Postpartum psychosis is a psychiatric emergency and the most severe postpartum mental disorder. In a systematic review of epidemiological data in six studies, VanderKruik et al. (2017) reported the incidence of postpartum psychosis ranged from .89 to 2.6 in 1,000 women in five studies and the prevalence in one study was 5 in 1,000 women. Symptoms can include delusions, hallucinations, racing thoughts, insomnia, mood lability, agitation, and confusion (Spinelli, 2021). The Diagnostic and Statistical Manual-5th edition-TR (American Psychiatric Association, 2022) includes a specifier of "with peripartum onset" if the onset of symptoms begins during pregnancy or in the first month after birth.
In the United States among pregnancy-related deaths for 2017-2019, the Maternal Mortality Review Committees determined that 8.4% (n = 82) were due to suicide (Trost et al., 2022). In the United Kingdom Confidential Enquiries into Maternal Deaths and Morbidity (Knight, 2018), maternal suicide was the leading cause of direct deaths occurring during pregnancy through the first 12 months postpartum, with 1 in 7 deaths between 6 weeks and 1 year after birth due to suicide. Infanticide, which is the killing of a child within the first year of life, can be another tragic consequence of postpartum psychosis. Brockington's (2017) infanticide review of 321 cases of childbearing psychosis found a different rate of infanticide depending on whether the woman experienced postpartum psychosis with depression (4.5%) or postpartum psychosis without depression (<1%).
Persons with psychosis in the general population have reported experiencing posttraumatic growth, which refers to positive changes in a person's life or beliefs due to their struggle with psychosis (Ng et al., 2021). There are very limited data about posttraumatic growth following postpartum psychosis in the literature. Therefore, the research question we investigated was "Are there positive changes in women's beliefs, emotions, and behaviors that may result from their struggles with having had postpartum psychosis?"
Theoretical Framework: Posttraumatic Growth Model
Posttraumatic growth refers to the positive psychological changes in emotions, cognitions, and behaviors that result from a person's struggle with stressful life events that challenge the person's core beliefs and assumptions about the world (Tedeschi & Calhoun, 2004). Posttraumatic growth involves changes in an individual beyond pre-trauma levels. Posttraumatic growth does not occur as a direct result of the trauma but instead occurs due to a person's struggle with the aftermath of the trauma. This growth can occur along with the distress of the trauma. In their posttraumatic growth model, Tedeschi et al. (2017) identified that there are five possible domains of posttraumatic growth: Appreciation of Life, Relating to Others, Personal Strength, New Possibilities, and Spiritual-Existential Change. With a greater appreciation of life comes a change of priorities in one's life and an increased appreciation for what a person still has. Creating more meaningful relationships with others includes a sense of increased closeness of relationships with people in one's life. Recognizing an increase in one's personal strength involves a feeling of self-reliance and knowledge that one can handle difficulties. New possibilities involve an individual establishing a new path in life and developing new interests that would not have happened otherwise. In spiritual and existential change an individual develops a better understanding of spiritual matters and a stronger religious faith.
Calhoun and Tedeschi (1998) used the metaphor of an earthquake to explain posttraumatic growth. The traumatic event needs to be strong enough to shake the foundations of an individual's core beliefs and force a reexamination of them. These core beliefs or assumptions about the world include six areas: the meaning of life, the belief that things happen to people are fair, relationships with other persons, one's strengths and weaknesses, spiritual beliefs, and a person's value as an individual (Cann et al., 2010). Cognitive rebuilding is needed after trauma just as physical buildings need to be rebuilt after an earthquake. In cognitive rebuilding, an individual reassesses their core beliefs about the world. Not all individuals who experience trauma will develop posttraumatic growth. If people do experience this type of growth, they do not necessarily experience growth in all five domains. Tedeschi et al. (2018) proposed a five-phase intervention for posttraumatic growth: psychoeducation, managing emotional distress, constructive self-disclosure, develop narratives of self, and articulating new principles of life and goals.
Postpartum Psychosis
Four recent qualitative studies provide insight into the experience of postpartum psychosis by using women's own voices (Beck, 2020a, 2020b; Forde et al., 2019; Jefferies et al., 2021; Wass et al., 2022). None of these studies, however, specifically examined posttraumatic growth. The samples in these studies were from women in the United Kingdom and Australia. In a qualitative study of 13 women with postpartum psychosis and eight family members in the United Kingdom, Forde et al. (2019) explored their experiences and preferences for psychological interventions. Three main themes developed: (1) seeking safety and containment, (2) recognizing and responding to the psychological impact, and (3) planning for the future.
Beck (2020a) conducted a narrative analysis of eight first-person stories of postpartum psychosis that were posted on the Action on Postpartum Psychosis website. Burke's (1969) method of narrative analysis provided the key elements of story: scene, act, purpose, agent, and agency. Burke's method focuses on identifying problematic areas, known as ratio imbalances, between any two of these elements. The ratio imbalance that appeared most frequently in these eight narratives was between the agent (the woman) and the psychological act of her delusions or hallucinations (Beck, 2020a). The ratio imbalance between scene to agent was the second most often problematic area identified. Problematic scenes for the agent (the woman) included the electroconvulsive therapy room, admission to a psychiatric hospital, and nighttime.
Ten women in Australia who had recovered from postpartum psychosis in the last 10 years participated in a qualitative interpretive study of their experiences (Jefferies et al., 2021). Jefferies et al. (2021) used the allegory of a river to present five key themes: (1) the banks of the river represented family history or pre-existing mental illness after a previous pregnancy; (2) muddy water represented problems during pregnancy, childbirth, or the early post period; (3) gathering momentum represented subtle changes in thoughts and behaviors; (4) the rapids represented symptoms of psychosis; and (5) the misty pool represented recovery.
Wass et al. (2022) conducted a grounded theory study on the impact of postpartum psychosis on couples' relationships with eight women and six partners in the United Kingdom. The process the couples experienced included the following four stages: (1) Our relationship before, (2) Relationship tests, (3) Picking up the pieces, and (4) Feeling like me again. These four qualitative studies helped shed light on women's experiences of postpartum psychosis; however, none of them focused on posttraumatic growth.
Methods
Design
We used a qualitative descriptive design which produces results that are closer to the data as given as opposed to a grounded theory or phenomenological design (Sandelowski, 2010). Although closer to data, qualitative descriptive designs are still interpretive and are not atheoretical. "The value of qualitative description lies not only in the knowledge its use can produce but also as a vehicle for preventing and treating research methods as living entities that resist simple classification" (Sandelowski, 2010, p. 83).
Procedure
We believe it is important that marginalized communities, particularly those that have experienced trauma and face stigma, are empowered, and served by research with them. Members of such communities can bring unique insights and value to the design, implementation, and analysis of research. These beliefs led us, one as an academic researcher, and one as a survivor-leader and independent scholar, to partner and fully collaborate on all aspects of this research. We hope this form of participatory research, involving survivors and researchers working together, becomes more common as it is consistent with the social-justice slogan "Nothing About Us Without Us" (Charlton, 1998).
We began recruitment after receiving the University's Institutional Review Board approval. Inclusion criteria included participants who (a) experienced postpartum psychosis, (b) experienced some aspect of personal growth after postpartum psychosis, (c) was at least 18 years of age, (d) could read and write English, and (e) could articulate their experience. We recruited women for 8 months through postings on three Facebook groups: (1) Postpartum Psychosis Forum (now renamed Pregnancy and Postpartum Psychosis Forum), (2) Postpartum Psychosis Activism and Advocacy, and (3) Beyond PP in Aus/NZ. The second author in this study is the founder and administrator of the first group and is the lead administrator of the second. The first author's university email address was included in the recruitment notice. Interested individuals were sent the directions, information sheet, and demographic characteristics form on attachment. If a woman agreed to participate, she was asked to respond to the following statement: Please describe in as much detail as you can remember your experiences of any positive changes in your beliefs or life as a result of your having had postpartum psychosis. Participants were told that if recalling their postpartum psychosis was upsetting, they did not have to finish writing their story. Participants sending their narratives on attachment to the researchers implied their informed consent. Recruitment continued until we reached saturation of the data when no new findings were discovered.
Confidentiality of the data was protected in several ways. Research records were labeled with a code and locked in a password-protected computer in a secure location. Information in publications and conference presentations would be presented in summary format with no identifying information. Instead of identifying participants by number, their comments are decontextualized to further protect their identities.
Data Analysis
Content analysis is a method that can be used with either qualitative or quantitative data and can be either inductive or deductive. In deductive content analysis existing theories, concepts, or categories are examined in a different context with new qualitative data (Kyngas & Kaakinen, 2020). The starting point is prior theoretical knowledge. Research questions and data collection methods used in qualitative deductive content analysis are based on this prior knowledge.
In deductive content analysis, we used prior theoretical knowledge to create the analytic matrix that guided the analysis of qualitative data (Kyngas & Kaakinen, 2020). We used the five domains of posttraumatic growth for the analytic matrix. All 13 narratives were reviewed for content and coded for correspondence with the domains of posttraumatic growth. We selected sentences that described one of the domains of posttraumatic growth as the unit of analysis. Codes were labels given to each unit of analysis and we recorded them in the analysis matrix. Both authors read the entire dataset and agreed on the categorization of the units of analysis into which of the five domains of posttraumatic growth they referred to.
Trustworthiness
Rigor was addressed by attending to credibility confirmability, transferability, and dependability (Lincoln & Guba, 1985). Credibility was enhanced by the first author writing field notes during data collection and analysis and by keeping a reflexive journal. Inclusion of rich, vivid quotes from participants helped increase the credibility and transferability of the findings. Recruitment continued till data saturation which also added to the credibility of the findings. An audit trail of the data analysis steps was kept for purposes of dependability. Confirmability was achieved by the two authors each independently reading the dataset, sharing their reviews with each other, discussing any differences, and reaching consensus on categorization of units of analysis into which of the five domains of posttraumatic growth they referred to.
Results
Sample
The sample consisted of 13 participants from the United States (n = 9), Australia (n = 2), United Kingdom (n = 1), and New Zealand (n = 1) (Table 1). Mean age was 40.3 years with a range from 30 to 69 years of age. The range of the length of time from when the participants had experienced postpartum psychosis was from 2 months to 43 years. Ten women were White, one was Hispanic, and one was European New Zealander. One participant left this characteristic blank on the form. All had at least a bachelor's degree and 10 were married. Most had vaginal births (n = 11). Eight women were multiparous women and five were primiparous women. All participants were diagnosed with postpartum psychosis and 12 had been hospitalized. Due to delusions and hallucinations during their postpartum psychosis, the actions of two participants threatened their child's life. Although no lasting harm was done, both women went to trial and were found not guilty by reason of insanity.
Relating to Others
This was the posttraumatic growth domain that had the most units of analysis (n = 54). Increased empathy and compassion for others was quite evident in participants' stories of their posttraumatic growth as this quote illustrates Trials give us more capacity to empathize with others and their pain, and to love unconditionally. One participant was a health care worker and recalled I was very judgmental about the psychotic patients we saw...I now realize how terrible and traumatizing these experiences are and believe I am a much better clinician for what I went through. Participants realized many people were struggling silently and as a result became less judgmental. As this participant recalled, The most dramatic change in my life after my postpartum psychosis was an increase in empathy for individuals who struggle and face challenges in their lives.
Some recounted that their relationships with their partners were strengthened. One participant wrote The beauty of my marriage was cranked up a notch after my postpartum psychosis episode. Seeing the selfless love and care of my husband for me when I've been at my worst has been nothing short of amazing. Participant stories indicated that marriage counseling can significantly aid this result. As one woman explained, My husband and I have had counseling and our marriage and teamwork are better than it has ever been.
Most participants stressed the importance of rebuilding the bond and relationship with their children that had been interrupted by their postpartum psychosis, as this quote illustrates. I'm blessed to have my children and not only are they alive, but they are thriving and my relationship with both of them is just as loving, trustworthy, and safe as it was for all the time before I ever encountered postpartum psychosis.
Participants repeatedly shared that they were so grateful for all the love and support they had received from family, friends, coworkers, and church members during their postpartum psychosis. Connections with these supportive individuals in their lives were deepened. Another type of relationship participants reported as being significant was enjoying being part of a sisterhood. Connecting with other women who have experienced postpartum psychosis created a special bond that one participant described as, like sisters to me.
Personal Strength
Personal strength was the domain with the second highest number of segments (n = 39). Confident, courageous, capable, and brave were some of the adjectives participants used to describe themselves in their growth after postpartum psychosis. A participant recounted, I have been able to take a traumatic period of time and find the positive in it. I am a fighter. Participants shared how their confidence in themselves greatly increased in many aspects of their lives. One notable area was participants' increase in confidence in their role as mothers after repairing and mending the bond with their children that was weakened due to the lost time with them during the worst of their postpartum psychosis. One participant recounted, I was found not guilty by reason of insanity and ever so painfully began the process of putting my life back together again and rebuilding with my children...With time I have much more confidence in parenting my children and my role as a mother to them now that the bond has been restored.
Increased confidence in the workplace and in their careers was also a part of participants' posttraumatic growth. One woman explained that in her workplace her co-workers would see a confident professional leading others and have no idea what she had been through. I see my confidence as an absence of fear. The best way I can describe it is that the worst thing I can ever imagine happening to me has happened and the rest is a bonus. I can live fearlessly towards the future. Another recalled that she finally had the personal strength to leave her abusive husband after many years of contemplation. Now living on my own with my children, I feel strong, alive, and at peace. I am starting to rediscover myself and build my self-confidence.
Appreciation of Life
This domain of posttraumatic growth had the third highest number of segments (n = 37). This quote captures this domain: There is not a day that I am not thankful for what I have in life and conscious of what was almost lost. One participant revealed that: I lost everything as a result of my postpartum psychosis. Well, almost everything. My children survived my illness and for that and that alone I'll be eternally grateful... Many women with stories like mine are in jail actually and literally grieving their children. Regarding her appreciation for her freedom, this participant recounted: I have an appreciation for my freedom these days. After spending 9 months in the hospital, I don't take a moment of that for granted...From being transported to and from the courthouse, shackled and handcuffed for status hearings to eventually being released on an ankle bracelet to my parents' house.
After surviving postpartum psychosis, participants expressed not taking for granted the little moments in their lives such as driving a car and reading books to their children at bedtime. As this participant depicted, I have developed a greater appreciation for what others might think of as mundane aspects of everyday life. I'm still surprised and delighted at how I can make a grocery list, do the shopping, put everything away, plan, and cook meals. Simple tasks like that were nearly impossible while I was sick. Participants also described that they have reprioritized aspects of their lives. They realized life is short and they wanted to invest more time with their families and activities they were interested in. One woman described how she now has an entirely new appreciation for literature. I delight in clever descriptive scenes. I feel this appreciation of literature is an unexpected gift that I gave myself. Participants also prioritized their health now as they learned to slow down and stop rushing through life and focus on self-care. This participant shared, I play ladies over 35 soccer in a wonderful community. It is a key part of my happiness and health. Another woman developed a deeper appreciation of art, nature, music, and history. Maintaining their mental health became a priority in participants' lives as they now concentrated on their sleep patterns, eating, exercise, and meditation.
New Possibilities
This domain received the fourth highest number of units of analysis (n = 16). Some participants followed new paths while recovering from postpartum psychosis, such as becoming active volunteers in various perinatal mental health organizations. Participants became advocates and were committed to helping other women and their families struggling with postpartum psychosis. Participants shared that they wanted to serve as role models for other women to illustrate how a woman can go on to lead a very successful and happy life after postpartum psychosis. One participant explained, I look forward to being a light in the dark for someone else someday. I want to show them life can be worthwhile again and while it's a long road to a better life, it does get better, so much better. Taking a 2-day training course in mental health first aid was another new path for some participants. They wanted to become more qualified to assist other women who might be struggling with postpartum psychosis.
Not all volunteerism was focused on perinatal mental health. One participant volunteered to provide meals for the homeless. She disclosed that her postpartum psychosis is a great equalizer. I may have been alongside them in the hospital or when I was in prison waiting for bail. They are just like any other person but are experiencing struggles, sometimes I can relate to. One woman began a life coaching business to help people find their purpose and passion in life. I think in many ways, my own experiences of losing myself and finding myself again have given me a sense of strength and optimism that I want to use to inspire others to take a similar self-discovery (without psychosis).
Spiritual and Existential Changes
This domain of posttraumatic growth had the least number of units of analysis (n = 8). An increased sense of connectedness was how one participant entitled her change in this domain. She confided, I am more spiritual, and I know definitively that there is a God...I feel more confident that there is meaning to life, and we are here to live out a specific purpose. We are all connected. Another participant recalled, It was humbling to see God's provision and sovereignty in the midst of my pain. I felt my heavenly father carrying me through the storm and shielding me. One woman recounted how her faith in God is now deeper and richer. I grew spiritually after my postpartum psychosis ... He [God] has grown me in the fruits of the spirit (love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control) through these hardships.
During her healing, one participant explained that her postpartum psychosis confronted my God concept and theologies and helped me deconstruct them...As I've healed, I've had to reconstruct my understanding of both reality and spirituality. One participant disclosed that at first she was a little reluctant to get too connected to anything spiritual again because her delusions during her postpartum psychosis were religious in nature. She went on to recount that her postpartum psychosis experience did make her spiritual practice stronger.
Discussion
Our results confirmed findings from Jordan et al.'s (2018) mixed-methods study of posttraumatic growth in the general population after a first episode psychosis. One of the themes in Jordan et al.'s (2018) qualitative strand focused on the positive changes in that sample which included (1) improved health, personality, and stronger sense of self; (2) stronger, more balanced religiosity and spirituality; (3) improved relationships with others; and (4) improved lifestyles, goals, and expectations for the future. All these positive changes were also described in the current study by the participants following postpartum psychosis. What was different though was that the participants' positive changes with postpartum psychosis occurred in the context of new motherhood. In Jordan et al.'s (2018) quantitative strand of their mixed-methods study, participants completed the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996). The researchers reported mean scores for each of the five posttraumatic growth domain subscales. The Relating to Others subscale received the highest mean score, whereas Spiritual and Existential Change subscale received the lowest mean score. Our results corroborated Jordan et al.'s findings. Relating to Others domain had the highest number of units of analysis from participants' narratives, whereas Spiritual and Existential Change domain had the fewest units of analysis.
Women's experiences of posttraumatic growth regarding a greater appreciation for life, increased personal strength, and improved relationships with others recounted in this qualitative study also confirmed results of two studies conducted specifically on postpartum psychosis. Aspects of Wass et al.'s (2022) grounded theory study focused on how partners and family members were instrumental in recovery from postpartum psychosis. Participants in Wass et al.'s study also spoke about how their partners helped build up their confidence in their role as a mother. In Holford et al.'s (2018) qualitative study of the impact of postpartum psychosis on partners, they shared their couple relationships had been strengthened.
Limitations
A limitation is that only participants who had online access comprised the sample. Recruitment used three Facebook groups specific for postpartum psychosis which can possibly limit the transferability of our findings. It is not known if women who do not use the support from online support groups on Facebook would describe their experiences of posttraumatic growth differently than what were identified in this study. As the length of time from when the participants had experienced postpartum psychosis ranged from 2 months to 43 years, the potential for recall bias should be noted. None of the participants, however, shared having any problems remembering the positive changes in their lives due to their struggles with postpartum psychosis. The accuracy of women's long-term memories of their childbirth experiences is supported in the literature (Takehara et al., 2014). In addition, this study did not distinguish between domains of growth at different points on the continuum of recovery. It is possible that those further from the event of psychosis experience different domains or of a different level of significance than those whose experience was more recent.
Implications for Practice
Twomey (2009) coined the term "post-recovery recovery" to impress upon practitioners and survivors that there are different levels of recovery from postpartum psychosis. "There is recovery from the biochemical illness itself and there is post-recovery recovery from having had the illness: the healing of psyche, ego, self-esteem, confidence, and relationships" (p. xvii). It may be valuable for practitioners to understand that it is this period, when the symptoms of psychosis have receded, that may be the most appropriate time for opportunities to enable and support posttraumatic growth.
Implications for clinical practice for nurses and other health care providers can be categorized into three phases of postpartum psychosis: acute, early recovery, and advanced recovery. Most women in the acute phase are hospitalized on a psychiatric unit. The results of this study are relevant in the acute phase for health care professionals who are interacting with families and partners who may be distressed and puzzled by the onset of a sudden and unexpected psychosis in their loved one. Clinicians can share with families and partners, that not only do most women recover but some even experience positive changes during their healing from postpartum psychosis. This also provides an opportunity and context for health care providers to discuss the various kinds of support, therapy, and other resources that may assist in recovery for both the woman and the family and can frame post-release recovery modalities as an important step toward wellness (Stacy & Schulkin, 2022).
In the early recovery phase, many women are sent home while they are still symptomatic. They may not have a detailed care plan or established relationships with providers or therapists at that time. Women and families must be adequately supported after discharge from a psychiatric facility to prevent maternal suicide and infanticide (Friedman et al., 2023). Some women are out-patient for a week or longer after release. This study provides a valuable base of understanding for those involved in outpatient care of these women.
Advanced recovery begins to occur when women are no longer acute or symptomatic of postpartum psychosis and are starting to process their trauma. It is during advanced recovery that this research may be valuable to these women directly (although it is not likely to be recommended during the transition from early to advanced recovery). Survivors of postpartum psychosis may find value in accessing our research findings where they can read other women's first-person accounts of how they experienced posttraumatic growth in their lives. This can aid them in processing their own trauma and recognizing and embracing their own areas of posttraumatic growth. The importance of hope for full recovery cannot be overstated for those affected by postpartum psychosis. Health care providers who work with these women, however, need to be careful not to give false hope that posttraumatic growth will happen in every survivor of traumatic experiences (Calhoun & Tedeschi, 2013). In fact, expressed expectations of posttraumatic growth could be harmful to someone grappling with their experience.
Nurses and other health care practitioners who wish to learn more about postpartum psychosis are referred to updated guidelines on screening and diagnosis of postpartum psychosis and guidelines for treatment and management of postpartum psychosis from the American College of Obstetricians and Gynecologists (2023a, (2023b). For a nursing perspective on postpartum psychosis, two publications from the Association of Women's Health, Obstetric, and Neonatal Nurses include information on postpartum psychosis (Beck, 2020b, 2021).
As nurses and other health care providers encourage and share about posttraumatic growth while being careful to not give false hope that this growth will happen for any survivor, it may be helpful to have analogies for posttraumatic growth. One analogy that may be helpful is that of the Japanese art of Kintsugi. Therefore, we would like to bring attention to some parallels between the process of Kintsugi and persons suffering from psychological distress from trauma that can lead to posttraumatic growth (Tedeschi & Moore, 2020). Kintsugi is a Japanese art practice from the 15th century where broken pottery is repaired by sealing the cracks with lacquer and painstakingly dusting with gold powder (Figure 1). The cracks are repaired not to hide them but instead to highlight their beauty and strength for everyone to see. A woman's struggle with postpartum psychosis can help to put the pieces of one's life back together even stronger than before when these cracks are not hidden but embraced. Incorporating Kintsugi as a metaphor in a person's life can help to view broken or painful parts of that person as having the potential to make one stronger and more beautiful (Kemske, 2021; Kumai, 2018; Tedeschi & Moore, 2020). Kintsugi is a slow process that can take many weeks to complete (Kemske, 2021). Just as in the slow process of Kintsugi, achieving posttraumatic growth also entailed a slow process as participants pieced their lives back together after surviving postpartum psychosis. One participant whose postpartum psychosis occurred 2 years prior shared Interwoven through the healing process is this strand of beauty called posttraumatic growth-when the soul rises up in new growth after being stripped bare and charred from the trauma.
Conclusion
This study illustrates that women who have experienced postpartum psychosis have the potential to experience all five of Tedeschi and Calhoun's domains of posttraumatic growth. Understanding this possibility can aid nurses and other health care providers in their care of and interactions with women who have had postpartum psychosis and those who support them so that the potential for such growth can be shared and maximized. However, because it is important to be careful not to give false hope, it is important to understand that the ways this information is used varies based upon the woman's level of recovery. An analogy that may be helpful is that of the art of Kintsugi.
CLINICAL IMPLICATIONS
* Implications and modalities of treatment vary based on whether a patient is in the acute, early recovery, or advanced recovery stage.
* Women and families need to be adequately supported after discharge from a psychiatric facility to help prevent maternal suicide or infanticide. Knowledge of the potential for posttraumatic growth can give hope to those providing support.
* In the advanced recovery phase women may benefit from reassurances and examples of women who have gone from surviving to thriving. This is the most appropriate time to discuss the possibility of posttraumatic growth with women.
* Nurses and other health care providers need to be careful not to give false hope that posttraumatic growth will happen in every survivor of traumatic experiences.
INSTRUCTIONS Posttraumatic Growth after Postpartum Psychosis
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References