Back in the 1950s, pediatrician and psychoanalyst Donald Winnicott coined the term “Good Enough Mother,” making the point that surviving a mother’s small failures gives children the resilience to live in an imperfect world. Winnicott’s focus was on how the child can benefit, rather than suffer, from a mother’s mistakes. But his message applies equally to the mother who suffers because she expects perfection from herself and inevitably falls short. Even the most loving parents get it wrong sometimes; what matters is that we get it right enough of the time.
The same is true in pregnancy.
We enter pregnancy with high hopes and big dreams — both for ourselves as mothers and for our children-to-be. We want desperately to think that if we do everything perfectly — avoid sushi, take prenatal vitamins, swear off alcohol, get enough sleep and exercise (but not too much!) — we will have a perfectly happy, healthy baby and that baby will grow into a perfectly happy, healthy adult.
But sometimes things don’t go as planned.
About 15 percent of women suffer from depression while pregnant, typically complicated by serious anxiety. In our daily practice as reproductive psychiatrists, women come to us for help making difficult decisions about treatment. Awash in advice from family, friends and Dr. Google, our patients are overwhelmed by uncertainty and want us to tell them what to do. Can I take a psychiatric medication when I’m pregnant? Will my anxiety harm my baby? What’s riskier for my baby: my depression or antidepressants?
Expectant mothers want perfect answers based on definitive data. But there are two problems. First, since it is unethical to do studies in which depressed pregnant women are randomly assigned medication or a placebo, randomized controlled trials that are the gold standard in medical decision-making do not exist. There are good studies that provide important information with which to advise our patients, but “the best” science isn’t an option. Second, even the best science couldn’t fully dispel the uncertainty that brings mothers to us in the first place: The literature, while sophisticated and nuanced, can never guarantee perfect outcomes.
Here’s what we do know for certain: Antidepressants may carry risks for obstetric outcomes and the health of offspring, but so do depression and anxiety themselves; there is no such thing as a risk-free decision; since no two expectant mothers (and their partners) are the same, the “right” or “best” decision for one couple is not the same as for another; and — this is important — the vast majority of babies do fine.
So in the absence of definitive information, how should women think about these decisions?
There’s a term from behavioral economics, initially conceived as a way to think about decision-making in an actual, rather than an ideal world: satisficing. A mash-up of satisfy and suffice, the term was introduced in the 1950s by Nobel laureate Herman Simon and refined by Yakov Ben-Haim as a strategy to solve problems too complex for mathematical optimization; in other words, when there are too many unknowns and variables to offer a definitive answer. Satisficing doesn’t ask “What decision will make everyone the happiest, now and forever?” It asks “What decision will suffice, producing a satisfactory outcome under the widest range of possible conditions?” Satisficing doesn’t pretend to consider the ideal outcome or even the best one; it asks what will produce the kind of success compatible with real-world possibilities? In other words, what result can one comfortably live with, accepting the reality that perfection is an elusive outcome that can never be attained.
Women struggling with the difficult decision about whether to take psychiatric medication during pregnancy know only too well that they live in an imperfect world rocked by emotional fluctuations. These women feel ashamed and guilty that the conventional wisdom and well-intentioned advice — Exercise! Do yoga! Eat better! — isn’t enough to keep them emotionally well.
As reproductive psychiatrists, we help expectant mothers to answer the question, “What can I live with?” The data doesn’t change from case to case. What does change is context: personal history, values, social support, family opinions, worldview, priorities. And these can be game-changers. For one woman, even the small chance of a birth defect makes life overwhelming and unmanageable; for another, the possibility of falling into a deep depression — and being unable to parent — is a bigger threat. Taking a satisficing approach, we encourage women to let go of the quest for perfection and instead try to be realistic about their options.
One thing we’ve learned in doing this work: We can all benefit from satisficing. Psychiatric illness or no, none of us lives in an ideal world. Things rarely (if ever!) go the way we imagine they will. Even if you obey all of the current rules of prenatal healthy living, there is no way to ensure a perfect baby.
On the surface, satisficing may seem like a concession or an unacceptable compromise. But a compromise with reality does not compromise you as a person — it may even hold a transformative promise. To satisfice is to acknowledge and accept that the future is inherently uncertain and that expecting perfection guarantees disappointment. By asking “What can I live with?” rather than “How can I achieve a perfect outcome?” we free ourselves to embrace the good enough.
Vivien K. Burt, MD, PhD is a professor emeritus of psychiatry at University of California at Los Angeles and the co-director of the Women’s Life Center at the Resnick Neuropsychiatric Hospital at UCLA.
Sonya Rasminsky, MD is an associate clinical professor of psychiatry at University of California at Irvine. She has a private practice in Newport Beach, Calif.
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