Spilt Milk

Perinatal Loss and Breakdown

Joan Raphael-Leff

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429919428
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

A collection of lectures by eminent members of the British Psycho-analytical Society. Includes papers on the experience of having a baby, pregnancy and the internal world, pregnancy after stillbirth or neonatal death, and therapeutic intervention for post-partum disturbance.

1
The experience of having a baby: a developmental view¹

Dana Birksted-Breen

Some moments in the life of a person necessitate change if they are to be lived, not just survived. It is from this perspective that I have been interested in the impact on women of becoming a mother.

There is a widely held belief that pregnancy is like an illness, that a woman will temporarily act and feel in odd ways and that after the birth of her baby she will get back to her old self again. This has its parallel in the psychiatric and psychological literature in studies whose models implicitly reflect a notion of the pregnant woman as temporarily disturbed, returning, in normal cases, to a previous pre-pregnancy state after the birth. This is what I have called the 'hurdle approach' (Breen 1975). On the contrary I would argue, in line with a developmental approach, that the birth of a baby, as any major life-event, offers an opportunity for a woman to work through internal conflicts and relationships, to modify her perception of herself and others, and integrate this new experience so that she will not be the same after the birth as she was before. Moreover, it is those women who are unable to integrate the experience and change with it who will run into serious difficulties in pregnancy, childbirth or post-natally.

To my mind, there is a continuity from pregnancy to early motherhood and women make use of this time in different ways and at different paces. Also, it is characteristic of conscious and unconscious thought processes that preoccupations come to the fore, then recede, only to come back again later in the same or a different form.Therefore it is only for the sake of clarity that I will, in this paper, go through the phases chronologically, describing the sorts of states of mind that occur typically in each stage of pregnancy and the postnatal phase.

Pregnancy is a time of psychological as well as physiological preparation. In a research project I carried out with 60 first-time mothers (Breen 1975) I found that the women who coped well once the baby was born were the ones who had been able to express a certain amount of anxiety in late pregnancy.² This gives an indication of the complex processes at work, in particular of the importance of this psychological preparation. The psychological work that takes place is not necessarily conscious, although it is well known that during pregnancy there is a tendency for women to become more introspective. Pregnancy is a time for reassessment of the past and for thoughts about the future, a time for thinking about one's place in the natural cycle of life and death. Unconscious phantasies often become conscious or appear with little disguise in dreams and symptoms, and thus offer a unique opportunity for integration, hence the potential for psychological growth. Imbalance and disorganisation often precede times of greatest change. And so in pregnancy a woman may feel that her world is being turned upside down.

During the first months of pregnancy a woman has to come to terms with being pregnant. Even when planned, the decision to have a baby and the conception, whether immediate or not, are followed by conscious or unconscious misgivings. These first months are filled with doubts, confusion, regrets, anxieties and disbelief. Of relevance will be how a woman generally deals with conflicting feelings. During pregnancy a woman is often afraid to acknowledge angry thoughts about the baby, even to herself, for fear that they can harm the child. The baby inside is felt to be able to read her mind. Dreams will be experienced not only as premonitions but will be felt to be 'inside' and in contact with the baby. All this is aggravated by the fact that minimal reassurance is available concerning the baby.

The withdrawal into herself so characteristic of pregnancy, however, is not only a consequence of anxious preoccupations. The following early pregnancy dream of a woman expecting her second baby expresses a sense of excitement and curiosity.

Some friends had bought a flat in a rather crummy area. The outside was dreadful but when I went in I realised that it was really quite special. There was a large square with grass inside, similar to a cloister; it was like a garden, only inside the flat, and there were lots of nice rooms. I fact I could see that it was quite a find.

The architectural reference in this dream describes a reversal: what should be outside, the garden, is now inside and the focus of interest. The inside — that is, the inside of the body — becomes special while the outside — that is, the outside world — becomes 'crummy', unimportant. The idea of the cloister adds to the dream's references to the state of seclusion, withdrawal and self-absorption common in pregnancy, during which a large amount of communication and interest is directed inside — to the baby — but also inside to inner feelings and phantasies, so that the garden refers not only to the growth of the baby but to her own psychological growth through the experience of having a baby. In this dream, the process of discovery, of the special flat once you get inside, expresses the discovery of new areas of her mind that will enable this development.

To my mind, each woman's experience could be depicted in terms of how she conceives of herself in terms of 'inside' and 'outside' and the sort of boundary that separates the two. For instance, does she think of herself and the baby as 'inside' as opposed to the outside world? Or is the baby an intruder and an invader getting into her as a dangerous representative of the outside world? Does the baby, from belonging to the outside, become a part of her, or, on the contrary, from being part of her separate out as if by parthenogenesis? Then the question arises as to the nature of the boundary between what is conceived of as inside and what is conceived of as outside. Is the boundary like a fortress behind which the woman protects herself —with her baby, or against her baby? Or is it more like a beaded curtain that can be easily opened and shut and never totally shut? Or is it more like an amoeba that expands and retracts with the vagaries of her changing states of mind?

Through dreams it is possible to explore how a woman's personal 'topography' changes. One woman, in the fifth month of pregnancy, dreamt that 'the baby is kept in hospital for four months and when I meet the baby again there is no relationship between us'. She is describing the baby in the womb as separated from her, outside of her. Some time later she dreamt that her 'navel gaped, forming a pouch; inside there is rubbish'. She woke up feeling anxious and wondering if her baby was normal. Here the pouch represents a state not quite 'inside' and not quite 'outside', but there is anxiety about what she is now able to see in this space. Towards the end of her pregnancy she dreamt that she could hold her baby's hand through the abdominal wall, thus creating a link between 'inside' and 'outside', perhaps to counter the earlier anxieties about being able to make contact with her infant. Nevertheless she also felt anxious after this dream because at its end the baby's hand got stuck in her skin.

One can also describe the nature of what is being kept 'inside' or 'outside', in particular where love and hate are located. If negative thoughts are felt to be a danger to the baby, these may be displaced and experienced as coming from 'outside'. This was the case with a woman who was convinced in early pregnancy that it was her partner who wanted her to abort her unplanned baby while she, consciously, harboured no such feelings. Another woman refused to see her sister-in-law during her pregnancy as she felt her to be a danger to the baby. A woman who had had three miscarriages started psychotherapy with me but broke off her treatment as soon as she had gone beyond the danger date (when she had previously miscarried); it seemed that she could only keep her baby inside her by turning me into a mother who miscarries — since the termination of her treatment was premature —and then running away from that aspect of herself. In that way the baby could be felt to be safe from her own hatred.

when the danger to the baby is felt to be 'outside' the self, then points of vulnerability are the body openings. For instance, danger will be feared to come in through the ears or eyes in the form of something unpleasant heard or seen, through the mouth in the form of food felt to be harmful, through the vagina during intercourse or an obstetrical examination.

Sometimes the worry is about how to keep the baby 'inside'. One woman was frightened that the baby could just drop out of her so she tensed up her muscles, jaw and perianal in particular, while another woman was afraid that sneezing would eject her baby.

If 'inside' is felt to be bad, then a woman may want to fill herself up with sweet thoughts, pretty pictures, special foods, and vomit out the poisonous feelings.

Sometimes 'good' and 'bad' are not split between 'inside' and 'outside', but are kept apart 'inside' the self. One woman dreamt of a 'peaceful island inside the dangerous jungle; the natives had taken the white children and put them safely in underground trenches'. This woman, who had not planned her pregnancy and did not feel settled in a relationship, now wanted to keep her womb, the island, as a very safe place, and the baby under the protection of the 'natural', 'primitive' part of herself (the natives) and away from the intellectual, 'educated' part of herself that wasn't prepared to have a baby.

During the middle months of pregnancy, in particular after 'quickening', the reality of the baby increases and now becomes more clearly the receptacle for specific phantasies and the embodiment of sometimes disowned -—parts of the self. A woman may feel, for greedily absorbing all the goodness in her body like a parasite; sre greedily absorbing all the goodness in her body like a parasite; she may experience her baby as a punitive figure who knows her secrtt thoughts and disapproves of them; she may feel that her baby is watching the parental intercourse.

Curiosity about what is going on inside her body may reawaken anxiety and guilt about curiosity felt to be forbidden in childhood in relation to the inside of her mother's body. Women sometimes feel it is not 'right' to know the sex of the baby, even if the information is available from an amniocentesis. One woman dreamt that she and her husband took the baby out to have a look at it but then they could not put it in again — presumably the punishment for their curiosity. She woke up in a state of anxiety.

With pregnancy a woman finds herself pulled back to her relationship with her own mother. In the diary of her pregnancy, Hermine Demoriane (1969) expresses this feeling as follows:

Living far from home, in a separate life, I have come to feel at times in charge of my destiny, free of my blood. But certain doubts leak through. I have been a daughter, I shall be a mother. But what is there between? Am I anchored to this line forever?

The wish to be fused with her own mother may be reawakened during pregnancy (Lester & Notman 1985). A woman may feel that she can recreate with her baby a union free from need and frustration. On the other hand, the state of fusion she now feels drawn to may be frightening to a woman whose sense of herself and of her boundaries is fragile. One woman dreamt that her unborn baby was in a glass tank, round like a womb but separate from herself; the baby was then born and it was made of wire netting, not cuddly, she explained. This woman needed to keep her baby behind glass and uncuddly in order to feel she could retain a separate identity; in her other relationships too, she felt she could not move freely between a sense of fusion and a sense of separate identity.

Women frequently expect to have the same sort of childbirth and pregnancy experience as their own mother had. Sometimes they feel that they must not 'do better' than she did. One woman I interviewed was frightened to have a second baby because her mother and her grandmother had each only had one child; this had been a factor in her parents' divorce, she thought, as her father had wanted another child. To have a second baby to her meant she was fulfilling her father's wishes and giving him another baby. Even long after the birth of this baby, she worried that something would happen to the child, the phantasy that a retaliating mother would come and take her away. In fact this woman was not sure that she was allowed to have a baby at all. During both her pregnancies she had the following dream:

I was in hospital and I'd had the baby and it was tiny — a tiny little thing; they showed me and I thought: that can't be, it's a doll.

How to become a woman with a baby rather than a girl with a doll is one of the tasks in pregnancy. The childhood phantasy, that the doll is her baby, now has its converse in the fear that her baby is only a doll. To have a baby and not a doll, a woman needs to negotiate internally her position in relation to her own mother. In the following dream, another woman expresses the anxiety that her pregnancy means robbing her mother of her fertility:

I was getting pains in my pelvis and my mother also had a swollen abdomen. The dream had to do with one or both of us being pregnant, and with a diagnosis for my mother which was either infertility, menopause or pregnancy.

It is relevant to note also, in this dream, the confusion between her own and her mother's body. Dinora Pines (1982) suggests that the experience of a child inside her own body can enable a woman to differentiate her body from that of her mother.

Pregnancy proceeds without respite. There is no going back, no slowing down. The precisely limited time factor and the inevitable progression towards childbirth are sometimes accompanied by feelings of helplessness and loss of control. Dreams about jungles (Lester & Notman 1985} and wild animals (Faraday 1972) express a fear that uncontrollable growth and untamed primitive instincts are taking over.

In the last months of pregnancy the sense of inevitability is particularly acute. A conflict between retention and expulsion is at the forefront. A woman may wish to hang on to her baby forever, or she may wish to be able to care for her baby externally.

The birth of the baby signifies that what was 'inside' will be 'outside' for all to see. The fears about giving birth to a 'monster' express the fear that all her badness will now be revealed, that what is inside her body, including her feelings, is monstrous (Langer 1964). Birth is the moment of truth. One author suggests that the unbearable need to find out if the baby is normal, and its opposite, the escape from the evidence that birth represents, can be one of the factors contributing in lengthening or shortening labour (Rojas Bermudez 1964).

These feelings have their origin in childhood, in how the little girl feels about her body and in the feelings she harbours towards her mother and her creativity. In having a baby now she may still feel that she is taking her mother's place or stealing her babies. If the baby is born with a handicap, this will be felt to confirm that inside her she is bad, or that she deserved to be punished. Few women take it for granted that the baby which comes out of them will be intact.

Specific rears emerge around particular representations of the body. For instance, Helene Deutsch (1945) describes the case of a woman who was seized with panic when her waters broke prematurely, because she had thought of the baby as a fish in water who would die without the fluid unless rescued immediately. Another woman, on the contrary, dreamt that a dog curled up like a fetus was drowning; her worry was that the baby would drown inside if it was not born soon as the expected date of delivery had just gone by.

Not only is a woman in pregnancy having to come to terms with enormous bodily changes and the meaning of these changes to her, and having to integrate a host of unexpected feelings, she is also involved in the family drama that cannot but take place with the arrival of a new member. Her own image of the fat her, as one who intrudes or supports, as dangerous or revered, as ideal or superfluous, will play into this drama, which will become either rigidly set or take many turns in the years to come.

In the last months, time is ticking over, at one and the same time unbearably quickly and unbearably slowly. The inevitable progression towards birth is like the inevitable progression towards death. The fear of death in childbirth is a primeval fear as if the birth of one being is inextricably linked to the death of another, and a new self emerges leaving the old one behind like a disused shell. This fear, which leads to all the rituals surrounding childbirth, can stem from a need to be punished for being successful, for usurping mother's place, for 'being God' and creating life. The fear of damage to herself or the baby can stem from a woman's feelings about childbirth as the first separation of mother and baby, a symbol for all future separations. Certain people and places become invested with these fears. For instance, the hospital may be felt to be a dangerous place to be avoided, or on the contrary the hospital may be the place which will protect her from danger. I think it is true to say that such persecutory fe...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Dedication
• Acknowledgements
• Introduction: Technical issues in perinatal therapy
• 1 The experience of having a baby: a developmental view
• 2 Pregnancy and the internal world
• 3 'Is there something wrong?': the impact of technology in pregnancy
• 4 Pregnancy after stillbirth or neonatal death: psychological risks and management
• 5 'Climbing the walls': therapeutic intervention for post-partum disturbance
• 6 Puerperal psychosis: vulnerability and aftermath
• Index