis of metaphors. The qualitative approach is needed to determine what will be considered as metaphor, whereas the quantitative approach is necessary to assess the frequency of metaphors in the corpus.

Data Analysis

The Pragglejaz Group (2007) developed the Metaphor Identification Procedure (MIP) as a method for identifying metaphorically used words in discourse. Below are its steps:

"1. Read the entire text-discourse to establish a general understanding of the meaning.

2. Determine the lexical units in the text-discourse

3. (a) For each lexical unit in the text, establish its meaning in context, that is, how it applies to an entity, relation, or attribute in the situation evoked by the text (contextual meaning). Take into account what comes before and after the lexical unit.

(b) For each lexical unit, determine if it has a more basic contemporary meaning in other contexts than the one in the given context. For our purposes, basic meanings tend to be more concrete (what they evoke is easier to imagine, see, hear, feel, smell, and taste); related to bodily action; more precise; and historically older;

(c). If the lexical unit has a more basic current-contemporary meaning in other contexts than the given context, decide whether the contextual meaning contrasts with the basic meaning but can be understood in comparison with it.

4. If yes, mark the lexical unit as metaphorical." (p.3)

Below is an example of MIP in this analysis of metaphors used in mothers' descriptions of their experiences of PTSD following childbirth.

"Mostly/ from/ the/ time/ he/ was/ born/ right/ up/ until/ recently/ I/ was/ like/ a/ robot/. I/ think/ I/ am/ a / bad/ mother/ because/ I'm/ a mechanical/ mother/ to/ him/."

Out of the 30 lexical units in these two sentences, two lexical units were judged as being used metaphorically: "robot" and "mechanical." Once all the lexical units were identified in the corpus, they were sorted into the metaphors most often used by mothers to describe their PTSD. Counts for each of these metaphors were done to identify their order of frequency.

Results

Nine different metaphors emerged from mothers' descriptions of their experiences of PTSD following traumatic childbirth (Figure 1). Each of these metaphors is described now in their order of frequency.

Figure 1. Word Cloud of PTSD After Birth Metaphors

PTSD due to Childbirth IS a Mechanical Robot

Common metaphorical expressions included zombie, numb, detached, empty shell, and mechanical. This structural metaphor revealed troubling implications regarding mother-infant bonding. Due to their traumatic births some women described feeling like a zombie caring for their babies: "I just felt very mechanical and detached. I just went through the motions of looking after my baby. I did what was required like a robot." One mother shared she was "totally shell-shocked with what happened during labor and delivery and became a zombie. I was afraid to look at myself in the eye. I felt like my soul had died giving birth." Another woman described that "I am having the hardest time trying to overcome this empty feeling of being dead. Everything is emotionally flat and a blur." Although this mother admitted that "I find I react slower to my son's tumbles and falls. I seem to watch them in slow motion and have lost that mother's ability to leap tall buildings in a single bound."

PTSD due to Childbirth IS a Ticking Time Bomb

For this structural metaphor women repeatedly shared how on a daily basis they were ready to explode. Trying to suppress the traumatic memories of their childbirth consumed mothers. Women not only tried to suppress the reliving of it all but also the festering anger they felt regarding their birth trauma that should not have happened. Here are some examples of their use of this metaphor to help explain their experiences with PTSD.

"I have to grit my teeth, almost crying to get through fighting memories that want to explode from inside me."

"For the next year I had to avoid the emotional landmines that were out there waiting for me each day."

"I know if I had gotten all my feelings back at once, I would have blown some mental fuses as a result of the power surges."

Other women who adopted this metaphor described it this way:

"As time went on, I knew that I was personally 'too hot to handle' and not nice to be with, as invariably you could not help but have some of your inner state ooze or jump out at those who did come close."

"I tried not to boil over each day, to keep a lid on it."

"To live daily with the fact that you were like a time bomb ready to go off was dreadful."

PTSD due to Childbirth IS an Invisible Wall

In this secondary qualitative data analysis of women's descriptions of their experiences living with PTSD following traumatic childbirth, two types of container metaphors were identified. The most frequent use of this container metaphor was the type where the PTSD surrounded the mothers. Women's use of this container metaphor has important implications for mother-infant bonding as the following quotes revealed:

"I felt as if there was a wall between this child and myself."

"Intimacy with my baby has a brick wall around it."

"I wanted to feel the feelings-to be a whole person, to be tuned physically, emotionally and spiritually to this new birth of this chosen child. But these feelings and spirituality were held at arm's length from me through some type of wall which prevented me from feeling and acknowledging my new role as a mother."

"Something I desperately wanted to feel, motherhood-I wanted to experience and embrace this. Why was I chained up in a vice-like grip of pain separating me from motherhood? This was my Gethsemane- my agony in the garden."

The second less frequently used container metaphor by mothers was the container of the self who was experiencing PTSD. One mother shared that she "put my trauma into sealed windows and locked the door." Another woman admitted that "I put up strong blocks and now I don't know how hard it will be to break through the wall to not need the blocked defenses but I want to." Others' use of this metaphor included:

"I need help to deal with my traumatic cesarean emotions. I boxed them up most of the time."

"My way of coping was to just block the whole traumatic birth away in a compartment."

PTSD due to Childbirth IS a Video on Constant Replay

For this structural metaphor mothers frequently used the concrete source domain of a video playing nonstop in their mind to help explain this aspect of the target domain of their PTSD. Distressing to these mothers was the total lack of control they had over stopping their "movies" of their traumatic births. The following quotes illustrate the women's adoption of this metaphor:

"It was like having a picture in a TV screen going on all the time, without my having any say or control."

"The last 20 minutes or so before he was born played over and over again in my head for a year."

"No one sees the loop track that runs when I close my eyes."

"When I'm alone that is when I watch my movies."

Featured predominantly in mothers' description of this metaphor was its effect on disrupting their sleep. Mothers already were sleep deprived due to their infants' nighttime feedings. Their PTSD now compounded their lack of sleep and resulting fatigue.

"The birth experience played in my head non-stop for almost 6 weeks afterward. The labor experience was what I woke up to, went to sleep to, and thought about in the middle of the night."

"Often I woke up sweating and trembling and feeling panicky. Then the video loop would start again."

"After the baby's first night feed, I could never get back to sleep because the birth kept playing in my head like a video on automatic replay."

PTSD due to Childbirth IS Enveloping Darkness

Many participants described the experience of PTSD following traumatic childbirth through the metaphor of enveloping darkness. This structural metaphor examined the voices of women in how they shared the darkness that surrounded their world of new motherhood. How different this was from what they had dreamed new motherhood would be. These quotes that follow reflected this difficult dark time in women's lives as they struggled in their new role as mothers.

"I could feel myself falling into spiritual and emotional darkness."

"Consequently all my burning issues had gone underground in darkness."

"I cannot remember too many of the actual emotions but do look back at it as darkness-a very dark period."

"Sometimes I felt as if the darkness of a black cloud of doom was hanging over my head and following me everywhere."

PTSD due to Childbirth IS a Dangerous Ocean

Source domain metaphors focusing on the sea, the ocean, waves, and floodgates frequently appeared in women's descriptions of the target domain of PTSD due to birth trauma. Women felt like they were drifting at sea with up swells of waves as they tried to keep their heads above water and not drown. As one mother described, "in a sea of pain and abandonment I relentlessly steamed through the dismal empty seas powered by my desire to care for my baby."

Another woman shared that "sometimes I describe the symptoms one has to live with is like one is constantly bobbing up and down in the sea and occasionally one's up raised hand is seen and seldom does another person ever bother to try and reach out to ease your situation by raising you out of that water."

Some women experienced "waves of panic," whereas others talked about the emotional up swells of waves of pain as they "waited for the waves to swallow me up." Keeping this mother's head above water was a daily trial: "I wanted to die. I thought about leaving the baby with someone while I ended my life. I honestly thought she would be better off without me. The guilt is indescribable. I had a healthy baby, a good husband and a family support but I was just managing to keep my head above the water."

Floods and floodgates were other metaphors expressed that were related to water. Women described "being afraid of the floodgates of emotions opening" and there being "a crack in the door and all the horror of the birth would all come flooding out."

PTSD due to Childbirth IS a Thief in the Night

In this personification metaphor PTSD following traumatic childbirth was given a human quality by some mothers as they referred to PTSD as a thief. The PTSD robbed mothers of joy, of energy, and their dreams of motherhood. Here are a few examples of their use of this metaphor.

"I feel I was robbed of the joy one should feel over the birth of their first child. Also the joy of watching everyone else be so excited and happy about my new baby. I didn't enjoy or share in their emotion."

"I desperately wanted to feel 'over it' as I just felt robbed of joy and energy to put into doing other things like being a mom."

"I feel like I had been cheated out of the joy of a new baby by being emotionally scarred by the horrible events that took place during labor."

PTSD due to Childbirth IS a Bottomless Abyss

Many women described their experience with PTSD due to traumatic childbirth as a bottomless abyss in this structural metaphor. They referred to feeling as if they were either teetering at the edge of a vast chasm or had actually fallen already into this bottomless pit. This metaphorical expression was reflected these quotes.

"I don't know how far I will come before I can speak about the birth without standing on the abyss and pulling myself back. Sometimes I can, sometimes it takes all my strength to find myself again."

"I felt like I was being sucked into an abyss. For a moment I looked over into an abyss."

"I had to manage to claw my way out of this frightening abyss."

PTSD due to Childbirth IS Suffocating Layers of Trauma

The structural metaphor of layers of trauma provided yet another aspect of PTSD as experienced by new mothers. Women repeatedly used the image of layers of trauma especially around their heart, which prevented them from reaching out and bonding with their precious new babies. Here are examples of a few quotes from the corpus illustrating this metaphor:

"I know the agony of a woman faced with death at the time of birth. There is no greater pain, no deeper pain. My heart was tortured by layers of trauma."

"Again I tried to acknowledge my baby. I knew that there were great layers of trauma around my heart."

"I suffered with thicker and thicker layers of torture and was in need of a massage and love and relief."

Some mothers used this metaphor of layers when describing their work with therapists.

"I remember telling her that I had talked about the birth a lot but that in doing so it didn't seem to put anything to rest. It was a though I was peeling away the layers of an onion. The next layer almost the same size and shape as the previous layer."

Yet again the metaphor of layers was used to explain how family and friends reacted to a mother's PTSD. For example, "It was very clear that either no one had the time or the inclination to allow those layers to come off or for those issues to be permitted expression and allowed to be exposed to the light of day, rather than keeping them hidden under all the layers."

Clinical Nursing Implications

"Metaphors are like a series of brush-strokes-so that no single metaphor adequately expresses the state" (Charteris-Black, 2012, p. 213). Different metaphors can structure different aspects of a concept. Nine different metaphors helped to structure women's experiences of PTSD following childbirth. Metaphors used by these mothers can provide rich insight into their daily issues that are not captured by medical jargon. Metaphorical expressions can open up a space for women to explain what they are experiencing. Clinical nursing implications can be derived from the valuable insights that metaphors can reveal.

When comparing the nine metaphors used by women to describe their PTSD due to traumatic childbirth with the four major categories of PTSD symptoms according to the DSM-V (APA, 2013), some patterns were revealed. By far the most frequently used metaphors fell under the category of negative alterations in cognitions and mood. In this symptom category, the DSM-V includes feelings of detachment from others, persistent inability to experience positive emotions, and persistent experience of negative emotions. The metaphors that fell under this symptom category were (1) mechanical robot, (2) invisible wall, (3) enveloping darkness, (4) dangerous ocean, (5) thief in the night, (6) bottomless abyss, and (7) suffocating layers of trauma. The symptom category of intrusive and involuntary distressing memories of the traumatic event was captured by one metaphor: a video on constant replay. The DSM-V symptom category of persistent avoidance of reminders of the trauma was highlighted in one metaphor: an invisible wall. Marked alterations in arousal was identified by two metaphors: (1) a ticking time bomb and (2) a video on constant replay that resulted in disrupting sleep.

Charteris-Black (2012) in his metaphorical analysis of depression reported that one of the metaphors was depression IS darkness. A similar metaphor was used by mothers suffering from PTSD due to traumatic childbirth. A limitation of this metaphorical analysis of PTSD in mothers of traumatic births was that in the primary study the participants were not asked if they also suffered from depression. Comorbidity of depression and PTSD has been documented in postpartum women (Beck et al., 2011). A possible alternative perspective of the metaphor of PTSD due to childbirth IS enveloping darkness can be that the women who voiced this metaphor may also have been experiencing some depression. Documentation of postpartum depression and PTSD due to traumatic childbirth is necessary in future research studies in order to clarify alternative perspectives in the use of metaphors.

When a metaphor is understood, something new is created (Ortony, 1993). These nine metaphors give a new voice to women's experiences of PTSD following traumatic births. Metaphor analysis can be a rich source for maternal-child nurses' evidence-based practice

Suggested Clinical Nursing Implications

The first step in helping women struggling with PTSD after birth is to identify who they are.

Listen intently to see if mothers are using any of these metaphors to describe how they are feeling after giving birth. If women are, they can be screened for posttraumatic stress symptoms.

Due to comorbidity of PTSD and depression, mothers who are suffering from one of these postpartum mood or anxiety disorders should be screened for the possibility of the other one.

A referral to a mental healthcare specialist may be necessary if nurses suspect PTSD.

Due to troubling implications regarding mother-infant bonding described in some of the metaphors, nurses need to be vigilant in observing mothers with their infants to identify a potentially struggling dyad.

Nurses can educate family members to the importance of listening and permitting women to express their experiences of traumatic childbirth so that some of the layers of their trauma can be uncovered.

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References