In the beginning egg and sperm met to form an embryo; maybe in a passionate embrace of two lovers longing to become parents. Or it just happened, or a man coerced his exhausted wife into having yet another offspring, or a woman persuaded her partner to have a child he was not very keen on. Or it happened in an IVF lab or at a clinic with a single mother fertilized by an anonymous donator. In any case, egg and sperm united and multiplied; 2, 4, 8, 16, 32 cells . . . The foetus settled and started growing in the womb. Everything was hazy and without visible forms. Buzzing sounds were everywhere, and the foetus’ budding nervous system could register the resistance from the uterus wall as it kicked and moved about in its habitat.
The Bible begins in a similar mystic, dark, and watery cosmos. Only after the sky had been erected did life on earth become possible. Light separated from darkness, day from night, matter above heaven from matter beneath, land from water, sun from moon. In this cosmic birth scene, numerous acts of separation took place before our planet became hospitable and friendly. The future mother may also feel that her womb is a cosmos where unknown and uncontrollable things occur. Whether she enjoys or fears it, pregnancy has its long and due course. She will start creating internal images or mental representations of the foetus. In her mind, it becomes more and more of an individual – though some women cannot, due to internal and external tensions, let their minds fly away in “silly fantasies”.
Finally comes birth, the great act of separation. It may be quick, prolonged, nice, terrifying, wonderful, or painful – or cause less feelings than expected. Whatever happens, the memory of it will be engraved in the mother’s mind. Then comes a time when she and the child form a unique relationship; confluent and coalescent, with passions running up and down the emotional thermometer. Yet, parenthood also implies separation. Unless the parents realize that their baby will leave them one day in a distant yet imaginable future, emotional problems will ensue sooner or later.
This balance of emotions around confluence and separation illuminates why pregnancy, delivery, and infancy make up such challenging eras of our lives. Another factor is that many things are concealed to the future parents yet arouse intense feelings. To illustrate, I am calling the foetus “it”, though thanks to ultrasound images the parents might already know if it is a boy or a girl. Yet, such knowledge is different from grasping emotionally what kind of human being will one day become their Tim or Lucy. Metaphorically, the parents also live in a formless universe shrouded in darkness. They google on the internet and prepare for delivery in maternity classes. The future mother avoids alcohol, drugs, and unsuitable food, and goes to the gym to make her fit for delivery. The father talks to his pals about what it means to become a dad and looks for the smartest pram on the web. Yet, these respectable efforts cannot fully illuminate this misty and unchartered landscape. Information from parents, midwives, friends, brochures, and web-sources dispel some worries but also tend to engender new qualms and questions. The full impact of the baby’s arrival cannot be felt until delivery. And not even then . . .
One day the foetus says, “Let there be light”, and floods of sound, light, odour, and temperature thrust towards him – or her – from outside the mother’s womb. Still, it is not clear to the newborn and the parents what it means to have entered infancy and parenthood. Whether delivery takes place at home, in a taxi, or in a hospital delivery ward, the newborn meets an unknown world. In our biblical paraphrase, life in the womb was “night” whereas the new existence is “day”. And now there is breastfeeding and sleep and awakening and crying and breastfeeding again – the first day. And the parents look at the baby and at each other in awe, amazement, anxiety, doubt, joy, hesitation, strength, weakness, exhaustion, resolve, and fear. Or, even more painful, they “feel nothing”.
This stage in life is crammed with emotional changes that may bring about the parents’ best assets, but also their limitations. It has a forward direction; parents prepare to take care of a future life embedded and embodied in the expectant mother. They mature and feel responsible, and they shift from egocentric preoccupations to caring for their young. But this era also has a backward direction. Seldom in life is the pull of regression – a movement towards more immature functioning – so insistent and distressing. This is because the parents’ implicit memories of babyhood are stirred up. In other terms, attachments to their own parents reawaken and affect their relationship with the child. Such recollections and patterns also contain painful and upsetting memories, which up until now were repressed more solidly; their childhood’s impotence, fears, isolation, and sadness. Now they may emerge – rarely as clear memories but as dark clouds that obscure their vision and prevent them from relishing their baby and enjoying parenthood.
In the words of the psychoanalyst Therese Benedek (1959), the mother was once herself a child who introjected – she instilled in her personality – from her mother what it felt like to be fed, nursed, and cared for. In her present mothering experience, she will relive with her baby “the pleasure and pains of infancy” (p. 395). Such phenomena constitute what Fraiberg (1987) called the ghosts in the nursery: “the visitors of the unremembered past of the parents; the uninvited guests at the christening” (p. 100). Unconscious fantasies can coax her into believing that she will not be a good mother, have a healthy baby, or enjoy parenthood.
Other periods in life may also be marked by regressive and progressive fluctuations. When we get ill, we may shrink to childlike behaviours and emotions and become helpless and whining. In adolescence, the skills and securities painstakingly acquired during childhood may crumble and we might feel indecisive, stupid, embarrassed, and flawed. To be true, imminent danger or positive possibilities can also make us progress and become courageous and enterprising. What then constitutes the perinatal period’s peculiar psychological characteristics? One answer is that progression and regression occur simultaneously. The parents feel weak and strong, certain and uncertain, silly and wise – all at once. As we shall see when discussing the concept “primary maternal preoccupation” in Chapter 2, parents need to go through such vacillations to become competent, loving, and reasonably secure in their identities. A second answer is that the perinatal period compels them to shift from love of oneself to love of the child; in other terms, from narcissism to object love. To accomplish this without feeling annoyed, disappointed, or angry is not easy. A third reply is that the mother’s body, including its sexual aspects, is involved from conception and onwards. If this was a thorny subject to her, it may interfere with her becoming a mother. The father’s sexual maturity is also challenged. While he perhaps feels proud of having conceived the child and become a dad, he may simultaneously feel uncertain as a man, competitive with his partner, and jealous of the child.
We will return to the issue of regression and progression throughout this book and a brief example will suffice here: A common cold can make anyone feel pitiable and weak. For a woman going through all the corporal changes during gestation, such a pull can be all the more powerful. Any man can feel resentful when his wife speaks appreciatively of her male colleague. It is all the easier for him to feel left out when pondering what goes on inside her body! But, pregnancy can also be a time of pride, joy, and progress for both parents. As Benedek (1959) puts it, “parenthood utilizes the same primary processes which operate from infancy on in mental growth and development” (p. 389). I would add that in parenthood the primary processes, that is, the more primitive levels of psychic functioning, are enforced and may take the upper hand. Our task is to understand the clinical consequences of such an imbalance and how we can treat them in psychotherapy, whether at length or – as is the focus of this book – in brief consultations.
Union and separation
Let us return to the Bible story. After completing the creation of cosmos and earth, it centres on the making of man. Unexpectedly, separation is now expressed as a force that promotes development. When Adam has been severed from a rib and Eve is created, the text concludes: “That is why a man leaves his father and mother and is united to his wife, and they become one flesh” (Gen. 2; 24). If we condone the text’s masculine bias, it conveys an important message: The creation of man and woman opens up the possibility of a future love relationship, but it will not come about unless they separate from their parents. In a love relationship, confluence and separation are intertwined and cannot exist without each other.
Other religious texts give more tragic renditions of separation. The pregnancies of the mothers of Moses, Jesus, and Muhammed were darkened by death and the threat of murder. In the book of Exodus, the Egyptian Pharaoh ordered all newborn Hebrew boys to be slain. Moses’ mother hid him for three months and then set him off in a basket on the Nile. He was saved by Pharaoh’s daughter who allowed a wet-nurse – Moses’ mother in disguise – to feed him. After weaning, their second and final separation occurred. Her pregnancy and his first months of life were thus marred by the fear of infanticide and abandonment.
In Matthew II, Herod orders all newborn boys to be slaughtered, but Joseph’s family flees. Like Moses, Jesus begins life in the shadow of infanticide. In Muhammed’s case, his father died during his mother’s pregnancy. When he was 5 years old, she fell ill and died. His grandfather became care-taker but soon died as well. Why have the three religions chosen such dreadful “in the beginning”-stories for their founders? The texts do not connect their childhood trauma with later achievements and personalities. In view of psychoanalytic theory, attachment research, and clinical experience their prognosis was grim. Their parents’ internal worlds must have been filled with fantasies of death, loss, and humiliation, and one may wonder how a secure attachment could come about in a child born in such dire straits. The authors must have intuited that intra-uterine life and the first years can be of decisive importance for the future. The enigma is how they imagined that the hero’s beginnings linked with his later deeds and personality.
I will use the spiritual leaders to illustrate a recurrent question: How are we to understand the cause of a psychological reaction? It is easy to imagine the perinatal stress of Moses’ mother. But can we claim that the calamities in his infancy caused later character flaws and emotional problems, such as his hot temper, lack of impulse control, and speech difficulties (as mentioned in Exodus)? In broader terms, what are the causal mechanisms behind a phenomenon, reaction, feeling, idea, relational pattern, etc.? We can approach such questions from the neuroscientist’s lab, the sociologist’s data sheet, the social psychologist’s questionnaire, and the psychotherapist’s caseload. Each method yields data with different kinds of validity, reliability, and generalizability. No method is inherently superior, none more true or “scientific”. The point is to (1) know on which method the investigator construes his/her findings, (2) report which instruments were used to amass the findings, and (3) comprehend that each method may use the same term but define it in divergent ways.
To illustrate, depression is said to be “one of the most common complications of pregnancy” (Marcus et al., 2011, p. 26). This statement relies on epidemiological data derived from questionnaires. The statistics showed that pregnancy is paralleled by depression more often than we have realized – and that we must consider this when we plan health care for future parents. Such studies search for general truths, while a therapist searches for individual truth. I may say that two patients are depressed but their stories, personalities, symptoms, behaviours, etc., diverge – and they will do so the more I get to know them in therapy. Therapists need to clarify to patients and health service policy makers that individuals are individual. Accordingly, when a psychoanalyst sets up hypotheses based on clinical phenomena, s/he should know that their validity is restricted to the present case. Then it is up to the readers to let it inspire – or not – their work. Consequently, this book contains many cases and you will have you to judge whether they cohere into a meaningful knowledge.
I will also present systematic research studies on the emotional sufferings of parents and infants. And, I will present psychoanalytic theory, because what I just wrote is not entirely true, namely that psychoanalytic validity is confined to the individual case presented. Therapists are often criticized by scientists for relying on “anecdotal evidence”. If we submit a vignette of a successful case and then claim that this is evidence of the general efficacy of our intervention, this is anathema to the scientist. “One swallow doesn’t make a summer”. In defence, we might claim that we applied it to several patients with good results. Yet, this would not satisfy the scientific mind, since our memory might be biased. There is, however, another argument that supports the validity of case vignettes. If they harmonize with the psychological theories underlying therapeutic work, this supports t...
