Motherhood and Personality

Psychosomatic aspects of childbirth

Leon Chertok

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415264181
• eBook ISBN:
  9781136425080
• Topic: Medicine
• Subtopic: Health Care Delivery

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1969 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

CHAPTER 1

History and Theory of Psychosomatic Methods of Preparation for Childbirth

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With the advent of psychosomatic methods of preparation for childbirth — Read’s method and the psychoprophylactic method — psychosomatics effectively launched itself into the field of obstetrics. The women who were the subjects of the present investigation were prepared by the psychoprophylactic method. In this chapter, however, the theoretical bases of all the methods will be reviewed so that the reader may get an overall view of the problems which have been the object of such lively controversy (29). We shall first of all give a brief historical account of those experiments in psychological analgesia which were the predecessors of the methods of preparation for childbirth in current use, and then proceed to describe the development of these methods and the theoretical problems to which they give rise.

HISTORICAL REVIEW¹

THE HYPNO-SUGGESTIVE METHOD

It is difficult to understand the current methods of preparation for childbirth without saying a word about the experiments in psychological analgesia in obstetrics which preceded them. These experiments were based essentially upon hypnosis. They were first tried at the end of the nineteenth century in France and elsewhere, and were resumed after the First World War in Germany and Austria. In Russia, experiments in hypnotic analgesia were begun about 1923 and continued, with interruptions, up to the present time; in the United States, they began in 1943. Nowhere did the experiments lead to mass application; thus in 1954 Velvovski et al (152) estimated the number of published cases of hypnotic analgesia in thirty years in the Soviet Union at 8,000. In the United States, the hypno-suggestive method has been used only on a limited scale.

We need not go into the complex reasons for the failure of hypnotic analgesia to be applied on a large scale. It need only be observed that hypnosis remains surrounded by a kind of magic halo which creates resistance, among doctors as well as among members of the public; and that the practice of hypnosis requires psychotherapeutic training. From a theoretical point of view, nevertheless, these experiments in hypnotic analgesia are of primary importance. They represent macroscopic and peculiarly impressive examples of analgesic effects obtained by psychological means. The material that has been left to us by these early researchers is valuable for the extent to which it casts light upon the problem of the experience of pain. These authors show us, in effect, the complexity of the problem by demonstrating empirically the variety of the ‘patterns’ of analgesia: the patient may be aware of contractions of the uterus without experiencing the slightest pain; or the pain may be lessened; or again, in spite of the pain, the patient may remain calm, or even say that she is not suffering while at the same time showing all the autonomic signs of pain; or she may even forget the whole thing.

An important phase in the history of psychological analgesia was reached through the work of the Viennese psychiatrist Kogerer (84) about 1922, which can be related to some old experiments of Liebeault (98). Liébeault had used hypnotic analgesia for minor surgical operations in a new way, obtaining the analgesic effect by post-hypnotic suggestion. The operations themselves were performed in the normal state of wakefulness. Kogerer adopted this procedure in the field of obstetrics. Where did he get the idea of doing this? He had been struck by an observation made by von Oettingen of Heidelberg (121). Von Oettingen had remarked that some prepared women were late in arriving at the labour ward, after the rupture of the membranes. They had, in fact, never felt the contractions. One of them had actually given birth without pain in a fully conscious state. Von Oettingen, believing this woman not to have been under hypnosis during labour, felt that he could not count her case as a success. But Kogerer saw the possibility of considerably extending the application of hypnotic analgesia in obstetrics, since it appeared no longer necessary to use hypnosis at the actual time of labour.

Theoretically, this discovery introduced a new dimension in hypnotically produced analgesia: the analgesia need not necessarily be the temporal accompaniment of hypnosis, but may be subject to a certain delay effect. Hypnosis being only, as we have stated, a particular kind of exaggerated and intense form of psychotherapeutic relationship, one might expect other forms of this relationship, even non-hypnotic forms, to be capable of producing deferred or contemporaneous analgesia. These other forms of relationship are seen at work in the non-hypnotic methods of obstetrical analgesia.

NATURAL CHILDBIRTH (NC) AND THE PSYCHOPROPHY-LACTIC METHOD (PPM)

The earliest stage in the history of psychological analgesia in childbirth was characterized by the use of hypnosis as the analgesic procedure. The methods which were subsequently elaborated and which today are widely applied no longer use hypnosis. These are Read’s method (137) and the psychoprophylactic method or PPM (151, 152). The latter, first used in 1949, is a direct outcome of the hypno-suggestive experiments which have just been discussed. The method developed by the English physician, Grantley Dick Read, described in 1933, was the result of a fruitful intuition: confronted with a woman in labour who refused chloroform, saying that she was not in pain, Read had the ‘revelation’, in his own words, ‘that there was no law in nature and no design that could justify the pain of childbirth’ (137, p. 6). From this starting-point, Read conceived his method of natural childbirth, the principles of which can be summarized as follows: certain sociocultural factors produce fear, which leads to tension, which, in turn, causes pain (the triad Fear-Tension-Pain). Fear is dissipated by information and education, and tension is removed by relaxation.

The psychoprophylactic method, introduced by Velvovski and his collaborators, started from an experimental basis. For twenty-five years they had been using hypno-suggestive methods, and had come to the following conclusions: pain is not a necessary accompaniment of childbirth; verbal suggestion can have an analgesic effect; finally, fear and anxiety are very important factors in pain during childbirth. These conclusions served as a theoretical basis for the elaboration of a new method which could be applied on a large scale and in which effects could be produced verbally by means other than hypnosis. These psychoprophylactic factors, which indeed played a supporting role in the hypno-suggestive method, for writers like Platonov (128), Shlifer (144a), Kopil-Levina (86), Zdravomyslov (158), etc., consist of information, education, the removal of fear, the creation of positive feeling, good relations between therapist and patient, and a favourable environment in the maternity department. In the PPM, it is hypnosis that now plays the supporting role in difficult cases.

The psychoprophylactic method has developed rapidly and seems to have given new impetus to Read’s method, which up to 1950 had met with only limited success. The success and spread of the PPM in France set the fashion, and the French doctors Lamaze (90) and Vellay (149, 150) were mainly responsible for its wide diffusion in Western Europe and South America.

THEORETICAL PROBLEMS

If one considers the principles stated by their authors, the two methods appear theoretically very different from one another. Read attributes to fear the main role in the development of pain and makes the removal of fear the essential condition of analgesia. The Soviet school, while admitting the importance of fear, brings in a whole series of conditioned mechanisms. But when one looks closer, one finds that both these interpretations are hypothetical. The famous triad referred to by Read — Fear-Tension-Pain — no doubt represents a fruitful intuition, but the idea requires to be elaborated and confirmed by physiological observation.

The psychoprophylactic method has been believed, outside the Soviet Union, to rest upon a monolithic explanation. In fact, the various authors are scarcely agreed on any but very general points, such as the role of the cortex in childbirth and in the perception of pain, and the particular importance of the spoken word. Their differences become apparent as soon as we come to the more specific problems, which are more important for a physiological interpretation of the method. Thus, uterine contraction is considered by Velvovski (as also by Read) as physiologically painless, but he is almost the only Soviet author to hold this view. Then again, Velvovski, who to start with viewed all pain during childbirth as a conditioned response, later admitted pains of localized somatic origin and ‘functional’ pains, the result of ‘cerebral’ disturbances provoked by fear, unpleasant emotions, beliefs, etc. But these views are likewise contested, the very idea of conditioned pain in childbirth being questioned (Davidenkov, 39).

Other differences are becoming apparent as to the mode of action of the essential factor in the PPM, education. For Velvovski, education produces analgesia in an entirely new way: whereas, in the hypnosuggestive method, analgesia was achieved by ‘cortical inhibition’ and involved a therapeutic process, according to Velvovski it is achieved in the PPM by ‘activation’, through raising of the cortical threshold for pain. The process is prophylactic, it aims at preventing pain and no longer at suppressing it. Here again, there are but few Soviet authors who follow Velvovski, and some (e.g. Doline and Salgannik, 46,143) even hold that, when there is analgesia in the PPM, it is always the result of a process of inhibition. For our part we would point out that the distinction between analgesia brought about by inhibition and analgesia resulting from activation has as yet no experimentally demonstrated basis.

The progress of electrophysiological investigation of the central nervous system has shown that inhibitory mechanisms are involved in ‘directional’ or oriented attention in animals. It has been demon-strated that, if a particularly meaningful stimulus is presented to an animal, there is inhibition of the transmission of information from other sensory modalities. The location of these inhibitory mechanisms, however, is still largely unsettled (Hernandez-Peon, Scherrer, and Jouvet, 69; Worden and Marsh, 157). Similarly, certain mechanisms of attention in man have been investigated neurophysiologically (Jouvet, 80). Now if the stimulus, instead of being limited to sensory impression, consists of a verbal or infra-verbal communication, its ‘significance’ is enriched by an affective charge which considerably increases its inhibitory power, in a manner which varies as a function of the personality of the subject and his relations with the operator. It is precisely a situation of this kind that is involved in suggestion.

A whole book could be written on the problem of suggestion. Here, it will suffice merely to indicate that the role of suggestion in the PPM is variously regarded by Soviet writers. In contrast to Velvovski, who regards it as negligible, some authors, such as Konstantinov (85), assign to it the principal role. We shall return to this problem when we examine in detail the factors involved in the method (p. 16 below).

Another difficult theoretical problem is the question of ‘nervous types’. Pavlov (125), renewing the Hippocratic tradition, established a fourfold classification for animals. He distinguished the following types:

well-balanced, calm type (phlegmatic)

well-balanced, lively type (sanguine)

strong excitatory type (choleric)

weak inhibitory type (melancholic).

How far must we take account of the nervous type in the application of the PPM? For Velvovski (151) this plays no part in childbirth, except in pathological cases. Other writers assign to it some importance. All agree that it is difficult to determine the nervous type, for this requires the consideration of a large number of parameters: the strength, the lability, and the nature of the relations between activation and inhibition; and certain peculiarities in the relations between the first and second signalling systems, and between the cortex and the sub-cortical region. The methods used are more or less elaborate: they depend on tests (e.g. tests of suggestibility, the word association test) and on anamnestic data. Some writers talk of particular typological characteristics, others of ‘emotional predispositions’. In other words, these methods are the kind of thing that we would call a psychological investigation of personality. Thus, in an anamnesis used by Plotitcher (130) to determine nervous type, inquiries are made about the relations of the expectant mother with her parents, her husband, her children, her relatives, and her social environment, about her professional activity, about her ability to adapt to new tasks, etc.

The difficulties experienced by Soviet writers in determining nervous type arise essentially from the fact that the classification, based initially on animals, cannot be transposed unmodified to man. In man, the social takes precedence over the biological. This is why certain words can exert an effect on one individual and have no effect on another; for the response depends upon past experience. It should be added that interpersonal relations are not necessarily established only on the verbal level, and that there is a level of emotional relationship in which speech is not necessarily involved. As Ajuriaguerra (3) has pointed out, a deaf mute can no doubt be effectively prepared for childbirth just like a normal woman. In short, the direct methods of investigation used by the Russian writers do not seem to be sufficient to reveal adequately the past experience of the individual. For this past experience includes both conscious and unconscious components and it is difficult to reach the latter by means of direct questioning. We must, of course, recognize that methods using modern psychoanalytic concepts with a view to laying bare the deep levels of the personality are still in course of development, as will emerge more clearly later, when the present research is described.

These controversies have not had much place in the theoretical writings of French adherents of the PPM. For some time they have used the terminology of Pavlovian physiology (4,153), adopting mainly the ideas of Velvovski. In 1956, one of the present writers (27) expressed certain reservations about the explanatory value of ideas derived exclusively from Pavlovian physiology, and has since insisted upon the need to study psychological and interpersonal aspects. This point of view seems to have gained ground.¹ A change began to appear in 1959. It was admitted that the first theoretical expositions of the method were, in the words actually used by one of them, ‘rough and narrowly conceived’ (109). New points of view were expressed. Vermorel (154) abandoned the use of Pavlovian terminology to ‘translate’ psychological phenomena, and resorted to a form of expression which included a number of concepts in their psychoanalytic sense — anxiety, unconscious motives, fantasies, orality, transference, etc. He made frequent reference to authors such as Helene Deutsch (44) and Gressot (66). For him, the PPM is above all a form of education, although he explicitly states, ‘it is its psychotherapeutic effects with which ...

Table of contents

• Cover
• Half Title
• The International Behavioural and Social Sciences Library
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Figures and Tables
• Foreword by Professor Norman Morris
• Preface
• 1 History and Theory of Psychosomatic Methods of Preparation for Childbirth
• 2 Psychoanalytical Perspectives and Obstetrics
• 3 Problems in the Study of Childbirth
• 4 The Research
• 5 Analytical Tools
• 6 The Confinements
• 7 Negativity: Negative Factors in the Woman's Physical and Psychological History
• 8 Relations between Negativity and Confinement
• 9 Conclusions
• Appendix I: Three Case-histories
• Appendix II: Critical Review of the Literature on the Psychology of Pregnancy and Childbirth and on Preparation for Childbirth
• Bibliography
• Name Index
• Subject Index