Researching pregnancy

In our qualitative and longitudinal research, we followed the pregnancy of 6 women through encounters in each trimester of gestation. These women were recruited through a public announcement posted on social networks.³ We restricted the study to those experiencing first-time pregnancies.

The three encounters consisted of an hour and a half of a free association narrative interview (FANI), followed by 30 to 40 minutes dedicated to the application of projective methods. The FANIs were set and conducted as proposed and described by Hollway and Jefferson (2000). The projective methods included the Rorschach Inkblot Test and some selected cards from Thematic Apperception Test.⁴ As proposed by Hollway and Jefferson, and as is common practice in psychoanalytic clinical psychology, the ideas, feelings and impressions of the interviewer were also collected. In order to do this, at the end of the interview, the interviewer produced a report that included: her first impressions of the participant, how those impressions changed, or not, during the interview and the application of projective tests, how the interviewer felt during the interaction, any particularities noticed about the rhythm of the dialogue or about the participant’s tone of voice, corporal postures or eye contact, and the feelings and thoughts noticed during or after the encounter.

Data were analysed in our research group by clinical psychologists with psychoanalytic training. The full transcripts were read aloud and then interpreted. The group reflected on the unconscious processes and meanings that lay beneath the manifest discourse (of the participants and of the interviewer), using their psychoanalytical theoretic and clinical perspectives. The attention was focused, in that floating way characteristic of a psychoanalytical trained listener, on the associative chains, the silences, the slips of the tongue, the contradictions, and on the affects and thoughts provoked by the material on ourselves. The notes of these group discussions were added to the original data, and then the whole material was subjected to a second round of analysis, made by the PhD researcher. This aimed at identifying patterns that brought core themes to light, observing their transformations along the trimesters. For an interpretation to be accepted it had to be sustained by diverse elements and levels of the material, as the episodes narrated and the characters of the interview narratives, the Rorschach and the TAT protocols, and had to be meaningful when confronted with the whole.

From pregnancy as regression to pregnancy as catastrophic change

We approached the data we collected with the following question in mind: how does a pregnant woman create and transform meanings about such a critical but also original experience as pregnancy?

Classically, the psychoanalytic literature understands pregnancy as a regressive period that restages the critical conflicts of infantile development, by bringing to the centre of the psychic stage the fundamental polarities of psychic life: me and not me, subject and object, inside and outside, body and mind, love and hate, creation and death, feminine and masculine, maternal and paternal. The psychosexual conflicts – oral, anal and phallic – that precede, nurture and sustain the Oedipal differentiations of beings, sexes and generations are then relived and renegotiated (Deutsch, 1925, 1949). As this regressive state offers the possibility of new elaborations of ancient conflicts, it also provides a maturational opportunity (Bibring, 1959; Bibring et al. 1961).

Since the pioneering works of Helen Deutsch and Greta Bibring, that established this way of understanding the psychic experience of pregnancy, many authors have focussed on different aspects of the regressive and maturational paths. So, to cite but a few, Winnicott (1956) described a mental state he called “primary maternal preoccupation,” characterized as an almost dissociative state with an amplified sensitivity, which begins at the end of the pregnancy, facilitating the postnatal identification with the baby’s physic and psychic needs. Pines (1982) highlighted the double orientation of the processes of identification to the baby and to the maternal internal object, linking those with the re-emergence of the ambivalent conflict around the process of separation-individuation. Lester and Notman (1988) distinguished three phases of pregnancy, linking those with the reorganization of identifications to the maternal internal object: the beginning of the pregnancy is characterized by diffuse anxieties related to the fear of a regressive fusion with the preoedipal mother; the perception of foetal movements triggers a separation from the original maternal object; finally, the proximity of the delivery arises anxiety with the disfigurement of the body and reactivates infantile fantasies with childbirth. Bydloski and Golse (2001) argued that prior to the period of primary maternal preoccupation exists a period of “psychic transparency,” where the intra psychic boundaries are blurred, which enables repressed infantile memories to become more easily available. Sirol (1999, 2003) explored the aggressive and destructive drives directed to the foetus during pregnancy. Finally, Hollway (2015) revisited Winnicott’s primary maternal preoccupation illuminated by Ettinger’s work, proposing that pregnancy solicits a regression to the pre-natal ‘matrixial’ experience of subjectivity as an encounter. These perspectives on the psychic experience of pregnancy mainly focus on what happens, and proposes it is largely universal.

While recognising those regressive movements, but taking a slightly different perspective, Raphael-Leff (1996, 2001, 2015) stressed the bizarre aspects of pregnancy, emphasising that both a pregnant women’s body and psyche operates as a transformative container (in Bion’s sense) where physical and psychic interchanges with the foetus take place. The permeability of the container influences not only the capacity to tolerate the regression. It also influences the quality of those interchanges, which Raphael-Leff explores as a ‘placental paradigm,’ one that takes different values and configurations for each woman, and for each pregnancy.

The work of Raphael-Leff encouraged us to concentrate on the psychic work of containment of this experience. Indeed, by asking how the mind makes sense of this experience, we came to a different way of understanding pregnancy that does not exclude the idea that those dimensions of the mind highlighted by the literature are pressured, but that focuses on the original and singular experience of pregnancy. We draw on Bion’s provoking idea that ‘thinking is a development forced on the psyche by the pressure of thoughts’ (1962, p. 306) and that one needs an ‘apparatus for thinking the thoughts’ (1962, p. 307). That is, an experience presents itself to the mind, and the mind must then make sense of it: to digest it and make it her own flesh and blood, giving it a subjective meaning and being transformed in the process. The mind is then, as Meltzer clarifies, the ‘theater where meaning is being constantly generated’ (1976, p. 429). Thus, we aimed to uncover the play that was playing in the theatre of these pregnant women’s minds.

In this sense, we state that pregnancy is lived as a catastrophic change (Bion, 1965), that is, an experience that violently solicits the transformative work of the apparatus for thinking the thoughts. This change or transformation cannot be seen as simply a remaking of an old play as this is entirely a new experience, and a bizarre one, as Raphael-Leff (2001) points. Every woman lives this change in a unique way, creating subjective meanings while trying to cope with all the experiences that arise in both her internal and external worlds.

We will share some elements of Petra’s pregnancy story to illustrate how difficult it can be to think the thoughts generated by that experience. Additionally, we aim to show how the creation of meaning is an evolving process of transformation that can be observed along the course of gestation. Finally, we highlight how a pregnant woman needs those who interact with her to be containers so that she can be a container of her own experience and of her baby-to-be.

Petra’s first trimester: unthinkable thoughts

Petra is 32 years old when we meet her, and she is in her 14^th week of pregnancy. She lives near Lisbon with her long-time boyfriend, Victor.

In this first interview, Petra describes her pregnancy almost as a traumatic event, that is, as an experience that the mind cannot symbolise, an experience that freezes the psychic space-time continuum. Petra uses terms as ‘shock,’ ‘chaos,’ ‘prison,’ ‘revolt,’ ‘panic’ and ‘lie.’ When the interviewer asks about the story of her pregnancy, which is the opening question, she evokes the time before becoming pregnant. What she tells evinces she cannot represent herself as a receptive container: she stopped taking the pill to ‘clean the body,’ but she doubted that she would become pregnant because she had a ‘retroverted uterus.’

Petra is having a difficult time transforming this emotional experience into thoughts. She states, ‘as much as I try to transform it into words, it’s… I don’t know, this is the confirmation that my whole life is going to change, and….’ This experience cannot find words because it has not been thought; it remains an undigested fact that cannot be placed in a subjective and meaningful chain of past and future experiences, which explains the pauses in her speech and this feeling of absolute and dramatic revolution that she expresses as ‘my whole life is going to change.’

Ultrasound consultations make visible something that Petra cannot represent. Consequently, she finds them deeply disturbing. She tells how her friend had told her that when she would ‘listen to the heartbeat’ (notice that it is a heart without an owner, not hers, not anyone else’s), her sadness would dissipate. However, it was a ‘lie.’ ‘I didn’t get happier. No, I even got angrier; I don’t know why.’ She continues by enumerating all the signs inscribed on her body that attest to her pregnancy, ultimately concluding ‘physically I am pregnant, but psychologically I am not yet.’ However, because she finds her doctor very ‘patient’ and non-intrusive, she can express her difficulties and look for signs even if she cannot ascribe meaning to them. She cannot digest and integrate this experience, but ‘not yet’ indicates that she is open to the possibility of doing so.

This view contrasts greatly with how she talks about obstetric consultations, in which the attitudes of her doctors seem to add unthinkable thoughts to her already burdened mind. The first doctor she consults tells her that ‘if an abortion occurs, it’s OK; don’t worry, you can try again;’ she leaves in panic. The second doctor was ‘unavailable’ and ‘only asked functional questions’ without ‘any supportive words,’ and Petra leaves the consultation ‘worse than when she entered.’ This same doctor becomes more trustworthy in a later consultation when, as Petra states, ‘she focused on me’ and offered her time and attention.

From a psychoanalytic perspective, we might view this way of picturing characters as tolerant or disturbing and toxic as reflecting parts of the self that are dealing with the experience. In fact, Petra intensely represents her experience in a dream she reported, in which a drug addicted uncle tries to kill her mother. Certainly, these representations of her encounters with her doctors tell the story of her struggle to think the thoughts of her pregnancy. However, they also indicate that she needs those around her to be tolerant and available. That tolerance and availability are not enough to help her think but at this point are certainly enough to prevent additional emotional pain.

She expresses this need vividly when she narrates the moment that she announced the pregnancy to her parents-in-law: she was crying so much that they thought that something had happened to Victor, who was working abroad. Her in-laws panicked, she says, ‘but then they understood it was this, and…. and they accepted and relaxed about it.’ We might surmise that through projective identification, she was causing them to feel the way that she felt, and then observing how they managed this emotional experience. Even if she cannot yet make any use of this experience, as the pause in her speech tells us, because she does not yet know what it was that her in-laws understood.

Thus, in this first interview, Petra struggles to think the thoughts of her pregnancy. People around her may either increase her sense of risk linked to the experience of pregnancy, or operate as a container for her undigested emotions. Doctors are crucial to this process, as those consultations are situations that highlight her difficulties with thinking about the pregnancy that she is currently living.

Petra’s second trimester: thoughts in search of a thinker

At the very beginning of the second interview, it is clear that Petra is still struggling, but it is also clear that something is changing in her mind and in the way that she can use other subjects’ minds. Note that we do not speak of significant others as objects, as traditionally psychoanalysis does. This is not because we do not recognise their function as objects, both internal and external; it is because we aim to emphasise their role as subjects on a path of meaning creation that we believe is always intersubjective and intersecting with the phantasised aspects of others as much as their real features.

Petra, now in her 26^th week, explains to the interviewer how the change had begun to occur: she felt tired, exhausted and frustrated; she complained repeatedly to her boyfriend; and repeatedly he stated, ‘you’re pregnant, you’re pregnant.’ There was also a nurse from the prenatal classes who explained that as pregnant women, they were living ‘a process of change [she mumbles] where we pass from being daughters to being mothers […] it doesn’t happen only at that time [the birth]; it’s already happening, and that calmed me.’ With their help, Petra started to think the experience of her pregnancy: ‘This thought has been moving inside me.’ The thought to which she refers is about her process of transformation from being contained to being a container. The thought is not yet about what she contains.

In fact, speaking of the ultrasound consultation, she states, ‘it’s inside me, but it’s something so distant from here, from my thought, that some dissonance enters here.’ Representing a baby within is not possible, is too scary. When she tries to approach this representation she fails as she talks about her fears and she again focuses on herself, not on the baby: ‘I am not capable of taking care of a handicapped child.’ She debates with her boyfriend and mother-in-law, who is a doctor, about the possibility of undergoing amniocentesis. She ‘relaxes’ only when her mother-in-law says that that are some diseases that she will not see. Accepting that she cannot see and cannot know somehow calms Petra and makes it possible to create a mental representation of a baby already born and to imagine herself as a mother.

In the first interview, she had explained how she would not be able to take maternity leave for more than a month because of her work. Now, during the second interview, she says that perhaps three months is not enough time with the baby because ‘he is going to be so little and… it’s not only for him, it’s for me.’ She explains, ‘OK Victor is there, and he can take care of the baby, but he is not going to replace me. And I want to have feelings and experience things with the baby.’ She then explains how this relates to her own experience as a child, when her mother sacrificed her career to stay at home and take care of her and her brother, while her father was always at work and absent from home.

Thus, Petra can start to create meanings about this pregnancy but only if displaced to the past or projected onto the future. The present is still a ‘room full of rubbish,’ which is the way that she portrays the space in her home that she still cannot prepare as a baby’s room. She wants to clean it and paint it, but she is not yet capable of doing so. We would like to suggest that transformation is possible because she has started using Victor, the prenatal class nurse and her mother, who she feels is being tolerant and supportive, as containers of her experience. At the same time, she is still rather dependent on their capability to do so.

Once again, this experience is clearly illustrated by an interaction with her doctor. For instance, she tells how upset she was by the lack of reassuring answers from her obstetric doctor. The doctor had asked if Petra was already feeling the baby moving, and when she answered that she is not sure and tried to describe her sensations, her doctor replied, ‘oh, I don’t know, I’m not a mother.’ ‘I don’t need a doctor to tell me this,’ Petra says. Her doctor could not help her understand what she was feeling. However, when the interviewer asks Petra to speak about those sensations, she expresses some joy for the first time: ‘it was funny […] it has been funny.’

In this second interview, supported by those who talked about her and not about a baby she cannot represent, by those who recognised her as the subject of this experience, and who offered open and flexible meanings that she could fill herself, a thought began to be silently thought. As that funny thing, her thought is moving.

Petra’s third trimester: being a container, holding thoughts

At the time of the last interview, Petra is in her 37th week of pregnancy. She explains how she became scared because a doctor told her that the baby was ‘too small’ and needed to grow. Some weeks later, another doctor saw the same figures about the baby’s growth percentiles and said everything was fine, treating her ‘like a crazy woman’ for being worried.

Petra could not experience these doctors as containers. Instead they mirrored her worst fears, as, we could say that she is truly afraid that inside her mind the thought of the baby is still too small, too fragile. Later, she clarifies, ‘OK, I’m pregnant… aren’t I? [she mumbles] I still don’t feel that I’m like preeeeegnant […] I still don’t live the pregnancy in a dreaming and fantasising way.’

Nevertheless, at the end of the interview, she narrates the most astonishing sequence of dreams, but only after telling the interviewer how supportive her mother has been, how she feels protected by Victor and how a nurse from the prenatal classes has told her about ‘the way of the baby through her body’ and, we add, through her mind. We will quote her extensively now to offer a full picture of her dream thoughts:

‘At the beginning, I had a weird dream I was holding the baby and, I don’t know if I told you, it was raining a lot, and then the baby was, it was like a newborn; he was getting soaked, and he was drowning because he was in a cylinder on my lap, and I thought he is going to get hypothermia, so I tried to take off his clothes, and I had to undress myself and him to create human warmth […] and tonight I dreamt that I was changing his diaper; he was really tiny, and I thought, oh, it’s a boy. I didn’t want a boy at all [she laughs] […] but I have to be happy, boy, I don’t have a preference, and then I went there to confirm again, and then I couldn’t well perceive what it was […] I think I don’t have preferences, but maybe I do after all.’

These dreams have multiple meanings, but we will focus only on the way the dreams are a means of condensing her journey through her pregnancy: first, one interpretation might be that she could not hold this experience directly; she needed another container, something that helped her support the idea of her pregnancy, represented by the cylinder interposed between her and the baby. She is now able to support this idea, to warm this idea. She has a psychic space/body in which to hold the baby, and this makes it possible to have preferences. However, it also makes it possible to tolerate what she cannot know/perceive while being open to knowing it, finding it, and recognising it. Petra and Victor did not want to know the sex of their baby until it was born. If, for Petra, this ‘not wanting to know’ initially reflected her inability to think the thoughts of her pregnancy, it has now become a way of being receptive and non-intrusive, as she tells us her mother has been, accepting her way of dealing with the pregnancy. The baby’s room, she says, is still very impersonal and not as cosy as she would like, but it is now painted and free of rubbish. It is an expectant space.

The journey

We have tried to convey the vast effort that Petra’s mind had to make to give birth to these dream thoughts. For Petra, as we have observed, pregnancy began as an imprisoned, painful and unthinkable place. During her second trimester, she began to understand her pregnancy as a journey from being a daughter to being a mother, but she does not yet have room, in her mind, to contain the idea of a baby. At the edge of the delivery of her baby, she can represent it, her pregnancy, her body and her mind, as a clean and free place not yet invested but expectant, a place where phantasies start to emerge and where fears and wishes can be dreamt after all. Her encounters with other subjects’ minds were, for better or worse, crucial to this transformational journey.

Finally, it is important to remark that the interviewer notes emphasise how engaged and attentive she felt when interviewing Petra and how frequently she found herself wanting to comfort and reassure her. When listening to the interviews to transcribe them, the interviewer was particularly attentive of the impact of her questions and comments on Petra, noticing how much they interfered with her associative thought chain, and these perceptions gave her, the interviewer, a sense of excessive responsibility and aroused some anguish. Subsequently, during the analysis of the interviews, the reflective group repeatedly remarked on how much they required a precise and exhausting focus of attention. For many long hours, we were puzzled or even troubled, but we were always genuinely interested in and frequently surprised by the way Petra’s mind tried to think about her pregnancy and communicate it. At the end of the last interview, the process of transformation expressed in her dream sequence amazed and moved us all. All of these observations furnished us with countertransferential information about Petra’s psychic experience through the three encounters – not only of the difficulty that her mind encountered when trying to think the thoughts of her pregnancy but also how invested she became in the process of thinking through the containing minds of others, which she unconsciously but vigorously solicited. How rich was the process of meaning creation surrounding her pregnancy, both for her and for us as researchers, as clinicians and as women.

Conclusion

Antonino Ferro has stated, ‘it is useful to bear in mind that beneath every psychic floor there is always a proto-emotional magma against which we must defend, but which at the same time contains extraordinary expressive potentialities’ (2011). We believe that Petra’s journey through her pregnancy illustrates this idea perfectly.

Thus, we argue that pregnant women need to be allowed to have the time and space to generate their own meanings, feel their fears, and dream their wishes. We emphasise this need because there is a tendency amongst health professionals, and in the wider social context, to neglect the fragility of this process and to assume meanings that pregnant women do not recognise as their own. One striking example is precisely the idea that the woman represents a baby within. From our data analysis, we consider that this may not be the case for most (if any) women. A baby will be born – that can be represented – but there is no baby yet. A baby is another person, thus it cannot be inside their bodies. What they can try to represent is not the baby but their experience of being pregnant, which is quite different. That experience can be quite difficult to think, as we exposed here.

At the beginning of the twentieth century, as Hanson states, there was ‘a shift in obstetric medicine, away from the health of the mother and towards the health of the foetus’ (2004, p. 8). Some psychoanalytic schools, with their insistence on the importance of maternal functions, currently extended to pregnant women, tend to support this perspective. However, if from the medical perspective there is a foetus, then from the perspective of the mind there is an experience – one that must be integrated through the creation of subjective meanings. Therefore, we suggest that our data implies we should take a step back in order to reinstate the pregnant woman as the subject of her own experience. In particular, we claim that the practices of health care professionals should aim to embody a profound respect for this critical and always singular experience of conceiving a mother, a baby and multiple meanings. Rephrasing Winnicott, there is no foetus without a woman who lives, feels, thinks and dreams her pregnancy. Pregnant women must be seen, recognised and contained along their journey so that, from the magma, new landscapes of meaning can be created.

Competing Interests

The authors declare that they have no competing interests.