PsychoanalyticPsychotherapy(1986)Vol2No1,45-52

THEINHIBITION OFMOURNING BYPREGNANCYACASESTUDY

EMANUEL LEWIS ANDPATRT!.KCASEMENT

SUMMARY

Pregnancytendstoinhibitthemourningprocesssothatabereavementwhichoccursduringpregnancymaybeinadequately mourned.Whenabereavementoccursduringtheperiod of"primarymaternalpreoccupation"(Winnicott)awomanhastheimpossibletaskofmaking"an exclusivedevotion"(Freud)totwopeople.Thebereavedwomanusuallyoptsforherlivebabyand mourningispostponed.Thecomplexitiesofthisprocessarediscussed;andtheseareillustratedbyacaseofpathologicalmourning,followingabereavementinpregnancy, thatwassuccessfullytreatedbypsychoanalyticalpsychotherapy.

INTRODUCTION

Pregnancytendstoinhibitmourningsothatwhenabereavementoccursduringpregnancyitisverydifficultforthebereavedwomantoinitiateandcarryonthenormalprocessofmourning(Lewis,1978,1979a).Bourne(1968)and Lewis (1976)haveshownthatstillbirth,andtoalesserextentneo-nataldeaths,aredifficulttomourn.Itisparticularly difficultforamothertomournherstillbirthduringasubsequentpregnancy.BourneLewis(1984),andLewisPage(1978),havediscussedthefailureofpsychotherapeuticattemptstohelpwomenmourntheirstillbornduringasubsequentpregnancy.AsaresultofthisexperienceLewisinvestigatedthedifficultyofmourningalllossesthathaveoccurredduringapregnancy,andmadesuggestionsaboutthemanagementofsuchabereavementatthetimeandsubsequently(Lewis,1979b).Inthispaperwediscusstherelevanceoftheseideastotheunderstanding ofacasetreatedbyCasement.

Freud(1917)describeshowinnormalmourningthereisanincorporationofthelostobject-"theshadowofthelostobjectfallsupontheego."Incomparingmourningwithmelancholiahewrote,"Profoundmourning,thereactiontothelossofsomeonewhoisloved,containsthesamepainfulframeofmind,thesamelossofinterestintheoutsideworld-insofarasitdoes notrecallhim-thesamelossofcapacitytoadoptanynewobjectoflove(whichwouldmeanreplacinghim)andthesameturning-awayfromanyactivitythatisnotconnectedwith

EMANUELLEWISPAT!l.ICK CASEMENT

thoughtsofhim.Itiseasytoseethatthisinhibitionandcircumscriptionoftheegoistheexpressionofanexclusivedevotiontomourningwhichleavesnothingoverforotherpurposesorotherinterests.Itisreallyonlybecauseweknowsowellhow toexplain it that the attitude does not seem tous pathological.''

Winnicott(1956)describespregnancyasastateofprimarymaternalpre­occupationwhich"couldbecomparedwithawithdrawnstate,or adissociatedstate,orafugue,orevenwithadisturbanceatadeeperlevelsuchasaschizoidepisode...''StrikinglysimilartowhatFreudhadsaidofmourningisWinnicott'saccountofprimarymaternalpreoccupationasacondition"that would be anillnesswereitnotforthefactofthepregnancy." During pregnancy a normalmotherissooccupiedwiththoughtsandfeelingsaboutthenewlifebeingcreatedwithinherthatshefindsitdifficulttogiveseriousconsideration to otheremotionalevents.Theonset ofquickeningfocusesamother's attentionupon thegrowingfoetusinsideher.Thoughtsandfeelingsaboutthebabyareintensifiedduringthethirdtrimesterofpregnancyandin the weeks following the birth.Thereislittleemotionaltimeorspaceleftforanyoneelse.Abereavementwhichoccursduringtheperiodofprimarymaternalpreoccupationconfronts awomanwiththeimpossibleneedtomake"anexclusivedevotion"totwopeople.Itisourexperiencethatthewomanusuallyoptsforherlivebabyandthatmourningispostponed. Thereasons for thisarecomplex.

MelanieKlein(1940)describeshowabereavementstirsupinfantile anxietiesaboutthelossoftheobject.Thedenialoftheguilt associatedwiththesenseofresponsibilityforthisearlyloss canleadtoadenialoftheneedforreparation,therebyinterferingwiththeworking-throughoftheseanxieties.Followingtheincorporationofthe deadobjecttherecanbemanicelationassociatedwiththefeelingsofpossessingtheidealisedlovedobjectinside.AdditionallyKleindescribesthemanictriumphofbeingaliveafterabereavementduetounresolvedinfantile feelingsofmanic triumph overtherivalbabiesinsidethebereaved's mother.

Theidentityofafoetusisnecessarilyvague.Likeidenticaltwins,untilyouknowthemthereislittletohelpdistinguishbetweenonefoetusandthenext.Itcanthereforebedifficultforapregnantwomantoseparateherfeelingsforherfoetusfromherfeelingsforherinternalfamily(theinternalobject).

Expectantmothershaveunconscious,ifnot conscious, ambivalent feelingsabouttheir foetus.Thediscomfortsofpregnancy, theexpectedimpactofababyonthemother'sworkandherfamily,the anxiety about the well-being of thebaby,andtheresponsibilitiesofparenthood,allgiverise to apprehension and mixedfeelingsaboutthepregnancy.Theseconcernsareareasonfortheexpectantmother tohavesomeunconscious hateevenforthemost wanted baby.

Bereavementre-awakensanxietiesaboutthelossoftheobject.Theworkofmourningrequirestheunderstandingandacceptanceofambivalencefortheincorporateddeadpersonandtheinternalobject.Becauseideasaboutthefoetusarevague,realitytestingisdifficultandamothercaneasilyconfusehermixedfeelingsforherfoetuswiththoseforthedeadpersonandfortheinternalobject.Toprotect

lNHIBITION OF MoURNING BY PREGNANCY

herfoetusfromadangeroussummationofhatefromallthesesourcesitcanbenecessaryforapregnantwomantoinhibittheworking through of herambivalenceforthedeadperson.Thisisanadditionalreasonwhyshepostponesmourning.

Mourninganexcessivelyidealisedpersontendsingeneraltobedifficult,butin

pregnancythereisanaddeddanger.Whenanidealisedpersondies,apregnant womancanidentifyherlovedbutvaguefoetuswiththeincorporatedidealiseddeadperson.Herlossisdenied.Thisidealisationcancontinuefortherestofherlife.Thebabymayevenbeimaginedtobethemagicalreincarnationofthedeadperson.Furthermore,alossduringpregnancycanencourageidealisationofthedeadpersontoavoidambivalencewhich isdifficulttoworkthroughinpregnancy.Anotherreasonforthedifficultyofmourningduringpregnancymaybethatpregnancy can predispose to the manic elation and manic triumph which,accordingtoKlein,canimpedethemourningprocess.Theexpectantmotherhas

thedouble triumph ofherownandofherbaby's survival.

Oncemourningisinhibitedduringprimarymaternalpreoccupation,itmayneverberesumed.Althoughitiswell-knownthattobecomepregnantcanbeawayofavoidingmourning,thecatastrophiceffectonthemotherandherfamilyofabereavementoccuringduringpregnancyis generallyoverlooked.The following casewastreatedbefore thedevelopmentoftheseideasaboutpregnancyandmourning.

THECASE

MrandMrsTcamebecauseofthewife'sfrigidityanddyspareunia.(SeealsoCasement, 1985,78-80). Thehusband hadback-ache anddyspepsia.

MrsTwasagedthirty-three.Herfatherdiedwhenshewasseventeen.ShewastwentyandMrTtwenty-onewhentheymarried.Afterbeingmarriedforfiveyearstheyhadason.Hebecameillwithanhereditarybraindisorderwhenhewassixmonthsoldanddiedninemonthslater.Twomonthsafterthis,MrsTgavebirtht.oadaughter.This babyappearedatfirsttobenormalbutdiedofthesamedisordragedtenmonths.Despitetheirbeingtoldtheone-in-fourgeneticrisk,anectopicpregnancyoccurredinthefollowingyearandMrsTthenagreedtobesterilised.

MrTwas theeldest offourchildren, his siblingscominginquick succession

afterhehadbeentheonlychildforthefirstfiveyears.Hisfatherdiedwhenhewasfourteen.

Attheinitialjointinterview,MrTwasveryanxious.Helethiswifedomostof

thetalking.MrsTwentoverthepainfuldetailsofthediscoverythatsomething was'wrong'withtheirfirstchild.Hescreamedcontinuouslyunlesssedated.Shenursedhimuntilhedied.Shewasthenseven-monthspregnant.Afterattending

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the funeral shefelt tearfulbut "helditin." Shenever cried, but felt numb.

EMANUELLEWISPATRICKCASEMENT

Immediatelyafterthechild'sfuneralshewassentshopping"totakehermindoffthings.''Shehadwantedtobeleftalonewithherhusband,butherfamilymadehershopand cookbeforeshehadtimeforittosink inthatherbabyhadjustbeenburied.MrsTcontinuedtoseekescapefromthe painofbereavementinactivity,firstfosteringchildrenandthenadoptingtwochildren-aboyandagirl.Bothchildrenwere livelyanddemanding,butinadditionto caringforthemshehelpedtorunaclub formentallyhandicappedchildren."Itseemedtooffersomekindoflinkwiththechildrenwehadlost.''

Thesexualdifficultybeganafterthefirstchildhaddied.MrTfeltexcludedand

retreatedintonight-work.Hisattemptsatintercourse wererejected.MrsTexplained:"EverytimemyhusbandapproachedmesexuallyIkeptonseeingmylittleboy'sface;"Whatwasmoststrikingherewasthatherownfaceandtoneofvoiceremained woodenandlifeless.Evenwhenshewastalkingofthechildren'sillnessandslow dyingsheshowednofeelingsatall,whereas,myfeelingsonlisteningtoherwereclosetobeing overwhelming. Iinterpreted that while shewastellingmeabouttheseextremelypainfulexperiencesshedidnotseemtobeabletobeintouchwithherownfeelingsofdistress,andthatIfeltasifsheweremakingmewishtocryhertearsforher.Sherepliedthatothershadmadesimilarcomments.Sometimesshefeltasifthereweretearsinhereyesbutshedidnothaveanyfeelingstogowiththem."Itallfeelstoofardowntobeabletoreachitnow."MrTsaidthathefoundithardtoberemindedaboutthedeadchildren,asitmadehimfacethefactthattheadoptedchildrenwerenothis.Hejustthoughtofthemreplacing thelostbabies, asahelptohiswife.

MrandMrsT'sphysicalsymptomswerethesomaticexpressionoftheavoidedpsychicpainoftheirseverallosses:thelossoftwobabies,theectopicpregnancyandthenthelossoffertilityafter the subsequent sterilisation. Ithought that ifMrsTcouldbehelpedtogetintouchwithherfeelings,ifshecouldcryherowntearsratherthanprojectherdistressintoothers,thentheywouldbothbeabletoforego their somatic symptoms.

WhenIsawMrandMrsTtogethertheyreenactedthepatternofthemarriage,

withMrTnotallowinghiswifetoexpressfeelingstowardanybodybuthimself

-andMrsTbeinginhibitedintalkingaboutthedeadchildreninhispresence.Itherefore sawthemseparatelyforatime.

WhatemergedinMrT'sindividualtherapywasthathismarriagehadbeenan

attempt toreplacetheearlyexclusiverelationship tohismother thathehadlostwhen hewas five. Hetherefore experienced hischildren asrivals forhiswife­mother, intruders whom he unconsciously wished to 'eliminate'. He had thenreactedtothedeathofeachchildasifhewereresponsible;andhisconsequentneedto punish himself for the unconscious guilt found expression in his pqysicalailmentswhichdevelopedwhenhisfirstchildwasdying.Laterhehadfeltthathe,rather than his wife, should have been sterilised. The stifling.of his wife'sexpression·of feelingsaboutthedeadchildrenalsoreflectedhisneedtorepressthemurderous impulseshehadfelttowardthem,. However,' asMrTbegan towork

INJiiBITIONOFMoURNINGBYPREGNANCY

throughhischildhoodjealousy,whichhehadbeenre-livinginthemarriage,he becamesensitivetohiswife'sneedsandallowedhertobegintomourn.Herdead childrenbecamepsychicallyhischildrentoo,whichhelpedhimtoshareinthemourning with hiswife.

Afterherfather'sdeathMrsTfeltsomething"godead"inherbutfoundthat

shecould"lose"herselfinsportandotheractivities,usingactivityasadefenceagainstmourning.Afterthechildrenhaddiedshefoundherselfsplitbetween theneedtospeakaboutthem,torememberthem,andthe wish to forget. People aroundherreadilycolludedwithanyavoidanceofthemourning,becauseofneedsoftheirown.InthetransferenceMrsTcouldbeseentobetryingtoprotectmefromfeelingssheassumedIwouldnottolerate,andsimilarlyprotectingherselffrommyexpectedrejection orprematurewithdrawalintheeventofherdaringtoshowherfeelings.Atonestageshetriedtoanticipatethisbyatemporaryflightintohealth, but returned for a slower and fullerperiod ofworking through.

MrsTwasabletorecognisethathergynaecologicalpainswereinpartaformof

aggressiontowardsherhusbandfornotallowinghertogrieve.Aftershehadfoundthatshecouldbemoredirectwithhimaboutthisshewasabletobegintoallowintercourse.Thefirsttimeshereachedorgasmwascrucial.Shebecamealarmedbyitssequel,assheimmediatelyfoundherself"cryingfromthedeepestdepths"inherself.Previouslyshecouldonlyseethechildrenastheyhadbeenwhentheywerealive.Nowshecouldalsoseethematthemomentshehadlastheldthem,beforegivingthemuptothehospital.Thenurseshadalmosttodragthefirstbabyfromherafterhehaddied.Bythetimeoftheseconddeathshehadlostherabilitytofeelanything.Shehadgonenumbtothepainofnursingeachchild,andcopedwiththeseconddeath"asazombie."Thesememoriespouredintoherasshewept.

Thisbreakthroughwassooverwhelmingthatsherevertedforatimetobeingagainafraidofintercourse,fearingtore-experiencethepaininhercrying.However,havingglimpsedherfeelingsofloss,afterthisorgasm,MrsTbegantoworkthroughherfearofremembering.Shefacedthefearbyactiverecallandsoonthephysicalpaindisappeared.

Therefollowedahoneymoonperiodduringwhichhusbandandwife enjoyedintercourse.Excitedbythisimprovementtheyresumed joint sessions andsuggestedthattheproblem was now cleared up. A datefor stopping treatmentwaset,despitemyconcernthatthis' seemed premature. The night before the'last'sesion,MrsT'sfrigidityreturned.Therefollowedafurtherfivemonthsofworkwiththiscoupleduringwhich theywereseenseparatelyandtogether. MrsTcontinuedtohaveintermittent,buttolerable,physicalpainsandshestillsometimescriedafterorgasm.Thetreatmenthadlastedayearwhentheystopped.Theywroteafewmonthslater tosaythattheimprovementinthemarriagehad continued:theyweremuchlesstroubledbyMrsT'sgynaecologicalpainsandMrT'sindigestion pad cleared up. Theirrelationship felteasier and stronger.

EMANUELLEWIS PATRICKCASEMENT

THEMODE OFTREATMENT

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Itisworthnotingthatthiscouplehadbeenseenbythesametherapist,separatelyaswellastogether;Contrarytowhatmanyanalystsmighthaveexpected,theresultingpressureswithin thetransferencedidnotimpedethetreatment. Instead,itwaspossibletousethesedifficultiestoillustratekeyproblemswhichthecouplehad notbeen abletoresolvebetween them. Iwillgivetwobrief examples.

Thehusband,beingjealousofthetherapist/wife relationship, clearlyparalleledhisearlierjealousyoftherelationshipbetweenhiswifeandtheirchildren,aswiththatbetweenhismother andherotherchildren.Thewife,expectingthetherapist tobedefendinghimselffromherpsychicpain,sometimesassumedthathewould onlyseethingsthroughherhusband'seyesratherthanthroughhers. Fromtransferences suchastheseitbecame,possibletoworkwithMrT'sdifficultyin

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communicatingfeelingswhichothershadformerlytreated asunbearable.Fromthisseparateworkthecouplebegantobeabletoincorporatethegrowthfromtheirindividualsessionsintothesharedworkofthejointsessions-andintothemarriage.

Whatmadeitpossibleforthiscoupletusethesametherapistinthesedifficultwayswasthattheyhad,fromtheinitialreferralfortherapy,presentedtogether.Theyknewthattheyhadashared problem,buttheyalsosensedthattheirindividualdifficultieshadbeenpreventingthemfrombeingable todealwiththis.Themodeoftreatmentreflectedtheinterplaybetweenthesedifferentdimensionstotheirrelationship.Also,havingbeenseenbysomany otherprofessionalsbeforebeingreferredtome,itwouldhavebeenquiteunwarrantedtohavereferredthemyetagain(totwoothertherapistsforindividualtherapy)unlessithadbeenmoreclearlynecessary.Theoutcomeoftreatmenthere,inourOtJinion,iustifiesthisdecision.

£DISCUSSION

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Effective mourning for thedead children of our couplehad been delayed for

Ciseveralyearsbeforetheycamefortreatment.Theanalystwashelpedtoaquickperceptionthatthefailedmourningwasacentralissueinthiscouple,particularlyforMrsT,throughhisawarenessofhiscountertransferencefeelings.Thetolerationandunderstandingofhiscountertransferenceexperienceenabledtheanalysttohold(beacontainerfor)hispatient'spainandfearofmourning,therebygraduallyenablinghertomourn.

DuringthetreatmentMrsTbecameabletorememberherdeadchildren,mparticular her first child, with a 'plastic' sense, and this was important m

INHIBITION OFMOURNING BYPREGNANCY

facilitating her mourning. Her plastic remembering is similarto thecaseofthefailed mourning of a stillbirth described by Lewis Page (1978). Theparentsdiscussedinthat paperhadnot seentheirstillborn,butthisimpediment totheirmourning was overcome by asking the mother detailed questions about theappearanceofherunseendeadbaby.Thisenabledthemothertobuildupanimageofherstillbornbaby,forcingherintoahelpfulawarenessoftherealityofherdeadbaby.Inthiswaytheunseenchildwas'broughtback todeath'inhermind'seye.The case described in our paper demonstrates how mourning was facilitated whenMrsTwasenabledtomakeintra-psychic, quasi-physical, contactwithherdeadchild.Asaresultofthiscontact,the'corpse'wasmademorefreelyavailableforpsychic incorporation. DuringcoitusandorgasmMrsTwasabletocreateaconcreteimageofherchildren.Shesawherchildrenastheyhadbeen,whenalive,but then also in her fantasy she saw and 'held' the dead children. She alsorememberedhowatthetimeherfirstbabydiedhehadalmosttobedraggedfromherarms.Shethenbecameabletocryfromherdeepestdepths.MrsTdescribed how before treatment shehad kept seeing her littleboy's face, when shewassexually approached by her husband. Her mental 'conception' of thedead childonlyoccurred duringtreatment. Itwas onlyafter thisthat hermourning, whichhadpreviously been inhibited duringpregnancy, andthenpostponed for severalyears, was got under way. The ghosts, conceived from the unmourned deaths

duringpregnancy, were psychotherapeutically laid.

AsthiscasewasseenbeforetheLewis'sideashadbeenformulated,itisofparticularinteresttoseehowthispatient ledthisanalysttowardssimilarclinicalfindings,particularlyinrelationtotechnique.ItbecameanimportantpartofthistherapythatMrsTcoulddescribeindetail,inhersessions,thevisualmemoriesofherdeadchildren.TheanalystfeltitappropriatetobeactivelyencouragingMrsTinherdescriptionofthesedetails.Itwasthusthatshewasabletoseeand,asitwere,toholdonceagainherdeadchildrenasanessentialsteptowardhereventualabilitytoletthemgo.Asshebecameabletoexperience,andto tolerateexperiencing,herpsychicpainshebecameabletorelinquishmuchofthesomatizationofthatpainwhichshehadinitiallypresentedasneedingtreatment.Itisalsointerestingtoseehowthissequencewas,inadifferentbutsimilarway,repeatedinthehusband.Theinhibitionofmourninghadbeencollusivelyshared.Theworking-through and recovery from this was mutual also.

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BoURNE, S.LEWIS, E.(1984).Pregnancyafterstillbirthorneonataldeath.Lancet

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CASEMENT,P.(1985).OnLearningfromthePatient.London:Tavistock.FREUD,S.(1917).Mourningandmelancholia.S.E.14,243-258.

KLEIN, M. (1940). Mourning and its relation to manic-depressive states. In

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LEWIS, E.PAGE, A. (1978). Failure to mourn a stillbirth: an overlookedcatastrophe.Brit.].Med.Psych.51,237-241.

LEWIS,E.(1979a).Twohiddenpredisposingfactorsinchildabuse.].ChildAbuse

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LEWIS, E. (1979b). Inhibition of mourning by pregnancy: psychopathology and management. Brit.Med.J.2,27-28.

WINNICOTT,D.(1956).Primarymaternalpreoccupation.InCollectedPapers(1958)London: Tavistock.

DrEmanuelLewis,TavistockClinic,120BelsizeLane,London NW3SBA.

MrPatrickCasement,122MansfieldRoad,LondonNW32JB.