Handbook of Prenatal and Perinatal Psychology: Integrating Research and Practice [1st ed.] 9783030417154, 9783030417161

Table of contents :
Front Matter ....Pages i-xxiii
Front Matter ....Pages 1-1
The History of Prenatal Psychology (Ludwig Janus)....Pages 3-8
Methodological Levels (Rupert Linder, Ludwig Janus)....Pages 9-15
Front Matter ....Pages 17-17
Prenatal Structural Brain Development: Genetic and Environmental Determinants (Otwin Linderkamp, Dagmar Beate Linderkamp-Skoruppa)....Pages 19-32
Continuity and Dialogue (Peter G. Fedor-Freybergh)....Pages 33-45
The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders (Thomas R. Verny)....Pages 47-62
Transgenerational Consequences of Perinatal Experiences: Programming of Health and Disease from Mother to Child and Subsequent Generations (Tanzi Hoover, Gerlinde A. S. Metz)....Pages 63-81
Prenatal Developmental Origins of Early Brain and Behavior Development, of Self-Regulation in Adolescence, and of Cognition and Central and Autonomic Nervous System Function in Adulthood (Bea R. H. Van den Bergh)....Pages 83-113
Prenatal Psychoneuroimmunology (Michaela Ott, Magdalena Singer, Harald R. Bliem, Christian Schubert)....Pages 115-147
Epigenetics (Hans von Lüpke)....Pages 149-154
Contemporary Environmental Stressors and Adverse Pregnancy Outcomes: OPERA (David M. Olson, Adrienne Ettinger, Gerlinde A. S. Metz, Suzanne King, Suzette Bremault-Phillips, Joanne K. Olson)....Pages 155-168
Traces of the Invisible World of Becoming – Epigenetics as a Molecular Correlate of Prenatal Psychology (Birte Assmann)....Pages 169-190
Front Matter ....Pages 191-191
Attachment-Guided Birth Culture as a Means to Avoid Pre- and Perinatal Health Disorders (Sven Hildebrandt)....Pages 193-206
Mother-Embryo-Dialogue (M-E-D) (Ute Auhagen-Stephanos)....Pages 207-225
Prenatal Roots of Attachment (Rien Verdult)....Pages 227-246
The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report (Rien Verdult)....Pages 247-275
Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy (Rupert Linder)....Pages 277-289
On the Psychodynamics of Preeclampsia and HELLP Syndrome (Rupert Linder)....Pages 291-307
A Visual Exploration of Psychodynamics in Problematic Pregnancies: Case Studies in Analytic-Aesthetic Art Therapy (Klaus Evertz)....Pages 309-331
Erik: Case Study of an Experienced One Twin Loss (Britta Dilcher)....Pages 333-336
Love, Pregnancy, Conflict, and Solution: On the Way to an Understanding of Conflicted Pregnancy (Rupert Linder)....Pages 337-346
Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice (Rupert Linder)....Pages 347-353
On the History of the Pregnancy Conflict (Ludwig Janus)....Pages 355-358
Front Matter ....Pages 359-359
Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care (W. E. Freud)....Pages 361-375
Family-Centered Individualized Developmental Care of the Preterm Baby (Otwin Linderkamp)....Pages 377-390
Front Matter ....Pages 391-391
Introduction: The Prenatal Dimension in Psychotherapy (Ludwig Janus)....Pages 393-396
Therapy Stories for Prenatal and Perinatal Experiences: How Young Children Express Prenatal and Perinatal Experiences in Psychotherapy (Antonia Stulz-Koller)....Pages 397-418
Analytical Psychotherapy and the Access to Early Trauma (Renate Hochauf)....Pages 419-447
Pre- and Perinatal Baby Therapy: Baby Body Language (Karlton Terry)....Pages 449-458
The Quality of an Original Experience of Being: The Fundamentals of Body Psychotherapy in the Context of Prenatal Psychology (Bettina Alberti, Heiner Max Alberti)....Pages 459-467
Prenatal Regression in Psychotherapy (Lutz Rosenberg)....Pages 469-479
The Arc of Life: Continuity Between Conception and Death. Art Therapy and Prenatal Psychology (Klaus Evertz)....Pages 481-502
Psychological Aspects of the First Trimester (Max Peschek)....Pages 503-511
Pre- and Peri-conceptional and Prenatal Psychology: Early Memories and Preverbal Approaches (Klaus Evertz)....Pages 513-517
Stress, Trauma, and Shock: The Failures and Successes of Cathartic Regression Therapy (William R. Emerson)....Pages 519-541
Psychotherapy with Infants and Children (William R. Emerson)....Pages 543-558
Birth Trauma: The Psychological Effects of Obstetrical Interventions (William R. Emerson)....Pages 559-575
Psychoanalytic Parent-Infant-Psychotherapy: Transition to Parenthood (Barbara von Kalckreuth)....Pages 577-584
Front Matter ....Pages 585-585
On the Fundamentals and Necessities of Promoting Parental Competence (Ludwig Janus)....Pages 587-594
Introduction to Prenatal Bonding (BA) (Gerhard Schroth)....Pages 595-598
The Impact of Parental Conflict on the Intrauterine Realm (Jenö Raffai)....Pages 599-609
Postpartum Mood Disorders: Prevention by Prenatal Bonding (BA) (Gerhard Schroth)....Pages 611-618
Family Midwifes: Early Prevention Built on Long-Term Trust and Respect (Jennifer Jaque-Rodney)....Pages 619-626
Early Care Networks in Germany and Initiation of the Pforzheim Study (Rupert Linder, Thomas Bernar, Brigitte Joggerst, Uwe Jung-Pätzold, Gerlinde A. S. Metz, David M. Olson et al.)....Pages 627-670
Front Matter ....Pages 671-671
Prenatal Dimension of Cultural Psychology (Ludwig Janus)....Pages 673-683
Reflections About the Interplay of Prenatal and Postnatal Experience (Ludwig Janus)....Pages 685-699
Are Music Taste and Language Development Influenced by Prenatal Acoustic Experience? (Felizitas E. Linderkamp, Laurids W. Linderkamp, Otwin Linderkamp)....Pages 701-706
Philosophical Aspects of Prenatal Time Using the Example of Peter Sloterdijk (Klaus Evertz)....Pages 707-711
The Prenatal Dimension: Images in Art and Therapy (Klaus Evertz)....Pages 713-751
The Mental Echo of Preverbal Existence (Horia Crisan)....Pages 753-781
Prenatal Psychology Holds the Key: Thoughts About the Cultural Meaning of Prenatal Psychology (Klaus Evertz)....Pages 783-798
Back Matter ....Pages 799-817

Citation preview

Klaus Evertz Ludwig Janus Rupert Linder  Editors

Handbook of Prenatal and Perinatal Psychology Integrating Research and Practice

Handbook of Prenatal and Perinatal Psychology

Klaus Evertz  •  Ludwig Janus Rupert Linder Editors

Handbook of Prenatal and Perinatal Psychology Integrating Research and Practice

Editors Klaus Evertz Institute for Art Therapy & Art Analysis HfWU Nuertingen-Geislingen University Köln, Nordrhein-Westfalen, Germany

Ludwig Janus St. Elizabeth University Bratislava Dossenheim, Baden-Württemberg, Germany

Rupert Linder Gynecology, Obstetrics and Psychotherapy Birkenfeld, Baden-Württemberg, Germany

ISBN 978-3-030-41715-4    ISBN 978-3-030-41716-1 (eBook) https://doi.org/10.1007/978-3-030-41716-1 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

For our children and grandchildren

Preface

Prenatal psychology today can now look back on 100  years of theory and practice. In the beginning, it was the effort of a small number of people outside the psychological mainstream (Otto Rank, Gustav Hans Graber), who investigated the true origins of the individual’s developmental history. Without a doubt, the individual human being emerges from within the emotional traditions of its parents and ancestors—and herein lie the origins of all psychology. The earliest experience of attachment is conceptional, then intrauterine, and later perinatal. Thus, earliest experience is the foundation for all later relations and attachments for all human beings. This insight is relevant and useful in moments of crisis and, therefore, a topic for the practical application of prenatal psychology. It is also critical for the etiology of many somatic and psychic disorders. It is about time to compile this information in a compact book, accessible to the public as well as to all professions involved. It is time for a Handbook of Prenatal and Perinatal Psychology. Its topics are of interest to many different specialized fields: obstetrics, child and adolescent psychotherapy, adult psychotherapy, psychology, social education, pedagogics, and others. The articles are intended to serve as a form of “introduction” and as a “foundation.” Easy to read, and in accessible language, they bring together the essentials in the fields of history, research, obstetrics, neonatology, psychotherapy, prevention, and cultural psychology. Prenatal psychology includes a great variety of approaches and methods. They reflect the spectrum of therapeutic efforts aimed at making the subtlety and fragility of earliest sensibility felt and once more accessible as a base for later behavior. Healing and bonding can thus become possible where before, vague fears and loneliness prevailed. It has been substantiated that the four known attachment types can be traced back as early as the prenatal realm where they are already established and formed. The true potential of prenatal psychology is revealed in daily therapeutic practice as well as in the history of thought. The Handbook of Prenatal and Perinatal Psychology aims to contribute to the enhancement of individual psychology and to deepen the concept of man, as it will be needed for the future of a global human community. The character of this handbook is special in a variety of ways. Usually, textbooks summarize the theoretic or practical knowledge of a specialized field or a field of practice once its central predicates have been validated and established. The field encompassing the prenatal period and birth, however, vii

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needs to be validated, delineated, and answered for in an interdisciplinary way. That is why this handbook is of interdisciplinary character. It compiles findings and results from different scientific fields and fields of practice that—in other contexts—rarely communicate with each other. The common denominator for these different scientific fields and fields of practice lies in the live events of pregnancy and birth. In this handbook, they are (for the first time) jointly presented in a systematic manner. The backdrop for this joint presentation is a reflection of the different methodologic planes that characterize each of the separate fields from their differing perspectives, while they all have a relation to the psychologic aspects of pregnancy and birth in common. Each of these methodologic planes is delineated in their own chapter. Important aspects include experiential research with regard to prenatal development, fetal programming, fetal stress, and epigenetics. Each of these aspects is presented in a separate chapter as well. Another field is the psychosomatics of pregnancy and obstetrics. Aspects of this field include ways of dealing with pregnancy and birth, the emergence of the earliest relationship between mother and child, the meaning of prenatal and preconceptional nutrition, avoiding risks during pregnancy by means of psychosomatic care, as well as the psychosomatics of life-threatening disorders such as preeclampsia and HELLP syndrome. The rapid development and extension of the physician-directed medical field of neonatology is a manifestation of the huge advancement of knowledge regarding the biopsychological processes during birth and the prenatal period. Knowledge in this field is a precondition for the support of premature children; and this became possible only a few decades ago. This is why we dedicate an entire chapter to this field. The observations that occur during psychotherapeutic situations are particularly important to understanding the biographical significance of prenatal life and birth. These early experiences are preverbal; they require a particular, enhanced sensitivity and psychological intuition. A precondition to this historic development was great mental clarity and an inner independence from contemporary presuppositions and prejudices that deemed psychical experiencing to be impossible before birth. After the first fundamental cognitions by the psychoanalysts Otto Rank and Gustav Graber during the 1920s, the cognitive process evolved in rocky and eclectic ways; these are delineated in a chapter about the history of prenatal psychology. Today, there is a multifaceted prenatal-therapeutic scene that is presented in the introduction to the chapter about psychotherapy. This chapter addresses the prenatal dimension of child psychotherapy, baby psychotherapy, analytic and depth psychological psychotherapy, body therapy, katathym-imaginative therapy, and art therapy. Questions regarding the empirical meaning of experiences during the first trimester of pregnancy present a particular challenge and are therefore presented in their own chapter. During its prenatal development, the child is exposed to more or less elementary experiences of shock on a scale that has been hitherto hardly known. These experiences may later provide the backdrop for seemingly irrational behavior as well as for somatic and psychic disorders. These correspondences are also presented in their own chapter.

Preface

Preface

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One consequence can be drawn from the many-layered observations concerning the biographical significance of pregnancy and birth: primary prevention is crucial. There are different approaches; we present two examples: encouraging support for parenthood in an obstetric practice and the special support of the prenatal parent-child relationship in the framework of the support of the prenatal mother-child relationship—the so-called attachment analysis. The final chapter of this book is called “Cultural Psychology.” It looks at the fact that the prenatal period and birth do not only constitute meaning for the individual’s life but also for collective experiences that are at the core of human concepts of the self and the world. The objective of this chapter is to create sensitivity toward this dimension of social and cultural figurations. These connections are very significant; we illustrate them with examples from the visual arts and movies. Individual and collective processing of early experience mutually explicates each other. This is also part of the reason why public reception of prenatal psychology is difficult. Individual history and collective history seem to proceed on completely different planes, while in reality, they are intertwined in the most intimate way. A psychology of the arts that includes the prenatal-psychological dimension can uncover these correlations. The way a society deals with pregnancy and birth shapes the mentality of its members. Vice versa, the mentality of a society has great influence on the way its children arrive in this world. Both aspects share a complex correlation. And prenatal psychology is a powerful means to understand and shape this correlation in a constructive way. The interdisciplinary character of this handbook is reflected in the editors’ different professional fields: Klaus Evertz is a painter, art and body therapist, and cultural scientist, Ludwig Janus is a psychotherapist and psychohistorian, and Rupert Linder is a gynecologist, obstetrician, and psychotherapist. This allows for a wide interdisciplinary spectrum—as it was realized in this textbook, and as it is required by the topic of prenatal psychology. The unifying connection between the editors is their qualification in prenatal and perinatal psychology, medicine, and cultural sciences, as it emerged from their respective professions, as well as their long-standing cooperation and connection of friendship. Not least because of the novelty of its various aspects, and the particular complexity of interdisciplinary presentation, we consider this handbook as a beginning and an encouragement for further research and integration. We hope that the integrative compilation that is accomplished by this book is suited to facilitate greater public recognition of the inevitably interdisciplinary field of prenatal psychology. The aim is that the essential aspects of prenatal psychology are sufficiently taken into account within the different fields of practice. Köln, Germany Dossenheim, Germany Birkenfeld, Germany May 2019

Klaus Evertz Ludwig Janus Rupert Linder

Acknowledgments

We would like to thank the many pioneers in prenatal psychology, men and women, who had the strength to hold the line. Furthermore, we also thank our teachers and clients and all people who work on the idea of a rational and empathic humanity.

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Contents

Part I Prenatal Psychology: Origins and Methodology  The History of Prenatal Psychology ������������������������������������������������������   3 Ludwig Janus Methodological Levels ����������������������������������������������������������������������������   9 Rupert Linder and Ludwig Janus Part II Empirical Research, Brain and Stress Studies  Prenatal Structural Brain Development: Genetic and Environmental Determinants����������������������������������������������������������  19 Otwin Linderkamp and Dagmar Beate Linderkamp-Skoruppa Continuity and Dialogue�������������������������������������������������������������������������  33 Peter G. Fedor-Freybergh  The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders ����������������������������������������������������������������������  47 Thomas R. Verny  Transgenerational Consequences of Perinatal Experiences: Programming of Health and Disease from Mother to Child and Subsequent Generations������������������������������������������������������������������  63 Tanzi Hoover and Gerlinde A. S. Metz  Prenatal Developmental Origins of Early Brain and Behavior Development, of Self-Regulation in Adolescence, and of Cognition and Central and Autonomic Nervous System Function in Adulthood ��������������������������������������������������������������������������������������������  83 Bea R. H. Van den Bergh Prenatal Psychoneuroimmunology�������������������������������������������������������� 115 Michaela Ott, Magdalena Singer, Harald R. Bliem, and Christian Schubert Epigenetics������������������������������������������������������������������������������������������������ 149 Hans von Lüpke

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 Contemporary Environmental Stressors and Adverse Pregnancy Outcomes: OPERA���������������������������������������������������������������������������������� 155 David M. Olson, Adrienne Ettinger, Gerlinde A. S. Metz, Suzanne King, Suzette Bremault-Phillips, and Joanne K. Olson  Traces of the Invisible World of Becoming – Epigenetics as a Molecular Correlate of Prenatal Psychology �������������������������������� 169 Birte Assmann Part III Psychosomatics of Pregnancy and Birth  Attachment-Guided Birth Culture as a Means to Avoid Pre- and Perinatal Health Disorders �������������������������������������� 193 Sven Hildebrandt Mother-Embryo-Dialogue (M-E-D) ������������������������������������������������������ 207 Ute Auhagen-Stephanos Prenatal Roots of Attachment���������������������������������������������������������������� 227 Rien Verdult  The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report ������������������������������������������������������������������������������������ 247 Rien Verdult  Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy�������������������������������������������� 277 Rupert Linder  the Psychodynamics of Preeclampsia and HELLP Syndrome������ 291 On Rupert Linder  Visual Exploration of Psychodynamics in Problematic A Pregnancies: Case Studies in Analytic-Aesthetic Art Therapy������������ 309 Klaus Evertz  Erik: Case Study of an Experienced One Twin Loss���������������������������� 333 Britta Dilcher  Love, Pregnancy, Conflict, and Solution: On the Way to an Understanding of Conflicted Pregnancy�������������������������������������� 337 Rupert Linder  Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice�������������������������������������������������������������� 347 Rupert Linder  the History of the Pregnancy Conflict �������������������������������������������� 355 On Ludwig Janus

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Part IV Neonatology  Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care���������������������������������������������������������������������� 361 W. E. Freud  Family-Centered Individualized Developmental Care of the Preterm Baby�������������������������������������������������������������������������������� 377 Otwin Linderkamp Part V Psychotherapy  Introduction: The Prenatal Dimension in Psychotherapy ������������������ 393 Ludwig Janus  Therapy Stories for Prenatal and Perinatal Experiences: How Young Children Express Prenatal and Perinatal Experiences in Psychotherapy�������������������������������������������������������������������������������������� 397 Antonia Stulz-Koller  Analytical Psychotherapy and the Access to Early Trauma���������������� 419 Renate Hochauf  Preand Perinatal Baby Therapy: Baby Body Language�������������������� 449 Karlton Terry  The Quality of an Original Experience of Being: The Fundamentals of Body Psychotherapy in the Context of Prenatal Psychology���������� 459 Bettina Alberti and Heiner Max Alberti  Prenatal Regression in Psychotherapy�������������������������������������������������� 469 Lutz Rosenberg  The Arc of Life: Continuity Between Conception and Death. Art Therapy and Prenatal Psychology�������������������������������������������������� 481 Klaus Evertz  Psychological Aspects of the First Trimester ���������������������������������������� 503 Max Peschek  Preand Peri-conceptional and Prenatal Psychology: Early Memories and Preverbal Approaches������������������������������������������ 513 Klaus Evertz  Stress, Trauma, and Shock: The Failures and Successes of Cathartic Regression Therapy������������������������������������������������������������ 519 William R. Emerson  Psychotherapy with Infants and Children�������������������������������������������� 543 William R. Emerson  Birth Trauma: The Psychological Effects of Obstetrical Interventions�������������������������������������������������������������������������������������������� 559 William R. Emerson

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Psychoanalytic Parent-Infant-­Psychotherapy: Transition to Parenthood ������������������������������������������������������������������������������������������ 577 Barbara von Kalckreuth Part VI Prevention  the Fundamentals and Necessities of Promoting Parental On Competence���������������������������������������������������������������������������������������������� 587 Ludwig Janus  Introduction to Prenatal Bonding (BA) ������������������������������������������������ 595 Gerhard Schroth The Impact of Parental Conflict on the Intrauterine Realm �������������� 599 Jenö Raffai  Postpartum Mood Disorders: Prevention by Prenatal Bonding (BA)�������������������������������������������������������������������������������������������� 611 Gerhard Schroth  Family Midwifes: Early Prevention Built on Long-Term Trust and Respect���������������������������������������������������������������������������������������������� 619 Jennifer Jaque-Rodney  Early Care Networks in Germany and Initiation of the Pforzheim Study���������������������������������������������������������������������������� 627 Rupert Linder, Thomas Bernar, Brigitte Joggerst, Uwe Jung-­Pätzold, Gerlinde A. S. Metz, David M. Olson, Petra Poscharsky, Valerie Unite, and Doris Winter Part VII Cultural Psychology  Prenatal Dimension of Cultural Psychology������������������������������������������ 673 Ludwig Janus  Reflections About the Interplay of Prenatal and Postnatal Experience������������������������������������������������������������������������������������������������ 685 Ludwig Janus  Are Music Taste and Language Development Influenced by Prenatal Acoustic Experience?���������������������������������������������������������� 701 Felizitas E. Linderkamp, Laurids W. Linderkamp, and Otwin Linderkamp  Philosophical Aspects of Prenatal Time Using the Example of Peter Sloterdijk������������������������������������������������������������������������������������ 707 Klaus Evertz The Prenatal Dimension: Images in Art and Therapy ������������������������ 713 Klaus Evertz  The Mental Echo of Preverbal Existence���������������������������������������������� 753 Horia Crisan

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 Prenatal Psychology Holds the Key: Thoughts About the Cultural Meaning of Prenatal Psychology������������������������������������������������������������ 783 Klaus Evertz  The Charter of “The Rights of the Child” Before, During and After Birth ���������������������������������������������������������������������������������������� 799  The Moscow Manifesto of Prenatal and Perinatal Psychology and Medicine�������������������������������������������������������������������������������������������� 803 Index���������������������������������������������������������������������������������������������������������� 805

About the Editors

Klaus  Evertz  works as psychotherapist and art and body therapist in his own office and at the Center for Palliative Medicine, University Hospital of Cologne. He is also a painter and a cultural psychologist. His research focuses on images as forms of consciousness. He also held lectureships at the University of Cologne, University of Dresden, and University for Art Therapy Nürtingen. Ludwig  Janus, M.D.,  is a lecturer and psychoanalysis instructor at the Psychoanalytic Training Institute in Heidelberg, Germany. He is past-­ president of the International Society for Prenatal and Perinatal Psychology and Medicine (ISPPM) and current coeditor of the International Journal of Prenatal and Perinatal Psychology. He has published numerous articles and books on prenatal and perinatal psychology and on psychohistory, including “The Enduring Effects of Prenatal Life.” Rupert Linder, M.D.,  is a gynecologist, obstetrician, and psychotherapist profoundly integrating these three specialties in private praxis. Dr. Linder directs research in prevention of premature birth and improvement of mother-­ child outcomes. He is past-president of the International Society for Prenatal and Perinatal Psychology and Medicine (ISPPM). He is intensely working on the integration of the medical and social realms of his area and supports programs for improving early mother-child interaction.

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Contributors

Bettina Alberti  Praxisgemeinschaft Meesenring, Lübeck, Germany Heiner Max Alberti  Praxisgemeinschaft Meesenring, Lübeck, Germany Birte Assmann  Private Practice, Osnabrück, Germany Ute Auhagen-Stephanos  Private Practice, Neu-Ulm, Germany Bea R. H. Van den Bergh  Department of Welfare, Public Health and Family, Flemish Government, Brussels, Belgium Health Psychology, University of Leuven – KU Leuven, Leuven, Belgium Thomas  Bernar Obstetrics and Gynecology, Helios Maternity Clinic, Pforzheim, Germany Harald  R.  Bliem Institute of Psychology, University of Innsbruck, Innsbruck, Austria Suzette Bremault-Phillips  Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada Horia Crisan  Psychosomatics, Psychotherapy and Internal Medicine, Buch am Irchel, Switzerland Britta Dilcher  Private Practice, Iserlohn, Germany William R. Emerson  Emerson Seminars, Petaluma, CA, USA Adrienne  Ettinger Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA Klaus  Evertz HfWU Nuertingen-Geislingen University, Institute for Art Therapy & Art Analysis, Köln, Germany Peter  G.  Fedor-Freybergh University of Bratislava, Hainburg an der Donau, Austria W. E. Freud  (Deceased) Heidelberg, Germany ·

Sven Hildebrandt  University of Applied Sciences, Fulda, Germany Renate Hochauf  Private Practice, Altenburg, Germany

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Tanzi Hoover  Canadian Centre for Behavioural Neuroscience, Department of Neuroscience, University of Lethbridge, Lethbridge, AB, Canada Ludwig Janus  St. Elizabeth University Bratislava, Dossenheim, Germany Jennifer Jaque-Rodney  Leben Lernen Wandeln, Bochum, Germany Brigitte  Joggerst Public Health Department of Enzkreis and Pforzheim, Pforzheim, Germany Uwe  Jung-Paetzold Youth and Social Welfare Office, Social Services Department, Pforzheim, Germany Barbara  von Kalckreuth Pediatrician and Psychotherapist in Private Practice, Freiburg, Germany Suzanne King  Douglas Institute, McGill University, Montreal, QC, Canada Rupert  Linder Gynecology, Obstetrics and Psychotherapy, Birkenfeld, Germany Felizitas E. Linderkamp  Institute for Prenatal Psychology and Medicine, Heidelberg, Germany Laurids W. Linderkamp  Institute for Prenatal Psychology and Medicine, Heidelberg, Germany Otwin  Linderkamp Institute for Prenatal Psychology and Medicine, Heidelberg, Germany Dagmar  Beate  Linderkamp-Skoruppa (Deceased) Institute for Prenatal Psychology and Medicine, Heidelberg, Germany Hans von Lüpke  Institute for Educational Rehabilitation, Johann Wolfgang Goethe University, Frankfurt, Germany Gerlinde  A.  S.  Metz Canadian Centre for Behavioural Neuroscience, Department of Neuroscience, University of Lethbridge, Lethbridge, AB, Canada David M. Olson  Departments of Obstetrics & Gynecology, Pediatrics and Physiology, University of Alberta, Edmonton, AB, Canada Joanne K. Olson  Faculty of Nursing, University of Alberta, Edmonton, AB, Canada Michaela Ott  Institute of Psychology, University of Innsbruck, Innsbruck, Austria Max Peschek  Praxis für Körperpsychotherapie, Bremen, Germany Petra  Poscharsky Network Coordination Early Care System, Pforzheim, Germany Jenö Raffai  (Deceased) Psychoanalyst, Budapest, Hungary Lutz Rosenberg  Private Practice, Bremen, Germany

Contributors

Contributors

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Gerhard  Schroth Director of Arbeitskreis Psychosomatik Vorderpfalz, Gleisweiler, Germany Christian Schubert  Clinic for Medical Psychology, The Medical University of Innsbruck, Innsbruck, Austria Magdalena  Singer Center for Public Health, Department of Medical Psychology, Medical University of Vienna, Vienna, Austria Antonia Stulz-Koller  Psychiatric Practice, Zürich, Switzerland Karlton Terry  Private Practice, Denver, CO, USA Valerie  Unite Childhood and Early Parenting Principles (CEPPs), London, UK Rien Verdult  Private Practice, Gors-Opleuuw, Belgium Thomas R. Verny  Associate Editor, Journal of Pre and Perinatal Psychology and Health (JOPPPAH), Stratford, Canada Doris Winter  Family Center Au, Pforzheim, Germany

Part I Prenatal Psychology: Origins and Methodology

The History of Prenatal Psychology Ludwig Janus

Introduction The history of prenatal psychology began during the last century with the slow development of the insight that birth is not only an external event but also an elementary experience at an affective level which not infrequently could also be associated with traumatic aspects. These insights also broadened the horizons of empathy for the fact that our relation to the mother before birth, or our prenatal relationship, is, from the point of view of life history, the starting point for our later life experience. These insights are an expression of the expansion of our empathy for our history as a child, as a baby, and the preceding time. This expansion is the result of the historical development of modern mindset since the Enlightenment with its new possibilities of reflecting one’s own experience and empathizing with the experience of others. In this way, the continued existence of our experiences as a toddler and as a pre-speech child has become accessible to us. It is precisely these experiences that form the core of our unconscious, and the history of prenatal psychology is a history of the awareness of these relationships. In practice, this history begins with the publication of two books in the context of psychoanalL. Janus (*) St. Elizabeth University Bratislava, Dossenheim, Germany

ysis in 1924, the “Trauma der Geburt” (“Trauma of Birth”) by Otto Rank and “Die Ambivalenz des Kindes” (“The Ambivalence of the Child”) by Gustav Hans Graber. Both books reflected for the first time the prenatal and perinatal origins of basal elements of our individuality. Rank writes that our coming into the world can be linked to elemental experiences of menace and survival, as well as loss and separation, which he summarized in the term “trauma of birth.” Yet birth is not only a world gained but also a world lost, the loss of the prenatal world of life. This aspect was a priority for Graber, and he inferred from this the feelings of ambivalence toward the world. Because we are born into the world so helpless and unready, we are on a lifelong search for a substitute that is initially found in the care of our parents, which offsets the deficiency by nurturing, warming, and carrying around. This compensation ensures our survival in the world. This need for protection later attaches itself to the father and the culture into which we are born. The prenatal root of the aspects of this need for protection reveals itself in that the father becomes the heavenly and cosmic Father, as described in our mythologies. This heavenly Father is intended to replace our lost womb world. And my society and my culture are equally my mystical home, which is why I devote my body and life to them. Here, it becomes clear that prenatal psychology deals not only with individual psychology but always with cultural psychology as well.

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The history of the discovery of the biographical significance of the pre-speech maternal experience in psychoanalysis took place in reverse. Freud first discovered the significance of the father as “paternal protection” for the childish experience and its mythological reflection, and only then did the early pre-speech maternal experience become accessible in the depth psychology of Jung and Adler. Here, Jung put the regenerative side of the early maternal experience in the foreground, while Adler made accessible the prenatal and postnatal menaces and traumas and the counterreaction of striving for power and security. However, this was only an initial approach, and it was not until the works of Rank and Graber that the significance of the early maternal experience for the life narrative became concrete. Graber assumed here the positive nature of the experience of a prenatal self which is safe in the security of the “dual unity” with the mother. The abrupt nature of birth and its traumatic aspects rip the child out of this security and establish a fundamental ambivalence in relation to the world, which cannot replace this dual unity but forces deforming adaptations upon us so that birth is linked with a loss of self. In this sense, Graber’s psychotherapy is concerned with making the experience of the prenatal self re-accessible and reestablishing one’s own individuality in this experience (Reiter 2005). Similarly, Rank stated that the strengthening of self-experience in the “analytic situation” should enable the end of therapy to be associated with true independence and individuation with an enrichment of self-­ experience and a self-gain and not with forlornness and a loss of self as originally at birth (Rank 1926–1931). The foregoing should make clear that the expansion of empathy into the prenatal time and the experience of birth, which has become possible through the development of modern mindset, has a paradigmatic character which requires a broader presentation (see the contribution of Ludwig Janus “Prenatal Dimension of Cultural Psychology” in this volume). The following presents an outline of the external history of prenatal psychology.

L. Janus

The History of Prenatal Psychology A brief glimpse of the prenatal psychological perspective can be seen in some authors of the Enlightenment, as, for example, Johann Karl Wezel (1747–1819) who formulated: “It has been noted that not all, but most, currently inexplicable phenomena that are exhibited in many people to the astonishment of the learned and unlearned, would be very easy to explain if someone made known an exact and detailed story of their fate in the womb from the first moment of their existence until their birth” (quoted from Bennholdt-­ Thomsen and Guzzoni (1990), p. 117). In Adam Bernds’ autobiography from 1738, prenatal-­ psychological connections have already been created in a very modern way when he writes: “... all of which (the fears of war) puts her (the mother) in great fear so that it comes as no surprise that he brought a melancholy disposition and a compressed heart into the world with him, whom the mother had carried nine months long under a heart worn with fear and anxiety, ‘partus enim sequitor conditionem ventris’” (quoted from Bennholdt-Thomsen and Guzzoni (1990), p. 116). This possibility of understanding, however, was forgotten in the nineteenth century which was dominated by the so-called scientific orientation so that actual prenatal psychology began in effect with the discoveries of Rank and Graber described above. Unfortunately, the recognition of their discoveries failed due to the continuing dominance of the scientific patriarchal zeitgeist. However, there was an underlying tradition of individual psychoanalysts who repeatedly reported on the updating of prenatal and perinatal experiences in their treatments (Janus 2000). Significant progress was made by the development of the traumatic aspects of prenatal life by the Hungarian analyst Nandor Fodor (1949). But the psychoanalytic societies were still so greatly influenced by the patriarchal zeitgeist that the prenatal psychological perspective could not gain wider scope within its framework. However, a gradually changing zeitgeist in the 1960s facilitated the founding in 1971 of the International Study Association for Prenatal Psychology

The History of Prenatal Psychology

(ISPP) which developed into an interdisciplinary society for the study of the biographical significance of the pre-birth period and childbirth, leading to an expansion of the name to International Society for Prenatal and Perinatal Psychology and Medicine (ISPPM). The ISPPM was, and still is, the scientific forum for prenatal psychology and medicine in Europe through its congresses (see www.isppm.de) and the International Journal of Prenatal and Perinatal Psychology and Medicine (see www.mattes.de). A literature review of the most important papers on psychotherapy can be found in the anthology “Prenatal Psychology and Psychotherapy” (Janus 2004). The foundation of an interdisciplinary scientific society similar to the ISPPM was initiated in 1982 by the Canadian psychotherapist Thomas Verny and the Americans David Chamberlain, Barbara Findeisen, and William Emerson (American Association for Prenatal Perinatal Psychology and Health, APPPAH; see www. birthpsychology.com). In 1981, Verny made the public aware of the topic of experience before and during birth with his world bestseller The Secret Life of the Unborn Child. Extensive observations in the psychotherapeutic situation led to the insight that a fundamental underlying condition for later mental illnesses lies in the immaturity of the parents and essentially unwanted pregnancy (Häsing and Janus 1994; Levend and Janus 2012; Hollweg 1998; Sonne 1996). It is not easy to broach this topic in psychotherapies, and this also applies to the therapists themselves; this, too, may be a significant reason for the problems of the acceptance of prenatal psychology in general psychotherapy. The assumption of the reality of prenatal development and the prenatal experience can often mean a devastating confrontation with one’s own having been unwanted and endangered at a very elementary level. Due to societal resistance, it was logical that further advances in the study of prenatal and perinatal experiences outside the established psychotherapeutic societies were carried out in humanist psychology. By using psychoactive substances such as LSD, it was possible to facilitate access to very early pre-speech layers of experience. In

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this way, Grof (1975) was able to recognize and describe the birth process with its phases of opening, expulsion, and passage in its continuity and in the symbolic and existential processing. In Germany, the Europäische Collegium für veränderte Bewusstseinszustände (“European Society for Altered States of Consciousness”) initiated by Hanscarl Leuner (1981) was a forum for this research. The work “The Knowledge of the Womb” (1980); see also Janus (1991) from the Greek psychiatrist and psychotherapist Athanassios Kafkalides was groundbreaking for the recording of prenatal traumas. In England, Frank Lake (1980); see also House (1999), Ridgway and House (2006) was able to specify the consequences of prenatal and perinatal traumas. At the same time, developed his method of gaining access to traumatic prenatal and perinatal experiences by intensifying pre-­speech feelings and bodily sensations, whereby during years of research, he also correlated the scientific evidence for the biographical reality of prenatal and perinatal experiences in detail with his observations (Janov 2012). Building upon all these influences, the American primary therapist and prenatal psychologist William Emerson (2012; see also www. emersonbirthrx.com) was able, during years of work with regression experiences in groups, to develop maps of the prenatal mental development and phases of birth, the publication of which is expected in the near future. His work is currently being taught in Europe by one of his most important students, Karlton Terry (see the article by Karlton Terry “Pre- and Perinatal Baby Therapy” in this volume; see also www.karltonterry.com, www.ippe.com). The body-therapeutic setting with its emphasis on sensations and feelings proved particularly suitable for facilitating access to the pre-speech level of prenatal and perinatal experience (Boadella 1998; Krens and Krens 2003; see the contribution by Bettina and Heiner Alberti “The Quality of an Original Experience of Being” in this volume.). It was possible to demonstrate the fundamental importance of a positive prenatal relationship and bonding experience for a later secure sense of self and relationship

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(Krens 2001). These psychotherapeutic approaches are supported by the results of psychotraumatological research, which allow us to grasp the occurrences of traumatization and their processing much more accurately (Hochauf 2007; see also the contribution of Renate Hochauf “Analytical Psychotherapy and the Access to Early Trauma” in this volume; Unfried 1999). Stress research has confirmed the longterm effects of maternal stress (Huizink 2000; see the contribution of Bea Van den Bergh “Antenatal Maternal Anxiety and Stress” as well as the contribution of Thomas Verny “The Preand Perinatal Origins of Childhood and Adult Diseases and Personality Disorders” in this volume). In general, it is now possible to integrate the different approaches as some recent publications have shown (Schindler 2012; Janus 2013; Renggli 2018; see also the introduction by Ludwig Janus to the chapter “Psychotherapy”). Quite independently of this, the realization is developing in medical-epidemiologic research that the prenatal milieu predetermines to a certain extent the basis of the physiological control of the organism. The extensive relevant research is summarized under the heading of “Fetal Programming” and has progressed so far today that empirical studies on these prenatal predeterminations are available for almost every significant area of disease. The titles of the fundamental works “The Fetal Matrix: Evolution, Development and Disease” (2004) and “Developmental Origins of Health and Disease” (2006) by the Australian/English epidemiologists Peter Gluckman and Mark Hanson express directly the claim of scientific explanation. In Germany, this new research was described in the book “Perinatal Programming. The State of the Art” edited by Andreas Plagemann (2011), in which the Dutch stress researcher Bea Van den Bergh in her article “Prenatal programming of cognition and emotion: From birth to age 20” forges a direct link between epidemiologic research and prenatal psychology. The basic neurophysiological processes in the prenatal predetermination of thinking, feeling, and behavior are described here.

Practical Consequences of the Development of Prenatal Psychology The field of psychotherapy, which had been earlier divided into individual schools and methods, is becoming increasingly integrated. Empirical research, neurophysiology, and psychotraumatology are gaining the attention they deserve. The areas of encounter and cooperation are developing in the various depth psychology approaches, such as body psychotherapy, depth-­psychological psychotherapy, and psychoanalysis. The new framework for this open field is “psychodynamic psychotherapy,” where the prenatal psychological approach can also find its place. This integrative and interdisciplinary approach was introduced to prenatal psychology in particular by the longtime president of the ISPPM, Peter Fedor-Freybergh (1987) and Fedor-Freybergh and Vogel (1989). This created a stable framework within which it was possible to combine the data from internal experience, developmental biology research, socialization research, psychotraumatology, and brain research. It is our responsibility to withstand the identity tension that results from such interdisciplinarity, whereby our practical competence as psychotherapists, obstetricians, midwives, cultural scientists, etc. is significantly enlarged (see the article by Ludwig Janus and Rupert Linder on “Methodological Levels” in this volume). Prenatal psychology has found a framework within this interdisciplinarity from which it can make its challenging observations and findings available to the other psychotherapeutic, medical, social-therapeutic, and cultural-scientific fields of science. In practical terms, dedicated midwives, birthing assistants, and obstetricians have facilitated the change of mindset in recent years from a purely medical to a relationship-oriented support of pregnancy and birth (Klaus et al. 1993, 2000; Janus 1995, 2005a, b, among others). This also means that those working in the field of obstetrics and birth preparation are going to have to deal with the conditions of their own beginning of life. Today, midwives and psychotherapists have the

The History of Prenatal Psychology

opportunity of acquiring prenatal and perinatal therapeutic competence through the continuing education programs of Karl Terry, William Emerson, Klaus Evertz, and Franz Renggli u. a. (see www.isppm.de). A central consequence of the insights into the biographical significance of prenatal life and childbirth is the promotion of parental competence, as has begun in recent years, but which should be even more decisively implemented. The books by Verny (2003) and Hidas and Raffai (2006), among others, offer an orientation (see also the contributions by Gerhard Schroth, Jenö Raffai, and Karl Heinz Brisch in this volume). The promotion of parental competence (Armbruster 2006; Franz 2009; Janus 2006), especially in the lower third of society, has a much greater health-related political and sociopolitical significance than previously realized (Grille 2005). A possibility exists here for decisively promoting the capability of dealing with conflict, the capacity for peace, as well as a humane atmosphere in society. These qualities in human societies have hitherto been impaired by the prenatal, perinatal, and postnatal traumatic burdens prevailing in the early parent-child relationship, which were later enacted at the adult level in the wars and hardships of history up to the present day (DeMause 1996, 2000, 2005; Fuchs 2019). The bibliography contains further sources on the history of “prenatal psychology.”

References Armbruster, M. (2006). Empowerment Eltern AG  – Programm für mehr Elternkompetenz in Problemfamilien (Empowerment for parents  – Program for more competence of parents in problematic families). Heidelberg: Carl Auer. Bernds, A.  Quoted from Bennholdt-Thomsen, A., & Guzzoni, A. (1990). Zur Theorie des Versehens im 18. Jh. (To the theory of “mistake” in the 18th century). In T. Kornbichler (Ed.), Klio und Psyche. Pfaffenweiler: Centaurus Boadella, D. (1998). Embryologie und Therapie (Embryology and therapy). International Journal of Prenatal and Perinatal Psychology and Medicine, 8, 171–212.

7 DeMause, L. (1996). Restaging fetal traumas in war and social violence. In Int J of Prenatal and Perinatal Psychology and Medicine, 8, 171–212. DeMause, L. (2000). Was ist Psychohistorie? (What is Psychohistory?) Gießen: Psychosozial. DeMause, L. (2005). Das emotionale Leben der Nationen (The Emotional Life of Nations). Klagenfurt: Drava. Emerson, W. (2012). Die Behandlung von Geburtstraumata bei Kindern und Jugendlichen. Heidelberg: Mattes. Fedor-Freybergh, P. (Ed.) (1987). Die Begegnung mit dem Ungeborenen (Encounter with the Unborn (German contribution on the Congress of ISPPM in Bad Gastein 1986)). [Available from Bischoff, A., Friedhofweg 8, 69118 Heidelberg]. Fedor-Freybergh, P., & Vogel, V. (Eds.). (1989). Encounter with the unborn (English contribution on the congress of ISPPM in Bad Gastein 1986). Edenbridge: Parthenon. Fodor, N. (1949). The search for the beloved. A clinical investigation of the trauma of birth and prenatal condition. New York: University Books. Franz, M. (2009). PALME  – Präventives Elterntraining (PALME – Preventive training for parents). Göttingen: Vandenhoeck und Rupprecht. Fuchs, S. (2019). Die Kindheit ist politisch! Kriege, Terror, Extremismus, Diktaturen und Gewalt als Folge destruktiver Kindheitserfahrungen (Childhood is political! Wars, terror, extremism, dictatorships as consequences of destructive childhood experiences). Heidelberg: Mattes. Gluckman, P., & Hanson, M. (2004). The fetal matrix: Evolution, development and disease. Cambridge: University Press. Gluckman, P., & Hanson, M.  A. (2006). Developmental origins of health and disease. Cambridge: University Press. Grille, R. (2005). Parenting for a peaceful world. Alexandria: Longueville Media. Grof, S. (1975). Realms of the human unconsciousness. New York: The Viking Press. Häsing, H., & Janus, L. (Eds.). (1994). Ungewollte Kinder (Unwanted children). Reinbek: Rowohlt. Hidas, G., & Raffai, J. (2006). Die Nabelschnur der Seele (The navel cord of the soul). Gießen: Psychosozial-Verlag. Hochauf, R. (2007). Frühes Trauma und Strukturdefizit (Early trauma and structural deficit). Kröning: Asanger. Hollweg, W. H. (1998). Der überlebte Abtreibungsversuch (The survived trial of abortion). International Journal of Prenatal and Perinatal Psychology and Medicine, 10, 256–262. House, S. (1999). Primal integration. The school of lake. International Journal of Prenatal and Perinatal Psychology and Medicine, 11, 437–458. Huizink, H. (2000). Prenatal stress and its effect on infant development. Utrecht: University Press. Janov, A. (2012). Life before birth. Portland: NTI Upstream.

8 Janus, L. (1991). Die frühe Ich-Entwicklung im Spiegel der LSD-Psychotherapie von Athanassios Kafkalides (The early development of the ego as it is reflected in the LSD-therapy of Athanassios Kafkalides). Zeitschrift für Individual psychologie, 16, 111–124. Janus, L. (1995). Entwicklungen zu einer neuen Kultur im Umgang mit Schwangerschaft undGeburt (Developments to a new culture in handling of pregnancy and birth). In W.  Schiefenhövel, D.  Sich, & C.  Gottschalk-Batschkus (Eds.), Gebären (Giving birth). Berlin: VWB. Janus, L. (2000). Die Psychoanalyse der vorgeburtlichen Lebenszeit und der Geburt (The psychoanalysis of prenatal lifetime and birth). Gießen: Psychosozial-Verlag. Janus, L. (Ed.). (2004). Pränatale Psychologie und Psychotherapie (Prenatal psychology and psychotherapy). Heidelberg: Mattes. Janus, L. (2005a). Schwangerschaft im psychokulturellen Spannungsfeld unserer Zeit (Pregnancy in cultural field of our time). In A.  Ludwig et  al. (Eds.), Anspruch und Wirklichkeit in der psychosomatischen Frauenheilkunde (Claim and reality in psychosomatic gynecology). Gießen: Psychosozial-Verlag. Janus, L. (2005b). Schwangerschaft und Geburt in psychologischer und kulturpsychologischer Sicht (Pregnancy and birth in psychological and cultural perspective). Hebammenfo 3/2005 [Association Newsletter BfHD (German Federation of Freelance Midwives), Deuil-­ la-­Barre-Str. 65, D – 60437 Frankfurt]. Janus, L. (Ed.). (2013). Die pränatale Dimension in der Psychotherapie (The prenatal dimension in psychotherapy). Heidelberg: Mattes. Janus, L. (2006). Der Umgang mit Schwangerschaft und Geburt im Wandel des psychokulturellen Feldes (The Handling of Pregancy and Birth in the Changes of the Psychocultural Fields). In: Stöbel- Richter, Y., Ludwig, A., Franke P., , Neises, M., Antje Lehmann, A. (Eds.) Anspruch und Wirklichkeit in der psychosomatischen Gynäkologie und Geburtshilfe (Claim and Reality in the Psychosomatic Gynecology and Obstetrics). Gießen: Psychosozial. Kafkalides, A. (1980). The knowledge of the womb. Autopsychognosia with psychedelic drugs. Athen: Olkos Publishing House.

L. Janus Klaus, M., Kennell, J., & Klaus, P. (1993). Doula. München: Mosaik. Klaus, M., Kennell, J., & Klaus, P. (2000). Der erste Bund fürs Leben (The first tie in life). Reinbek: Rowohlt. Krens, I. (2001). Die erste Beziehung (The first relationship). International Journal of Prenatal and Perinatal Psychology and Medicine, 13, 127–152. Krens, I., & Krens, H. (2003). Die pränatale Beziehung  – Überlegungen zur Ätiologie der Persönlichkeitsstörungen (The prenatal relation  – Reflections to the etiology of personality disorders). Persönlichkeitsstörungen, 7, 17–31. Lake, F. (1980). Constricted confusions (unpublished). Leuner, H. (1981). Halluzinogene (Hallucinogens). Bern: Huber. Levend, H., & Janus, L. (2012). Bindung beginnt vor der Geburt (Bonding begins before birth). Heidelberg: Mattes. Plagemann, A. (Ed.). (2011). Perinatal programming. The state of the art. Berlin: DeGruyter. Reiter, A. (Ed.). (2005). Die vorgeburtlichen Wurzeln der Individuation. Die Wiederentdeckung Gustav Hans Grabers (The prenatal roots of individuation. The rediscovery of Gustav Hans Graber). Heidelberg: Mattes. Renggli, F. (2018). Früheste Erlebnisse  – ein Schlüssel zum Leben (Early experiences – a key for life). Gießen: Psychosozial. Ridgway, R., & House, S. (2006). The unborn child. London: Karnac. Schindler, P. (2012). Am Anfang des Lebens (At the beginning of life). Basel: Huber. Sonne, J. (1996). Interpreting the dread of being aborted in therapy. International Journal of Prenatal and Perinatal Psychology and Medicine, 8, 317–339. Unfried, N. (1999). Erfahrungsbilanz der Behandlung von Kindern mit prä- und perinatalen Traumen (Results of the treatment of children with prenatal and perinatal traumas). International Journal of Prenatal and Perinatal Psychology and Medicine, l1(4), 518–528. Verny, T. (2003). Das Baby von Morgen (The Baby of Tomorrow). Frankfurt: Zweitausendeins.

Methodological Levels Rupert Linder and Ludwig Janus

Introduction Several methodological levels usually have to be considered and balanced according to their respective significance. They have been named and developed during the past few years, also during special congresses of the International Society for Pre- and Perinatal Psychology and Medicine (ISPPM), for example, 2007, in Heidelberg. Five methodological levels are important: 1 . The quantitative level 2. The qualitative level 3. The level of empathic insight 4. The level of practical knowledge of professional groups 5. The level of cultural psychological comparison An approach including all these different levels is vital for sufficient dealing with pregnancy and birth, because therapeutic or preventive actions have to cover all aspects of the situation, particularly since the developing child does not yet have any direct means of codetermination. R. Linder (*) Gynecology, Obstetrics and Psychotherapy, Birkenfeld, Germany e-mail: [email protected] L. Janus St. Elizabeth University Bratislava, Dossenheim, Germany

In a group discussion about Problems of Monolinear Models, each participant could cast three votes on the question as to what would be missing if there were restrictions at the methodological level. At the quantitative level (1), the individual characteristics, the individual situation of each person, the emotions and the complex interweaving at many levels are not sufficiently allowed for. It would not be possible to represent adequately individual development, the certainty of a ‘healing encounter’, by reducing the complexity. Would the reduction at this level not be more of an expression of defence? The problem of conflict of interests in scientific studies (industry…)? The danger of one-sidedness, care when generalising? It is often necessary to have a period of 20–30  years to obtain significant results. In the end with some things, calculation is appropriate, with others’ emotions. The restriction to the qualitative level (2) would harbour the danger that physical collapse is not detected soon enough. This could go so far that one could call it loss of reality. There is also the question of how it is possible to draw universally relevant conclusions from individual experience. And the question remains of how language can access unconscious processes. Statements based on empathetic insight (3) can be inaccurate due to false interpretation, problems of dissociation on the part of the ther-

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apists and their subjectivity. Their self-perception and self-awareness are essential in precisely this area. It might be difficult to differentiate between pre-speech memory and reconstruction in hindsight. A postnatal trauma could be concealed behind a ‘prenatal and perinatal experience’. Myth creation could develop, especially with ‘charismatic teachers’. Certain types of therapists can selectively attract certain types of clients, which harbours the danger of false generalisation. So it is also possible that one-sidedness can prevail at this level, every level of perception is necessary and the restriction to level three alone could also be of a defensive nature. In practical experience (4), it is exactly the wealth of experience of the midwife’s craft that should be considered. Important know-how can also be had from laymen. Fear and power are the two extremes that make this difficult to accept. In cultural psychological comparison (5), literary reports from Africa were presented. Among others, trance was described as a culturally overlapping therapeutically effective procedure. It is, however, often the case that there is a cultural dependence on effectiveness. The subjective views and existential orientation of the dyad patient–therapist are of great significance. Knowledge from this area is of course not transferable on a one-to-one basis to another. Here also lies the danger of an incomplete observation. In an additional category, the importance of intuition was highlighted, and the importance of introspection by therapists was emphasised. They have to be able to combine everything into a complete whole. The analysis of the votes showed that one-­ sided restrictions at the methodological level hold dangerous problems and decisively limit the validity of the results. On the other hand, it is clear that there are no alternatives to integration and balancing of the methodological levels in theory and practice.

R. Linder and L. Janus

 ractical Aspects of Methodological P Levels in Obstetrics and Psychotherapy The integrated use of obstetrical and psychotherapeutic measures enables the integrated use of the five methodological levels. In this connection, economic and legal factors are of additional importance. The special complexity of the gynaecological examination and treatment situations requires a permanent observation of the different methodological levels and their integration and balancing. In the process, one level can be of more importance at times, as, for example, the level of quantitative measurement when ascertaining obstetrical findings, the qualitative level when ascertaining personal and relationship characteristics, the empathic level when ascertaining the psychological dynamics of conflict, the practical level when including obstetrical know-how and the level of cultural comparison when dealing with members of another culture. The obstetrical consultation situation, which includes a psychotherapeutic aspect, contains a unique complexity with which the doctor has to deal in the course of his therapeutic duties. It is exactly this conjunction of the objects of care, the pregnant woman, the unborn child and the expectant father that requires an integrative overall view of all three. This has, especially in impending morbidity, to include the environment as well as the subjective inner life and the previous history of those involved. In this relation, the self-awareness and self-reflection on the part of doctors and therapists are of great importance and of great relevance in particular for those clients with impending pathology. The systematic discussion of methodology should be continued in this area.

‘ How Can the Balance of Methodological Levels Be Maintained?’ There are again results from another group discussion on the topic ‘How can the Balance of Methodological Levels be maintained?’. The par-

Methodological Levels

ticipants or small groups, respectively, could cast their own votes. Important prerequisites for the necessary inquisitiveness and candour are here assurance, self-confidence and the dialogical inner exploration of therapists. New assessment and further development can develop from self-­ reflection. Profound self-awareness is a prerequisite for impartial empathy towards patients. The patient’s biography can be understood in accordance with the dialogical principle. Access to the different levels can arise quite spontaneously in time the assurance increases and allows the possibility of conscious reflection. As special topics arose the question of how non-verbal communication can be documented and the ascertainment that gender-specific means of access are possible.

 hysical Illnesses During Pregnancy P with Psychosomatic Aspects In the following psychosomatic problem areas, psychological aspects play a greater or lesser role in each case. It is necessary to clarify these individually in order to gauge the possibilities of psychotherapeutic/psychosomatic treatment: 1. Threatened miscarriage 2. Status after recurrent miscarriage 3. Morning sickness 4. Premature contractions/premature birth 5. Preeclampsia 6. HELLP syndrome 7. ‘Symphysial slackening’ and pelvic pains 8. Breech presentation 9. Dealing with overdue delivery 10. After birth: mastitis

Perceptive Attitude in Gynaecological Practice Prenatal psychology has taught us how important the early pre-speech stage is. Preverbal experience can express itself in dreams, emotions, moods, bodily sensations and feelings as well as

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in scenic realisation. Here, I want to expressly include associations and restimulation. We know from the experience of Balint groups that the background of a problematic situation can reveal itself in the group. And it is exactly these aspects, which are sometimes seen as chaotic and perhaps hard to digest, that are of psychodynamic importance. They are therefore an important diagnostic instrument. This can also be observed in the subsequent case histories. There aren’t always instant right answers; some questions remain open. Sometimes, it isn’t possible to pigeonhole things. This is why openness, enduring not knowing and repeated appointments are so important. What might remain unclear in one session can be understood in a later one. What isn’t possible in one session can happen of its own accord in a later one. Gynaecological action can only arise from an understanding of the whole situation based on the interactions of the relationships in consultation. Here, the fundamental setting of gynaecological practice is analogous to free-­ floating attention in psychoanalysis, although there the patient brings into the session the totality of a concrete life situation in free association with different levels of their communications and behaviour, including bodily expressions. As a result of the great responsibility in understanding and taking action, a special intensity develops in the diagnostic and therapeutic situation. This exceeds the bounds of the normal psychotherapeutic situation and requires of the gynaecologist great presence and the permanent re-evaluation of experiences and perceptions. Case histories deal with ongoing therapies, as interconnections can then be more vividly and authentically described. I would like to point out that I have to present the complexity of the cases as they exist so that you can comprehend how it is eventually possible to distinguish the really important dynamically effective aspects which then facilitate sensible action. This happens in a kind of circular process. When one particular aspect becomes comprehensible, the therapist can then provide a stimulus relating to it, creating a new situation that facili-

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tates new possibilities of understanding, and this in turn activates a further level. This process repeats itself several times. The whole thing has similarities with the mechanisms of a psychotherapeutic process; only all levels of reality are present. In addition, it could almost be said that the structure of this process is similar to the dialectic process described by Hegel with the progression from thesis to antithesis and then to synthesis, which in turn becomes the starting point for a new dialectic triple step. Now for the concrete case histories. Case History I:  Denial of pregnancy in the prior history and its repercussions Mrs. A., in the second half of her twenties, lived together with her friend. She came to me in the 24th week of pregnancy with severe morning sickness requiring a certificate of illness. She was in her third year of nursing training. It soon became obvious that she also had a drug problem. She had smoked a lot of marihuana. In passing, she said that she had always had problems concluding things. This was a spontaneous statement, the significance of which would later become clear from her biography. To begin with, I gave her a certificate of illness in order to take pressure off her. She wasn’t able to give up smoking for the whole length of the pregnancy. We kept talking about it: Sometimes, it seemed as if she had managed to stop, and then it was clear that she hadn’t. Luckily, this point turned out to be not that important as the child was developing well. The ultrasound examinations never revealed any developmental deficits. I gave her an anamnesis questionnaire about her biography to fill in. These questions appeared on it: 1. Pecularities during the pregnancy (of your mother with you)? 2. How did your birth progress? 3. What about the months afterwards? 4. What do you know about your parents’ relationship at the time? The prior history of this patient is really special because on the questionnaire, she described

R. Linder and L. Janus

how she had been conceived. Her mother had her first child at the age of 17. She was the second child, conceived during a chance encounter with a man at a summer festival 200  km away. Her mother had denied the existence of the pregnancy, although she had already had a child and must have been familiar with all the changes and the child’s movements within her. Apparently, no one around her had noticed anything. There must have been some awareness somewhere, but it had quickly vanished. In the end, she went to hospital with suspected appendicitis. This was the birth of the woman who was now herself pregnant. Therefore, it was fitting that she said ‘I can’t conclude things’. I find this very logical in view of the mother’s transference when seen from the trans-generational viewpoint. Now, this is how it continued: Unfortunately, she developed severe gestational diabetes. I am not depicting this from a theoretical viewpoint but from the practical viewpoint as things developed in my practice where all the background elements of the different levels are always present and significant: the quantitative, qualitative, empathetic and the others. Mrs. A. had in many respects, as could be expected from her prior history, a way of refusing to believe things. She visited the diabetes doctor irregularly  – I worked together with an internist diabetologist. She also had difficulties keeping to agreements and missed appointments because ‘her mother or friend hadn’t given her a lift’. These are obviously the kind of things that frequently happen when there is a background problem with drugs. To begin with, she often didn’t have the sheets with her daily blood sugar measurements with her. She gradually managed to improve measuring and bringing the results with her. For a long time, she was undecided if she wanted to have a house birth or not. But in the end, the diabetes and the necessity of intensive monitoring of the child made delivery in the clinic advisable. The delivery date was 1 week overdue which, in the case of diabetes, required greatly increased attention and patience. However, the delivery went well and Mrs. A. was really very happy and contented.

Methodological Levels

I have to add here that it wasn’t possible for the patient to come to terms critically with her mother because she was too dependent in reality on her mother and her support. I did, however, keep bringing up the subject cautiously. I hope it has become clear that the whole situation of the patient and the supportive care during pregnancy was overshadowed by the denial situation in the time before her birth. Knowing about this facilitated caring for her as well as possible under the given circumstances. Without this holistic approach, there was a danger that individual aspects could cause one-sided interventions which in their turn would cause a chain of further reactions which could have had severe consequences. Case History II:  Repercussions of being unwanted in the prior history Mrs. B. was 43 years old when she came under my treatment 2  years ago. The friend lived in another flat and she was newly pregnant. It was her second pregnancy. Her first child, a daughter, had been born 17 years earlier. She required prenatal diagnosis on account of her age. Due to anomalies in the region of the neck, I advised further clarification by standardised ultrasound screening with a colleague. He then calculated her risk factor. Going by age alone, this was 1:25 that the child had Morbus Down (Down’s syndrome) and after the examination 1:15, i.e. even higher. We then discussed the matter, and after a detailed process of information, she wanted no further diagnosis carried out. It was noticeable that she always had a radiant smile on her face when she believed in the intactness of her child. Parallel to this, there was a serious crisis with her partner that led to a separation. She had to go through a lot during the process. In relation to this, premature contractions set in, which, however, disappeared after the strain had been relieved by the discussions and temporary certification of illness. She was always able to regain courage and bore the child normally. The collapse came 6 months after the birth. She then had a mental

13

breakdown, and I made an application for formal psychotherapy. In this context, it first became apparent to what extent the issue of being unwanted was important to her: She was the fourth child; the mother had got pregnant against her will by the child’s alcoholic father. She kept arriving at the point where her feeling of security threatened to breakdown, which resulted in her feeling that she simply wasn’t able to look after her child. She said she sat in her flat and could do nothing – regardless of whether the child cried or not. She had also started smoking heavily again and wasn’t eating regularly so that she finally weighed less than 50 kilos. This depressive psychosomatic reaction had been triggered by the fact that the father of her child had promised her a certain sum of money and not kept to it. She felt that she was just hanging in mid-air. The non-­ appearance of the money had triggered her own prior history of being unwanted. Another impression was that when she railed against the father in her distress, often the child was with her and it always screamed. We were then able to discuss this, and she was able to understand it. Of course, she still has much to come to terms with and that can happen in the continuing psychotherapy. Case History III:  The effects of a lost twin in prior history Mrs. C. was 27 and had got pregnant unexpectedly. She hadn’t expected it because she suffers from Crohn’s disease; had 20 operations on her abdomen and intestines, including an anal extirpation; and lived with a stoma. She came recently, in the 24th week of pregnancy, complaining of stomach pains and wanting a certificate of illness. This seemed to me to be a sensible way of relieving strain as she seemed to be overstressed and there was a suspicion of premature contractions despite her fundamentally marked commitment. The emotional and/or physical overtaxing of women is the most frequent cause of premature birth, and this is often underestimated. After 2  weeks, everything had calmed down.

R. Linder and L. Janus

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Her record revealed that she had previously suffered from pronounced neurodermatitis, and it transpired that her mother had assumed she had a miscarriage due to bleeding early in the pregnancy and thought the pregnancy was over. The mother had turned out to be wrong, and in the end, the patient had then been born. The situation of the lost twin and her own endangerment was discussed with her at length. She had made it but her twin had not. She was able to take in the interconnections. I think that the therapeutic efficacy of this work lies in the fact that people can talk about the traumas and share the feelings. So it was in this particular case, and this is why I’m not really worried about the further progress of the pregnancy. She is now in the 34th week of pregnancy. The question of the form of birth, i.e. how she is going to deliver the child, is still unresolved. Her surgeon, in whom she has great confidence due to her years of illness, has voted for a caesarean section due to the scarring caused by the operations for Crohn’s disease. My idea was rather this: The womb is the only undamaged organ so why subject it to this operation? I have now spoken to the chief physician of one of our gynaecological clinics – in this situation, you’re always the go-between – with whom it was possible to discuss the situation. He agreed with my opinion. It is, however, possible that the patient herself will want to have the caesarean section due to the traumatisation of the many operations, in the assumption that her maltreated pelvic floor would be the better spared. There is to be further discussion here.

Concluding Remarks An important observation in bonding analysis is that burdens in the prior history of the expectant mother and her mother are of far greater significance in the ongoing situation than is assumed in the normal view of maternity care, so confined to the present situation. This observation can be fully confirmed from the viewpoint of the psychotherapeutic–psychosomatic gynaecological practice; only here is even more complexity

in the consequences of burdens from the patient’s own prior history as well as the mother’s, among others in the prevailing corporeality. It is evident that the early burdens shape the whole life situation of the expectant mother and the arrangement of her relationships. The awareness of the trans-­generational depth of the prevailing situation makes it possible for the gynaecologist to take into consideration the different existential and methodological levels and so find a new balance between these levels. This is what makes possible holistic understanding of the patient’s complex reality and so appropriate action.

Literature (2007, September). Methodological levels in prenatal psychology. 20th Heidelberg Conference. Press release. http://www.isppm.de/20_hd_workshop_ press_release_11_2007.pdf. (2007, September). Methodological levels in prenatal psychology. 20th Heidelberg Conference. Abstracts of papers (post congress). http://www.isppm.de/20_HD_ workshop_Abstracts_09_2007.pdf. Bail, B.  W. (2007). Mother’s signature  – A journal of dreams books. London: Master of Publishing. isppm. Charter on the rights of the child before, during and after birth. http://www.isppm.de/charta_en.html. Janus, L. (2001). The enduring effects of prenatal experiencing  – Echoes from the womb. Heidelberg: Mattes-Verlag. Linder, R. (1997). Psychosoziale Belastung und Frühgeburt --Erfahrungen mit einem psychosomatischen Konzept in der Praxis. Archives of Gynecology and Obstetrics, 260(1–4), 71–78. Linder, R. (2000). Ermutigende Mutterschaftsvorsorge am Beispiel des Umgangs mit der drohenden Frühgeburt? in Heiss G. (ed.) Wie krank ist unser Gesundheitswesen?: Das Gesundheitswesen in Deutschland und Europa an der Schwelle zum 21. Jahrhundert, pg. 1175–1191, Merz u. Böhmer Verlag, Mainz. Linder, R. (2006). How women can carry their unborn babies to term -The prevention of premature birth through psychosomatic methods. Journal of Prenatal & Perinatal Psychology & Health, 20, 293–304. Linder, R. (Ed.). (2008). Liebe, Schwangerschaft, Konflikt und Lösung  – Erkundungen zur Psychodynamik des Schwangerschaftskonflikts. Heidelberg: Mattes Verlag. Rank, O. Das Trauma der Geburt und seine Bedeutung für die Psychoanalyse. Gießen: Psychosozial-Verlag. Rauchfuss, M. (2002). Bio-psycho-soziale Prädiktoren der Frühgeburtlichkeit und Differrentialdiagnose

Methodological Levels zur intrauterinen fetalen Retardierung  – Ergebnisse einer prospektiven Studie. Charite Berlin: Habilitationsschrift. http://edoc.hu-berlin.de/ habilitationen/rauchfuss-martina-2003-06-26/PDF/ Rauchfuss.pdf.

15 Saling, E., Lüthje, J., Schreiber, M. Late abortions and premature births – General information. http://www. saling-institut.de/eng/04infoph/01allg.html. Verny, T.  R. (1991). Nurturing the unborn child (with Pamela Weintraub). Delacorte Press, New York.

Part II Empirical Research, Brain and Stress Studies

Prenatal Structural Brain Development: Genetic and Environmental Determinants Otwin Linderkamp and Dagmar Beate Linderkamp-Skoruppa

Introduction

1996; Verny 2003; Ridgway and House 2006; Linder 2008; Janov 2011; Chamberlain 2013; Until a few decades ago, it was widely believed that Findeisen 2017; Janus et al. 2018). the prenatal brain development is solely genetically During the last 20 years, foetal brain developdetermined, that no stimuli reach the unborn infant ment has become an essential topic of neurosciand that mother-infant bonding does not develop ence as a result of modern non-invasive and before birth. Sigmund Freud (1921) described the computational techniques and animal models. foetus as mostly sleeping with “absence of stimula- The results allow quantitative description of the tion and avoidance of objects”. Konrad Lorenz structure and development of individual nerve (1935) postulated that infants of various species cells and entire networks within specific brain “imprint” onto their mothers within 24–48  hours areas and to relate the structures to the functions after birth but do not bond before birth. In 1985, an at both the single neuron and network levels editorial in the BMJ concluded that “we don’t (Borsani et al. 2019; Zhao et al. 2019). We now know” if a foetus feels pain (Richards 1985). Up to know that the steps of early brain network formathe early 2000s, some authors advocated that all tion are genetically programmed but are modified human behavioural traits are inheritable (Pinker by epigenetic and environmental influences (De 2002) and challenged experiential effects on cere- Graaf-Peters and Hadders-Algra 2006; bral cortical development before full term (Volpe Linderkamp et  al. 2009; Lagercrantz 2016; 2008). On the other hand, publications on prenatal Marin-Padilla 2016; Walker 2016; Oldham and psychology emphasized the importance of environ- Fornito 2018; Gao et al. 2019). ment and experience for the normal psychological Our report is designed to review the present development of the foetus for decades (Fedor-­ knowledge of the sequence of genetically proFreybergh and Vogel 1988; Van de Carr and Lehrer grammed processes and of some epigenetic and environmental influences resulting in the formation of a functioning neural network before birth. The author “Dagmar Beate Linderkamp-Skoruppa” has died at the time of publication of this chapter. O. Linderkamp (*) · D. B. Linderkamp-Skoruppa (Deceased) Institute for Prenatal Psychology and Medicine, Heidelberg, Germany

Early Human Brain Development The brain development begins at approximately 3 weeks after conception (5 weeks of gestation) with the formation of the neural plate at the back

© Springer Nature Switzerland AG 2021 K. Evertz et al. (eds.), Handbook of Prenatal and Perinatal Psychology, https://doi.org/10.1007/978-3-030-41716-1_3

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O. Linderkamp and D. B. Linderkamp-Skoruppa

20

of the embryo. A few days later, the plate folds to form the neural tube around a canal. In the brain, the canal later widens to the ventricles; in the spinal cord, it forms the central canal. At the time of neural tube closure, the neural wall consists of one or two layers of epithelial cells (neuroepithelium) which are the precursors of an enormous variety of neurons and the macroglia. The development of the cerebral cortex occurs in precisely timed stages (Table  1 and Fig.  1). Each developmental process is also a vulnerable period which is sensitive to environmental insults rendering the brain susceptible to structural malformations and functional impairments.

Neurogenesis: “Raw Material” for the Brain Billions of nerve cells (neurons) are produced during the development of the central nervous system. Neurogenesis mainly occurs at the

inner edge of the neural tube wall, the later ventricles (brain) and central canal (spinal cord), respectively (Fig.  2). In preterm infants, the reproduction zone is still visible on ultrasound scans (“subependymal germinal matrix”). Cell division begins once the neural tube has closed at 4–5  weeks after conception (6–7  weeks of gestation). The majority of neurons are formed at 12–18  weeks of gestation. Approximately 100,000 neurons are produced during each second to provide a number of at least 200 billion (2  ×  1011) neurons in the human brain and 40 billion in the neocortex alone. Approximately 50% of the neurons are eliminated during the later maturation process, resulting in a final number of 100 billion neurons at 40 weeks (full term). Proliferation of neurons during the first 22  weeks of gestation is mainly determined by genetic factors (Bourgeois 2002; Kostovic et  al. 2019). However, severe maternal stress during the first trimester (i.e. neurulation and early neurogen-

Table 1  Major events in prenatal cortical development (for references, see text) Gestational age (PMA) 3–7 wk

Major developmental events Neural tube formation

Function Formation of the brain and spinal cord

8–20 wk

Neurogenesis

Formation of neurons

12–20 wk

Migration of neurons

18–36 wk

Subplate neurons

Formation of the cortical cell layers (grey matter) Initial neuronal network

20 wk–24 mo

Formation of axons, dendrites and synapses

20 wk–5 years

Synaptogenesis

20–36 wk

Selective elimination of synapses, dendrites, axons and neurons (apoptosis) Glia cells proliferate and differentiate Myelination

18–38 wk 28 wk–24 mo

Formation of the permanent neuronal network (white matter) Formation of new synapses in response to activities Adjustment of the neural network to the individual (environmental) demands See Table 2 Speed of nerve conduction

Abnormal development Spina bifidaa Anencephalya Encephalocelea Meningomyelocelea Facial cleftsa Encephalocelea Microbraina Schizophrenia and autisma Heterotopies, disorders of gyration and intelligence lossa Impairments of motor, cognitive and behavioural functions; ADHSa Impairments of motor, cognitive, behavioural and sensory functions; ADHSa Low-sensory input due to poor activity or to stress → impairments of motor, cognitive, behavioural and sensory functions; ADHSa Low activity or stress → permanent impairments (e.g. vision, cognition)a

Dysfunction of axons and cognitive and psychiatric disordersa

Abbreviations: wk weeks PMA, mo months PNA, PMA postmenstrual age, PNA postnatal age a Increased risk due to maternal stress

Prenatal Structural Brain Development: Genetic and Environmental Determinants Fig. 1  Timetable of developmental events of the human brain during foetal and postnatal life. Black-shaded areas indicate peak activities; open-lined areas indicate low or medium activity (Linderkamp et al. 2009)

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Fig. 2  Section through the cortex at approximately 24 weeks of gestation. Note that the germinal zone adjoins to the ventricle at the inner edge of the cortex. Newly formed neurons migrate along the radial glia through the subplate and previously formed neuronal layers to the upper layer of the cortical plate (Linderkamp et al. 2009)

esis) has been linked to an increased risk of malformations (Lubinsky 2018), e.g. encephalocele (Hansen et al. 2000) and schizophrenia (Khashan et al. 2008), suggesting that the expression of genes

in early foetal life is influenced by external factors. Stress-induced reduction of neurons in late foetal life is probably the result of increased damage of neurons (Fabricius et al. 2008).

O. Linderkamp and D. B. Linderkamp-Skoruppa

22 Table 2  Maturation of neurons in the cortex Step Neurogenesis

Radial glia

Migration Contact to subplate neurons Formation of six cortical layers

Astrocyte formation Lifelong neurogenesis

Events Neuronal stem cells divide symmetrically in the germinal zone (Fig. 2) Generated from same stem cells as neurons; they form long processes through the entire cortex (Fig. 2) Neurons climb on radial glia to cortical surface (Fig. 2) Migration through subplate neurons (Fig. 2) and contact to thalamo-­ cortical and cortico-cortical fibres accelerate their maturation Neurons migrate through previously formed layers to the cortical surface. Neurons assemble in columns above the stem cells and are therefore clonally related Astrocytes are generated from radial glia New neurons are generated from remaining subventricular stem cells and locally from radial glia

If the brain is sufficiently used and trained, new neurons are generated throughout life. Neural stem cells and pluripotent radial glial cells are able to differentiate into neurons in the adult brain (Cope and Gould 2019). In mice, neurogenesis increased the efficiency of learning but did not affect long-term memory (Zhang et al. 2008). The formation of new synapses and the prevention of neuronal damage are far more important mechanisms for lifelong learning than the formation of new neurons (Uylings et al. 2005).

 igration of Neurons: Finding M the Right Place After several divisions, neuroblasts lose their ability to divide, and they begin to move away from the inner multiplication zone to the outer edges of the growing neural tube wall. Once a neuron has reached its final destination within the correct cortical layer, it will stay there for life. The first neurons start migration with the beginning of multiplication, and the majority of cells move to their layer between 12 and 20 weeks of gestation (Gressens 2005).

Both passive pushing by subsequently migrating neurons and active movement of neurons are mechanisms of migration. In the cortex, neurons move radially outwards to the surface along specialized radial glial fibres (Fig. 2), which span the entire thickness of the hemisphere from the ­ventricular surface to the external pial surface (Geschwind and Rakic 2013). This “ladder” facilitates the journey through the earlier arriving cell layers. At the brain surface, the neurons leave the ladder and move laterally to give way to the subsequently arriving neurons and to form a layer at the surface of the cortex. Then the next group of migrating cells passes through this layer and forms a new layer at the surface. This process continues until six layers have been formed. Thus, the earlier generated neurons form the deepest cortical layer, and the latest cells settle in the most superficial layer (inside-out order). The radial migration of neurons originating from the same reproduction site results in columns of clonally related cells. This may be important for their specialized functions in their final cortical destination. Insufficient movement or migrations to wrong places result in heterotopias which may be associated with serious malformations as lissencephaly (reduced gyration, “flat brain”), epilepsy and mental retardation (Gressens 2005; Nicolic and Reynolds 2008). Although normal migration of neurons to the right location is probably determined by genes (Rutter 2006), abnormal migration is mostly the result of environmental factors. Maternal stress during the gestational age of maximal neuronal migration has been shown to predispose the offspring to a variety of impairments including reduced attention span, cognitive problems and depressive symptoms (Van den Bergh et al. 2017, 2018).

Organization of the Neural Network The first two steps, multiplication and migration of primitive nerve cells, are mostly completed at 22 weeks of gestation. At the beginning of migration, neurons are not yet specialized, but they lose their pluripotency once they have reached

Prenatal Structural Brain Development: Genetic and Environmental Determinants

their final position in a specialized region of the central nervous system. Organization of an individual neuron refers to the establishment of connections with other cells and the specialization to distinct functions within the neural network. Organization of the total central nervous system refers to the formation of the entire neuronal network and its capacity to operate as an integrated whole. The process of organization starts at approximately 22 weeks of gestation and includes actions of subplate neurons, outgrowth of neural fibres, synaptogenesis and myelination.

 ubplate Neurons: Pioneers Paving S the Wire Tracks Subplate neurons play a major role in the development of the gigantic network connecting billions of neurons and are probably responsible for the evolution of the neocortex. The subplate zone is situated between the intermediate zone (precursor of white matter) and the cortical plate with the six layers of neurons (Fig.  2). In magnetic resonance images, the subplate is visible as a continuous band in the entire cortex at 20–27 weeks of gestation, starts to disappear in the parietal lobe at 28 weeks, but remains prominent in the frontal lobe up to 35 weeks (Perkins et  al. 2008). At 38  weeks, 90% of the subplate neurons have disappeared. The subplate neurons excrete neurotransmitters that attract axons ascending from the thalamus and dendrites descending from cortical neurons for transient connections with the subplate neurons. When the subplate neurons die, the thalamic and cortical neurons become directly connected (thalamo-cortical tracts). Moreover, subplate neurons help cortical neurons to establish connections with other cortical neurons in both hemispheres and to guide the final migration of cortical neurons within the six layers. They help to balance excitation and inhibition in cortical layers, which is important for the “plasticity” of brain functions (Kanold and Shatz 2006). The transient connections among various brain centres via subplate neurons are

23

the basis for early foetal (and preterm’s) behaviour (Kostović et al. 2019). Maternal stress during the peak actions of subplate neurons from 22 to 34 weeks gestation has been linked to developmental delays, lower IQ, behavioural problems and schizophrenia in offsprings (Van den Bergh et al. 2018; Cook et al. 2018). It is likely that the stress exposure of preterm infants during intensive care can alter subplate neurons, thereby contributing to the high risk of preterm infants to long-term cognitive and behavioural problems (Linderkamp 2017).

 iring the Neural Network: Axons, W Dendrites and Synapses The setup of a functioning neural network connecting all parts of the central nervous system and other target organs requires trillions of connections among neurons via axons, dendrites and synapses. The migrating cells have no functioning axons and dendrites. Having migrated to the appropriate position, axons and dendrites begin to grow out of the young neurons. Usually, one axon only arises from each cell (Fig. 3). Axons are the long nerve fibres connecting distant parts within the central nervous system and with peripheral organs (e.g. muscles and glands). Their final length can be more than a meter in adults, but also just a few μm, if they connect adjacent neurons. Axons develop many branches at the tip, and each final branch can form a synapse with a final branch of a dendrite or sometimes another axon or a nerve cell body. Dendrites emerge from many points along the cell body and appear very much like branches on a tree. Axons and dendrites find their target cells principally by growing in the direction of the targets. This growth is guided by molecules bound to cells (for short-range chemoattraction) or diffused in the environment (long-range chemoattraction, e.g. nerve growth factor). Target cells also present and secrete chemorepellents that inhibit the growth of connecting nerve fibres to these cells. The search of outgrowing fibres for target neurons can be highly specific or more or less arbitrary. Specific connections are formed

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O. Linderkamp and D. B. Linderkamp-Skoruppa

Fig. 3  Neurons with one axon and several dendrites arising from the neuronal cell body. The left neuron represents the development in the sensory cortex at approximately 24–28 weeks, and the right neuron at 32–40 weeks. Note the marked differences in ramifications between the two neurons (Linderkamp et al. 2009)

between neurons that express specific marker molecules, thereby giving the connecting cells no choice (cell specificity). Other neurons are attracted to send fibres to neurons in a defined region (topographic specificity). Synapses are formed by proteins acting as molecular switches between two nerve fibres. Chemoattractants determine when and where synapses are formed and their specificity and stability. Moreover, formation, specificity and stability of a synapse depend on the quality and quantity of impulses travelling through the connecting fibres. Synaptic activity provides critical information about the usefulness of synaptic connections, thereby influencing synapse stability and maintenance (Waites et  al. 2005; Pratt et al. 2008). Synaptic activity promotes the formation of new synapses and strengthens existing synapses in the neighbourhood. Thus, synapse formation and stabilization are dynamic processes, requiring bidirectional communication between connected partners. Subtle alterations in synaptic connections are the means by which learning wires the pathways to memory (Ge et al. 2007). Although the first synapses are produced already at 8 weeks of gestation, synapse formation is slow until 24 weeks of gestation resulting in a total number of synapses that is not much higher than the total number of neurons. From

24 weeks gestation to 12 months of postnatal age, a myriad of connections is formed among billions of neurons. At full term, each cortical neuron is linked with approximately 2500 other neurons, at 12  months of postnatal age with 15,000 (Petanjek et  al. 2008). Synaptogenesis begins in a relatively short time period in all cortical regions, but the maximum synaptic density is reached at different times after full term, ranging from 3 months in the auditory and visual cortex to 15  months in the prefrontal cortex (Bourgeois 2002). After the first year of postnatal life, the total synapse number slowly increases and reaches the maximum at 5  years when the child’s brain weighs almost as much as in adults. Then the number of synapses plateaus until about 10 years and begins to decrease by approximately 40% with the onset of puberty. Thus, during the first 5–10 years of life, the child achieves the highest number of synapses, thereby enabling the child to acquire enormous behavioural, social, environmental, linguistic and cultural information. After the age of 5 years, synaptogenesis continues as a local event (Bourgeois 2002) in dependence on the activity of neighbouring synapses. Formation of new synapses and changes of specificity and stability of synapses are fundamental to lifelong learning, memory and cognition in the mature brain (Waites et al. 2005).

Prenatal Structural Brain Development: Genetic and Environmental Determinants

Outgrowth of fibres and formation of synapses are largely influenced by environmental factors, including sensory experience. Both decreased sensory input of the foetus and maternal stress may cause a marked reduction of axons, dendrites and synapses in the prefrontal cortex, the hippocampus and other brain centres. Prenatal stress may impair cognitive and executive functions into old age and even increase the risk of Alzheimer’s disease (Jafari et al. 2019).

Table 3  Functions of glial cells (neuroglia) and myelin Cell type  Structure Radial glia  Long radial processes spanning the thickness of the cortical wall

Astrozyten  Short, thick processes support neurons (protoplasmic astrocytes); long, Glial Cells and Myelination thin processes support nerve fibres (fibrous astrocytes) Glial cells (also called neuroglia) are non-­ neuronal cells that outnumber neurons by about Oligodendrocytes ten times, but they constitute only half of the Schwann cells  Small cells with few brain volume since they are smaller than neurons. processes; Glial cells surround neurons and hold them in production of myelin

place; play an important role in neuronal and axonal guidance; supply nutrients and oxygen to neurons; produce and remove chemical transmitters; insulate axons by myelin; destroy pathogens, dead neurons and other debris; and contribute to formation of new neurons. Glial cells are crucial in the development of the nervous system and in processes such as synaptic plasticity and synaptogenesis. Various types of glial cells are defined by origin, appearance and functions (Table 3). Macroglial cells comprise radial glia, astrocytes and oligodendrocytes and develop from the same stem cells in the ventricular zone of the neural tube as the neurons. Radial glial cells are the progenitors of astrocytes, some oligodendrocytes and neurons. In the developing brain, radial glia functions as a “ladder” upon which neurons migrate to the surface of the cortex. Microglia are specialized immune cells capable of phagocytosis. They are derived from haemopoietic precursors as other immune cells. Oligodendrocytes produce myelin that forms insulating sheaths around axons. Schwann cells provide myelination to axons in the peripheral nervous system. Myelin is a white fatty material wrapped around most neural axons. It prevents the leakage of ions and thus of electrical current from the axon, thereby increasing the speed of

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Microglia  Resemble blood monocytes

Functions Progenitors of neurons and astrocytes Guidance of neurons and nerve fibres Regulation of synaptic plasticity Structural support of nerve fibres and cell bodies, secretion and elimination of neurotransmitters, chemical homeostasis, oxygen and nutrient supply for neurons, blood-brain barrier and regulation of local blood flow Functions of myelin:  Increases the speed of nerve conduction by 10–100 times  Improves the accurately targeted propagation of excitation  Inhibits the formation of new fibres for new connections  Involved in cognition and learning Immune cells (phagocytosis of pathogens, cell debris)

nerve conduction by 10–100 times. Moreover, myelin prevents erratic activation of adjacent axons. Without myelin, electric activity would be aimlessly distributed throughout the brain, and information would become chaotic. Myelination also inhibits plasticity, since a myelinated axon has less ability to branch out and connect with other neurons. Myelin is involved in cognitive functions and learning (Fields 2008). Myelination starts in the spinal cord (at about 12 weeks gestation), then in brainstem (14 weeks) and thalamic axons (20 weeks) and finally in the cortex (35  weeks) and continues for decades in the human brain (Miller et al. 2003). Axons connecting the frontal-limbic system (responsible for complex cognitive functions) start to myelinate after birth. Late myelination explains that the brains of infants and young children are slow compared with adult brains. Myelination is mod-

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ifiable by experience, and severe maternal or postnatal stress may inhibit myelination, thereby contributing to psychiatric disorders, including schizophrenia and depression, and cognitive impairment (Fields 2008).

 haping the Brain by Elimination S of Excess Neurons and Circuits At least twice as many neurons as necessary are produced during the time period of active neuronal multiplication, and most of the excess neurons are eliminated during maturation of the neuronal network (“programmed cell death” or apoptosis). Three peak periods of neuronal death can be distinguished (Fig. 1): (1) at the beginning of neurogenesis, (2) from 24 to 38 weeks gestation and (3) between the onset of puberty and adulthood (Lossi et al. 2015). The second and third periods are linked to selective elimination of axons, dendrites and synapses. Production of neurons and growth of axons and dendrites in the direction of target cells are not very selective and result in overproduction of connections. The initial wiring is diffuse, with a lot of overlap making communication inaccurate and disorganized. Elimination of fibres, synapses and entire neurons allows quantitative adjustments of connections between neurons and to compensate for errors of cell migration (mislocation) and projection of axons and dendrites (misprojection). Elimination of neurons, fibres and synapses parallels the formation of new connections to match the number of outgrowing fibres to the capacity of target cells (Lossi et al. 2015). The fittest neurons survive in competition for limited resources in the brain as electrical impulses, neurotransmitters (e.g. nerve growth factor) and nutrients within the neural network. Active cells with many connections to target cells receive more of these life-savers than less active neurons. Thus, overproduction and subsequent elimination of excess neurons and connections are not a waste of resources but necessary to allow optimal locations and interconnections of neurons.

O. Linderkamp and D. B. Linderkamp-Skoruppa

Synapses are newly formed and eliminated throughout life. This allows continuous reorganization of the neural network in accordance with the requirements of the environment and is thus the basis of lifelong neural development and plasticity (Goda and Davis 2003). Between the onset of puberty and adult age, approximately 40% of synapses and nerve fibres (Bourgeois 2002) and a substantial portion of neurons are eliminated, particularly in the prefrontal cortex, the brain region involved in major cognitive abilities. In accordance with the “use it or lose it” principle, cells with apparently redundant connections for unused (not useless!) skills are discarded to enhance abilities that have been extensively utilized (Lopez et al. 2008). Adjustment of neurons and connections to the demands of the individual environment usually makes sense but can result in severe impairments of sensory, behavioural and cognitive functions, if the foetus or young infant is deprived from normal sensory input or exposed to severe stress (Fabricius et al. 2008; Trachtenberg et al. 2016). The hippocampus (stores memory!) is particularly sensitive to the apoptotic actions of corticosteroids transmitted to the foetus as a result of maternal stress (Fenoglio et al. 2006; Hong et al. 2016).

Epigenetic and Environmental Influences The question of the contribution of genes or nature and environment or nurture to brain development is still under discussion. More and Shenk (2017) criticize the discussion as fallacy since there is sufficient evidence to conclude that epigenetics is the link between nature and nurture. The proponents of the gene hypothesis argue that approximately 50% of our entire genome is assigned to producing the brain that constitutes only 2% of the adult body weight. On the other hand, the genome analysis has revealed that it comprises a total of 25,000 genes only, and it appears unlikely that the location of each of the billions of neurons and each of the trillions of connections is determined by genes alone.

Prenatal Structural Brain Development: Genetic and Environmental Determinants

Moreover, the genome of the modern European has not changed during the last 25,000  years (Caramelli et  al. 2003), while cognitive and behavioural abilities have considerably changed. Broad scientific evidence clearly indicates that all stages of human brain development (including neurogenesis and migration) are the result of mutual interaction of genes and environment (Eliot 2000; Turkewitz 2007; Tammen et al. 2013). Eliot (2000) states that there is no sensory, cognitive, emotional or motor skill that is not influenced by both genes and environment. She concludes: “We can’t do much about the genes we are born with -- or the genes we transfer to our children, but we do influence environment. We know the effect of environment on early experience is to actually change the structure of individual brain cells”. Genes function by controlling the manufacture of specific proteins in cells. Proteins are involved in virtually all functions of cells and the whole body. Without genes and gene-dependent protein production, neither neurons nor other cells can grow, specialize and function. All cells of an individual contain the same genetic information. Whether genes are activated or not depends on environmental factors. This explains the specialization of cells in different organs and within various organs, e.g. the specialization of epidermal cells to skin and neural cells, of neuroepithelial cells to neurons and glia and of pluripotent neuroblasts to a large variety of mature specialized neurons. Moreover, many genes are expressed only during distinct time periods, and if defined, environmental triggers act on these genes. Thus, genes can express their information only if appropriate environmental conditions are present. The dependency of gene expression on experience prompted Ridley (2003) to define his thesis of nature-via-nurture for brain development. According to this thesis, genes are no blueprints but act in response to experience, thereby accounting for the uniqueness of each individual. Gottlieb (1997) proposed that experience influences properties of the cytoplasm in neurons via electrical impulses which in turn affect the activity of genes. Increased gene activity has then a

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reciprocal influence on the cytoplasm (“probabilistic epigenesis”). The following examples illustrate that gene expression in neural cells requires experience: • Visual deprivation during the sensitive period results in downregulation of gene expression in visual cortex neurons, thereby causing permanently impaired vision (Majdan and Shatz 2006). • Long-term memory traces are probably persistently stored within individual neurons through modifications of DNA (Arshavsky 2017). • Analyses of genes and intelligence in children demonstrated that genes merely determine the possible range of intelligence for each individual, while experience determines the individual intellectual abilities within this range (Plomin and Spinath 2004). This explains the effect of the socioeconomic status on the IQ (Sauce and Matzel 2018). • Genetic susceptibility to impaired infant-­ mother attachment can be compensated for by a favourable environment (Bakermans-­ Kranenburg and van Ijzendoorn 2007). • Psychiatric disorders as autism and schizophrenia develop as a result of a complex gene-­ environment interplay (Rutter 2006; Walker et al. 2013). • Marceau et al. (2014) describe genetic, prenatal, endocrine and parenting influences contributing to internalizing and externalizing problems in children and conclude that only prenatal and parenting factors contribute to these behavioural traits. It appears likely that the early steps of brain development are largely determined by genes and that only adverse environmental conditions (e.g. maternal stress; see Table 1) change the development. These early steps include neurogenesis and neuronal migration. Moreover, growth of axons and dendrites to their approximate final locations is probably genetically determined (Eliot 2000; Turkewitz 2007). However, the environment is involved in the development of the more specific circuits and the number and stability of the

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s­ynapses connecting these circuits. Thus, environment and experience reshape and refine the preliminary connections to adapt the neural network to the individual environment. While genes are generalists, environments are specialists, adjusting brain functions, including behaviour and intelligence, to the individual environment.

O. Linderkamp and D. B. Linderkamp-Skoruppa

Experience-expectant plasticity results from incorporation of environmental information that is ubiquitous in the environment and common to all species members, such as the basic elements of sensory perception. Experience-expectant processes have evolved as a neural preparation for incorporating specific information. Experience-­ expectant information storage is only possible during the “critical period” (or “sensitive period”) Experience-Expectant of each function. Thus, this type of plasticity is linked to a developmental timetable. Without and Experience-Dependent appropriate experience and information storage Plasticity during the critical period, the neural function will Brain plasticity (also called neuroplasticity or not develop normally. Experience-expectant cortical remapping) refers to the changes that plasticity is important for the development of occur in the central nervous system as a result of sensory functions (vision, hearing, etc.). experience. Plasticity allows the adjustment of A well-known example of experience-­ the brain’s development to the individual envi- expectant plasticity is the dependence of lifelong ronment and needs. Information that is appropri- vision on early visual experience. Although the ate in a given environment and society favours foetal eyes receive little light, connections brain development. On the other hand, inappro- develop between the retina and the visual cortex priate information (i.e. sensory deprivation or before birth due to genetic determinants. With the stress) inhibits brain development. Plasticity thus marked surge in light and visual expressions explains that humans are able to acquire a gigan- entering the eyes after birth, there is a sudden tic lexical memory and to solve complex mathe- increase in firing activity in the connections matical problems, although the genome has not resulting in a surge in synapses within the visual changed during the last 25,000 years (Caramelli cortex, thereby dramatically improving vision. et al. 2003). But plasticity also explains the socio- Usually, vision of both eyes develops similarly as economic determination of cognitive abilities. a result of equal light input before and after birth. Grenough et al. (1987) postulated that there are When one eye is deprived of vision during a spetwo types of brain plasticity: experience-­ cific time window after birth, the surge in synexpectant and experience-dependent (Table 4). apses does not take place, and already existing connections leading from this eye to the brain are Table 4  Major steps of neural organization of the cortex disrupted and disappear (Maffei et al. 2006). This explains that visual deprivation (e.g. due to conGoal genital cataract) during the critical period in early  Establishment of a functioning neural network Major period infancy results in permanent visual impairment.  20 weeks of gestation to years after birth Experience-dependent plasticity is indepenSteps dent from a timetable and allows the develop Formation of subplate neurons with initial fibre and ment of special skills for later use. It results from synapse formation incorporation of environmental information that  Formation of the cortical plate with six layers of is unique to the individual. Experiencealigned neurons  Outgrowth of nerve fibres (axons, dendrites) and dependent information storage is the basis of their ramifications important human abilities as memory and learn Synaptogenesis ing, flexibility, adaptation and individual differ Selective elimination of neurons (apoptosis), nerve ences in social and intellectual development. fibres and synapses  Proliferation and differentiation of neuroglia However, these higher cognitive abilities also

Prenatal Structural Brain Development: Genetic and Environmental Determinants

show pattern of experience-expectant plasticity, including ­ sensitive periods for their development. Abandoned Romanian children are a sad example for impaired cognition and attention as adults due to early deprivation. If these children were placed in foster care before 6  months of postnatal age, their abilities improved significantly more than in infants reared in institutions beyond the first 6  months, suggesting an early sensitive period for neurodevelopmental programming of cognitive and behavioural abilities (Colvert et al. 2008). Principally all developmental processes (Table 1) contribute to brain plasticity: 1. Excessive neurogenesis and formation of axons and dendrites independent of experience 2. Development of more specific circuits and synapses linked to experience 3. Elimination of excess neurons and fibres to adjust their locations and numbers to the individual requirements 4. Continuous formation and elimination of synapses and changes of synaptic stability according to their activity 5. Myelination 6. Lifelong neurogenesis Experience-expectant plasticity is linked to rapid and excessive nerve fibre and synapse formation during critical periods and subsequent selective elimination of fibres and synapses to adjust the neuronal network to the sensory information storage. Experiencedependent plasticity mainly results from the formation of new synapses (“synaptic plasticity”). Under basal conditions, loss and gain of synaptic contacts are well balanced, and there is little net change in connectivity. Activation of synaptic contacts increases connectivity of neurons by increasing the number and strength of synapses. The increase in synaptic contacts and synaptic stability is the basis for lifelong experience-dependent plasticity (Naves et  al. 2008).

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Elimination processes of excess neurons and connections are important for plasticity during prenatal and early postnatal brain development and again during puberty. Active neurons and connections firing together have a better chance to survive than less active cells and connections. Deprivation or severe stress during brain development can result in reduction of neurons and connections in the frontal-limbic system, thereby causing lifelong behavioural and cognitive impairments. The stress effects are mediated by maternal corticosteroids and activation of foetal stress receptors (Van den Bergh et al. 2018). On the other hand, enriched behavioural experience results in lifelong increase of the number of cortical neurons due to less programmed neuronal death (Yang et al. 2007). Axonal myelination plays important roles in plasticity (Kaller et al. 2017). It responds to experience and influences sensory, behavioural and learning processes. On the one hand, myelin improves the functions of the brain centres connected by axons. On the other hand, the myelin sheath around axons inhibits the formation of new connections, thereby inhibiting experience-­ dependent plasticity. This may explain that behavioural and cognitive abilities are easier to acquire during the first years after birth, when axonal myelination is not yet finished (Fields 2008). The brain continues to be plastic throughout life, thereby allowing lifelong learning, but plasticity declines in adulthood. Newly formed adult neurons show a pattern of plasticity similar to that in foetal and neonatal brain cells (Ge et  al. 2007). New neurons have a “critical period” with high plasticity before they settle into the less plastic properties of mature brain cells. Thus, sensory abilities can markedly improve, if they are trained in later life (Lazzouni and Lepore 2014). We conclude that experience-driven development (“plasticity”) allows adjustment of brain functions to individual requirements. Plasticity of brain functions is the prerequisite for specific human abilities but makes the brain also vulnerable to unfavourable experience and

O. Linderkamp and D. B. Linderkamp-Skoruppa

30 Table 5  Types of plasticity Types of plasticity Experience-independent (basic structural brain development)

Determinants Genetic factors; environmental influences on molecular and cellular properties

Experience-expectant: Sensory abilities depend on a timetable with critical periods

Gene expression is adjusted to the individual needs. Appropriate sensory input is required during critical time periods for normal development of specific senses (e.g., vision) Appropriate experience, individual information storage and learning; socioeconomic conditions

Experience-dependent (development of special skills as memory, association, attention, flexibility, social competence; no timetable)

deprivation from appropriate sensory experience (Table 5).

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Developmental events Neurogenesis and neuronal migration Cortical layer formation, early neurite and synapse formation Overproduction of neurons, neurites and synapses; elimination of neurons and synapses to adjust the neural network to individual needs Myelination Formation of new synapses; increase in synapse stability; late neurogenesis Inhibited by myelin

Prevalent time period 6–23 weeks gestation 22–34 weeks gestation 24 weeks gestation to first postnatal year and (for some functions) to 7–10 years Birth to 7–10 years From birth to end of life

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Continuity and Dialogue Peter G. Fedor-Freybergh Life is a whole, the personality a unity. (W. Stern) All real life is encounter. (Martin Buber) We are all born for love: it is the principle of existence and its only end. (Benjamin Disraeli) Alles geben die Götter, die unendlichen, Ihren Lieblingen ganz, Alle Freuden, die unendlichen, Alle Schmerzen, die unendlichen, ganz (All the gods, the infinite, give to all their darlings, all the joys, the infinite, all the pain, the infinite, whole). (Goethe)

The encounter with the unborn is the beginning of the continuum of human life toward self-­ realization. We need to extend the standard definition of life’s continuum to include the prenatal experience, which is part of life’s continuum, helping to shape us and determine who we are and what we will become. For the unborn, it is primarily through the imprinting process that this experience is initiated and realized. For the mother, pregnancy, the encounter with the unborn is a chance for self-realization. For the rest of us, this encounter with the unborn is the chance to extend and deepen our own understanding of this life continuum wherein there can be found no possible separation between the physical and psychological dimensions of our existence. Life in my understanding is characterized by two important phenomena, and these are continuity and dialogue. Continuity of life from conception is one of the basic characteristics and needs of man. In order to maintain homeostasis and equilibrium, a continuum of life begins in the P. G. Fedor-Freybergh (*) University of Bratislava, Hainburg an der Donau, Austria e-mail: [email protected]

womb, and it is not possible to separate the various stages of human development from the whole of the individual life. In this continuum, the individual represents an inseparable unity of all functions on the physical, psychological, spiritual, and social level. Any discontinuity represents a great danger, and because of this discontinuity, nations, religions, and different cultures were threatened in the history. In the prenatal and perinatal psychology, we are particularly aware of the dangers of discontinuity in the development of the child in the womb and during and after childbirth. Prenatal and perinatal psychology and medicine is a relatively new interdisciplinary scientific field within medical and psychological research, the practice of which attempts to integrate different disciplines dealing with the basic questions of life and its disturbances (Blazy 1999; Caruso 1973; Fedor-Freybergh 1987, 1993, 2002; Hruby and Fedor-Freybergh 2013; Janus 2000, 2010b, 2011, 2013a, b; Kruse 1974; Mittendorfer 1980; Rascovsky 1978; Schindler 1973, 1979, 1987). Emphasis is placed on the interdisciplinary character, which enables different scientific specialties such as medicine, psychology, psychoanalysis, anthropology, human ethology, sociology, philosophy, and others to meet, find a

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common language, and go through the process of a mutually creative influence or, as it were, a “cross-fertilization.” Prenatal and perinatal psychology and medicine can also serve as a “psychosomatic” model stressing the indivisibility of “psychological” and “physical” processes in the continuum of human life from its very beginning and also the ­indivisible development of all functions of the central nervous system and the immunological and neuroendocrinological processes (Dalton 1968, Fedor-Freybergh 1994a, 1999b, Hruby et al. 2013; Linderkamp et al. 2009). One of the important intentions of this scientific field is the publication of different methodologies, both from experimentally oriented methods and studies and also from more introspective methods —with an effort to look for and find a common language, in order to diminish semantic misunderstandings, as well as to define a scientific theory applicable to this new interdisciplinary and integrative approach (Schindler 1973; Fedor-Freybergh and Zador 1977; Fedor-­ Freybergh 1982). Integration linguistically means, among others, assimilation, fusion, incorporation, combination, unification, and harmony. The latter, harmony, should be stressed in particular—harmony and cooperation between different integrated approaches and views, methods and methodologies, theories, ideologies, and practices, rather than confrontation and disagreement. Prenatal and perinatal psychology and medicine has become an organic part of integrated and integrative neurosciences. Society at large must encourage a sense of responsibility in parents-to-be and counsel couples long before conception about their commitment toward the new life; it is essential that this new life be highly respected from the very beginning and be considered as an equal partner in the dialogue. This dialogue begins at conception and continues through the prenatal, perinatal, and postnatal stages of life. It influences the outcome of the birth and the way the individual during its childhood, adolescence, and adult life will treat other people, as well as her/his ability to love and respect others and to make commitments (Fedor-­ Freybergh 2000; Fedor-Freybergh and Maas

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2011; Janus 2004; Liley 1972; Linder 2009; Matejcek 1987, 1994; Minarovicova 2013b; Rausch 1987; von Lüpke 2010b) It is not possible not to communicate and everything that is communicated, how and by whatever means, is real. (Watzlawik)

The prenatal stage of life represents a unique opportunity for the primary prevention of psychological, emotional, and physical disorders in later life (Fedor-Freybergh and Vogel 1988; Fedor-Freybergh 1954). At this stage, we also can develop preventive procedures to decrease premature birth and perinatal morbidity and mortality. In order to understand the enormous potential power of the prenatal processes and their impact on the individual’s prenatal and postnatal health, we must ask ourselves what does the prenatal stage of life imply (Janus 1987, 2004, 2010c; Minarovicova 2013a; von Lüpke 1987). Savoir pour prévoir, Prévoir pour prévenir. (Auguste Comte)

Pregnancy can be conceived as an active dialogue between mother and child (Fedor-­ Freybergh 1983a, b). This dialogue is not limited but is enlarged via the dialogue between the mother and the father and the mother’s psychosocial environment (Blazy 2010a; Brekhman 2001; Fedor-Freybergh 1982a, 1999a; Janus 2009, 2010a; Kruse 1969, 1978, 1979; Levend and Janus 2011; Miklosko, Mikloskova 2013; Turner and Turner-Groot 1997). This discourse is part of a very active and mutually interdependent process taking place on several levels. Minimally, these include the psychological, emotional, biochemical, and psychoneuroendocrinological levels. The human ‘being-in-the-world’ is always and from the beginning constituted by the ‘being-with’ and just this ‘being-with’ is given by the ecological situation of the fetus by the form of his mother from the beginning. (Condrau)

I have never heard a mother refer to the child in her womb as “my embryo” or “my fetus.” The mother says “my baby” or even calls the child by a personal name. I stopped for a long time ago to speak about embryo or fetus; I always use the

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term “prenatal child,” and in this way, I stress the high competency of this child. Generally, pregnant mothers show a high degree of sensitivity and sensibility toward their unborn child, which, by contrast, many professionals lack. The child is a very active partner in the pregnancy, an “active passenger in utero” (Chamberlain 1988). The mother-child interaction, consequently, not only has a biological but also a psychological and social character. Imagination is more important than knowledge. (Einstein)

This mother-child dialogue begins on an unconscious level—probably from the very beginning of the unborn child’s development. From the mother’s side, the dialogue will become a reality when she, consciously or unconsciously, makes the move to experience the unborn “it” as the unborn “you.” Here starts the first social interaction in human life. This event initiates her into the beginning of a conscious encounter with her child. The transition from “it” to “you” is just one consequence of the sensitivity and sensibility of the unborn and the enormous creative potential in the psyche of the mother. This dialogical experience is independent of the degree of morphological development of the child. The first social interaction lays the basis for the further development of feelings of empathy, partnerships, love, and even parenthood in the child’s postnatal life (Fedor-Freybergh 1974, 1983a, b). Der Mensch wird am Du zum Ich (Man becomes the ego through thee (that you)). (Martin Buber)

There is a strong impact of hormonal, psychological, and immunological influences on the whole embryonal and fetal development. Birth is part of a comprehensive human development. The circumstances around the birth, the birth itself, and the consequences for the child, the mother, and the father in the postnatal period will essentially depend on the prenatal stage of life and its bonding impact on the child, the mother, and the father. It is wise not to separate the role of the father from the role of the mother and child and also not to separate the labor from the continuum of the prenatal experience.

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The father should be involved and incorporated in the entire prenatal care from the very beginning and treated as an equal partner in the process. The father’s experience will vitally influence his activity during labor and very much his bonding abilities with the child during birth, as well as the prenatal and postnatal periods. Pregnancy can be considered as the first ecological position of the human being, the womb as the first ecological environment (Fedor-Freybergh 1983a, b, 1988a, b, c). It is surprising to see how few professionals, even psychologists, realize this basic fact. There are still a large number of obstetricians, gynecologists, and other professionals who consider the womb merely as a “baby-carrying” anatomical organ and who are still unaware of the “toxic pollution” of potential psychological and social threats to the unborn child. The dialogue between the unborn child, mother, and father creates a “primary togetherness” (Fedor-Freybergh and Vogel 1988), which in turn helps to foster strongly compelling psychophysical predispositions. Potentially, any such inborn predilection has the ability to orient and shape forthcoming emotional and social responses, especially with regard to interpersonal relationships. The consequences of these experiences of primary togetherness run along a wide range, including love and ethical behavior. The human life should be considered as an indivisible continuum where each of the developmental stages is equally important, all stages interdependent and inseparable from the whole individual’s life continuum (Janus and Evertz 2008; Zweig 1931). In this continuum, the individual represents an indivisible entity of all functions on both physiological or physical, psychological, and social levels. The physical, biochemical, endocrinological, immunological, and psychological processes represent a whole, which cannot be divided (Fedor-Freybergh 1988a, b, c). In order to understand the process during the prenatal stages of life, a new language is required and a new scientific theory is needed. Such a language must assist us in getting beyond the semantic problems and confusions which exist in so

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much medical and psychological vernacular (Fedor-Freybergh 1990a, b). It is not possible to separate any stage of human development from the rest of an individual’s life continuum. The life continuum is one of the basic needs in human life in order to maintain homeostasis and equilibrium. The disturbance of the individual’s life continuum on a momentous scale would lead to illness, or in extreme cases, where homeostasis cannot be regained, death is the result. Any discontinuity from outside or from inside the individual organism will violate these basic biological and psychological needs, both on prenatal and postnatal life. Discontinuity has increasingly become a more serious problem today causing the spread of ecological, social, and political disturbances throughout the world. No group of people or any nation is entirely immune from the upheaval of disorienting developments on ecological and social levels (Tyano, Personal Communication, 1987; Fedor-Freybergh and Vogel 1988). Many in the scientific community are very much aware of the effects of such events, and see how the discontinuity and disequilibrium beget many of today’s mental and social diseases. In the field of prenatal and perinatal psychology and medicine, we are very much aware of the dangers which discontinuity can generate in the unborn and in the newborn. The latest development of two relatively new and innovative lines of medical and psychological research, namely, psychoneuroendocrinology and psychoneuroimmunology, are very promising. Research in these two areas is particularly important in serving as the scientific basis for the philosophy behind prenatal and perinatal psychology and medicine. Various highly specific biochemical functions (hormones, neurotransmitters, and other polypeptide structures) are needed in direct connection with input phenomena for the transformation and storage of both sensorial and mental types of information. Some of these functions, crucial to the formation of the primary central nervous system on the hypothalamic-­pituitary-adrenal level, are already detectable at the very beginning of the develop-

P. G. Fedor-Freybergh

ment of the human being. Thus, the embryo successively develops a high sensibility and competency for the potential ability of perception and learning (Fedor-Freybergh 1985). The intrauterine experience is also a learning process for the child (Fedor-Freybergh 1985). This learning is a vital prerequisite for survival since it makes it possible for the organism to adapt itself to new circumstances. Without adaptation, there would be no survival, and one cannot adapt without making and having had experiences upon which to base the adaptation. Such a process requires memory, whether consciously retained or subconsciously imprinted. The information processing which reaches the child from the very beginning of its development will be received via the different biochemical pathways and then transformed and stored as memory traces (this could eventually be useful to a theoretical understanding of certain psychotherapeutic procedures, such as hypnosis, dream analysis, prenatal memories, etc.). At this stage, the prenatal child already shows evidence of responding to and retaining the impact or imprint of sensory experiences in a biochemical language, which remain as a potential learning source. These pre-­ birth memory imprints may in turn be revoked as informational sources (whether negative, positive, or ambivalent in character) during later life. The invisible must be penetrated with the aid of the visible. (Marc Chagall)

The implications of these preliminary findings are far reaching. These will require nothing less than radical rethinking of the standard human-­ embryo development paradigm wherein structure is presumed to precede function. To the contrary, as we have indicated earlier, there is strong evidence (Fedor-Freybergh 1983a, b) which supports the primacy of function over structure, the morphological organ. It is the morphological structure, which develops as a result of the inborn primal functional urge. An organ would not develop if there was no functional urge compelling it to do so. In the same way, the mental capacity of the human is not posterior to the completed morphological structure of the brain, nor

Continuity and Dialogue

to its subsequent introduction into and experiencing of a particular sociocultural environment after birth, or in philosophical terms, the consciousness precedes the being and not the other way around. The unborn already has its psychological processes which function long before birth; no child is tabula rasa. We must reaffirm that the mother is not just a “receptacle” for the child’s growth but an active initiator and participator. Today, it is imperative to reestablish the woman as the primary choice maker in this powerfully creative process. Indeed, she is involved in a procreative process with great creative powers of her own. The future mother needs to be aware of these powers and how to be in touch with them in order to be better equipped to guide and augment this creative undertaking. Pregnancy can also enable the mother to withdraw into a kind of “creative regression” in order to enter into an intimate dialogue with her unborn child.

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The ideal child should already be loved prenatally. There should not be unwanted children. Unless we can achieve these mental and social conditions concerning the prenatal stage of life, all positive changes in the world would be superficial, and there would also be the danger of a threat to basic human needs and rights, to cultural and traditional values, and to civilization and freedom itself (Fedor-Freybergh 1992b; David et al. 1988; Matejcek and Dytrych 1994). The visible is not only the truth, Nor is it the whole truth.

Pregnancy can sometimes be experienced by both the mother and the father as a life crisis, which does not necessarily imply a negatively charged situation. Any crisis may be envisioned as a challenge, which can bring about creative and positive solutions or alternatives. We can quite often see during pregnancy that old, latent, and unsolved conflicts become manifest. The same soul dominates the two bodies … the Frequently, these can be worked out during the wishes of the mother can often be found impressively in the child she carries at the time of the course of the pregnancy in a very constructive wish …. (Leonardo da Vinci) way. Indeed, it should be pointed out that many of the conflicts and problems that a pregnant In order to make an informed and stress-free woman may experience are not the direct result choice, family planning education must begin of her pregnancy or her baby. Unresolved issues well before conception. Responsible parenting is may reevoke psychological conflicts within her not necessarily an automatically bestowed gift own personal psyche. In this way, the pregnancy from “nature” or even an easily acquired talent, often gives the mother and father a unique opporbut it very often needs to be taught. This requires tunity to further their own inner psychological research concerning appropriate socio-­development, sometimes within psychotherapeupedagogical implementation within the family tic settings (Fedor-Freybergh 1977b; Fedor-­ and in our educational system. It is vital that an Freybergh and Vogel 1988). integration of prenatal and perinatal studies into Psychotherapeutic research and practice have medical and psychological curricula at the uni- shown how decisive negative emotional influversities is provided. We need to establish a new ences and disturbances in the prenatal dialogue educational system and prepare people for con- are on mental conditions and diseases in later scious parenthood. Radical change of prenatal life. Ludwig Janus has observed that psychologicare is necessary, where not only medical but also cal traumas and prenatal and perinatal problems psychological and social life circumstances of have largely been shown in about two-thirds of both parents are to be taken into serious consider- psychotherapeutic adult patients. It becomes ation. The prenatal care should consider the child exceedingly evident how important the emotional as an active partner in a psychosocial dialogue maturity, mental health, and social awareness of with his parents who are given the opportunity to the parents of the unborn child are (Benedetti have encounter with their unborn child in a free 1987;  Blazy 1996; Brekhman and Fedor-­ and nonviolent society. Freybergh 2005; Evertz 2008a, b, 2013; Fedor-­

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Freybergh 1994b; Freud 1987; Häsing and Janus 1994; Janus 1996, 2004; Milakovic 1976, 1982; Peltonen and Fedor-Freybergh 1983; Turner and Turner 2009; Zikmund 1993). The need for psychotherapeutic intervention on both the pregnant mother and father-to-be is becoming more relevant. No guilt or inferiority feelings should be imposed upon the pregnant parents nor any moral judgment placed upon them. We need to be aware that not all pregnant women have the opportunity or possibility to provide their unborn child with optimal nurturing conditions either economically or emotionally or within their social structures. Pregnancy is always a dynamic process of constantly fluctuating emotions, attitudes, and even intellectual discourses. The mother-child dialogue is almost always characterized by a mixture of positive, negative, and ambivalent emotions. The society has a responsibility to ensure that the mother-father-child unit cannot only survive but develop and grow in the best possible circumstances. Moreover, it must be added that a living organism has a strong propensity to adapt and even to repair damage or to compensate for some failure from a previous developmental stage of the life continuum. What is unfulfilled in one stage of experience can be applied to the next and, eventually, worked out to the inner satisfaction of the human being. The term “risk pregnancy” is still used almost exclusively in its biological sense. This means it is reserved for somatic disturbances, physical diseases, or handicaps experienced by the mother during pregnancy, which could have a bearing on the biological health of the baby. In a holistic and comprehensive view of human life, we cannot make divisions between so-called “somatic” and “psychological” phenomena. Psychologically, medically, and anthropologically considered, all life events are experienced as indivisible phenomenological situations wherein body and mind (soma and psyche) represent an entity of mutual influence and interdependence within a particular sociocultural environment. In this way, all events of either a so-called “somatic” or “psychological” character, which could adversely affect the

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well-being and health of the mother or her unborn child, are seen as potential or real risks. It is therefore necessary to create a new kind of prenatal care whereby all risks can be screened in good time and where parents are given the opportunity for comprehensive care, including access to psychotherapeutic counseling (Fedor-Freybergh 1977b, 1988a, b, c). Pregnancy and delivery are not diseases per se, only very exceptionally, but they sometimes can become a disease due to a doctor’s intervention. We have to give credit to the inner wisdom of the pregnant woman and help her with our knowledge, our empathy, and the scientific information to cope with her problems and with the potential or real risks if and when they occur. Portman has aptly referred to humans as “premature births” who need the protection of a “social uterus” in the first phase of their lives. Thus, the role of the “uterus” after birth does not cease, but the mother continues to represent the child’s next environment, fulfilling the task of social protection, which at the same time provides psychological and biological protection at this stage of life (Portmann 1973).

This brings us to the topic of health. What was said before about the holistic and comprehensive view of all human functions will be true also in considering the issues of health and disease. The definition of health by World Health Organization (1986) is “a state of complete physical and mental well-being which results when disease-free people live in harmony with their environment and with one another” (World Health Organization 1986). As Zikmund (1993) points out, this definition, though including all three dimensions of life manifestations of man, biological, psychological, and social, has several shortcomings. In his analysis of the dimensions of health and disease, he accentuates the functional aspects of health and disease and defines health as a functional optimum of all of life’s processes—biological, psychological, and social. The psychophysical organism tries constantly to maintain its health. It strives toward recovery, away from destruction; it strives toward homeostasis, away from disorganization and chaos. Health has clearly a very strong dynamic and cre-

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ative dimension, and in 1974 (Fedor-Freybergh 1976), I described health as “the dynamic movement along the creative path towards self-­ realization.” Self-realization must be understood as containing biological, psychological, and social dimensions: self-realization with regard to (a) the constructive integration of the dialectically changing, individually depending ­conditions with a simultaneous maintenance of the homeostasis of the “milieu interieur” and (b) the balance in the striving for satisfaction of the individual during the continuous confrontation and adaptation of the psychoendocrine system with and to the “milieu exterieur” of ordinary day-to-­day life situations. Adaptation means not just the adaption of the individual to the environment but also the possibility to transform the environment to suit oneself. We must abandon the restrictive, positivistic, and objective approach to the individual and to the society. These approaches ignore the subjective specificities of each individual and each society with their own soul and spirituality and their own needs, feelings, and thoughts. We have to strive after the renaissance of individual human uniqueness in a world where the individual and his environment should represent a spiritual unity in ecological and ethnic peace. This is even more true for such a subtle situation as the prenatal stage of human development. But is it not so that, from a subtle and delicate process, large and important movements in philosophy, practice, and global change can result? According to the “butterfly effect,” events are interdependent to that degree that the very subtle and seemingly insignificant movements of a butterfly’s wing are able to set off, somewhere far away, a large typhoon. This butterfly effect can be likened to the prenatal stage of human development. With this in mind, therein lies the unique opportunity for prevention. The next topic I wish to stress is the basic needs of the human being. Invariably, these needs are described as eating, sleeping, and sex, and with my addition also continuity. But I feel that there is one more, very basic need which has never been addressed, and that is the need for taking care of someone and the need for being taken

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care of. The being for whom we care becomes the most important being in our life and also a part of our life. It is irrelevant whether the one we care for is an adult, a child, a prenatal child, a dog, a cat, or a small bird—in other words, all living things. A person you love is irreplaceable and indispensable as she or he is with us in dialogue and continuity. This being cared for and being taken care of is one of the prerequisites of our survival and provides the homeostasis and equilibrium between us and our environment. When we are being taken care of, we can be healed and cured, and when taking care of someone, we can heal and cure as well. Another wonderful way to express this is with the words of Antoine de Saint-Exupéry: “On ne connait que les choses que I ‘on apprivoise,’ … ‘Tu deviens responsable pour toujours de ce que tu as apprivois’” (de Saint-Exupéry 1946). In this way, the bonding process is created and feelings of reassurance and well-being are established. In order to predict how successful the bonding process between mother, father, and child will be, we need to have a good knowledge of the personalities of the father and mother, their past, their expectations and visions, and their fears and ambivalences. The importance of individual family history is becoming increasingly more apparent. The individual’s life starts at the latest in the house of its grandparents, who do or do not pass on to their children (the present parents-­to-be) the basic values of morality, ethics, and respect for life, who then will or will not pass on these values to their unborn child. Ehrfurcht ist der Angelpunkt der Welt, Ehrfurcht gegenuber der Natur, dem Mitmenschen und Gott (Respect is the key point of the world, respect for nature, a neighbor and to God). (Goethe)

An interdisciplinary approach invites interdisciplinary discussions where the same topic can be viewed from different aspects. It should serve as a unique opportunity for the cross-fertilization between the different sciences and practices rather than the more traditional multidisciplinary approach. Or it was expressed in the leading arti-

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cle of Lancet in 1985, “Psychiatrists and immunologists do not meet much, and when they do they tend to speak in different tongues” (Leading article, Lancet, 1985). An interdisciplinary dialogue is not only possible but even extremely creative and vitally necessary; the possibility of common understanding and thought within the language of different disciplines, primarily between the “humanistic” and “natural” sciences, is reachable. In our journal— the International Journal of Prenatal and Perinatal Psychology and Medicine (Int J Prenat Perinat Psychol Medicine) that I founded in 1989 and since then more than 2000 articles were published—there has been an interdisciplinary (not to be confused with multidisciplinary) dialogue from the very beginning, which has contributed to tearing down many established barriers to a common ground. I believe we have succeeded so far because of the use of “prenatal science” as a model for the indivisibility of the “psychological” and “somatic” processes in the continuum of human life and because of the phenomena and processes of the central nervous system and inseparable immuno- and neuroendocrine processes that have been put into the praxis. In our journal, psychoanalysis, endocrinology, immunology, developmental psychology, obstetrics, and midwifery, just to mention a few, have crossed each other’s paths, and today, we are able to talk together at our congresses and read each other’s thoughts in the journal without interpreters. In order to undertake such a challenge, a common language is required, a language that would be understood across disciplines and also would be able to assist in getting beyond semantic problems. One of the confusions is due to the reductionism that still so very much is inherited in the medical and psychological vernacular and which represents one of the major epistemological problems in the science of prenatal and perinatal life. There is a contradiction in the major tendencies in society at large as well as in the family and in individuals. On the one hand, there are increasing tendencies toward integrative processes within politics, economics, etc. on a world scale, while, on the other hand, there is a disintegration

P. G. Fedor-Freybergh

of the family and of micro-social structures with the consequent alienation of the individual. Enormous progress is being made in information processing and communication with Internet, email, and cell phones in most everyone’s possession while, at the same time, a decrease in and deterioration of communication from person to person. Fairy tales are out; CD-ROMs are in. There is a clandestine decline and disappearance of traditions and cultural values, of good education and good manners, of sensitivity and common sense, and the ever-increasing alienation of the individual from the very beginning of his life (Matejcek and Dytrych 1994). The prenatal child has become an object of research and observation. He or she is born as an object in alienated surroundings, brought up as an object, and lives as an object patronized by authorities. Basic values such as closeness, love, solidarity, intimacy, intuition, and natural instincts are suppressed by technocratic and bureaucratic manners. In this world of uncertainty and alienation, the individual is threatened by the deprivation of his or her basic rights and needs. In our International Journal of Prenatal and Perinatal Psychology and Medicine, we have been very conscious of the dimensions of health and disease, both in children and in families, and have stressed the importance of primary health and primary prevention as early as in the prenatal stage of life. We strongly believe that the health of the individual is determined very early in prenatal life and that we should put emphasis on our possibilities to optimize prenatal care for mother and child worldwide. We must guarantee the most optimal conditions possible at the very primary stages of development, whether in a human being or in a society. Only then can we achieve a true primary prevention of illness, mental and physical disturbance, hate, intolerance, violence, and war in the individual, in the family, and in society. The farther we see into the past, the further you can see into the future. (Winston Churchill)

The world can be changed only if we achieve a change in the basic understanding of respect for life from the very beginning. It starts with a

Continuity and Dialogue

deep respect for the unborn child in its first ecological position in the womb, respect for the mother, and respect for the child at birth and welcoming it with great dignity as an equal partner in society. Respect for human life from the beginning will also bring about new ways of treating prematurely born children with dignity (Marina Marcovich, Otwin Linderkamp, Ernest W. Freud) (Condrau 1976; Fedor-Freybergh and Mittendorfer 1981; Freud 1996; Klimek, Walas-­ Skolicka 1995; Linder 2010; Linderkamp et  al. 1995; Marcovich 1995; von Lüpke 2010a). This also has to do with learning empathy for other human beings. We have said that the life of the individual begins, at the latest, in the home of its grandparents. There, the parents of this individual receive all basic norms and values of ethics, morality, empathy, and respect for life, which they will then pass on to their own children even before they are conceived. Thus, we need to review the restrictive, positivistic, and objective approaches to the individual and to society—an approach that ignores the subjective specificity of each individual and of each society with their own soul and spirituality and their own needs, feelings, and thoughts. We must strive for the renaissance of individual human uniqueness— that the individual and his environment should represent a spiritual unity in ecological peace. The great humanist, writer, and philosopher, Vaclav Havel, President of the Czech Republic, stressed in his speech in Philadelphia, USA, on July 4, 1994, the uniqueness of the individual, their rights, their individual knowledge and the ability to transcend, and the individual’s respect toward the miracle of being and wonder of the cosmos, of nature, and of his own existence. He said, “The only reliable way towards coexistence and togetherness in peace and creative cooperation in the multicultural world of today must be anchored in human hearts and minds much deeper than any political opinions, antipathies or sympathies, namely, in the human ability to transcend -- transcendence as an understanding hand offered to someone close as well as to a stranger, to the human community, to all living beings, to nature, to the cosmos; transcendence as the

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deeply and joyfully experienced need for harmony with that which is not us, with that which we do not understand, which seems to be distant in time and space, but with which we are secretly in contact because this, together with us, builds one, unique world. Transcendence as the only real alternative to non-existence” (translation from Czech by the author). In the last few decades or, even more so, in the last few years, we have witnessed rapid changes in the world where, at great speed, most positive tendencies toward liberalization and democratization of societies have taken place. At the same time, new dangers and fears from different movements toward new totalitarianism and fundamentalism in philosophy and practice are growing. It is therefore of extreme importance in this time of philosophical, political, and social transitions to stress the awareness of the optimalization of human life conditions from the beginning. We are convinced that only a change of attitude, basic philosophy, and practice concerning the prenatal conditions of human life would lead to a humanization of the society toward nonviolence and common respect for life and tolerance for individual freedom and self-realization. When you change the way you look at things, the things you look at change. (Max Planck)

Unless we can achieve these mental and social approaches concerning the prenatal stage of life, all positive changes in the world would stay on the surface, and there would always be a danger of threats against basic human needs and rights, against cultural and traditional values, and against civilization and freedom. The vision is of a society with high respect for life expressed by every individual and hence to achieve a socially healthy, nonviolent world. Indeed, the history of humanity is also the history of children, and this history begins at the very start of life, at the very latest at conception. Studies of Psychohistory (Lloyd DeMause, Robert MacFarland, Alenka Puhar, et al.), studies in Epidemiology (Matejcek, Dytrych, Hau, et al.), and studies in Psychotherapy (Janus, Hau, Caruso, Benedetti, et al.) have clearly shown the impact of being loved, wanted, and respected and

P. G. Fedor-Freybergh

42

the ability to cope with own problems as well as with the problems in society. There is a change in the consciousness of society concerning the vital importance of the events from the prenatal and perinatal periods for the physical, mental, and social health of humans. There is an increasing awareness, interest, and even involvement in both professional and ­political environments for the importance of and the need to improve prenatal life and the circumstances surrounding birth.  If we can ensure that every child is loved and wanted from the very beginning, that it will be given respect, and that respect for life is placed highest on the scale of human values and if we can optimize the prenatal and perinatal stages of life without frustration of basic needs and without aggression and psychotoxic influences, the result could be a nonviolent society. The way you treat your child is the way the child will treat the world. This includes the unborn child, and this is also the whole truth about primary prevention. I indeed agree with what André Gide said: “Everything has been said already, but as no-one listens, we must begin again.” The child does not need a star or a planet; his mother is his planet and his star. (Paracelsus) Des Menschen Seele gleicht dem Wasser: Vom Himmel kommt es, zum Himmel steigt es und wieder nieder zur Erde muss es, ewig wechselnd. The human soul is like water: comes from heaven, rising to the heavens and must back to the earth again in the eternal alternation. (Goethe)

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45 attachment disorder. International Journal of Prenatal and Perinatal Psychology and Medicine, 21(1–2), 63–75. Turner, J.  R. G., & Turner-Groot, T.  G. N. (1997). Personal growth in parenting: A vital link to prevention in prenatal psychology. International Journal of Prenatal and Perinatal Psychology and Medicine, 9(3), 275–285. von Lüpke, H. (1987). Pränatale mütterliche Phantasien und postnatale Mutter-Kind-Beziehung. In P.  G. Fedor-Freybergh (Ed.), Pränatale und Perinatale Psychologie und Medizin. Begegnung mit dem Ungeborenen (pp. 35–43). Berlin: Rotation. von Lüpke, H. (2010a). “Now moments” in self psychology. International Journal of Prenatal and Perinatal Psychology and Medicine, 22(1–2), 65–72. von Lüpke, H. (2010b). More than neighbors: A common basis for relationship-centered medicine and science. International Journal of Prenatal and Perinatal Psychology and Medicine, 22(3–4), 205–216. World Health Organization. (1986). Health research strategy for health for all by the year 2000. Geneva: WHO. Zikmund, V. (1993). Dimensions of health and disease: Biological, psychological and social. International Journal of Prenatal and Perinatal Psychology and Medicine, 5(3), 265–276. Zweig, S. (1931). Die Heilung durch den Geist. Leipzig: Insel-Verlag.

The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders Thomas R. Verny

Introduction Stress Stress refers to both the internal and external demands that we face to accommodate change. Stress becomes negative when adaptation or coping mechanisms fail. The primary hormonal mediators of the stress response are glucocorticoids (hormones secreted by the hypothalamus, pituitary gland, and the adrenal cortex) and catecholamines (secreted by the inner core of the adrenal gland). These hormones have both protective and damaging effects on the body. When they act for short periods of time, they serve the functions of adaptation, homeostasis, and survival “allostasis” (McEwen 2000). However, if the stress becomes chronic, associated hormones exacta cost, referred to as “allostatic load,” can accelerate disease processes. The concepts of allostasis and allostatic load center around the brain as interpreter and responder to environmental challenges and as a target of those challenges. Stress can be caused by a variety of factors such as: T. R. Verny (*) Associate Editor, Journal of Pre and Perinatal Psychology and Health (JOPPPAH), Stratford, Canada

• Exposure to chemical toxins, electromagnetic fields, ionizing radiation, etc. • Anxiety • Depression • Smoking and alcohol • Undernutrition • Disease and infection • Physical trauma • Birth complication In this chapter, we shall focus almost entirely on psychological factors. Before we do, we need to take a brief look at the developing brain.

Brief Introduction to Neuroscience The last 20 years have produced more knowledge about the brain and how it develops than scientists had gleaned in the previous centuries. In the past, we learned about the brain through animal studies, autopsies, physical size and appearance of different brains, microscopic examination of brain tissue, and electrical stimulation of various parts of the brain, for example, Wilder Penfield and EEGs. Also, observation of prenates with fiber optics  – plus EEG leads  – demonstrated that the unborn child experiences REM sleep. In other words, he/she is most probably dreaming while asleep.

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Current Neuroscience • Ultrasound imaging  – echoes produced by sound waves • Magnetic resonance imaging (MRI) – exposes the body to a magnetic field • Functional MRI (magnetic field  – computers – detailed images) • Positron emission tomography (PET) scan  – we can observe brain structure and activity levels of various parts of the brain; it shows how the brain uses energy. A person is injected with a tracer chemical similar to glucose which produces color-coded X-sectional images. • Correlating EEGs with videotapes, for example, REM sleep studies • Analysis of saliva for cortisol  – measures stress hormone levels In view of recent brain research, the nature vs. nurture controversy is dead. It is the dynamic relationship between nature and nurture that shapes human development. While genes play a role in determining temperament, the intrauterine environment that reflects what the mother is eating, drinking, inhaling, and experiencing has decisive influence on fetal development including temperament. The brain develops from the outward-most layer, the ectoderm, of the very early embryo. The ectoderm forms a neural tube, and this structure gradually gives rise to the cerebral hemispheres and the central and peripheral nervous system. At birth, we have 100 billion neurons, roughly as many nerve cells as there are stars in the Milky Way. Forming and reinforcing neural circuits are the key processes of early brain development. Also in place are a trillion glial cells, named after the Greek word for glue. Axons hook up with dendrites as a result of stimulation resulting in synapses. Each individual neuron may be connected to as many as 15,000 other neurons forming brain wiring or circuitry. Those synapses that are reinforced by virtue of repeated experience tend to become permanent; the synapses that were not used often enough tend to be eliminated.

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Brain development is a “use it or lose it” process, in which respect it is like a muscle. 0–3: In the first 3 years, production of synapses outpaces elimination. 3–10: The next 7 years, production and elimination are roughly balanced. 10+: After age 10, elimination is the dominant process. The pruning process is largely confined to the cerebral cortex while the hardwired areas of the brain such as the brain stem are left intact. At birth, the human brain weighs 25% of its eventual adult weight. In comparison, our closest primate relation, the chimpanzee, is born with about 45% of its brain weight already developed, and its brain growth slows down shortly after birth. Seventy-five percent of the human brain develops after birth, in direct relationship with the external environment. By the age of 2, toddlers’ brains are as active as those of adults, and the number of synapses reaches adult levels. A 3-year-old has 1000  billion synapses – about twice as many as her pediatrician – and her brain consumes twice as much energy. This suggests that young children – particularly toddlers and infants  – are biologically primed for learning. The cerebral cortex of higher forms is made up of six cell layers. Each layer has its distinct pattern of organization and connections. During the developmental phase, the cells initially move from the neural tube to form the deepest or sixth

Fig. 1 (a) Cortical cell migrations. (b) Cortical ladder

The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders

layer (Fig.  1a). Each successive migration ascends farther, progressively forming more superficial (fifth, fourth, third, second, and first) layers beyond the layer that was initially laid down. Thus, each group of migrating cells must pass through the layers already laid down by the earlier arrivals, thereby following an inside-out sequence of development. The later arriving cells migrate along the same radial glial guide cells or cortical ladders (Fig. 1b) used by the earlier immigrants. It is, accordingly, very important that the earlier groups succeed in “getting off” the glial ladder before the next wave of immigrant cells tries to come up and through. Unless they do release their hold, the next wave of cells coming up the ladder may not be able to get by on their way to a more distant destination. When this happens, the ensuing traffic pileup produces developmental anomalies, which can lead to abnormal neuronal connections and disturbed behavior (Scheibel 1997). Mustafa Sahin, Assistant Professor of Neurology at Harvard Medical School, sees autism as a developmental disconnection syndrome – there are either too many connections or too few connections between different parts of the brain. In mouse models, Nie et  al. (2010a, b) found an exuberance of connections, consistent with the idea that autism may involve a sensory overload and/or a lack of filtering of information. This study adds to growing evidence that autism is caused by a miswiring of connections in a child’s developing brain, resulting in impaired information flow. Furthermore, as a cell climbs along the cortical ladder, it comes in contact with other neurons. This passing acquaintance activates various genes that define the cell’s identity, location, and mission. However, adverse environmental conditions, for example, too much cortisol, nicotine, or other neurotoxin can interrupt this journey. Imagine a neuron, let us call it Neuron A, that is genetically programmed to move to point X in the cerebral cortex. If there is too much cortisone, nicotine, or other brain toxic substances in the maternal blood, Neuron A may end up not at X but at Y. Or if there is a very high concentration of these toxins, the neuron will be actually destroyed. Since this would be happen-

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ing to thousands of neurons not just one, this child would be born with a miswired brain. He would be handicapped from the beginning. This process also reminds us once again that genes provide the blueprints. But the environment determines how the blueprint is executed.

Stress Pathways The stress response can be subdivided into rapid and slow response. Rapid response occurs through the sympathetic system (one part of the autonomic nervous system) by way of increased adrenaline and noradrenaline production. This is often referred to as the flight/fight response. Signals from the hypothalamus activate the adrenal medulla, which responds by producing adrenaline and noradrenaline. Also, the hypothalamus activates the locus coeruleus, which produces noradrenaline. Adrenaline and noradrenaline stimulate the vagus nerve, which supplies the heart, lungs, and gastrointestinal tract and is part of the parasympathetic system. The activation of this system will result in increased heart rate, blood pressure, blood sugar, and insulin resistance. Also, because the body is being readied for fight or flight, blood is diverted from the internal organs such as the GI tract to the large muscles. But the GI tract is not the only organ that is affected this way. Blood is also diverted from the uterus and what that means for a pregnant woman is that her baby is getting less than optimal oxygen and nutrients. If this state persists, the consequences can be quite dire. It should be added that stimulation of the sympathetic system is accompanied by inhibition of the parasympathetic system that leads to inhibition of sleeping and eating. This response is wonderful for a person being chased by a lion but not so great for a pregnant mother. Slow response is mediated through the hypothalamic-­ pituitary-adrenal (HPA) axis (Fig. 2) and results in increased concentrations of cortisol. Stimuli associated with danger activate the amygdala. By way of neural pathways from the amygdala to the paraventricular nucleus of the

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Fig. 2  HPA axis

hypothalamus (PVN Hypo), corticotrophin-­ set at a certain temperature. When the temperature releasing factor (CRF) is sent to the pituitary in the room falls, let us say, three degrees below gland, which, in turn, releases adrenocortico- the set temperature, the thermostat will send an tropic hormone (ACTH) into the bloodstream. electrical signal to the furnace and the furnace will ACTH then acts on the adrenal cortex, causing it respond by producing heat. After a little while, the to release steroid hormones (CORT) into the heat reaches three degrees above the set temperabloodstream. CORT freely travels from the blood ture, and the thermostat will kick in and tell the into the brain, where it binds to specialized recep- furnace to shut down. Everything is quiet for a tors on neurons in regions of the hippocampus while and then the whole process is repeated. and amygdala, as well as other regions. Through However, should this be winter and you live in the hippocampus, CORT inhibits the further Canada and you left the window open in the room release of CRF from the PVN. However, as long where the thermostat is, no matter how hard the as the emotional stimulus is present, the amyg- furnace works, the temperature in the room will dala will attempt to cause PVN to release not rise. So the thermostat keeps sending inforCRF. The balance between the excitatory inputs mation to the furnace – it’s cold – and the furnace (+) from the amygdala and the inhibitory inputs keeps pumping heat into the house. If this contin(−) from the hippocampus to PVN determines ues long enough, the furnace will break down. how much CRF, ACTH, and ultimately CORT Similarly, with the body, if a pregnant woman will be released. runs to catch a streetcar, she will experience This system works beautifully under normal stress, but after she reaches the streetcar and sits conditions. It is “designed,” for lack of a better down, her system will quickly return to normal. term, to preserve homeostasis or, at times of stress, No harm was done. On the other hand, if this to restore homeostasis as quickly as possible. It is pregnant woman is a single mother, unemployed, a closed system similar to the heating systems of suffering of several addictions, undernourished, most apartments or houses where a thermostat is and constantly worried about how she will sup-

The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders

port the child she is carrying, she will be in a chronic state of stress. And like the house with the open window, her glands and CNS will be responding to the stress she is experiencing by an overproduction of cortisone, adrenaline, and noradrenaline. Needless to say, everything that the mother experiences and everything she eats, drinks, or inhales are passed to her unborn child through the umbilical circulation in the same way her hormones are passed. A study of 100 mothers at Queen Charlotte’s Hospital, at 32 weeks’ gestation, demonstrated a strong correlation between plasma levels of the stress hormone cortisol in the mother and in the fetus (Glover 1999; Teixeira et al. 1999). The following discussion will examine the effects of this kind of chronic stress on the unborn child.

 ffect of Maternal Stress E on the Unborn Child As we have already shown, large concentrations of cortisol will lead in the brain to: 1. Cell migration to the wrong destination resulting in the formation of wrong circuits. 2. Destruction of neurons. 3. Destruction of synapses. –– When this occurs in the amygdala and hippocampus, it will interfere with memory. –– When this occurs in the hypothalamic and reticular activating system, it will interfere with internal states such as sleep and digestion. 4. Inhibition of dendritic branching. Figure 3 shows neurons from unstressed (control) and stressed (subordinate) tree shrews, a mammalian species related to early primate evolution. The stress in this experiment involved exposing subordinate males to a dominant male. Repeated social stress of this type reduced the branching and length of dendrites. Compare the top half of the cell from

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Fig. 3  Dendrites shriveled by social stress

the unstressed control and from the stressed subordinate (Magarinos et al. 1996). Returning now to the effects of cortisol on the brain, we discover: 5. Gene regulation. Although we do not have space here to discuss it, it is an important part of the picture. The new science of epigenetics teaches us that genes get turned on or off by the environment (Lipton 2005). 6. Decreases brain corticosteroid receptors. 7. Sensitizes certain receptor sites. 8. Decreases serotonin (5-HT1A) in the brain. Serotonin is anxiolytic and may buffer aversive events. It is a known contributor to feelings of well-being. Stress, anxiety, and depression decrease receptors for serotonin. In animals, in addition to trophic properties, serotonin participates in most biological functions, especially those associated with limbic and brain stem circuits. The ability to change morphology, stimulate neurogenesis and differentiation, or promote cell survival is influenced by acetylcholine, GABA, catecholamines, EAAs (glutamate and glycine), and neuropeptides. However, only serotonin has the evolutionary and anatomical properties to serve as a global regulator unifying the whole brain into a cohesive biological system (Pasternak et  al. 2005; Kolar and Machackova 2005). Serotonin has an important function in prenatal development, where its expression pattern is tightly regulated, and in adult neurogenesis.

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In the human brain, serotonin neurons are more numerous (>250,000) than in other species and form a tight, small cluster along the midline of the brain stem (Tork and Hornung 1990). Serotonin is manufactured in the brain using the essential amino acid tryptophan, which is found in foods such as bananas, pineapples, plums, turkey, and milk. Modulation of serotonin at synapses is thought to be a major action of several classes of pharmacological antidepressants. The dual role of serotonin as a neurotransmitter and a neurotrophic factor has a significant impact on behavior and risk for neuropsychiatric disorders through altered development of limbic neurocircuitry involved in emotional processing, and development of the serotonergic neurons, during early brain development (Nordquist and Oreland 2010). Low serotonin contributes to increased risk for depression and violence in men. It also regulates respiration, heart rate, body temperature, and arousal from sleep. Hypothesis: The precursor of serotonin is tryptophan that adults obtain from certain foods and convert to serotonin. 5-HT from maternal blood begins to bathe the developing fetus from conception, providing a very early start to its functioning as a homeostatic regulator in the dynamic emerging connections of the brain (Azmitia 2007). But what happens when the pregnant mother is low in 5-HT because of depression? I believe this may lead to a deficiency in serotonin in her unborn child. This is, at the moment, only a hypothesis that needs to be either proved or disproved. Continuing now our discussion of the effect of maternal stress on the unborn child: 9. Increases neuronal irritability. 10. Reduces brain weight because of destruction of neurons and dendrites. 11. ANS becomes overcharged. This results in health risks and pathological personality traits as will be demonstrated subsequently. 12. Suppresses immune and inflammatory response.

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13. Inhibits development of the corpus callosum. This structure is a communication channel between the left and right brain. The corpus callosum is larger in women than men. This variance is given as one explanation for the different ways women and men see and relate to the world. There are other small but significant differences between male and female brains (Brizendine 2006). 14. Inhibits development of the cerebellum, which may be related to autism. In the past, the cerebellum was considered involved only in postural balance. Today, there is evidence that it may also be involved in emotional balance. 15. Decreases production of oxytocin. Oxytocin produces uterine contractions during parturition and ejection of milk when the baby latches onto the breast. However, it also increases male and female social and sexual responsiveness, caretaking in both sexes; in males, it energizes gentler aspects of male behavior and, finally, as recent observations have shown, it increases trust. Therefore, it is not surprising that Michel Odent (1999) has referred to oxytocin as the “Love Hormone.” 16. Increases production of vasopressin. Vasopressin, on the other hand, is largely a male hormone, although also present in women but to a lesser extent. It increases male sexual persistence, such as in courtship. (Please observe how tactful this science scribe can be on occasion.) In females, it energizes the more aggressive aspects of maternal behavior, for example, protecting their young from perceived harm. 17. Males tend to become feminized, and females masculinized. More of this later. 18. Decreases capacity to learn. This is due to the loss of neurons in the amygdala and the hippocampus. 19. Inhibition of prefrontal cortex, thereby favoring instinctual responses over more complex intellectual functions. 20. Facilitates the encoding of aversively charged emotional memories starting at the amygdala.

The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders

Representative Research on the Effect of Maternal Emotions on Fetal Behavior Animal Studies Stress and Personality  Hutchings and Gibbon (1970) reported on research done by Thompson in 1957 and Ader and Belfer in 1962. Female rats were trained to avoid shock when a conditional stimulus (CS), a loud buzzer, was presented. After training, they were mated. During their pregnancies, the CS, but no shock, was presented. Therefore, these animals, every time they heard the buzzer, are expected to be shocked. Consequently, they were stressed psychologically without the physical stress of shock. Another group of pregnant rats were exposed to the sound of the buzzer also. However, since they did not have the previous experience of associating the sound with an unpleasant experience, they were not made anxious by the buzzer. After birth half of pups from the trained, anxious mothers were given to be reared by the non-anxious mothers and vice versa – a procedure known as cross fostering. What they found was: • Regardless of which mothers they were reared by, pups from anxious mothers were more anxious, measured by the fact that when placed in an open field, they demonstrated increased defecation and decreased activity. • Stressed mothers demonstrated a different parenting style, eliciting more negative reactions in the pups they raised. • Stressed pups elicited more negative maternal behavior from unstressed mothers. Consider the implications of this and similar studies on the practice of adoption. Stress and Testosterone  Paanksepp (1999, 2004) found that in a normal unstressed male rat litter, there are 80% what he called sexual studs and 20% sexual duds. In a stressed litter, there were still 20% duds, but the number of studs fell to 20%, and 60% of the litter turned out to be bior homosexual. Generally, he found the male rats

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became more nurturing and female rats less nurturing (Fig. 4). According to Paanksepp (1999, 2004), both the brain and body of mammals are initially organized according to a female characteristic plan. Maleness emerges from two distinct influences of testosterone on body tissues – masculinization of the brain being mediated by estrogen (E) and of the body by dihydrotestosterone (DHT). Different tissues can convert testosterone to different products because of the enzymes they contain. DHT is manufactured in cells containing 5-a-reductase, and E is manufactured in those that contain aromatase. Paanksepp’s model suggests that stress can interfere with the enzymes 5-a-reductase and aromatase. Depending on when during gestation the stress is experienced and on the degree of stress, a man can develop a more stereotypically female brain in a stereotypically male body or vice versa or any combination of these.

Human Studies Project Ice Storm  Project Ice Storm was designed to study the effects of in utero exposure to varying levels of prenatal maternal stress (PNMS), resulting from an independent stressor on the children’s development from birth through childhood. In January 1998, the Quebec Ice Storm left millions of people without electricity for up to 40 days. In Project Ice Storm, researchers at McGill University (LaPlante et  al. 2004, 2008) were able to separate the “objective” stressors (days without power) from the “subjective” reactions (post-traumatic stress symptoms) and physiological reactions (cortisol over 24 hours) and maternal personality factors of 178 pregnant women exposed to the disaster. Child follow-ups at ages 6  months and 2, 4, 5.5, and 6.5 years show significant effects of objective and subjective PNMS on temperament, parent- and teacher-rated behavior problems, motor development, physical development, and IQ, attention, and language development. The majority of these effects have persisted as of November 16, 2011 (King et al. 2011–ongoing).

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T. R. Verny

Fig. 4  The effect of testosterone on brain and body

The researchers conclude the more severe the level of prenatal stress, the poorer the outcome. The difference of an average of 15 IQ points between the high- and low-stress groups was largely maintained as of 2009, that is, for eight and a half years (Laplante et al. 2010).

ogy. Altered gray matter volume in brain regions affected by prenatal maternal anxiety may render the developing individual more vulnerable to neurodevelopmental and psychiatric disorders as well as cognitive and intellectual impairment (Buss et al. 2010).

Stress and Brain Morphology  In a parallel Stress and Low Birth Weight  Low birth weight study, at UC Irvine, researchers evaluated the (Nathanielsz 1999) increases risk for adult meninfluence of stress during human pregnancy on tal health disorders according to a study in which brain morphology (Buss et al. 2010). The study 4627 subjects were tracked from birth to age 53 included 35 women for whom serial data on (Coleman 2005; Wysong 2005). An additional kg pregnancy anxiety was available at 19, 25, and of body weight was associated with a 17% reduc31 weeks gestation. When the offspring from the tion in the likelihood of a mental disorder. Being target pregnancy were between 6 and 9 years of born small isn’t necessarily a problem. It is a age, their neurodevelopmental stage was assessed problem if you were born small because of by a structural MRI scan. With the application of adverse conditions in the womb. voxel-based morphometry, the researchers found Coleman reported, “We found that even peoregional reductions in gray matter density in ple who had just mild or moderate symptoms of association with pregnancy anxiety after control- depression or anxiety over their life course were ling for total gray matter volume, age, gestational smaller babies than those who had better mental age at birth, handedness, and postpartum-­ health. It suggests a dose-response relationship. perceived stress. As birth weight progressively decreases, it’s Specifically, independent of postnatal stress, more likely that an individual will suffer from pregnancy anxiety at 19  weeks gestation was depression and anxiety later in life” (Coleman associated with gray matter volume reductions in 2005, 2007). the prefrontal cortex, the premotor cortex, the Low-birth-weight babies also tended to have medial temporal lobe, the lateral temporal cortex, shorter height and lower body weight at ages 6 the postcentral gyrus as well as the cerebellum and 11 years and did poorly on cognitive tests at extending to the middle occipital gyrus, and the ages 8 and 11  years. Even when other factors fusiform gyrus. High pregnancy anxiety at 25 known to contribute to mental health were taken and 31  weeks gestation was not significantly into account, such as major stressful life events associated with local reductions in gray matter and parental divorce, low birth weight was still volume. associated with increased risk. This is the first prospective study to show that a specific temporal pattern of pregnancy anxiety Low Birth Weight and ADHD  Researchers from is related to specific changes in brain morphol- Michigan State University analyzed data from

The Pre- and Perinatal Origins of Childhood and Adult Diseases and Personality Disorders

low-birth-weight and normal-weight children born from 1983 through 1985 in two major hospitals in Detroit. The investigators discovered that among the teens living in the disadvantaged urban community, those with a low birth weight had an approximately threefold greater risk of having attention problems. Notably, the increased risk was greatest among teens whose birth weight was 1500 g or less. By comparison, teens living in the middle-class suburbs had no significant increased risk for attention problems associated with low birth weight. Children with low birth weight also appear to be at higher risk for psychiatric disturbances than normal-birth-weight children (Bohnert and Breslau 2008).

Prematurity and IQ  A study of 18,000 children at McGill University by Yang et  al. (2010) of babies born before 39 weeks found that at age six and a half, they showed slightly lower IQs compared to babies born at 39–40 weeks, increased mortality in infancy, and increased risk of neonatal seizures. This is troubling because an increased number of births are induced at 38 or 37 weeks.

Extreme Prematurity and Behavior Problems  Children born extremely premature (at or before 25  weeks of gestation) may be at significantly higher risk for behavior problems by age 6, with boys particularly vulnerable. The investigators found that overall, 19.4% of the extremely preterm children had behavior problems, but just 3.4% of the control children did. Notably, boys were twice as likely as girls to suffer behavioral problems, the team discovered (Verrips et al. 2008).

Maternal Asthma  A study of 16,000 children in Manitoba (Liem 2006) has shown that mothers who had asthma going back 5 years gave birth to children born prematurely 6.3% of the time as compared to 2.8% of non-asthmatic mothers. Asthmatic mothers had 4.9% low-birth-weight babies compared to non-asthmatic mothers who had 3.0% low-birth-weight babies. Why is this

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study relevant to our exploration of the effects of stress on the unborn? There are two factors at play here. One, asthmatic sufferers when they experience an attack have huge difficulty in breathing. Panic ensues with its outpouring of cortisol, adrenaline, and all the other neurohormones of stress. Two, what do asthmatics do to prevent or treat asthma? They take cortisol sprays.

Maternal Stress and Autism  Autism risk doubles in babies born prematurely and low birth weight, according to a study by D. Schendel and T Karapurkar Bhasin (2008) at the National Center on Birth Defects. Baby girls born 1, and the measures with the highest values on each of the components were selected; comparable neonatal measures were then introduced in the models. Fetal sex was introduced as a second predictor variable since our data showed that male fetuses were more active than female fetuses. Maternal anxiety postpartum had no significant association with neonatal behavioral measures and was not introduced in the neonatal LISREL model. However, as maternal anxiety 7  months after delivery was significantly associated with the infant activity measure, we introduced it as a second predictor to examine the link with infant activity at 7 months. The models were tested on n = 28 fetuses/neonates for whom all data were available. As can be seen in Fig.  2 model A, LISREL modelling showed that fetuses of high anxious mothers made more general movements and head movements and that male fetuses made more general movements than females (Note: Only the final model of nested LISREL models is shown). The prenatal influence of maternal state anxiety also was reflected in neonatal behavior; infants who made more head movements as fetuses made more general movements and more head movements as neonates. The observation that the percentage of fetal head movements (rather than the percentage of fetal general movements) was significantly related to neonatal head and general movements may indicate that the newborns had

B. R. H. Van den Bergh

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Fig. 2  LISREL models A, B, and C concerning the relation between maternal anxiety during pregnancy, fetal and neonatal behavioral states and motor activity, and infant activity. 7 months = 7 months after delivery; df = degrees of freedom; Epoch C1F-MD: mean duration of epochs of coincidence State 1  in the fetus; Epoch 1  N-MD: mean duration of

epochs of State 1 in the neonate; % GM = percentage of general movements; % HM = percentage of head movements; NoC1F  =  epochs of coincidence other than State 1F; C24F = epochs of coincidence 2F and 4F; Trim2 = second trimester of pregnancy; Trim3  =  third trimester of pregnancy. (Adapted and translated from Van den Bergh 1989)

difficulties in adjusting to gravidity, which may have more effect on making body movements than on making head movements (Michel and Moore 1995; Prechtl 1984). Model B illustrates that maternal trait anxiety had a negative influence on the mean duration of epochs of ­coincidence of fetal State 1 and that infants who have shorter epochs of State 1F as fetuses also have shorter duration of epochs of State 1 as neonates. Model C reveals that at 7  months after birth, maternal anxiety during pregnancy had an indirect effect on activity level of the infant (i.e., via influencing fetal general movements) and

maternal anxiety measured at 7  months after delivery had a direct influence on infant activity level. By this time, the mother and infant would have had much more opportunity to interact than at 4 or 5 days after birth. Of course, these differences may have resulted because infant activity was reported by the mother and reflect her bias. In the future, direct observation of maternalinfant interactions at this age might be useful in untangling these effects. In summary, the LISREL modelling, together with other results from this cohort (e.g., those showing that infants of high anxious pregnant

Prenatal Developmental Origins of Early Brain and Behavior Development, of Self-Regulation…

mothers had a more difficult temperament at 10 weeks and cried more, were hungrier, and had more stomach cramps at 7 months than infants of mothers who were less anxious; see Van den Bergh 1989, 1990, 1992), answered our two research aims cited above in a positive way. Results of study 1 can be integrated into our DOBHaD model (see Fig.  1) in the following way: prenatal exposure to maternal anxiety (early life events) in interaction with supposed (epi) genetic factors may have an enduring influence on (or programs) fetal/neonatal brain development and behavioral functioning as reflected in higher fetal and neonatal reactivity. This higher reactivity may evolve into a programmed phenotype including seeking out arousal-inducing events. Moreover, the induced behavioral alterations observed in the offspring of mothers with high anxiety levels may influence the quality of the interaction between mother and child (i.e., the caregiving environment) in a negative way, increasing the risk of subsequent offspring behavioral or mental health problems. Further explanation of the (use of the) DOBHaD model will be described in the final section which will clarify the integration of the results of this study. A link between the level of stress and anxiety of the mother during pregnancy and ultrasonographically observed fetal behavior and fetal rate is now well established (for a review, see DiPietro et al. 2000; Kafalí et al. 2011; Monk et al. 2011; Van den Bergh et  al. 2005b). Most studies have reported that increased maternal anxiety was associated with increased fetal arousal/wakefulness and increased FHR variability and % of body movements during states 2F and 4F. As an example, DiPietro and colleagues (2002) observed that fetuses of women with a positive versus negative attitude toward pregnancy exhibited different overall levels of motor activity (reduced versus increased, respectively). Although positive (pleasant, optimistic) emotions and negative stressors are believed to be regulated by the same physiological system [hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS)], the negative emotions may have reflected chronic negative conditions, which were both unpredictable and uncontrollable and triggered a

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stress response, involving cortisol release (Koolhaas et  al. 2011), while positive emotions (optimism) have been linked to lower levels of cortisol responses under stress (Jobin et al. 2014).

 tudy 2: Relationship Between Fetal S Behavioral State and Child and Adolescent Self-Regulation Having observed in study 1 that maternal anxiety did influence fetal behavioral state and was associated with alterations in state-related fetal activity level, we turned our attention to the influence of fetal states on self-regulation. Specifically, we addressed the question: Is fetal behavioral state organization a biological precursor of child and adolescent self-regulation? (Van den Bergh and Mulder 2012).

Background Sleep plays a critical role in early brain development, arousal regulation, attention, and cognition (Graven and Browne 2008; Mirmiran et al. 2003; Mulder et al. 2011; Peirano et al. 2003), and the study of sleep ontogeny (i.e., behavioral state organization) can be used to identify patterns of brain maturation (Scher 2008). For example, in one study (Scher et al. 1996), sleep measures of both the healthy preterm infant (assessed at term equivalent age) and the healthy full-term newborn were predictive of performance on the Bayley scales of mental development at 12 and 24 months. In another study (Holditch-Davis and Edwards 1998), in high-risk premature infants born at gestational ages from 27 to 29  weeks onward, the degree of sleep state control after birth was associated with postnatal neurodevelopmental status at term equivalent age. The predictive value of these measures for behavioral developmental outcome in later life has remained unexplored due to a lack of long-term follow-up studies. Therefore, in a nonclinical sample (see study 1 for a description of this sample), we examined whether differences in sleep state organization in the near-term fetus could account for differences in child and adolescent self-­regulation (Van den Bergh and Mulder 2012).

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Theories of self-regulation presume that humans, from prenatal life or birth onward, display individual differences in reactivity and regulation that have implications for subsequent development and adaptation (Calkins and Fox 2002; Gunnar et al. 2009; Henrichs and Van den Bergh 2015; Kochanska et al. 2001; Kopp 1982; Posner and Rothbart 2000; Pruessner et  al. 2010). Reactivity is understood as the arousability of physiological and behavioral systems, while self-­regulation refers to neural and behavioral processes which function to modulate this reactivity. Interestingly, in some theories, temperament has been defined as constitutionally based individual differences in reactivity and regulation (Rothbart and Ahadi 1994; Rothbart and Bates 1998; Rothbart and Derryberry 1981; Rothbart et  al. 2011). As the infant and child mature, later-­ developing neural structures become integrated into the existing neural organization, which involves reorganization of circuits (Michel and Moore 1995). Due to this patterned reorganization, initial reactive forms of regulation are supplemented by an increasing capacity for volitional, effortful control or selfregulation (Derryberry and Rothbart 1997). Much of the self-regulation development results from increasing volitional control over attentional processes and enhanced inhibitory control over motor behavior (Calkins and Fox 2002). Starting in childhood and continuing throughout adolescence, executive functions such as attentional focusing, maintenance and shift of focusing, and inhibitory control become integrated into complex emotional and behavioral regulatory processes. These processes, in turn, are involved in planning and goal setting, responsible decision-­ making, emotional and motivational changes, and interpersonal relationships (Nelson et  al. 2002; Rothbart and Bates, 1998; Van den Bergh and Mulder 2012, p. 585). Failure of self-­regulation in one way or another is a characteristic feature of behavioral problems and mental disorders (Henrichs and Van den Bergh 2015). At the time of our study, we could find no empirical work on individual differences in typical fetal brain maturation processes, such as

B. R. H. Van den Bergh

expressed in fetal behavioral state organization or in relation to the long-term consequences for selfregulation. Thus, the aim of this prospective longitudinal study was to examine which measures of fetal behavioral state organization in the normal, near-term fetus are predictors of measures of self-regulation obtained from the same individuals when they were 8–9 and 14–15 years of age. A total of 73/86 offspring participated in this second study. Twenty-five mother-offspring pairs who had participated in the fetal observation part of the Leuven study detailed above and had complete data for both the fetal behavioral observation session at the end of pregnancy and a follow-up study on the offspring at ages 8–9 or 14–15 were included. The reference (i.e., comparison) group consisted of 48 mothers and their children/adolescents who participated only in the follow-up study but not in the fetal observation study. For the follow-up study reported here, the mothers completed Dutch versions of temperament questionnaires, measuring concepts of reactivity (i.e., positive reactivity (or surgency) and negative reactivity) and of self-regulation (i.e., effortful control). The Children’s Behavior Questionnaire (CBQ; Ahadi et al. 1993; Rothbart et al. 2001, translated and validated for a Dutch-­ speaking sample by Van den Bergh and Ackx 2003) was used when their children were 8–9 years of age, and the revised Early Adolescent Temperament Questionnaire (EATQ-R; Capaldi and Rothbart 1992; Ellis and Rothbart 2001; translated and validated for a Dutch-speaking sample by Hartman et al. 2002) was used when the children were 14–15 years old. Only the temperament data concerning self-regulation are used in this study. Statistical modelling of the fetal-child-adolescent data demonstrated that one behavioral state measure, namely, the time a typically developing fetus takes to pass from quiet sleep (S1F) to active sleep (S2F) in the last month before birth, is associated with her/his degree of self-regulation in childhood and adolescence. In particular, fetuses exhibiting sharp, synchronous transitions from quiet sleep into active sleep compared with fetuses showing nonsynchronized transitions (lasting >3 min) reached a higher level

Prenatal Developmental Origins of Early Brain and Behavior Development, of Self-Regulation…

of effortful control (i.e., higher than the reference group but within normal ranges) both at 8–9 years and 14–15  years. Although the mechanisms underlying fetal state transitions are yet unknown and in need of future study, our results demonstrate that studies of sleep ontogeny can provide insights into fetal brain maturational processes which have implications for later environmental adaptation as well as developmental consequences for behavior. The results of study 2 can be integrated in our DOBHaD model (Fig.  1). The supposed interaction between fetal environmental and (epi)genetic factors is reflected in synchronous fetal state transitions from quiet into active sleep in some fetuses and in asynchronous ones in other fetuses; these types of transitions are one element of early brain-behavior processes. These early differences may evolve into a programmed phenotype implying optimal self-­ regulation in the former group and implying suboptimal self-regulation in the latter ones.

 tudy 3: Maternal Anxiety During S Pregnancy Is Associated with Cognitive Control and Functional Brain Correlates in 20-Year-Old Men In recent years, evidence from neuroimaging studies is building for short- and long-term functional and structural brain alterations in offspring exposed to maternal psychological distress during pregnancy. These changes are seen as more or less permanent markers of exposure to maternal distress during pregnancy, potentially increasing the risk for cognitive, behavioral, and affective deficits and disorders (for recent reviews, see Franke et al. 2017; Scheinost et al. 2016; Van den Bergh et al. 2017, 2018). In prior studies of our cohort, high maternal anxiety during pregnancy was related to high fetal motor activity (as measured with ultrasound) and higher neonatal motor activity (Van den Bergh 1990; see also study 1 above) and to ADHD symptoms, externalizing problems and anxiety at the age of 8–9  years (Van den Bergh and Marcoen 2004). At the age of 14–15 (Van den Bergh et  al. 2005a, 2006a, b) and 17

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(Mennes et  al. 2006), high maternal anxiety at 12–22  weeks of pregnancy was associated with specific cognitive deficits, i.e., endogenous but not exogenous cognitive control, as measured with a battery of cognitive tasks. Endogenous cognitive control refers to the ability to generate triggers from within oneself (i.e., endogenously) in order to control actions, decisions, strategies, and thoughts interfering with optimal task performance. It is opposed to exogenous cognitive control where cognitive control is triggered by external signals (e.g., a sound) (Brass and von Cramon 2004). In a subsequent study in the 17-year-olds, electroencephalography (EEG) was used to measure event-related potentials (ERPs) while the participants were performing two tasks. A go/no-go task measured exogenous cognitive control, and a gambling paradigm measured endogenous cognitive control, i.e., in the latter paradigm, participants had to assess risks, make decisions, monitor their total scores, and deal with gains and losses, all requiring endogenous cognitive control (Mennes et al. 2009). Results showed that effects of prenatal exposure to maternal anxiety were present in the gambling paradigm, but not in the go/no-go task. Importantly, the dissociation in the effect of antenatal maternal anxiety on exogenous versus endogenous cognitive control was evident in cognitive performance as well as in brain activity (Mennes et al. 2009). While ERPs are measured with millisecond accuracy and have an excellent temporal resolution regarding the ongoing cognitive processes, ERPs lack spatial specificity, preventing tying specific cognitive processes to specific brain regions. Therefore, to complement the ERP results with spatial information about which areas in the prefrontal cortex show differences in functionality related to prenatal exposure to maternal anxiety, we assessed endogenous cognitive control using functional magnetic resonance imaging (fMRI) in the follow-­up phase of the Leuven cohort at age 20. Data were acquired on a 3.0  T MR system (Achieva, Philips, Best, the Netherlands) with an eight-channel phasedarray head coil. During fMRI scans, the bloodoxygen-level-dependent (BOLD) response is measured while performing (cognitive) tasks.

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Based on the ratio of deoxy- and oxygenated hemoglobin in the blood, the BOLD response is thought to be coupled with oxygen consumption in the context of neuronal processes. As such, fMRI is said to provide an indirect measure of neuronal activity (Menon 2012). By relating variations in the BOLD response over time to timing of events in an experimental paradigm, cognitive processes can be related to specific areas in the brain (Van den Bergh et  al. 2015, p.  324). We investigated the 20-year-olds with the gambling paradigm used before with ERP in the 17-year-olds (Mennes et al. 2009); however, two changes were made to optimize it for use in fMRI (Mennes et  al. 2018). Four decision trial conditions could be dissociated in this paradigm for analysis purposes. While the whole paradigm requires endogenous cognitive control, we dissociated two trial types that were more exogenous in nature and two that were more endogenous. As the prefrontal cortex and its connected circuitry is regarded the control center for such complex executive behavior, we expect different prefrontal areas to be modulated by this task (Mennes et al. 2018). For the study in the 20-year-olds, 18 20-year-­ old male participants were selected based on the anxiety grouping at age 17. At that age, the participants were divided into a low-average anxiety group and a high anxiety group based on whether the anxiety scores of their mothers during weeks 12–22 of their pregnancy were lower than 43 (< Pc 75) or at least 43 (>  =  Pc 75) (see Mennes et al. 2006). Ten of these participants were part of the high anxiety group, and except for one participant who could not be contacted and one participant who wore braces (i.e., was not MRI compatible), all were included in the high anxiety group of the current study (n = 8). The data of the participants in the high anxiety group were compared to those of ten participants of the low-­ average anxiety group. The participants of the low-average anxiety group were selected to match the cognitive abilities of those in the high anxiety group. Mean Performance IQ (WAIS-III) in the low-average group was 99.67 (SD = 9.95), compared to 98.25 (SD  =  8.65) for the participants in the high anxiety group. This difference

B. R. H. Van den Bergh

was not significant, proving that both groups were appropriately matched. Results showed that participants in the high anxiety group performed significantly worse on the gambling task compared to the low-average anxiety group; they exhibited altered, endogenously controlled decision-making (p   0.05). All results are consistent with those seen in the 17-year-olds, involving EEG measures. We therefore conclude that both a deficit in endogenous cognitive control and the associated functional brain alterations are to be seen as markers of exposure to maternal anxiety during pregnancy which are persistent until at least the age of 20 years. The results of study 3 can be integrated in our DOBHaD model (Fig. 1); prenatal exposure to maternal anxiety (early life events) in interaction with supposed (epi)genetic factors leads to changes in the prefrontal cortex which are associated with altered endogenous cognitive control, a programmed phenotype that may lead to mental health problems. To the best of our knowledge, the Leuven project cohort is the only cohort in the DO(B) HaD field that includes offspring cognitive and multimodal brain imaging measures across adolescence and adulthood. However, due to the small sample size, our results are to be considered as preliminary. The internal validity of our results is sound considering valid data gathering and data analyzing techniques; however, external validity will only be guaranteed after the results would have been confirmed in a larger sample. The current results also suggest that the matura-

Prenatal Developmental Origins of Early Brain and Behavior Development, of Self-Regulation…

tion of prefrontal cortex and functional brain networks should receive special interest in future DO(B)HaD research. Further research into the mechanisms underlying this relationship is needed. Results of these studies may then lead to a better understanding of offspring enhanced susceptibility to disorders (Mennes et al. 2018).

 tudy 4: Maternal Anxiety During S Pregnancy Is Associated with Increased Dyspnea Perception in the Adult Offspring The autonomic nervous system (ANS) controls and regulates the internal physiology of the body. It consists of two branches (sympathetic and parasympathetic), both of which exert antagonistic effects on most bodily functions and also contribute to homeostasis in the body. Moreover, the autonomic nervous system is responsible for maintaining involuntary vital parameters, including blood pressure, heart rate, respiration, gastrointestinal secretions, and temperature control (Andreassi 2017). Physiological measures of ANS function (such as breathing, heart rate variability, and galvanic skin response) are important markers of health and of disease prognosis (Mohammed et  al. 2015, 2018). The effects of adverse experiences in early, prenatal life on ANS dysfunction remain widely unknown (for reviews, see Young 2002; Van den Bergh et  al. 2017). In this study, we examine the association between maternal anxiety during pregnancy and “dyspnea” (or “breathlessness,” “shortness of breath”) in the 28-year-old offspring. Dyspnea can be defined as “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity” (Laviolette and Laveneziana 2014). It is the aversive cardinal symptom in various prevalent conditions such as respiratory, cardiovascular, and neuromuscular diseases and is associated with great individual and socioeconomic burden. From the original Leuven project cohort, 40 healthy adults could be included. Spirometric lung function was measured, and additionally, levels of state and trait anxiety, dyspnea-specific

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anxiety, and somatic symptom burden were assessed with validated questionnaires. Subsequently, the perception of dyspnea was examined in two magnitude estimation tasks (MET), during which four inspiratory threshold loads (Respironics, Parsippany, NJ, USA) with different resistances (0, 5, 20, and 40 cmH2O/L/ Sec) were repeatedly being presented. Subjects wore a nose clip and breathed through an antibacterial filter being connected to a two-way, nonrebreathing valve (Hans Rudolph Inc., Shawnee, KS, USA). The inspiratory port was connected to a tube (diameter, 2  cm; length, 150  cm) where threshold loads were introduced. In the first MET, subjects breathed through the loads for one inspiration and rated the intensity of dyspnea on a Borg scale (Borg 1982). Each load was presented four times in random order. In the second MET, subjects breathed for five subsequent inspirations through the loads and rated both the intensity and unpleasantness of dyspnea on a Borg scale (Borg 1982). Each load was presented twice in random order. For the analyses, subjects were grouped into a low prenatal anxiety (LA) and a high prenatal anxiety group (HA); grouping was based on trait anxiety ratings of their mothers during the 12th to 22nd week of pregnancy (low  0.05). However, the HA group demonstrated significantly higher slopes for dyspnea unpleasantness than the LA group (p  cortex) and top-down (cortex > limbic system > brainstem) information processes strive for a cooperative working together. Dysfunction

Prenatal Roots of Attachment

on one level of the triune system may cause significant functional changes on other levels and in the system as a whole. Melzack and Wall (in Janov 2000) proposed a gate-control theory for emotional pain. If there is an emotional pain, and this pain gets to intense, then the gates between different brain regions get closed. If the pain is caused by a threatening trauma the gates between limbic system and prefrontal cortex get closed, leaving the individual in a state of unmanageable emotional arousal; if the pain is so intense that it becomes life-threatening or shocking then the gates between brainstem and limbic system get closed, leaving the individual in a pure physiological modus of survival. Stress and trauma can disorganize the synchronicity in functioning of the whole brain. Stress (or pain) is the extreme end of affect regulation. Stress is a high state of arousal that is proving difficult to manage, either because there is no respite or because the process of recovery is not working. Survival depends on the scanning of the environment for cues (Is the environment safe, threatening, or life-threatening?) and alarming the system when threatening cues are detected, energizing the system so that adaptive behavior can be performed. These are all functions of the limbic system, in cooperation with the brainstem and polyvagal system. The limbic system and the brainstem are the heart of the affect system. Two major systems regulate detected threat or stress: the hypothalamus-­ pituitary gland-adrenal gland axis (HPA-axis) system and the autonomic nervous system. The HPA-axis also has a connection to brainstem nuclei, and by this pathway to the polyvagal system, regulating body functions at stressful situations so that mobilizing or immobilizing reactions are made possible. The hormonal stress regulating system (HPA-axis) is almost fully programmed by 5  months of gestational age. When this system is activated by threat, a cascade of chemical reactions is trigged by the hypothalamus. The autonomic nervous system starts functioning at about the same age, according to Porges (2010). On theoretical and clinical grounds, I assume that the oldest branch of the polyvagal system, regulating immobilization,

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starts being programmed earlier (before the HPA-­ axis), together with the prenatal heart (Verdult 2012). The phylogenetic younger branch, the sympathetic nervous system, is programmed somewhat later, making fight or flight reactions possible. In the prenatal child, persisting stress, high levels of cortisol remaining in the body over a longer period of time, can have damaging effects on the body and the brain. Adverse experiences can program the brainstem and limbic system in a suboptimal direction. Stress levels are prenatally set. For example, prenatal maternal stress can program the fetal HPAaxis and make this system hyperactive and overreacting in stressful situations (Robles de Medina 2004). For the prenatal child the womb, placenta, and umbilical cord are his/her environment, and through these organs he/she is connected to the body and psyche of his/her mother, and through her with the broader world. His/her mother is his/ her exclusive caregiver, ideally providing him/ her with nutrition and energy, and also with love and security. The fetus eats what she eats and feels what she feels. In optimal or “good-enough” circumstances the womb is a protecting environment, facilitating a secure attachment for the fetus, so that he/she can develop into a physically and mentally healthy baby. The prenatal child can only survive in interaction with his/her mother. That is why his/her biological mother can be called the attachment figure for the prenatal child and their relationship can be called a prenatal attachment relation.

The Primal Stage of Life As stated before, a developmental theory should describe critical stages and explain developmental processes. In this paragraph I would like to propose a stage theory for prenatal attachment development; in the next paragraph I describe three processes that program the prenatal attachment development. The prenatal child goes through a number of normative developmental steps. Each biological development step has its psychological counter-

R. Verdult

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part. In our development from zygote to baby, we go through these stages and each stage has its own developmental crisis. The influential developmental psychologist Erik Erikson (1902– 1994) has researched an epigenetic model of the postnatal psychosocial development (Erikson 1963, 1997). He used the concept of epigenetics differently from modern genetics. For Erikson, epigenetic meant that every developmental stage has an influence on the outcome of the next stage and has a permanent influence for the rest of life. He described psychosocial development in eight stages. In each development stage, the individual goes through a crisis, which can be described in a continuum between positive and negative poles. The child goes through these stages in relation to his/her environment. For example, the developmental crisis for the baby is: trust versus mistrust. In relationship to its attachment figures, the baby experiences security and develops a basic sense of trust. If the attachment figures are disorganized, then the baby will build a basic sense of mistrust. In the following description of the primal stage of life (from conception to the psychological birth at 6–8  months), I would like to expand Erikson’s model to the prenatal period, using Emerson’s model of prenatal development (Emerson 1998a). In the primal stage, I would Table 1  The developmental crises of the primal stage of life Developmental stage Preconception

Attachment theme Journey

Conception

Fusion

Implantation

Connection

Umbilical affect

Exchange

Discovery

Recognition

Birth

Transition

Imprinting moment Psychological birth

Contact Separation

Developmental crisis Embodiment versus Splitting Trust in life versus Obstruction to life Survival versus Near-death Facilitation versus Deprivation or Poisoning Being desired versus Rejection Moving forward versus Being stuck Affiliation versus Isolation Individuality versus Stagnation

like to describe eight sensitive developmental periods: preconception, conception, implantation, the discovery stage, the stage of umbilical affect, birth, the imprinting moment, and the psychological birth (Verdult and Stroecken 2010; Verdult 2014a, b). Each stage has its influence on the next step in attachment development and has a lasting outcome on adult attachment patterns (see Table 1 The developmental crises of the primal stage of life).

Preconception Life begins with conception, or, even better, before conception in the wish of parents for a child and in the history of the sperm and egg. For biologists the reproductive drive is given by nature. For psychologists, unconscious motives play an important role in the wish for children. Unconscious motives can be symbiotic (“in a pregnancy I can feel one with my child, how I never felt before”) or narcissistic (“my child can give me everything, what I missed”). These motives can be covered up in conscious aspects of the desire to have children. The degree to which the pregnancy is wanted has critical implications for general appraisal of the pregnancy itself and related moods. Unwanted pregnancies can be linked to maladaptive maternal behaviors and increased stress and anxiety (Tremblay and Soliday 2012). Unwanted children show long-­ term detrimental effects on mental health (Häsing and Janus 1994). Sperm cells and the egg cell also have their history of the development before they meet in conception. The therapist Karlton Terry (Terry 2005a, b) has described the respective journey of sperm and of the egg cell. Sperm cells grow in the testis of the man in 3 months. Then the small sperm cells make a journey that starts with ejaculation. They must overcome many hostile thresholds, adapting to a sour environment. Many die and only one achieves the goal. Paternal and maternal emotions are connected with this journey and are imprinted in the sperm and egg cells, especially in the mitochondria. The egg journey can be regarded as the opposite of the

Prenatal Roots of Attachment

sperm journey. Sperm is all about moving forward, egg is about being moved; sperm has a short history, eggs have a prenatal history. Leaving the ovary is saying goodbye to the sister eggs with whom the egg has lived for so many years. Ovulation results in a drift, a transition from the ovary to the fallopian tube, where the odyssey to the place of conception can take place. The sperm journey can be associated with stillness and waiting, sudden changes, death and mourning, near-death, being fueled by energy or losing energy, death versus immortality. The egg journey can be associated with themes like competition, leaving home and homesickness, being alone, life and death, connecting, being welcomed or not. If the egg and/or the sperm experience trauma or shock during their journeys, then these experiences are brought with them into the preconceptional field of attraction. The whole conceiving field can get contracted.

Conception At conception the egg chooses a sperm. The dance can begin. After the embryologist Jaap van der Wal (2007, 2013), conception is not a penetration of the sperm cell into the egg, but it is more like a dance of egg cell and sperm cell. A preconceptional field of attraction is formed and the two parties take their time to fuse. The biological transformation procedures begin, as soon as the head of the sperm cell is attached to the egg by biochemical connections. Conception is however not just a biological process of the fusion of sperm and egg cell. The conception is the first existential meeting, creating new life and embodying consciousness. The Australian psychiatrist Graham Farrant stated: “The conception is not duality, but a trilogy: the sperm cell, the egg cell and the soul meet (Farant 1988).” In the conception, the soul embodies itself. The preconceptional field of attraction should be charged in such a way that embodiment is made possible. The emotional conditions at conception are thereby of great importance. It is clear that an affectionate conception offers very different emotional conditions than rape. In all substages of the conception, trauma and shock are possible. If during concep-

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tion trauma or shock occurs, first splitting in consciousness arises. Cells, also sperm, egg cell, and zygote, react very sensitively to their environment and they can store these experiences in their cellular memory. Emotional messages are translated into biochemical information. These biochemical reactions of the cell membrane to signals from the environment are stored in the cell and become the forerunner of the later physical sensations, emotions, feelings, and attachment patterns. In an affectionate conception, the cells will reach out for each other, will open, and are longing to connect. A basis for trust in life and living is formed. The foundation is laid for secure attachment. In a traumatic conception, the sperm and egg become defensive, can withdraw themselves, can turn away, or can become closed or impermeable. Life is obstructed. Avoidant attachment, to me attachment patterns based on most “primitive” physiological mechanisms (Verdult 2012), can be formed.

Implantation The stage of implantation begins with the fallopian tube journey, the fall into the uterus, the process of hatching, and then finding a place to attach to the uterus (Terry 2013). During the fallopian tube journey, the zygote still remains in the zona pellucida. The cell divisions continue, without new energy coming into the dividing organism. As time pushes, new energy is necessary. The fertilized egg needs a fertile place, where it finds new energy to grow. An intense and active dialogue between blastocyst and uterus wall takes place on a biochemical level (Brosens et al. 2014). if the blastocyst finds a fertile spot on the endometrial epithelium, then a basic sense of connectedness starts to develop and lays the foundation for secure attachment. His survival is guaranteed. The negative pole of this development crisis is a life-threatening and frightening experience, because the blastocyst gets too little nutrition and energy. If the uterus is not providing enough essential nutrients, then life is at risk. Implantation can be a near-death experience that can be stored in consciousness. The stored message can be: “I have to be on alert, whenever

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I connect to somebody, because I cannot be sure that my basic needs are fulfilled.” An ambivalent attachment pattern can develop out of this biochemical message. At implantation a lot of twin loss appears. There are more babies conceived than there are implanted. The so-called “vanishing twin” syndrome is an inner experience of a lost twin that can be stored in the body. It is important to realize that the surviving twin has lived in about the same environment as the lost twin, indicating that the surviving twin might have gone through a near-death experience (Verdult 2014b). Surviving twins can feel lonely and guilty, can have difficulties with intimate relationships, and can long for a closeness they never find (Hayton 2007). Implantation can be associated with a threatening and painful loss experience. If implantation has taken place, the rapid development of the embryo can begin. In 2 months, a complete person grows out of the fertilized egg. All organs develop, the skeleton becomes visible, and the senses start to function. The embryo gets its human characteristics.

Umbilical Affect The fourth sensitive stage of prenatal development is called “umbilical affect.” When the embryo is attached to the uterus wall, the exchange between the embryo and the uterus wall begins to intensify. This is the beginning of a process, which is important during the entire 9 months of pregnancy: the permanent exchange of physical and emotional information between mother and child. This exchange takes place over the umbilical cord. Emotional messages are translated into biochemical messages and received and understood by the fetus. Francis Mott called this exchange “umbilical affect.” Frank Lake described it as: “The strong, impressing experiences of the others and their internal and outside world reach the fetus and define the relationship with intra-uterine reality in a way, which remains in the adult age” (Maret 1997, p 5). He called this exchange “affect flow.” On one hand it can be a facilitating exchange, which feels for the fetus as a confirmation, acknowl-

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edgment, acceptance, and joy, contributing to a secure attachment development. On the other hand it can be a deprived exchange, which feels for the fetus like a physiological and/or emotional deficit. The fetus can be deprived from basic needs. If this is a severe and lasting condition, and the fetus has to slow down his/her development, then the fetus can go into a parasympathetic shock and become paralyzed. The fetus can become suicidal and desire its own death. It can lead to a avoidant attachment pattern. A toxic umbilical affect is characterized by poisonous messages that the fetus receives, like a rejection, emotional confusion on part of his/ her mother, or narcissistic occupation. This can result in ambivalent attachment patterns. Important to remember is that the fetus only has very limited coping possibilities to handle a negative affect flow. Although Lake’s model was based solely on clinical research, it is mostly confirmed by the empirical, prenatal stress research. Umbilical affect is a more psychotherapeutic concept, as the empirical counterpart is called prenatal maternal anxiety, depression, or stress. I would like to differentiate between “early” and “late” umbilical affect. Early “umbilical affect” starts with the first heartbeat, when the embryo starts to build its own cardiovascular system. The embryo needs a mechanism to transport energy and nutrients across the fast- growing body. The bloodstream and heart provide a transport mechanism. Starting from conception, the first heart cells begin to knock 21–22 days after that. With three to four weeks, the heart with its four ventricles is completely developed. A biological law states: during rapid development an organ or organism is most vulnerable. If, during the stage of embryonic heart development, the “umbilical affect flow” is toxic, the cells can go into contraction. If this makes an opposition reaction necessary in order to secure surviving, then the heart can go into contraction and in the later life increase in cardiac infarct risk can occur. “Late” umbilical affect refers to the stage in the embryonic development wherein the placenta and umbilical cord have fully developed. The areas around the navel can be affected by toxic or stressful messages that come across the umbilical

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cord. The navel itself, the psoas muscles, and the diaphragm can be infected by these messages (Verdult 2014b).

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a sensitive, active, communicative, and social human being. This is reflected in the increasing activity of the brain. The fetus is preparing for life outside the womb. He/she is exercising body movements, learning how to breath, or learning Discovery to adapt to his/her mother’s emotional state. Birth is coming. Birth is a tremendous transition. As When the mother starts noticing physical changes Verny (2002) stated: “How we enter this world and is assuming that she can be pregnant, mostly plays a crucial role in how we live in it (p 70).” when the menstruation stays away, the stage of For the baby, birth can be stressful or even traudiscovery begins. In prenatal attachment devel- matic. The outcomes of previous developmental opment, this stage is not about how the mother stages influence the birth process. In our baby feels with her pregnancy, but how her feelings psychotherapeutic practice, we often see that work out on the prenatal child. This stage is about babies traumatized at birth also have had prenatal her recognition (or not) of the child’s coming into detrimental experiences, like toxic umbilical her internal world. Her first and spontaneous affect (Verdult and Stroecken 2010). Artificially reaction to her possible pregnancy creates an reproduced babies (IVF/ICSI) mostly have a emotional climate, which is converted into a traumatic birth, being born too early, or a birth complex mixture of biochemical messages to the with many medical interventions. baby. This emotional attitude of his/her mother, A birth process can run smoothly if mother both consciously and unconsciously, can give dif- and child can cooperate well and are in charge ferent messages to the fetus. The positive pole of of the process, so that the overwhelming change this development crisis is the affirmation of its is made possible. Then the birth is a stabilizaexistence. If the baby is consciously wanted by tion of the relationship between mother and his parents and if his/her mother’s body is child. But complications during the passage of responding with acceptance and joy to his/her the birth channel or medical interventions can presence, then the fetus can feel desired. “I am disturb the physical and emotional interactions. the one for my mother.” If its mother is deeply According to Emerson (Emerson 1998b), birth pleased about her pregnancy, then her baby gets a trauma is characterized by three aspects: a “hormonal” affirmation. He gets the right to live. chronic shock pattern can be formed, an invaIf its mother or her body rejects or denies the sion-control complex can develop from birth pregnancy, because this is deeply unwanted for experiences because the baby feels invaded in her, then the fetus can feel intensely rejected. this process and loses control, and attachment Biochemical messages will restrain his/her self-­ problems can be strengthened. Traumatic birth confidence and his/her self-actualization. disturbs the attachment relation. It is important Depression, self-destructive behavior, or aggres- to realize that for the baby what happens during sion can be clinically linked to prenatal rejection birth is caused by his/her mother or at least her (Emerson 1998b). As research showed the conse- body, implying that his/her mother can be held quences of being unwanted can become manifest responsible for his/her pain. Ambivalent or many years later, especially in adolescence avoidant attachment patterns may result out of (Häsing and Janus 1994). threatening or life-threatening birth experiences. For example, caesarean birth can be life saving for the baby, but at the same time can be Birth sudden, unexpected, rough, and frightening, leaving the baby in despair and chaos. Tactile In the fetal phase, the fetus is preparing for life defensiveness is one of the most prominent feaafter birth. It not only grows, but also its psycho- tures of a caesarean-section baby, making it for logical functions differentiate more and more. As the mother more difficult to bond (Verdult David Chamberlain (1998) described, the fetus is 2009a, b).

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Imprinting Moment Immediately after birth, when the baby is laid on the belly of the mother a magic moment can occur, the so-called imprinting moment. Research by Klaus, Kenell, and Klaus et al. (1995) was a pioneering work, changing the birth practice. The baby needs to restore contact with his/her mother’s body immediately after birth, without delay. This could be done by leaving the infant on his/ her mother’s belly for 20  min, waiting till the umbilical cord stops pulsing, so that the baby can come to rest by restoring his/her physiological equilibrium and make eye contact with his/her mother. The positive pole of this developmental crisis is: restoring contact. When the baby has found the breast of his mother and can look her in the eyes, then he/she can find reassurance and affiliation. The negative pole of the continuum is finding absence or rejection in her eyes, leading to painful loneliness and isolation.

Psychological Birth The primal stage of life ends with the psychological birth. In the months directly after birth, the baby is strongly attached to his/her mother, her body, and soul. With the growing motor, sensory, and cognitive abilities, the baby starts to enlarge his/her environment. He/she begins to explore the world around him/herself. When he/she is half a year old, the psychological birth starts (Mahler et al. 1975). This process of separation from the mother and progressively individualizing will last till about 12–14 months. More and more the baby develops his/her own autonomy and identity. The infant starts to experience that it can also function without its mother. The baby needs confidence, security, and pacing to develop in this autonomous direction. In the psychological birth, the outcome of the previous stages can be seen clearly. A baby with more positive attachment experiences will enjoy exploring his/her world, learn new things, and grow up. It will discover his/her possibilities and boundaries. An insecure ambivalent infant will be more anxious, keeping his/her world small, and sticking closely to his/her

mother. He/she is sometimes literally clinging to his/her mother. He/she can be frustrated and activated quickly. He/she is afraid of new things and strangers. His/her development stagnates. The avoidant infant is often called an “easy and quiet” baby. No fussing and clinging, more withdrawn, little or no exploration. In insecure infants, the psychological birth begins later and takes more time. After describing the primal stage of life and its eight stages, the question remains which processes drive this development. Or to say it in other words: how is attachment being programmed prenatally?

Prenatal Programming of Attachment Allan Shore‘s research found out that attachment behavior is organized and adjusted by a control system in the brain. This control system is located in the orbitofrontal cortex of the right hemisphere (Schore 2001). This region is the circuit between the “low” emotional area and the “higher” mental brain regions. This region integrates and coordinates cognitive and emotional processes, and helps us in regulating emotions and controlling our impulses. Just as importantly is however the function of the orbitofrontal cortex for attachment. The orbitofrontal cortex plays an important role in the development of the internal working model of attachment. It plays a role in: reading (from birth on) facial expressions, recognizing emotional signals, connecting emotional expressions and contextual references, and communicating through eye contact. These are basic abilities for attachment. Emotional neglect leaves children with a reduced synapse formation of the orbitofrontal cortex and leads to a decrease of emotional learning opportunities and experiences. The orbitofrontal cortex is the highest level of behavior control, in particular for emotional behavior. It is a controlling general manager of the entire right hemisphere. It controls the limbic excitation. The right hemisphere, dominantly during unconscious processes, possesses a nonverbal affect lexicon; it dominates physical

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and emotional self-experiences; it is actively involved in survival mechanisms and stress management. The right hemisphere contributes to development of the mutual interactions in the regularization system of mother and child and obtains the ability to synchronize, a regularization mechanism of attachment. Researchers like Allan Schore (2001) and Daniel Siegel (1999) have made clear that attachment and affect regulation belong together. Schore describes how the orbitofrontal cortex is functioning and what its role is in attachment and affect regulation. According to his research the orbitofrontal cortex has an explosion of synaptic connections in the last quarter of the first year, linking this to the development of attachment according to the traditional attachment theory. In my opinion, Schore does not describe how the orbitofrontal cortex is being programmed. What he describes is the functioning of this control system at the end stage of the process of programming. The functioning of brain regions, like the limbic system or the orbitofrontal cortex, is not an all or nothing process. Brain development is activity-dependent, which means that experiences contribute to the development of brain functions and that the more we learn the more the brain region and its function develops. The brain is being programmed by learning experiences. Programming attachment development, or, more specific, the programming of the internal working model of attachment, begins prenatally and three substantial processes can be described explaining the drive beyond the stages of prenatal development. The first process is embryonic imprinting, the second process is the programming of the autonomic nervous system and the stress regulation system (HPA-axis), and the third process, postnatal early interaction with the attachment figures.

Embryonic Attachment As Bruce Lipton (2005) stated: “the cell’s operations are primarily molded by its interactions with the environment, not by its genetic code (p 49).” Cell survival, the first and utmost task

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of any living organism, depends on the ability to dynamically adjust to the ever-changing environment. The “magical membrane” (better: the membrane’s receptors and effector proteins) with its gates and channels is the central processing unit of the cell, converting environmental information into behavioral language of the cell. For example, eukaryotic single-celled organisms, like the slipper animalcules, can communicate with their environment and can learn from their experiences. If they become aware of a positive environmental signal, they can turn toward that signal, look for proximity and contact, open their membrane, turn on their energy motors, take in whatever the signal is offering, and expand their body. If the signal is negative for the single-celled organisms, then they can turn away in defense, avoiding proximity and contact, close their membrane, set boundaries, turn off their energy motors if necessary, and keep still; their body can go in contraction or they can even pretend to be dead. These are fundamental biological mechanisms of a cell. They can cope with environmental signals, learn to adapt to their environment, or, if necessary, they can defense against signals. The functions required for a single cell to stay alive are the same as required by a community of cells to stay alive. That is to say, all human cells (brain and body cells) possess these abilities. Verny agrees with Lipton that the cell membrane represents the brain of the cell. It functions as an organic computer chip and memory is stored in the cell membrane through changes in the structure of their proteins. Their “central processing unit” is programmable (through experience) and it forms the basis of the cellular memory (Verny 2014). Nobel prize winner Konrad Lorenz demonstrated how incubator-hatched geese would imprint on the first suitable moving stimulus they saw within what he called a critical period between 13 and 16  h shortly after hatching. Imprinting is a fast kind of learning, used very early in life. Imprinting means to impress a memory to every aspect of our being: in the blood vessels, in organs, muscles, nerve cells, or hormones (Janov 2000). Each subsystem engraves the

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memory in its own way. Engraving means that the memory endures and has lasting effects on our neurobiology, and can alter the structure of that neurobiology and our later behavior. According to Janov (2000), there are three critical factors in creating an imprint: the quantity of the input, response to the input, and the timing of it. All three factors converge to produce a lasting memory that alters our being. Too many intense signals, limited coping possibilities, and very early stage of life can make a traumatic imprint. As embryonic imprinting takes place during preconception, conception, implantation, early “umbilical affect,” and discovery, the embryo is still very vulnerable. It can be overwhelmed by information from the environment (the mother’s body and psyche) and has only limited defense possibilities (primitive fight, flight, freeze mechanisms). An imprint can come out of a facilitating, traumatic, or shocking experience. In this continuum of experiences, the level of stress is raising higher and higher and at the end becoming transmarginal. If the experiences at the preconception stage facilitate the meeting of the sperm and egg, for example, because the sperm and egg cells do not carry trauma in themselves and the sexual partners love each other, then the preconceptional field of attraction feels safe. The conceiving sperm and egg can have a loving contact, and can take their time exploring each other in an unforced way. The basic matrix of secure attachment is formed. If conception is traumatic, for example, because the mother’s body and psyche are burdened by childhood trauma, then the zygote finds it difficult, but not impossible, to stay in contact with itself, and a certain splitting of the consciousness is necessary; the zygote finds it difficult to stay in close contact to its environment, but eventually does make the contact. The zygote can go into a sympathetic activation. This is a basic matrix of ambivalent insecure attachment. If implantation is shocking, for example, when the blastocyst cannot find a fertile place to implant and nearly dies, then the blastocyst cannot cope with this life-threatening experience. It can go into parasympathetic shock, turning the embryo into a freeze or collapse modus. The

embryo can become paralyzed, surviving at a minimum of energy. This is the basic matrix for an insecure avoidant attachment pattern. According to Erikson’s epigenetic principle, embryonic imprints from the five earliest stage of primal life have a lasting influence during the rest of the life span and have an influence on the outcome of the next developmental process. Embryonic imprints lay the foundation of body responses to safe, dangerous, or life-threatening experiences. They form psychobiological patterns that are the rudimentary forerunners of stress responses and attachment patterns; both are linked together. They form the bodily self and the psychobiological basis of the internal working models.

Fetal Attachment The embryonic stage is more about building the body, the organs, and the placenta, while the fetal stage is more about differentiating functions. Survival remains the main task. Regulation of body functions is important and that is why the brainstem and the autonomic nervous system start functioning early in prenatal life. Interacting with the environment and learning to interpret the signals is a second task. Is the environment facilitating, dangerous, or life-threatening? Does it generate security or stress, trauma or shock? In order to be able to deal with a dangerous or life-­ threatening environment, the fetus has to develop an alarm system (the amygdala) and a stress regulating mechanism (the polyvagal system and the HPA-axis). The both start gradually functioning in the fetal period. The embryonic imprints determine the direction and range of the next developmental stage. Because neurodevelopment is important for surviving, the embryonic imprints influence the structure and functioning of important brain regions in brainstem and limbic system. Due to these embryonic imprinting, neural circuits, arranged by synaptic connections, are formed that promote attachment or defense against trauma or shock. If an embryo’s existence is in danger or even in great threat, then the fetus will develop

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defense systems that are activated. The fetus will be in a defense mode and will develop psychoneurological systems that will be in defense modus too. The autonomous nervous system and the brainstem will be in defense modus, as well as the amygdala and HPA-axis. The programming of these systems will be guided by stress or transmarginal stress. The amygdala is our alarm system and is active starting from the fifth pregnancy month. The amygdala can activate our autonomous nervous system over the vagus nerve and initiate autonomous reaction of the body to danger. Over its connection with the hypothalamus, the amygdala can activate the stress system of the hypothalamus-pituitary gland-adrenal gland axis (HPA-axis). Stress and fear are processed over the vagus nerve (autonomous) and the HPA-axis (endocrinal). Insecure-­ambivalent attachment is associated with sympathetic activation of autonomous nervous system and with strongly reactive HPA-axis and leads to “fight or flight” reactions. Insecure-­avoidant attachment is associated with parasympathetic reaction patterns and leads to “freeze or collapse” reactions (Cozolino 2002). Research has confirmed that securely attached babies function within an open window of tolerance, while insecurely attached babies function either sympathetically (in case of ambivalent) or parasympathetically (in case of avoidant attachment). If the stage of late “umbilical affect” is very toxic, for example, because the mother is depressive or is smoking, then the fetus will go in overdrive to deal with these dangerous messages. His/her heart rate, blood pressure, and temperature will rise. He/she will show more motoric unrest. If the umbilical affect shows deprivation, for example, because of placenta insufficiency, then the fetus can become hypoactive, slowing down its functioning, withdrawing from the environment. He/she can keep still in order to survive. If the fetus experiences trauma at birth, for example, by medical intervention at birth, or after birth during the imprinting moment, for example, by being separated from the mother, then the developed neurophysiological patterns will be reinforced. The fetal programming of the autonomic nervous system and of the stress regulation sys-

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tem leads to psychoneurological patterns that lay the foundations for postnatal attachment patterns. Affect regulation finds its origin in these patterns. The internal working model is now grounded in affect regulation.

Postnatal Attachment The third step in the development of the internal working model of attachment is the postnatal interactions between mother and baby, starting at birth. In the traditional attachment theory, the quality of attachment between mother and infant is essential. Mothers tend to repeat their own attachment pattern to their mothers in relationship with their baby. Secure attached mothers have secure attached babies with high probability. Insecure attached or traumatized mothers are frequently less-sensitive mothers. Mary Ainsworth defined maternal sensitivity toward the feeling and messages of the infant by four characteristics (Cassidy and Shaver 1999). A mother should be sensitive to the expressions of the baby, should be responsive to his needs, should give an immediate reaction, and a reaction that is appropriate to the expressed need. The sensitivity of the mother is a crucial factor in the attachment behavior of the infant. As we have seen that attachment behavior has its history in the embryonic and fetal programming of respectively psychobiological and psychoneurological pattern, the baby comes into the world with a temperament. Temperament can be defined as relatively stable individual characteristics in emotional behavior patterns, which are strongly linked to physiological patterns and not caused by pathologies (Zentner 2004). It can be difficult for the mother to respond to her infant’s temperament. A stressed fetus can become a hyperactive baby, showing unrest, sleep disturbances, or eating problems (Verdult 2014a, b). The demands of a hyperactive baby can put many strains on the mother and father and can be such a burden that the relationship is disturbed. The mother can find her baby too demanding and withdraw one min and bond another minute. The ambivalent attachment pattern is reinforced.

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The hyporeactive or paralyzed fetus can become a very quiet baby, difficult to bond to, resisting physical contact. He/she can be withdrawn. This can make it difficult for the mother, because she can feel rejected by her baby who is not responding to her tender, loving care. The avoidant attachment can be reinforced. Birth can be traumatic or shocking for the newborn baby, in which case prenatally programmed patterns can get activated. If birth is traumatic or even shocking, then the imprinting moment is so too. For example, the baby born by forceps will be taken away from its mother for medical examination. What is seen as attachment behavior in the last quarter of the first year has a long history and can be seen in the light of the psychological birth. Separation from the mother is more difficult for insecure babies. In other words, hyperactive or hyporeactive babies find it more difficult to individualize. They are restricted by psychoneurological functioning that limits their explorative behavior.

Attachment-Oriented Prenatal Psychotherapy A basic assumption in all forms of psychotherapy is that individuals can change. Psychotherapy tries to bring change from a condition of being trapped in old patterns to more openness to experiences, making selfactualization possible; a change from vulnerability and helplessness to inner strength and self-reliance; a change from an internal regularization constantly guided by past experiences to affect regulation that is more appropriate to the actual situation; or a change from energy trapped in the body to free-floating energy that can be used effectively. The brain has the plasticity to change, but the older parts of the brain, like the brainstem, possess less plasticity. This is in accordance to the findings in psychotherapy that early prenatal developmental traumas, stored in the brainstem, are more difficult to treat than later traumas.

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Through the plasticity of the brain, psychotherapeutic treatments can change the brain in such a way that healing, reorganization, and recovery are made possible into a healthy function mode. The degree of the brain plasticity varies among clients and depends on two substantial factors: the region and/or the system of the brain and the phase of the development of this brain structure or brain system (Perry 2005). I would like to add a third factor: (prenatal) traumatization during critical stages in brain development. Based on the above described psychobiological and psychoneurological programming of the early attachment, a new paradigm for therapeutic interventions can be developed for infants, children, and adults. If we understand the contextual and attachment characteristics of building neural circuits that either facilitate behavior or that stick to defensive behavior strategies, then it is possible to develop new psychotherapeutic strategies for healing clients. Traditional attachment-oriented psychotherapy sees the psychotherapeutic relationship as an attachment relation. Helpful treatment involves a client’s capacity to make use of the therapy and the therapist as a secure attachment figure. The psychotherapy should provide the clients a means to contemplate and reexperience their life story, including their relationships to essential attachment figures, and in doing so giving new meaning to themselves and to their relations (Slade 1999). For me, working with attachment problems is just the top layer in psychotherapy. The more in-depth forerunners of the attachment patterns, namely the stress-regulation patterns and the psychobiological imprints, should be dealt with as well. As the founder of the gestalt psychotherapy, Fitz Pearls has stated: “psychotherapy is like pealing an onion. It is impossible to go directly to the heart of the client’s emotional problems. I go back in time step by step; from adulthood to childhood, from infancy to birth, from fetal life to embryonic life.” Bruce Perry (2005, 2007) suggested a neurosequential model of psychotherapy, indicating that

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interventions in psychotherapeutic treatments should refer to brain structures and brain functions, which are damaged by stress, trauma, or shock. Chaos, threat, maltreatment, traumatic stress, abuse, neglect, or early separation are experiences that change the developing brain in such a way that long- and short-term emotional, behavioral, cognitive, social, and physical problems can develop. The neurosequential model is based on six basic principles. First principle: the brain is hierarchically organized, meaning that all sensory information is first processed in low brain regions before higher more complex regions are switched on. Second principle: Neurons and neural circuits develop in an activity-dependent way. “Use it or lose it” seems to be a basic law of the brain development. Third principle: the brain develops in a sequential way, meaning that the lowest brain regions develop and function earlier than higher regions. Fourth principle: the brain develops fastest in the prenatal time and in the early childhood. Fifth principle: neural systems can change, and there are systems that are more or less changeable. In general, it is valid that low systems such as brainstem and diencephalon have less plasticity; the cortex has the greatest plasticity. Sixth and last principle: the human brain is made for another world. The greatest part of the evolution of brain has taken place in times where humans lived in small groups. The brain prefers affective relations and naturally enriched environments to the isolation, deprivation, or overstimulation of modern societies. Stress, trauma, and shock program brain structures most intensively at the moment of their occurrence. They program different neural systems in the brain. Embryonic imprints can exert a profound influence on programming of the biological functions of all cells, including the stem cells that will build the nervous system. Fetal experiences can have a profound influence on the brainstem (and through the polyvagal system on the body) and on the limbic system (HPA-axis), and childhood experiences program higher brain regions like the prefrontal cortex. In this neurosequential model (prenatal) survival strategies

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should be included in psychotherapy. These survival strategies were at time our friends, who helped us survive, but they become our enemies later in life, because they impair our functioning. Behind the attachment patterns, early survival strategies can be assumed: uncertain-­ambivalent is connected to sympathetic activation, with “fight/flight” reactions; uncertain-­ avoidant is connected to immobilization, with “freeze/collapse” reactions. In the psychotherapeutic process, the working is through “top-­down,” starting with the client’s attachment pattern (programmed in the orbitofrontal cortex), to stress reaction patterns (programmed in the limbic system), to autonomous reaction patterns (programmed in the brainstem), and to early, embryonic imprints (programmed in each cell of the whole body). The “bottom-up” programming of the emotional brain and the “top-down” regularization of the rational brain should be considered likewise, but psychotherapy needs to start with the programmed patterns in the client’s brain and body. Psychotherapy means to modulate emotional reactions that are processed on the deepest levels of the brain. Reexperiencing pre- and perinatal traumas can only take place through the body. Psychotherapy should be a process of both the “bottom-up” and the “top-down” reexperiencing, giving meaning to bodily felt pain. To speak with Janov (2000): “Words won’t do.” Telling a (fantasized) story about our prenatal history will not be effective. The emotional brain (brainstem and limbic system) should take part in the healing process. Emotions organize the brain and control the problems of the clients. Because emotions have a bodily felt meaning, emotional pain can only be uncovered by working with the body in order to let the brainstem and limbic system speak about what they have experienced. Experiences such as conception, implantation, umbilical affect, or birth are stored in the body, or better in the cells of the body. They can only be processed through the body. In my opinion, only experiential and body-oriented psychotherapies can promote the “fully functioning clients” (Rogers).

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Conclusions

References

Attachment, the bonding of the child to the mother, should be differentiated from bonding of the mother to her child. In the discovery stage, her attitude toward her baby will have an immense influence on the baby’s well-being. Bonding of the mother plays an important role, but should be distinguished from attachment in order to recognize the emotional development of the fetus. But the proposed developmental theory in this chapter focusses on prenatal attachment: the embryo’s and fetus’ relationship to his/her mother’s body and psyche. Eight critical stages in the primal life stage have been described and three fundamental processes that drive prenatal development of attachment. The traditional attachment theory does not take into account the prenatal programming of psychobiological and psychoneurological patterns that form the basic matrix for attachment patterns. The neurosequential model by Perry, expanded to prenatal life, can be a helpful tool to guide a prenatal psychotherapy. In the integral attachment theory that I propose here, prenatal attachment is the forerunner of postnatal attachment. Based on Erikson’s epigenetic principle, embryonic imprints direct the fetal programming of neurophysiological survival mechanisms and these in turn guide the postnatal interactions that lead to the attachment patterns that will guide our lives until death. An attachment-oriented psychotherapy should take prenatal developmental stages and processes into account. Threatening experiences in the embryonic stage will switch the embryo in a defense modus (sympathetic), while life-threatening experiences will lead to a keep still modus (parasympathetic). The autonomous nervous system (through the polyvagal system) and the limbic system (amygdala and HPA-axis) will be programmed in hyper-modus or a hypo-modus. These are the fundamental patterns that form later attachment patterns. It is important to see attachment in the light of its prenatal programming. Adults and babies in psychotherapy can only be healed from early prenatal trauma and shock by taking their prenatal experiences, in terms of stage and processes, seriously.

Ahnert, L. (2004). Frühe Bindungen (early attachments). München: Ernst Reinhardt Verlag. Belsky, J. (1999). Patterns of attachment in modern evolutionary perspective. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications. New York: The Guilford press. Bowlby, J. (1969/1982). Attachment and loss (volume one): Attachment. London: The Hogarth press. Brandon, A., Pitts, S., Denton, W., Stringer, A., & Evans, H. (2009). A history of the theory of prenatal attachment. J Prenat Perinat Psychol Health, 23(4), 201–222. Bretherton, I., & Munholland, K. (1999). Internal working models in attachment relationships: a construct revisited. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications. New York: The Guilford Press. Brosens, J., Salker, M., Teklenburg, G., et  al. (2014). Uterine selection of human embryos at implantation. Scientific Reports, 4, 2045–2322. Bureau, J-F, Martin, J., Lyons-Ruth, K. (2010). Attachment dysregulation as hidden trauma in infancy: Early stress, maternal buffering and psychiatric morbidity in young adulthood. In: Lanius, R., Vermetten, E. and Pain, C. The impact of early life trauma on health and disease. Cambridge: Cambridge university press. Carlis, T. (2015). The resulting effects of in utero attachment on the personality development of an adopted individual. J Prenat Perinat Psychol Health, 29(4), 245–263. Carter, S., Ahnert, L., Grossmann, K., Hrdy, S., Lamb, M., Porges, S., & Sachser, N. (2005). Attachment and bonding: A new synthesis. Cambridge, MA: The IT press. Cassidy, J., & Shaver, P. (1999). Handbook of attachment: Theory, research and clinical applications. New York: The Guilford Press. Chamberlain, D. (1998). The mind of your newborn baby. Berkeley: North Atlantic Books. Chamberlain, D. (2013). Windows on the womb: Revealing the conscious baby from conception to birth. Berkeley: North Atlantic Books. Cozolino, L. (2002). The neuroscience of psychotherapy. New York: W.W. Norton. DiPietro, J. (2010). Psychology and psychophysiological considerations regarding the maternal-fetal relationship. Infant and Child Development, 19, 27–38. Eichhorn, N. (2012). Maternal fetal attachment: Can acceptance of fetal sentience impact the maternal-­ fetal attachment relationship? Journal of Prenatal and Perinatal Psychology and Health, 27(1), 47–55. Emerson, W. R. (1998a). Birth trauma: The psychological effects of obstetrical interventions. Journal of Prenatal and Perinatal Psychology and Health, 13(1), 11–44. Emerson, W.  R. (1998b). The vulnerable prenate. International Journal of Prenatal Psychology Medicine, 10(1), 5–19.

Prenatal Roots of Attachment Erikson, E. (1963). Childhood and society. New  York: W.W. Norton. Erikson, E. (1997). The life cycle completed. New York: W.W. Norton. Farant G. (1988). Cellular consciousness and conception. In: Raymond, S. (Ed.), at interview with Dr. Graham Farrant. Pre & perinatal psychology news (2(2)) (buzzers) IPPE: https://www.ippe.com/. Francis, R. (2011). Epigenetics: How environment shapes our genes. New York: W.W. Norton. Grossmann, K., & Grossmann, K. E. (2004). Bindungen - das Gefüge psychischer sicherheit (Attachment, the feeling of security). Stuttgart: Klett-Gotta. Häsing, H., & Janus, L. (1994). Ungewollte Kinder (unwanted children). Wiesbaden: Rowolt. Hayton, A. (2007). Untwinned: Perspectives on the death of a twin before birth. St Albans: Wren. Hrubẏ, R., & Fedor-Freybergh, P. (2014). Prenatal and perinatal medicine and psychology towards integrated neurosciences: General remarks and future perspectives. Journal of Prenatal and Perinatal Psychology and Health, 28(2), 76–100. Janov, A. (2000). The biology of love. Amherst: Prometheus Books. Klaus, M., Kennell, J., & Klaus, P. (1995). Bonding: Building the foundations of secure attachment and independence. Reading: Addison-Wesley. Lamb, M., Thompson, R., Charnove, E., & Estes, D. (1985). Infant-mother attachment. Hillsdale: Erlbaum. Lipton, B. (2005). The biology of belief. Santa Rosa: Elite Books. MacLean, P. (1990). The triune brain in evolution: Role in paleocerebral functions. New York: Plenum Press. Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic Books. Maret, S. M. (1997). The prenatal person: Frank Lake’s maternal–fetal distress syndromes. New  York: University Press of America. Nathanielsz, P. (1999). Life in the womb: The origin of health and disease. Ithaca: Promethean Press. Narvaez, D., Panksepp, J., Schore, A., & Gleason, T. (2013). Evolution, Early experience and human development. New York: Oxford University Press. Oerter, R., & Montada, L. (2002). Entwicklungspsychology (developmental psychology). Berlin: Beltz Verlag. Perry, B. (2005). The neurosequential model of therapeutics. In N. Boyd Webb (Ed.), Working with traumatized children in child welfare. New York: Guilford press. Perry, B., & Szalavitz, M. (2007). The boy who was raised as a dog and other stories from a psychiatrist’s notebook. New York: Basic Books. Porges, S. (2005). Role of social engagement in attachment and bonding. In S. Carter, L. Ahnert, K. Grossmann, S.  Hrdy, M.  Lamb, S.  Porges, & N.  Sachser (Eds.), Attachment and bonding: A new synthesis. Cambridge: The MIT Press.

245 Porges, S. (2010). The Polyvagal theory: Neurophysiological foundations of emotions, attachment, communication and self-regulation. New York: W.W. Norton& company. Porges, S. W. (2011). The polyvagal theory; neurophysiological foundations of emotions, attachment, communication and self-regulation. New York: W.W. Norton & Company. Robles de Medina, P. (2004). Prenatal maternal stress and its effects on fetal development. Utrecht: University Press. Schore, A. (2001). The effects of a secure attachment relationship on right brain development, affect regulation and infant mental health. Infant Mental Health Journal, 22, 7–66. Schore, A. (2013). Bowlby’s “environment of evolutionary adaptedness”: Recent studies on the interpersonal neurobiology of attachment and emotional development. In D.  Narvaez, J.  Panksepp, A.  Schore, & T.  Gleason (Eds.), Evolution, early experience and human development. Oxford: Oxford university press. Siegel, D. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York: The Guilford Press. Slade, A. (1999). Attachment theory and research: implications for the theory and practice of individual psychotherapy with adults. In J.  Cassidy & P.  Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications. New York: The Guilford Press. Terry K. (2005a). The sperm journey: Five biological stages and some psychological correlates. IPPE; see www.ippe.info. Terry K. (2005b). The egg journey: Biological stages and some psychological consequences. IPPE; see www. ippe.info. Terry, K. (2013). Implantation journey: The original human myth. Journal of Prenatal and Perinatal Psychology and Health, 27(4), 276–288. Tremblay, K., & Soliday, E. (2012). Effect of planning, wantedness and attachment on prenatal anxiety. Journal of Prenatal and Perinatal Psychology and Health, 27(2), 97–119. Van der Wal, J. (2007). The speech of the embryo. In M.  Shea (Ed.), Biodynamic craniosacral therapy (vol 1). Berkeley: North Atlantic Books. Van der Wal, J. (2013). The embryo in us: A phenomenological search for soul and consciousness in the prenatal body. Journal of Prenatal and Perinatal Psychology and Health, 27(3), 151–161. Verdult, R. (2009a). Caesarean birth, psychological aspects in adults. International Journal of Prenatal and Perinatal Psychology and Medicine, 21(1/2), 17–28. Verdult, R. (2009b). Caesarean birth, psychological aspects in babies. International Journal of Prenatal and Perinatal Psychology and Medicine, 21(1/2), 29–41. Verdult, R. (2011). Die Neuverdrahtung des Gehirns; Zerebrale Entwicklung, pränatale Bindung und ihre

246 Konsequenzen für die Psychotherapie (Rewiring of the brain: cerebral development, prenatal attachment and its consequences for psychotherapy). In P.  Schindler (Ed.), Am Anfang des Lebens (at the beginning the life). Basel: Schwabe. Verdult, R. (2012). Binding in der frühkindlichen Entwicklung; pränatale Programmierung späterer Beziehungsfähigkeit (Attachment in early development: prenatal programming of later relational capabilities). In S.  Hildebrandt, J.  Schacht, & H.  Blazy (Eds.), Wurzeln des Lebens (Roots of the life). Heidelberg: Mattes Verlag. Verdult, R. (2013a). Präntal programmierte Überlebensstrategien und das neurosequentielle Modell für die Psychotherapie. (prenatal programmed survival strategies and the neurosequential model for psychotherapy). In L. Janus (Ed.), Die pränatale Dimension in der Psychotherapie (The prenatal dimension in psychotherapy). Heidelberg: Mattes Verlag. Verdult, R. (2013b). Essstörungen bei Babys; ein pränatales Stressphänomen. (eating disorders in babies: A prenatal stress phenomenon). In L.  Janus (Ed.), Die pränatale Dimension in der psychosomatischen Medizin (the prenatal dimension in psychosomatic medicine). Giessen: Psychosozial Verlag. Verdult, R. (2014a). Pränatale Bindungsentwicklung; auf dem Weg zu einer pränatalen Entwicklungstheorie (Prenatal attachment development – towards a prenatal developmental psychology) In Evertz K, Linder R and Janus L. (Eds.) Lehrbuch der pränatalen Psychologie.

R. Verdult (Textbook of the prenatal psychology). Heidelberg: Mattes Verlag. Verdult, R. (2014b). Bindungstheorie und Bindungsanalyse. (attachment theory and bondinganalyses) In: Blazy, H. (Ed). “Und am Anfang riesige Räume und dort erschien das Baby“: Berichte aus dem intrauterine Raum. (“And at the beginning a hugh space and then the baby came”: Messages from in the intra-uterine space). Heidelberg: Mattes Verlag. Verny, T. (2002). Tomorrow’s baby: The art and science of parenting from conception through infancy. New York: Simon & Schuster. Verny, T. (2014). What cells remember: Towards a unified theory of memory. Journal of Prenatal and Perinatal Psychology and Health, 29(1), 16–29. Zentner, M. (2004). Temperament in Entwicklung (Developing temperament). Heidelberg: Spectrum Verlag. Rien Verdult  is a developmental psychologist and psychotherapist. Together with his wife Gaby Stroecken, he works as a private practitioner in Belgium. He works with adults and babies. His principal orientation is prenatal attachment. He is a student of William Emerson and Karlton Terry. Together with his wife he wrote several books (in Dutch) on psychotherapy, including on prenatal themes. He also wrote several articles (in German) on prenatal development. He is a longtime member of ISPPM, APPPAH, and DOHaD.

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report Rien Verdult

Introduction According to Allan Schore, American culture may be deviating increasingly from traditional social practices that emerged in our ancestral “environment of evolutionary adaptedness,” a concept introduced by John Bowlby, the founding father of attachment theory (Schore 2013). Artificial reproduction is far from our ancestral human mammalian milieu. My intention is to show that artificial reproduction is a social activity that is a serious departure from an optimal “environment of evolutionary adaptedness,” not only in US culture but worldwide. Since the birth of Louise Brown in 1978, rather since her conception in 1977, nearly 5  million babies have been born as a result of assisted reproduction technologies (ART). It is estimated that about 2% of all babies are conceived by ART. Since the sixties of the last century, the number of infertility has risen. Infertility can be defined as the inability to conceive after one full year of normal, regular heterosexual intercourse without the use of any contraception. The World Health Organization (WHO) estimates that about 5–10% of couples in their reproductive age suffer from infertility. Reasons are as follows: more venereal diseases, the use of more medication, and recreational drugs, and above all, in the R. Verdult (*) Private Practice, Gors-Opleuuw, Belgium

Western society, women plan to become pregnant later in their reproductive lives and find themselves less fertile. From time to time, alarming messages appear in the media about the so-called sperm crisis. The quantity and quality of sperms are decreasing, leading to more infertility. In recent years, obesity has considered a major factor in declined fertility. In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are the most widely ART techniques used to deal with infertility. In IVF (in vitro fertilization) the sperm and egg cells are brought together in petri dish and in ICSI (intracytoplasmic sperm injection) a single, selected sperm cell is inserted into the nucleus of the egg cell. Now many new assisted reproduction and related technologies have been developed, for example, TESE (TEsticular Sperm Extraction) or MESA (microsurgical epididymal sperm aspiration), processes in which sperm cells can be harvested from the testis. These techniques are all used in combination with ICSI. Embryo selection based on preimplantation genetic screening, or family balancing and social freezing are more recent developments in ART. The latest development is the production of germ cells out of skin cells, which should make it possible for lesbian couples to have a child that is genetically from both parents. With this report I do not want to induce fear or guilt in parents. I want to inform future parents about the possible traumatic aspects of ART, so

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that they can take these aspects into account and come to a fully informed consent. A technological imperative has been inaugurated. Now that the reproductive techniques are available, they must be used. Technoscientific developments have permeated a very human and very intimate process, that of procreation. We have developed sophisticated ways to join the sperm and egg outside the body’s natural process without a full understanding of the intricate developmental processes that we have supplanted with pipettes and petri dishes.

Ethical Discussions From the very beginning of the development of ART, the ethics of the treatments were questioned, mostly by religious groups. Jewish and Islamic groups have no objections to ART, but Christian groups have protested against IVF because they consider children to be a gift of God and it was not up to man to play God. Also, some feminist groups were against IVF, as infertility is mostly a male problem and it is the woman who has to undergo the burdening treatment. Now it seems that IVF is widely accepted as a safe method to solve infertility in a couple. A technological imperative has developed since the birth of Louise Brown. Before 1978 infertility was a fate. After 1978 an infertile couple had a choice: using the IVF treatment or not and so an emotional transition took place from fate to choice. Infertile couples who choose not to undergo IVF choose to stay infertile. The development of ART also raises questions about the motivation of parents to have children. As IVF and ICSI are very stressful and expensive treatments and sometimes couples have to undergo up to 10 cycles to become pregnant, the question is: Why do couples make so much of an effort to have a child. Can they not accept the fact that they are infertile? Can they not mourn about the fact that they won’t become parents? Do they need a child so badly? The longing for a baby can be motivated by unresolved narcissistic and symbiotic needs of the parents-to-be. This is also true for fertile couples. Staying childless as a couple can be a painful situation with which the couple

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has to deal, but it does not imply necessarily that life is useless without children. The childfree movement tries to make a statement: reproduction is not a necessary condition for happiness. Men and women can choose not to reproduce (Gillespie 2003; Hird 2003). Although millions of couples are confronted with the problem of infertility, this does not mean that all of them look for help by the reproductive medicine. According to a metaresearch by Boivin et al. (2007), worldwide 56% of infertile couples actually seek help in ART, and 44% do not, mostly for ethical, religious or medical reasons. Childless marriage or adoption can be an alternative to ART. More reproductive techniques are currently being developed and will be developed in the future, leading to new ethical and psychological problems. For example, social freezing is one of the latest issues. Women who want to have a career first (financially supported by companies such as Apple and Facebook) freeze their eggs at a younger age and use their harvest later in their life when the production of eggs has diminished because of their age. Another example is that the British parliament recently decided to legalize the three-person babies’ technique, a new ART-­related technique to prevent deadly genetic diseases from being passed from mother to child, because of defective mitochondria in the mother. The technique uses a modified version of IVF to combine the DNA of the two parents with the healthy mitochondria of a woman donor. Either the embryo will be repaired (adding the parent’s pronuclei to the donor embryo) or the mother’s egg (the mother’s genetic material is inserted into the donor egg). The philosopher and bioethicist Julian Savulescu pleat for human enhancement by genetic manipulation of the human embryo, not only for medical reasons, but also for moral reasons (Savulesco and Bostron 2009). The key question in these technological developments is When the embryo is seen as not human or not yet human than arguments used are base on three considerations: nature itself does not protect embryos as many blastocysts die in the natural setting, nor does nature respect identity as identical twins exist, and finally, the embryo as a human being is just a creation in our imagination since no qualities of a human being can be seen in the

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

embryo, and the embryo cannot be considered to be a human being as it cannot survive independent from the mother (Maio 2012). The opposite position, that the embryo is a human being from the very beginning of life, uses four arguments: the embryo has the potential to become a human being and thus is a human being; the embryo belongs to the human race and is thus human; it already has a form of consciousness; and no break can be found in the continuity of human development (Maio 2012). The medical profession usually refers to the Hippocratic oath (“Do no harm”) when making decisions about how and when to intervene medically in such matters and states that it is a doctor’s duty to help patients in need, when they want to become pregnant. In the ethical discussions, the deep psychological consequences for the child-to-be do not play a major role. IVF/ICSI babies are considered to be healthy babies, showing no cognitive or psychosocial problems in the long run. There does not seem to be a psychological problem with IVF/ICSI children. This is not surprising, as doctors still deny the consciousness and the cellular memory of the prenatal child. If one considers an embryo, up to a certain stage in its development, as a “not yet human,” then all kinds of manipulations can be carried out. In this chapter, I hope to show that ART is traumatic to the child at a deep, unconscious level. My intention is not to explain how potential traumas during ART can occur. For a theory on the cellular memory, I refer to Verny (2014) and Verdult (2014). In this chapter, I want to focus on what is going on in the baby’s psyche, on a deep psychological level, when he is conceived by ART. This contribution is a clinical report, not a research report. It is based on the psychotherapeutic treatment of about 40 IVF/ICSI babies in our practice, in which I work together with my wife Gaby Stroecken.

Some Medical Implications of Art The driving force in the medical field has always been a better treatment outcome. The question is: What is the definition of success in assisted

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reproduction? In ART statistics it is important to differentiate between biochemical pregnancy (increase of pregnancy hormones indicating a pregnancy), clinical pregnancy (in the womb an embryo with heartbeat can be observed with echography) and baby-take-home rates (a baby actually been born after ART). Min et al. (2004) suggested a definition of a success of ART as “BESST”: Birth Emphasizing a Successful Singleton at Term. Defined in this way, the success rate of ART is about 65%, or one-third of infertile couples do not have a child after a cycle of assisted reproduction. Considering the magnitude and the continuous increase in the number of ART cycles IVF/ ICSI performed every year, complications from ART is a worldwide iatrogenic health problem (Serour 2008). Iatrogenic means that the health problem has been caused by medical intervention itself and not by disease. The ESHRE (the European register of ART) consensus meeting in 2002 indicated that although ART is an effective treatment for subfertile couples, so far little attention has been paid to the safety of ART, that is the adverse events and complications (Land and Evers 2003). Complications from ART are often underreported for clinical and commercial reasons. An overall incidence of 2% for major medical complications during treatments was found in several research reviews. Ovulation induction and the collection of oocytes can lead to complications. The most serious iatrogenic condition in ART is the ovarian hyperstimulation syndrome (OHSS), which is in its most severe form a lethal disease for women. Other complications like abdominal complications after oocyte collection, pelvic infection, bleeding, ectopic pregnancy or early pregnancy complications (including miscarriage) occur less frequently, but are nevertheless a physical and emotional burden to the women and their partners. ART can lead to pregnancy complications such as miscarriage, ectopic and heterotopic pregnancy, and multiple pregnancy. The most common obstetrical complications are first-trimester bleedings and pregnancy-induced hypertension. The perinatal outcomes of ART pregnancies show higher rates

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of stillbirth, perinatal mortality and infant mortality than in naturally conceived babies. When we focus on child development, infantile cerebral paresis and epilepsy occur more often with ART children, probably due to prematurity. The risk of abnormalities is about 30% higher than with naturally conceived children. After ICSI, chromosomal anomalies are more frequent (Sutcliffe and Ludwig 2007). The risks for epigenetic changes after ART are still unclear. As most epigenetic changes take place in the embryonic stage of development, it can be expected that interventions in this stage (as in IVF/ICSI) can have a potentially disturbing effect on gene expression by epigenetic mechanisms. There are indications that there is a higher risk for very rare imprinting diseases as a result of epigenetic changes (De Rycke 2008). Angelman syndrome (hyperactivity combined with the slowing down of development) or the Beckwith-­ Wiedermann syndrome (extreme growth with abnormalities and tumors) can be observed more frequently in ART children. It remains unclear whether these difficulties are due to the reproductive techniques themselves or whether they are risk factors in the couples who use ART.  In the physical development, no differences in height and weight are found between ART children and spontaneously conceived children. There are contradictory findings whether or not IVF children show more infant diseases, are more often hospitalized and have to undergo more surgeries. A small higher risk for childhood cancers is found in IVF/ICSI children. Overall, researchers conclude that no long-term differences in health outcomes can be found between IVF/ICSI children and naturally conceived children (Fauser et al. 2014). In the medical profession the question remains whether the ART process itself results in an increased risk of obstetric problems. Women with pregnancies conceived after ART are generally older and are more often primiparous. They also are more likely to have multiple pregnancies. These recognized risk factors probably play a large role in the increased complications seen in ART pregnancies. In the evaluation of ART complications, developmental psychological factors do not play a

major role or are even denied. Risk factors are mostly discussed concerning medical complications in the treated women and almost none concerning psychological complications by the babies or children. It is said that methodological and conceptual difficulties exist in psychological research in this area, including difficulty in matching controls and small sample sizes. Also, there is debate on the validity of various questionnaires used, and a tendency of positive self-­reporting by couples undergoing ART. In retrospective studies, perception of the stress of the treatment may be influenced by the impact of treatment failure. Generally, ART participation is reported as very stressful with a negative impact on lifestyle. It can also result well in depression and diminished martial satisfaction after failure. IVF mothers are more anxious than matched controls about the survival and normality of their unborn babies. This emotional state can be damaging during birth and postnatal separation (Serour 2008).

Are ART Children Different? Immediately after the introduction of IVF, questions were raised about the possible influences of the treatment on the development of the child. Research mainly focused on the development of child–parent interactions. The psychodynamic or intrapsychic development of the IVF/ICSI child is more difficult to investigate and is usually not pursued. In studies on parenting and the children’s psychological development, no significant differences are found between IVF families and matched control families (Colpin and Soenen 2002). In the often-referred-to European Study of Assisted Reproduction Families, Golombok and her colleagues found that there were slightly more positive psychosocial interactions in the IVF families compared with spontaneously conceiving families. Bindt (2002) concluded that compared to a naturally conceiving control group, no more manifestations of neurosis or personality disorders were found among ART couples. Furthermore, it was expected that parents who had to make such an effort to conceive and

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

who often had to wait for such a long time to have a child would overprotect their highly desired IVF/ICSI child. In research, a slightly higher incidence of overprotecting in IVF mothers was found (Golombok et al. 1996, 2002). Greater difficulties in parenting and child development are reported in IVF families with twins or triplets compared with families with singletons from IVF/ICSI (Olivennes et  al. 2005). Most follow­up research confirms these findings. The conclusion from this and other research is that IVF families are not families at risk. Reviewing the available research on socalled non-standard situations and relationships (single mothers, lesbian and homosexual couples and transsexual people), where such families had children after donor insemination or IVF/ICSI, De Wert et al. (2014) concluded that psychological implications are no ground for refusing ART to these families, although more research is needed. Psychological problems can result from the use of anonymous sperm donors, as is mostly preferred by single mothers and lesbian couples. More donor-conceived children seem to seek their missing identity. Also sharing motherhood can lead to maternal jealousy among lesbian co-­mothers, and surrogate mothering, as can be the case in homosexual couples, implicates a problematic prenatal attachment development for the baby. The German medical psychologist Dr. Tewes Wischmann (2012) concludes, after reviewing the research literature on IVF/ICSI children: “There are more medical risks, but most studies show that no differences can be found in the psychomotor, psychological and social development of ART children, nor can differences be found in parent-child interactions. The development of twins or triplets after ART is more problematic.” I want to question Dr. Wischmann’s statement. First, the consensus is not absolute among researchers regarding the psychological effects on child development. Second, much of the research has methodological limitations, and so is most of the research retrospective in nature and not longitudinal. No prenatal conditions are taken into account. For example, maternal anxiety during pregnancy in IVF/ICSI mothers will have a

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significant influence on birth and on developmental outcome in the babies. Third, in general, postnatal difficulties receive attention, but prenatal traumas are mostly overlooked or denied. Prenatal trauma in children can be expressed in subtle symptoms that can be statistically ruled out in research designs. Fourth, most psychological follow-up research is on the cognitive, psychosocial and psychomotor development of IVF children, not emotional development, attachment or self-regulation. The question remains whether or not deep psychodynamic imprints of artificial conception remain in the unconscious of the IVF/ICSI child, that is in the body of the child. As Verny (2014) has pointed out: Cells can remember. They are capable of amassing vast amounts of memory as demonstrated by the ovum and sperm cells. Distinct bits of information (about our conception) are encoded in cells throughout our bodies. In our psychotherapeutic practice for babies, we treat babies conceived after ART. We find that they are proportionally overrepresented in our clients. Although they seem to show similar psychological symptoms as non-IVF/ICSI babies with psychological distress, some subtle complications can be observed in IVF/ICSI babies. In general, Karlton Terry (2004) stated, IVF babies need help finding structure, need help “finding their bodies” and need support in feeling safe with their emotions. Most IVF/ICSI babies seem to have some sort of disconnection from their bodies. These babies seem to have difficulty being grounded, organized and relaxed in their bodies. These subtle symptoms make the treatment more difficult. In our clinical experience, at a very deep level these babies are very difficult to reach in their deepest emotional pain. These subtle clinical findings are difficult to catch in empirical research.

Natural Conception: The Dance In order to describe what makes IVF/ICSI traumatic for the embryo, which I believe is the case, it is necessary to define what natural conception is. I

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want to stress that fertilization (the merging of the sperm and the ovum) is not all there is not to say about conception. Many prenatal researchers and clinicians assume that there is “something else” going on at conception. Fertilization in medical handbooks is often described in terms of a battle between offensive, attacking sperm cells (warriors) and passive, defenseless egg cells (victims). According to the Dutch embryologist Jaap Van der Wal (2002), this very common and somewhat aggressive image of a sperm cell penetrating the egg cell is not correct. He would describe conception more like a dance between two partners. As the emotional circumstances of conception matter as well, I would like to add to this metaphor: first, the female body (fallopian tube) is the ballroom in which this dance takes place, and second, the music is delivered by the couple making love. I have the idea, which can be inspired by my personal preferences, that the encountering sperm and egg would prefer the ballroom over the disco and major classical music (my preference which is shared by fetuses) over rock, metal or rap. My image of a disco is people dancing alone in an atmosphere where communication is almost impossible. The music should be going to the heart and activate emotions of love, tenderness, and connectedness and should not cross certain sensory thresholds, which may cause stress in the body. In conception, three dimensions can be distinguished: the physiological dimension, the psychobiological dimension and the spiritual dimension.

The Physiological Dimension The woman’s age is an important factor in fertility. Female fertility declines after the age of 25. Also, male fertility declines after the age of 50. The success rates achieved by ART also decline as the age of the women increases. The prevalence of obesity in women in the reproductive age continues to increase, and its impact has been the subject of debate. Fertility declines in women with a body mass index (BMI) > 27. Obesity also has a negative impact on fetal development.

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The parent-to-be should avoid endocrine disrupting chemicals (EDCs) as they disturb the functioning of the hormone system. Pesticides are the best-known source of ECD’s. Research by Michel Odent (2006) on primal health has shown that the lifestyle of the mother-­ to-­be plays an important role in the future development of the child. Also, research on the developmental origin of health and disease shows the same (epigenetic) influence of lifestyle and early experiences on development (Nathanielsz 1999). It is well known that the mother should stop smoking and drinking alcohol 1 year before conceiving, but also diet plays an important role. The consumption of caffeine is controversial in regard to its effect on reproduction. Over the years, we all have accumulated hundreds of chemicals in our tissues that have polluted our bodies and will be a threat to future generations. Odent proposes an “accordion method” as a preconception program for improving primal health of the baby-to-be. The objective of this method is to reduce the body’s burden of fat-soluble chemicals during the period before conception by lipid mobilization (fasting and physical exercise) in order to renew the stored fat. Simon House (2014) states that it is now known how we can create healthy brains and thus make the most of genetic potential. The elements are love, the right food, the right stimuli and the right activity. The nutrition and health of both mother and father before conception will influence brain development of the future generation. Folic acid’s special importance in pregnancy is now widely known. A fish-rich diet, sustaining levels of omega-3, DHA and EPA, will enhance the child’s development. Preconception care should check nutrient deficits, personal and environmental toxins and infections. Infertility can, in some cases, be associated with the nutrition and health status of both partners. Also, stress before conception can seriously increase the risk of premature birth of the baby, as Danish research has shown. Severe life events for close relatives during the 6  months before conception increase the risk of preterm birth by 16%, and severe life events in the mother’s older

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

children in the 6  months before conception increase the risk by 23%. Optimal lifelong health can be powerfully influenced by early events. Nathanielsz (1999) showed how prenatal experiences have profound influence on health. The nature of the womb environment is critical to the success the individual will have in surviving, enjoying life an reproduction. Health and disease are being programmed in preconceptional and prenatal stages of development.

The Psychobiological Dimension As a psychologist I would like to formulate the psychobiological dimensions of conception, linking biological steps to psychological themes. This is based on the assumption that every biological developmental step has a psychological counterpart. From this point of view conception can be defined as an existential encounter of sperm and egg, which starts an intense process of fusion through interaction and exchange of information. During this process the development of the essential core of our Self begins. If no trauma occurs during pre-conception and conception, an integrated or undivided bodily Self can start to develop. Based on the assumption that all biological developmental steps leave an imprint in our psyche, conception can be seen as the first key experience in the primary period of life (from conception to the end of first year). The differentiated steps of the sperm journey, the egg journey, and conception itself (seen as the fusion of the sperm and egg within a pre-conception field of attraction) leave imprints in our body and psyche, which constitute the deepest fundamental blueprints of our Self (integrated or divided). Van der Wal (2002) gives a description of conception. He states: “Both cells, the egg and the sperm, seem to exchange and settle mutually within the chemical and biological conditions for the eventual decision of whether or not a sperm cell will enter (fuse), and if so, where, which one and when. In a very subtle mutual process of encounter and exchange of signals and substances both cells prepare themselves for the actual pro-

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cess of fertilization and conception. This process takes place within a pre-conception field of attraction. As the sperm cells approach, the egg’s movements slow down and stop. When the sperm comes closer and makes contact with her outer layers, the egg actually begins to spin in the opposite direction. This is the ‘conception dance’. Now a biological entity is formed by an egg cell with some sperm cells. We are dealing with a state of activity, that is more than just a kind of passive composition and sum of two cell types. Specific interactions take place within this biological complex. It is a biologically active and interacting whole that is occurring here. Within the initial few hours that this complex exists, a conception is possible, but whether this actually happens or not depends on a large number of subtle reciprocal chemical interactions and exchanges. Eventually it might result in a fusion of the cell membrane of the egg cell with that of a sperm cell. If the circumstances and conditions at a given moment and at a given place are appropriate, only then can the fusion of cell membranes take place and the content of the sperm cell (nucleus and the small amount of cytoplasm with some important cell parts) be brought into the egg cell. The continuity of the egg cell membrane is never interrupted or broken. In the pre-­conception attraction complex there is no question of an active partner versus a passive partner complex, nor of a penetrating versus penetrated partner, nor fertilizing versus fertilized one. Rather cell and cell qualities are equivalent as a subtle equilibrium of exchange and interaction are maintained.” I would like to make two comments on Van der Wal’s concept of the pre-conception attraction complex. First, the sperm cells and the egg do not come into this process without a history. As Terry (2005a) has described, sperm and egg make their journey to conception, and on these journeys, they register what they are e­ xperiencing. Second, from a system theory point of view, processes cannot be seen independent from the environment they take place in. The process of conception cannot be seen separated from the emotional circumstances in which it takes place: the ballroom (place + atmosphere) and the music (atmosphere).

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Therefore, I propose a three-layer model of the psychobiological dimension of conception. In the emotional energetic field of conception three layers can be distinguished. First, the above by Van der Wal described pre-conception field of attraction (the dance), including the sperm’s and egg’s history; the second layer, the maternal intra-psychic field containing her, often unconscious, attitudes to life (the ballroom); and third, the couple’s relational field as expressed during sexual intercourse (the music). See Fig. 1. First Layer: The Preconceptional Field of Attraction  Central and crucial in this model is the preconception attraction complex, where the conditions for the actual conception interact with one another (the dance). The way the partners dance with one another depends on how they move their bodies, which is based on their emotional histories. In other words, the emotional quality of this preconception attraction complex depends on two elements: the history of the sperm before its encounter with the egg (sperm journey) and the history of the egg before conception (egg journey). Before the sperm encounters the egg, it

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has made a journey from the testis of the man into the fallopian tube of the woman. Terry (2002) describes four stages in the sperm journey: repose (the sperm cells are produced and rest in the testis), ejaculation (sperm cells are shot out), holocaust (millions of sperm cells die on their way through the female body), trekking (sperm swimming or crawling through the fallopian tube) and then conception. Each stage has its specific biological task and has psychological correlations, which the sperm brings in the pre-­ conception attraction complex. For example, if the sperm that encounters the egg in the pre-­conception attraction complex has experienced a lot of welcoming encouragement or opposite rejection, then he will bring this into the conception field. The biochemical messages of the female’s body are imprinted in the sperm’s body. The egg also has her own journey, which started long ago, namely in the prenatal life of the woman. Terry (2005a) describes five stages in the egg journey. The slumber party (sister egg cells waiting for ovulation), ovulation (the chosen egg leaves her sisters and goes on her way), drift (the egg floats and falls into the fallopian tube), odyssey (the egg is moved

Pre-conception attraction complex Maternal intrapsychic field Couple’s relational field

Fig. 1  Three layers at conception

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

through the fallopian tube), and ending the journey in conception. The egg can feel fed, nourished and loved on her journey, or she can feel lonely, unwelcome or even poisoned. The imprints of her experiences are brought into the pre-conception attraction complex. Second Layer: The Maternal Intrapsychic Field  All human cells are responsive to human thoughts, emotions and intentions. As conception takes place within the body of the woman, her emotional life creates the second layer. Embryological research by neonatologist Relier (2001) shows that as early as the two-cell stage of development of a newly fertilized zygote the distribution of IGF (insulin-like growth factor) receptors on its cell walls can vary, in part based on the mother’s “psychoaffective quality,” as Relier calls it. This implicates that the mother’s mental and emotional state can enhance or diminish the action of IGF, which governs the early growth of the embryo and the vascular organization of the placenta. The maternal intra-psychic field contains all the conscious and unconscious elements of the mother-to-be, with regard to bodily felt emotions and attitudes about her being a woman, her sexuality, her conceiving, her pregnancy and her becoming a parent. Inner psychological conflicts can be activated as well as new conflicts about separation, individuation or dependency. Old conflicts can be related to her childhood, her own prenatal and perinatal experiences. This is how the ballroom for the conception dance is furnished, how its atmosphere is activated. An in-contact continuum can be described. On the positive side, the mother-to-be is in contact with herself, with her body, her needs and emotions; she will be more open and receptive. On the negative side the mother-to-be is not in contact with herself, her body, and her emotions; she will be more closed, tense and contracted. These psychological conditions are expressed in her body and in the biological processes, like those that take place at conception. The Third Layer: The Couple’s Relational Field  This layer creates the atmosphere for the conception dance; it is the music being played.

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When the mother is living in a relationship, this will influence her emotions, longings, needs and thoughts. It creates the moment, the here and now. Her (intimate) relationship with her partner can be tender, loving, caring, or it can be unsupportive, rejecting and even violent. The quality of her attachment relationship to her partner will influence the way in which the couple conceives. The parents’ inner atmosphere, their thoughts and feelings towards each other and towards their baby-to-be are communicated to the individual being created. If for one or if for both parents-to­be, conception is unwanted, then lifelong negative effects can be imprinted on the baby. It is known that unwanted conception has a high risk of neonatal death and of schizophrenia and affective disorders.

The Spiritual Dimension Conception is more than fertilization. Many prenatal psychotherapists would say that conception is not a pure biological process; a third factor is involved or “something else is happening.” This “third factor” has different names, like God, spirit, soul, cosmic consciousness, quantum shift or “big bang.” In some religious traditions, God is coming into our life at conception. Carman and Carman (1999) suggest that we already have a self prior to conception. Emerson speaks of a pre-­ conceptional phase in which the spirit is embodying (Schmid and Emerson 2012). The Australian psychotherapist Graham Farrant (1988) states that conception is not a duality but a triune constellation: the sperm, the egg and the soul meet. The Dutch psychoanalyst Lietaert Peerbolte (1975), who “discovered” conception shock in the early forties of the last century, spoke of a psychic energy incarnating in the zygote and this energy comes out of a source in the cosmos. Within holistic healing models, such as craniosacral therapy, conception has to do with forces that organize and inform the unfolding of new life. These forces are seen as the inherent intelligence within the body and mind, which, if unimpeded, continually animate and motivate the organism towards healing and growth (Axness 2012). The

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different concepts and theories which try to describe what is actually happening at conception from a transcendental point a view indicate that the third factor or “something else” exists but is hard to describe. This can be called the mystery of conception or the spiritual/cosmic/transcendent dimension of conception. It is likely that this “third force” at conception lies in the realm of waves (energy) rather than the realm of particles (matter), as energy is involved in the informational signaling of cellular processes (Axness 2012). I would like to consider consciousness as an organizing principle. Consciousness is embodied at conception and leaves the body at death. The Dutch cardiologist Pim Van Lommel (2007) writes that according to our current medical concepts, it is not possible to experience consciousness during a cardiac arrest, when circulation and breathing have ceased. But during the period of unconsciousness due to a life-­ threatening crisis like cardiac arrest patients may report the paradoxical occurrence of enhanced consciousness experienced in a dimension outside of our conventional concept of time and space, with cognitive functions, with emotions, with self-identity, with memories from early childhood and sometimes with (extrasensory) perception far above their lifeless body. Since the publication of these prospective studies on near-­death experiences (NDE) in survivors of cardiac arrest, with strikingly similar results and conclusions, the phenomenon of NDE can no longer be scientifically ignored. It is an authentic experience which cannot be simply reduced to imagination, fear of death, hallucination, psychosis, the use of drugs or oxygen deficiency, and people appear to be permanently changed by an NDE during a cardiac arrest of only some minutes’ duration. According to these studies, the current materialistic view of the relationship between the brain and consciousness held by most physicians, philosophers and psychologists is too restricted for a proper understanding of this phenomenon. There are good reasons to assume that our consciousness does not always coincide with the functioning of our brain: enhanced consciousness can sometimes be expe-

rienced separate from the body. Van Lommel has come to the inevitable conclusion that most likely the brain must have a facilitating and not a producing function to experience consciousness. By making a scientific case for consciousness as a nonlocal and thus ubiquitous phenomenon, he puts into question the purely materialistic paradigm in science. I assume that what is happening at conception is a reverse process of what happens at death. At conception, nonlocal consciousness is embodied and this is the starting point of further development of a more personal consciousness. This makes conception a most notable moment in our life. The embodiment of consciousness is to me the “third” factor or the “something else.” In the treatment of IVF/ICSI babies, I assume that the process of embodying consciousness is being disturbed and that this disturbance is expressed in the dysfunction of connections over crucial body axes.

 rtificial Reproduction: No A Ballroom? No Music? No Dance Van der Wal (2002) describes artificial reproduction as follows: “The classical in vitro fertilization can be interpreted as the forced i.e. manipulation of the conditions that are necessary but not sufficient for a human conception. Obviously, a pre-conception attraction complex cannot function optimally under such artificial conditions as in IVF and ICSI.  The difference with natural conception is time and place. The ICSI procedure is no more or less than biological and psychological violence! If one has an open mind for it, one could observe that the egg cell sprawls under the attack of the incoming needle. The needle is not received with hospitality as it seems. Suddenly the cell membrane (zona pellucida) collapses and the needle intrudes. A rape on cellular level? This is very far from the subtle “are-we-going-to-or-are-wenot-going-to-dynamics” of a pre-conception attraction complex, it looks like a rough corruption of the latter. Nothing is perceivable anymore of the subtle freedom and liberty that is so

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

characteristic of a human conception. In ICSI we deal with biological constraint and compulsion”. For medical reasons, every treatment cycle in IVF/ICSI programs must be highly organized and precisely timed, just as the fertilization process is organized and timed in nature. At every step there are chemical and mechanical interventions which affect the cells and influence the process. IVF/ ICSI procedures are based on some variation of the following steps: preparation for treatment, induction of ovulation, egg retrieval and sperm preparation, fertilization process and embryo transfer (Sher et al. 1995; D’Hooghe et al. 2005). The first step in the IVF/ICSI treatment is the medical assessment of the couple. A complete medical and psychological evaluation is done in the preparation stage on the treatment. The couple has to undergo all the routine steps of an infertility assessment. They also have to share background information on lifestyle and personality. Once accepted into the program, additional medical tests are conducted, like sperm-­ evaluation test, sperm antibody test, a pelvic evaluation, uterine measurement, an HIV test and staining of cervical secretions. Most programs routinely perform a hysteroscopy. Some important decisions have to be made by the couple. How many eggs will be fertilized and what will be done with the remaining embryos? Are they willing to risk a multiple pregnancy? How do they intend to deal with a multiple pregnancy? What is their attitude towards pregnancy reduction or embryo reduction? These decisions can be stressful to the couple. The music is turned off and neon lights are turned on in the ballroom. The second step is the induction of ovulation. A woman undergoing IVF/ICSI is given fertility drugs for two reasons: to enhance the growth and development of her ovarian follicles in order to produce as many healthy eggs as possible and to control the timing of the ovulation so the eggs can be surgically retrieved before they are ovulated. This process is called controlled ovarian hyperstimulation. Here the psychobiological aspects of IVF/ICSI start for the baby-to-be, as the egg journey is being forced.

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In the third step, needle-aspirated egg retrieval under guidance by ultrasound is performed. This is done just before the eggs ovulate. The follicles are pricked and the content is aspirated. As many eggs as possible are harvested. In the laboratory the embryologist looks for the eggs in the egg-­ cumulus complex. The egg is washed and put in an incubator. Biological research on eukaryotic species has shown that they can respond to threats, going into a defensive mode in order to protect their survival. The manipulations on the egg can put the egg into a survival mode. Contraction is a defensive strategy. On the same day the sperms will be prepared. A masturbation specimen is produced on demand. As freshly ejaculated sperm cannot fertilize an egg without undergoing a process of capacitation, the sperm is washed in a special medium in order to induce capacitation, altering the plasma membrane that covers the acrosome on the sperm’s head. By centrifuging the semen, they are separated from the seminal fluid. An additional medium is added and the sperm cells are recentrifuged. The washed sperms are placed in an incubator. All these manipulations can activate the defensive mode in the sperm, which is substances are sometimes added to enhance the sperm motility, to “wake them up,” to get them out of a parasympathetic shock. The fourth step is the insemination or fertilization. In IVF, the embryologist adds a drop of the medium containing about 50,000 capacitated sperm cells into the petri dish containing the egg. The petri dish is placed in the incubator and now the couple has to wait to see if actual fertilization takes place. The pre-conception attraction complex can be seen developing under the microscope. There is a ball room, but a cold and technical one and there is no music. After insemination, the fertilized egg is transferred into a growth medium in order to promote its development and encourage cell division. In nature, the cumulus granulosa and corona radiate cells are eroded away as the fertilized egg passes through the fallopian tube. In the laboratory, these cells must be carefully removed. This is called the peeling of the egg. In ICSI, a technique developed at the University of Brussels, the sperm

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cells and egg are not brought together in a petri dish, but only one selected sperm cell is injected directly into the egg’s cytoplasm by means of a little needle. No pre-conception attraction complex can develop; there is no ballroom and no music. The fifth and final step is embryo transfer. Although embryo transfer is the shortest step in the IVF/ICSI procedure and appears at first glance to be the simplest, it is really the most critical phase of the entire process. The timing depends on the state of cleavage of the most rapidly dividing embryos. With a transfer catheter, under guidance by ultrasound, the gynecologist injects the embryo or embryos into the uterus, where they remain for several days before implanting. The woman should be as relaxed as possible during the embryo transfer, because stress hormones can cause the uterus to contract. In summary, in ART the sperm cells and the eggs are being deprived of the natural journeys they normally make. They are manipulated many times during the procedure and they are separated from their natural environment (the ball room). They cannot be stimulated by the emotional atmosphere, laid down in the woman’s body, nor the affective bonding and intimate intercourse of the couple. No music is playing in IVF/ICSI. As all living species do, even the most primitive ones, the sperm cells, the egg cells and the embryos react to these manipulations and separations. Survival strategies are activated, making conception not impossible (as the results of IVF/ ICSI show), but making them more forced. What should have been a spontaneous and unforced process in a living environment has become an invasive procedure in a laboratory.

Trauma in IVF/ICSI Babies This is a clinical report, not empirical research. On the basis of the treatment of about 40 IVF/ ICSI babies, I would say that a mosaic pattern of symptoms can be observed in these babies, indicating a variety of potential psychological traumas. Why am I considering IVF/ICSI as a potentially traumatic experience for the baby/

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child even though there are no indications in the research that something is wrong with these children? My assumption is that whatever experience that differs from a natural process, that goes against our ancestral “environment of evolutionary adaptedness,” can be potentially traumatic. Although cesarean birth can be seen as a “different doorway,” it is a traumatic experience for the baby (and often to the mother too), because it is an unnatural way of leaving the womb (Verdult 2009). Vaginal birth is the natural way and the baby being born has the birth experience of tens of thousands of generations incorporated in his body. Natural conception and birth belong to our ancestral evolutionary history, imprinted in our genes. If we interfere in subtle natural processes, then trauma and shock can be induced. Second, I myself and so many other baby psychotherapists have clinical evidence that conception can be re-­experienced and can be recapitulated in actual behavior, and that from these findings we can say that ART is in a very subtle way traumatic. Stress, trauma and shock form a continuum. In stress some coping is possible, although it is difficult to keep an inner equilibrium. In trauma, the system is overwhelmed but not to such an extent that no coping is possible. In trauma the survival of the organism is not under threat, fight or flight as survival strategies are still possible. In my definition of shock, to freeze or even to collapse are the dominant survival strategies, indicating that the event is a direct threat for the survival of the organism. Not all ART interventions have the same traumatic or shocking weight. A trauma-­ continuum can be observed in ART babies. In general, one can say that the more and the earlier the interventions begin, the more traumatized the baby will be. In our experience, artificial ­insemination is less traumatizing than IVF and IVF is less shocking than ICSI. IVF/ICSI babies show general symptoms of trauma like other traumatized babies do. For example, they show disturbances in regulation of stress and emotions. Beside these general trauma symptoms, IVF/ICSI babies show specific symptoms, mostly related to their disturbed relationship to their body and bodily felt emotions. Some

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

of these potential traumatic experiences are directly related to the ART procedure, like pre-­ conception, conception and implantation trauma. Others are more indirectly connected to ART, like prenatal maternal stress, birth complications and neonatal intensive care unit (NICU) admission. That is to say that not all IVF/ICSI babies show the same pattern, but that they may show different aspects of these potentially traumatic events. In the treatment of these babies we look for the primary presentation of pre-conception traumas, conception trauma, implantation trauma, embodiment trauma and twin loss trauma.

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and floats to the fallopian tube and is being caught by the fimbriae of the fallopian tube. Once the egg is in the fallopian tube it is safe, as it can no longer drift away into death. The preconception fallopian tube journey is the journey to the place where conception takes place. The fallopian tube consists of tissue that are rich with maternal blood supply. All of the hormones, steroids and neuropeptides flushing through the circulatory system create a biochemical medium for the egg. This environment can differ, depending on the emotional attitude and mood of the woman. It can be accepting, loving and nourishing, but it can also be cold, impermeable or toxic. In the case of the ART egg, when the egg has reached Pre-conception Trauma optimal maturity, the entire cumulus mass is placed in a petri dish in a nourishing liquid called A woman under IVF is given fertility drugs for an insemination medium. We know for certain two reasons: (1) to enhance the growth and devel- that the petri dish in which the retrieved eggs are opment of her ovarian follicles in order to pro- placed in IVF is emotionally cold. It is not what duce as many healthy eggs as possible and (2) to an egg expects to end up in a cold, outer-body, control the timing of ovulation so the eggs can be object. In the IVF procedure, the natural pacing surgically retrieved before they ovulate. In terms of the ovulation is being forced into a stimulated of Karlton Terry’s egg journey, this would mean and controlled process. Losing her pacing is the that the “slumber party” is disrupted and that sev- first step in the process of losing connection with eral eggs are forced out of the ovarian. The sister- her bodily self, and this is stored in the egg’s celhood or sorority is being broken suddenly. I lular memory. These profound cellular experipresume that the egg competition, the rivalry ences during the IVF procedure penetrate the between the prophase eggs in the ovary, will be baby’s psyche and can be recapitulated in baby strengthened by the hyperstimulation of the ova- behavior. ries. There will be no one (or two in the case of The sperm journey in IVF differs only partly twins) “queen egg” as in a natural menstrual from the sperm journey in the natural process. cycle. In IVF, between five and ten eggs can be Of course, ejaculation takes place after masturselected to become the “queen egg” retrieved bation in the “masturbatorium” and not during from the ovarian. The shared experience, dating sexual intercourse, which can be stressful to the from the prenatal life of the woman in her moth- man, because he has to produce a specimen er’s womb, is abruptly ended. The forced surgical upon demand under an artificial situation. The ovulation is the next violation of the egg journey. sperms are not ejaculated into the vagina and Leaving their sisters behind, the stimulated eggs don’t swim and crawl to the egg through the are not given the chance to drift naturally from womb and the fallopian tube. Instead they are the ovary to the fallopian tube. Instead they are being washed or centrifuged for selective reapicked up by a surgical instrument. Needle-­ sons. The last part of their journey, the so-called aspirated egg retrieval under guidance of ultra- penetration of the egg, takes place in the petri sound sucks the eggs into the needle and then dish and not in a fallopian tube. In ICSI, the they are re-expelled to a petri dish. In a natural sperm undergoes a totally different journey. process, drift is the stage of transition from the This method is mostly indicated when the ovarian to the fallopian tube. As the egg cell has mobility of the sperm is low or when only a few no locomotive ability of her own, the egg falls sperms are available. In ICSI, one sperm cell is

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used. This sperm cell can be selected from the ejaculate or from the testes by MESA (microsurgical epididymal sperm aspiration) or TESE (testicular sperm extraction) when no sperm is available in the ejaculate. In the sperm journey Terry describes the following stages: repose, ejaculation, holocaust and trekking, ending in conception. In “repose,” the sperms reside within the exclusive environment of the father. In IVF, this stage is undisturbed or can be slightly disturbed by the man’s stress. Ejaculation, which is the sudden transition from repose to speed, takes place. Ejaculation leads to an invasion of sperm into the hostile environment of the vagina leading to a massive death among the sperm cells. As the sperm cells recover from their collective shock by the first killing of so many brothers, those who are living and vital swim further in the woman’s body. A cooperation between the sperms takes place so that after a long journey one sperm cell reaches the egg. In ICSI, however, the repose stage is disrupted by the medical intervention and ejaculation does not take place. The holocaust stage is replaced by a selective laboratory process. As the sperm is brought into the egg cell by a needle, pushing it through the zona pellucida. Trekking does not have to take place, meaning that one of the most characteristic aspects of the sperm, namely its swimming capacities, does not take place. In my observations one can see this compression of the mobility in the sperm cell used in ICSI in the psychomotor expressions of the baby. Artificial reproduction reduces the connection from where we came, and reduces some of the most characteristic aspects of the egg cell and sperm cell. The shock patterns that occur in the gamete are taken with them into conception.

Trauma at Conception In non-assisted reproduction the egg begins to spin when the few remaining sperm cells approach the egg. The pre-conceptional field of attraction appears. The egg selects the sperm cell she wants to enter her cell body. The sperm cells

have a helmet-like covering called the acrosome, which contains an enzyme that is capable of thinning the zona radiate of the egg. Rubbing their heads against the outer body of her cell, the sperms turn and undulate and twist into the many portals of the egg. Before the embryologist adds a drop or two of capacitated sperm to the petri dish containing the egg, he must peel the egg cell. The corona radiata cells have condensed around the egg cell. In nature these cells are eroded away as the zygote (the fertilized egg) passes through the fallopian tube. Peeling is achieved by sucking the fertilized egg and its attached corona radiate into a small-­ gauge syringe needle and then flushing the fertilized egg out through a small opening, thus separating it from the corona. The egg, surrounded by the sperm cells, is placed in an incubator. Fertilization, the actual entry of the sperm into the egg, normally takes place within the first hours after insemination. In ICSI, conception is forced by the intervention in which the sperm cell is brought into the egg cell. The needle is pushed through the cell membrane and the sperm cell is pushed out of the needle.

Embodiment Trauma I agree with Karlton Terry’s observations that IVF/ICSI babies find it difficult to get in contact with their bodies. They seem to have difficulties in finding their body (Terry 2004). He refers to this problem as an embodiment trauma: the soul finds it difficult to come into the body. Embodiment is a concept that has many different interpretations, depending on the scientific or therapeutic field it is used in. For example, in cognitive science and artificial intelligence, embodiment means the interdisciplinary field of research aiming to explain the mechanisms underlying intelligent behavior that emerges from the interplay between brain, body and world (see Wikipedia). The concept of embodiment, as it is used by Terry, is more a therapeutic concept than a scientific one. That is not to say that it does not have a relevant meaning. In the late fifties of

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

the last century, “umbilical affect” was introduced in psychotherapy by Francis Mott (1959) and later in the early eighties by Frank Lake (Maret 1997). It took researchers more than half a century to give scientific proof of these ideas originating from clinical practice. Now this research is called maternal prenatal stress research. The problem with the concept embodiment, as the soul or nonlocal consciousness coming into the body at conception, is that it is linked to more spiritual experience and that is more difficult to operationalize in scientific terms. As stated earlier, one might say that universal or cosmic energy or endless consciousness is embodying in the conceived baby. This endless consciousness is undivided. In IVF and even more in ICSI babies, this embodiment process is disturbed. There is no full internal connection to the body in IVF/ICSI babies, leaving them in a state of the divided self, which makes it difficult for them to feel themselves in their body and to deal with bodily felt emotions. As the saying goes: “the eyes reflect the soul,” in IVF/ICSI babies one can see the divided Self or the longing for the undivided self-reflected in their eyes. One could say that their first intensive shock experiences forced them to split their consciousness, resulting in a sort of dissociated state of mind. Many IVF/ICSI babies have a deep longing for the undivided condition they came from. Emerson has called this “divine home sickness” (Schmid and Emerson 2012). The divine, in my opinion, is the undivided state of the Self before a split has taken place, resulting in a divided Self. As consciousness can be considered as an organizing principle and embodiment of consciousness takes place in the very early stages of embryonic development, I assume that the embodiment trauma of IVF and ICSI babies can be observed in the disconnection within the principal body axes. Order and orientation are carried in the human body throughout life as functions of our wholeness and self-­ regulation. Embryonic development is a process of self-regulation based on orientation, which is coupled to symmetry (Shea 2007). As we know from embryology, this development starts with the core and then goes further around two major

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axes, namely the dorsoventral axis and the rostrocaudal axis. The latter is better known as the vertical midline. When I work with osteopaths, they report that the midline dynamics are disturbed in IVF/ICSI babies. First, embryonic development occurs through radial symmetry around a fulcrum in the first 2  weeks of embryonic development. This can also be called the “core” of the embryo. During the first week the embryo grows inward around its fulcrum and in the second week it expands outward from its fulcrum. Second, orientation to axial symmetry around the midline (rostrocaudal axis) begins at 3  weeks post-conception. In the third week the embryo gets a front and a back, a head and a tail to orient its growth toward these new body postures. Third, the embryo goes through a period of flexion, as it bends forward at the beginning of the fourth week, and finally develops to extension when it prepares for an upright standing position (Shea 2007). It can be said that in the very early stages the zygote first has a core and from there it starts to develop along its body axes. This is not to say that body malformations take place in the development of IVF/ICSI babies, but that the functional connections over these body axes show subtle changes, which are expressed in movements. I assume the connectivity across these fundamental body axes as an expression of the process of embodying consciousness.

Implantation Trauma After the fertilized egg has been transferred to the womb, the embryo has to find a location to implant, in a specific area of the maternal endometrium. This adhesion has to take place within the “implantation window,” which is within 6–7 days after conception. If the embryo cannot find a proper place in time, it will run out of energy and die. The molecular mechanisms of implantation are very complex. Successful implantation requires a functionally normal blastocyst and a receptive endometrium. Implantation is a highly regulated mechanism involving many systems at the paracrine-autocrine level

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(Dominguez et  al. 2008). Implantation is an active dialogue between embryo and endometrial cells in which up to now about 36 different discovered biochemicals are involved (Brosens et al. 2014). In my opinion, the receptivity of the maternal endometrium is crucial. It is a hormonally regulated tissue that responds through paracrine pathways to the presence of the blastocyst. We know that hormonally regulated systems are, to a great extent, influenced by emotions. I presume that the second layer, the maternal intrapsychic field, plays a crucial role in the receptivity. On a psychological level, implantation can be seen as an all or nothing experience. It can include a near-death experience. Endometrial receptivity can be experienced as indication for being wanted. If a blastocyst implants in “fertile grounds,” this can be experienced as an accepting welcome. If the blastocyst, on the other hand, implants in a “poisonous” endometrium, this can be experienced as a rejection. All kinds of subtle signals can be received by the blastocyst from the maternal endometrium, thus from the mother, and these signals are imprinted in the baby’s cellular memory (see Terry 2013a, b, c).

that embryos and fetuses can experience the loss of a twin brother or sister. According to the late Althea Hayton (2007), losing a twin is one of the most powerful events in the womb, resulting in grief, feelings of loneliness, abandonment and sadness.

Maternal Stress

The question of whether stress can be seen as one of the causes of infertility remains without a clear answer. Although there is evidence that life style factors such as stress have a negative influence on the hormone household of a woman and can lead to contractions of the fallopian tubes, most scientific research seems to confirm that there is no hard proof for this hypothesis (D’Hooghe et  al. 2005). Some IVF studies have demonstrated that the chances of conceiving and bringing the pregnancy to a good end is smaller if the patient reports more stress and anxiety at the onset of the treatment (Demyttenaere et al. 1994). Stress from infertility, that is, stress associated with the inability to have a child, is linked to aspects of marital satisfaction and to dimensions of quality of life. Most couples seeking medical help for infertility really suffer from not having a baby Twin Loss they are longing for. The treatment can give new hope, but at the same time disappointments can The incidence of first-trimester bleeding is high be great when the treatment is not successful. in ART pregnancies, varying between 29% and Depressive reactions are observed in women and 36% (Serour 2008). It has been shown that first-­ men after unsuccessful ART cycles. The IVF/ trimester bleeding is correlated with an increased ICSI procedure is in itself stressful for most risk of miscarriages. In ART, many singleton women and couples. Not only can the different pregnancies result from a vanishing twin, which stages of the ART cycle be painful and stressful, was signaled by bleeding in the first trimester. it also puts couples in a position to make some Also, the technique of embryo reduction can be difficult choices, like: How many treatment used in Art in order to reduce the number of cycles do we undergo? What do we do with the embryos in order to avoid triplets and more preg- leftover embryos? What do we tell family and nancies or to remove malformed embryos, which friends? The treatment cycles are strictly have a lower chance of survival. In ART the loss ­organized and this can be a burden too. Research of a twin half occurs more frequently than in nat- has shown that these stressful aspects of the treaturally conceived twins. We consider the disap- ment itself have no negative influence on the outpearance of a twin half more a loss to the come itself (Boivin et al. 2011). surviving baby. That is why in psychotherapy Even if the treatment is successful that does with IVF/ICSI babies we always focus on possi- not mean that the stress is over. Pregnancies after ble twin loss, as we know from clinical evidence IVF/ICSI are considered high-risk pregnancies,

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

especially when the woman is pregnant with twins. This means that ART conceiving couples can still remain stressed during the course of the pregnancy. A “delayed” pregnancy is a possible option, that is to say that the possibility that something still can go wrong makes it emotionally difficult to engage in the pregnancy and to connect to the baby out of fear of a miscarriage and a (new) disappointment. In our practice, we have observed that IVF/ICSI parents have shown more stress and anxiety during the pregnancy of their desired baby than non-ART parents. This also increases the risk on postpartum depression. The conclusion can, therefore, be made that women undergoing IVF/ICSI are not only stressed during the treatment cycle(s) but also more anxious and stressed during the pregnancy. It can be considered a scientific fact that prenatal maternal stress affects the development of the embryo and fetus in several domains. Both animal research and research on human fetuses show that pregnant women with high levels of stress and/or anxiety are at increased risk for spontaneous abortion, pre-eclampsia, preterm labor and delivery and for having a malformed or growth-retarded babies (Mulder et al. 2002). The transmission of maternal stress to the unborn baby can occur by three mechanisms, which may operate simultaneously and may amplify each other’s effect. The mechanisms involved are (1) reduction of blood flow to the uterus and fetus at increased levels of stress, (2) transplacental transport of maternal hormones and (3) stress-induced release of placental CRH (cortisol-releasing hormone is a stress hormone) to the intrauterine environment (Mulder et al. 2002). Van den Bergh (1992) found many effects of prenatal maternal stress on the behavior of the fetus. She found an overall increased level of activity (arousal) in fetuses of high stress and anxious women, a decrease in quiet sleep and high percentage of general movements (an indication of unrest). Also heart rate variability was increased in stressed fetuses. These effects were most profound for stress experienced in the first and third trimesters of the pregnancy. Her research has been confirmed by other research groups (Robles de Medina et al. 2003). Van den Bergh continued

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her observations of her control and experimental group after birth until adolescence. Her longitudinal research revealed that in childhood the offspring of highly anxious mothers showed poorer attention, more hyperactivity, more behavioral and emotional problems, and increased risk for ADHD (attention-deficit/hyperactivity disorder) problems. In adolescence, girls had a higher chance to develop depressed mood when their mother had been anxious when she was 12–22  weeks pregnant. Boys showed problems with cognitive control, scored lower on intelligence test, and showed more externalizing behavior, like ADHD (Van den Bergh and Marcoen 2004). Research like this shows that prenatal maternal stress and anxiety not only have a direct influence on fetal behavior, pregnancy complications and birth processes, but also have long-term effects on children’s emotional, cognitive, and behavioral functioning into adolescence. The German attachment researcher Brisch (2003) states that maternal prenatal anxiety has negative effects on the attachment development of the fetus. According to him, this maternal anxiety can be experienced by the fetus as a kind emotional rejection.

Birth Complications Louise Brown was delivered by cesarean birth. A review research shows that children born after IVF treatment have a greater risk of complications ranging from preterm birth, still birth to neonatal death within the first 28 days of delivery (Bower and Hansen 2005). The risks of birth complications are somewhat higher in ICSI than in IVF, and are higher in IVF/ICSI twins than naturally conceived twins. Also, more medical interventions are seen in IVF/ICSI conceived babies compared with naturally conceived babies. In our practice all of the 40 IVF/ICSI babies had birth complications. The conclusion can be that ART babies in general show more birth complications. Birth complications can be traumatic to babies. Emerson (1998) suggests, on more than 30  years of experience in treating babies, that birth traumas lead to three clusters of emotional

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problems: (1) the formation of a shock pattern, (2), attachment problems and (3) an invasion-­ control complex. Birth trauma can lead to serious and long-term emotional and behavioral problems. The so-called regulation disturbances in babies, like sleeping disturbances, eating problems, restlessness and hyperalertness, can be associated with birth complications.

NICU Admission The effects of physical affection immediately after birth on optimal functioning of babies have been extensively studied (Klaus and Kennell 1983). The first hour after birth is considered to be a sensitive period for bonding (Navarez et al. 2013; Trevathan 2013). For most mammalian offspring, losing contact with the birth-giving mother is distressing. Even short periods of separation from the mother can cause lifelong changes in stress responsivity (Navarez et  al. 2013). Physical touch and closeness to the mother’s body have long-­lasting positive effects on health and well-being of the child. For example, skin-toskin contact promotes healthy sleep cycles, adaptive behavioral arousals and exploratory activities (McKenna et al. 2007). IVF and ICSI babies are considered to be more at risk, so they are admitted to neonatal intensive care units almost four times more than naturally conceived babies (Serour 2008). IVF/ ICSI babies are born premature more frequently and with more birth complications. More medical complications lead to more medical interventions. Very often babies have to undergo invasive medical interventions like frequent heel sticking, intubation and catheter insertion. Preterm babies can experience up to 60 invasive procedures before being discharged from the neonatal intensive care unit (Anand et al. 2005). Painful stimuli lead to a stress response as early as the newborn period and research has shown that repetitive pain has adverse effects on neonatal development (Field and Hernandez-Reif 2013). The separation from their mother, combined with painful interventions, can lead to an enforcement of the shock pattern and to more attachment

problems. We have seen relatively more insecure-­ avoidant attachment problems in our clinical report group than in the naturally conceived babies that consult our practice. The insecure avoidant attachment pattern is associated with a parasympathetic shock pattern, indicating that the baby, at some time during his prenatal and perinatal life, used a freeze or even a collapse survival strategy against an overwhelming stressor (Verdult 2014). To summarize, in baby psychotherapy with IVF/ICSI babies we need to address the potential traumatic experiences. We need to look at how their pre-conception themes are recapitulating in their actual behavior and how conception and implantation traumas express themselves in their symptoms. We need to observe how they relate to their body and to their bodily felt emotions. IVF/ ICSI babies can mourn over a lost twin brother or sister. Besides these potential traumas that are directly related to ART, we need to look at prenatal maternal stress complications, birth traumas and the insecure attachment patterns exacerbated by NICU admission.

Baby Psychotherapy Why are babies brought for psychotherapy? The major motivation for parents to come to our psychotherapeutic practice is that they cannot handle the behavior of their baby. Their baby cries intensively, or does not sleep much at night, is difficult to handle during diaper changing or dressing due to motoric unrest, is not eating well or has gastric acid reflux. Parents usually have no clues about the suffering of their child, which has resulted in the symptoms they see. Quite often they tell us that everything went well during pregnancy and birth, while at the same time the baby is telling a different story. Using ART is still a social taboo, and parents sometimes keep silent about this, but their baby cannot keep quiet about this experience. Pioneering therapists such as Graham Farrant, Frank Lake, and William Emerson (2000) have tried to make processes of pre-conception and conception into therapeutic tools, which make it possible to deal with potential trauma in this

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

early and crucial period of life. Karlton Terry (2005b), pupil of William Emerson, has developed concrete therapeutic exercises, which correspond to the different biological steps in the process of conception. We still have sperm and egg movements stored in our body. In our cellular memory we have imprints of these early experiences. As research on single-cell organisms has shown, these organisms can open or close in reaction to an input from the environment. They can reach out for contact or turn away; they can attack and defend; they can expand or contract, take in or close down. They make movements to survive. They show primitive forms of survival strategies, as our sperm cells and egg cells can do. Real experiences leave an imprint of the activated survival movements in our cellular memories and are passed through to the next generations of cells, organs and structures. I myself am trained within the Emerson-Terry model. In the course of my own development as a baby psychotherapist, I prefer to speak of our work as Psychodynamic Trauma Psychotherapy for Babys (PTPB). First of all, this way of naming the baby work as trauma therapy indicates that babies can suffer from trauma and shock, which is still too frequently denied by other professions. Second, in our psychotherapeutic work the concept of early trauma is crucial. It has become my conviction that prenatal, perinatal and early trauma are central in the development of psychological difficulties. Third, many new baby counselling methods have been developed in the last decades, like infant mental health approach. Most of these approaches focus on the interactions between parents and their babies, overlooking the traumas the baby might have experienced and these are presently disturbing the baby’s interactions with its environment. In our practice, the focus is primarily on the traumas in the baby and second on the interactions with its parents. For us it is important to involve the parents, especially the mother, in the baby’s process of connecting to and working through the emotional pain that is buried in the baby’s body. The goal of baby psychotherapy is not to do psychotherapy with the parents. The parents can have emotional problems themselves. This is

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very likely as pregnancy and birth of a baby can activate prenatal and perinatal themes in the parents themselves, which can influence their attitudes towards their baby. But to us, it is not ethical to change the purpose from baby psychotherapy to psychotherapy with the parents, when the parents have not formulated a question for therapeutic help for themselves. In addition, psychotherapy with adults on their prenatal and perinatal themes takes more time than baby psychotherapy. Separated treatment of parents and the baby is possible, but not a mixture of the two in sessions that are meant to be for the baby. The goals of PTPB are as follows: (1) healing prenatal, perinatal and early trauma in babies, (2) restoring the self-healing capacities in the baby, (3) liberating the locked-in energy in the organism of the traumatized baby, (4) empowering the baby so that he can better cope with stress, (5) restoring the connection to the authentic Self of the baby, and (6) restoring the connection to significant others in its environment. The PTPB model is based on theoretical assumptions, which stresses the importance of certain conditions and is a combination of cathartic and empowerment techniques. The baby psychotherapy is based on assumptions of the new paradigm on prenatal life (Chaimberlain 2013). In this new paradigm, prenatal children are considered to be sensitive, communicative, active and conscious human beings. We recognize that babies are vulnerable, both physically and psychologically, and that they also have a strong tendency towards self-actualization. They strive to survive and to remain an authentic self. Babies experience from the very beginning of their lives, that is from conception onwards. These very early experiences are imprinted in the organism of the baby. The development of the (prenatal) baby is experience-dependent. Experiences can be not only an enrichment and strengthen the fetus, but also traumatic or shocking. These prenatal experiences can have dramatic and ­long-­term influences on subsequent life events. The body of the baby can remember its early experiences. The body is an expressive communication instrument for the baby. We work with Erik Erikson’s concept of “epigenetic develop-

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ment” (Erikson 1963). Previous critical developmental stages have a lifespan influence and have an impact on the following developmental crisis. For example, prenatal traumas can have an impact on the birth process, or prenatal and birth trauma can impair bonding at birth. We assume that babies can express themselves meaningfully and that they respond to the parents’ and psychotherapist’s feelings, intentions and behavior in a meaningful way. Supporting babies to express themselves, even when this means the expression of very painful memories, is healing to them. By acknowledging their (painful) feelings, we help them overcome their emotional pain. For the healing process, two aspects are crucial: the accurate conceptualization of the baby’s psyche and its expressions, and the catharsis of feelings that are associated with traumatic events. Babies can recover from the effects of the hurtful experiences by releasing their feelings when these feelings are accurately and empathetically mirrored by the psychotherapist and/or the parents. In the PTPB model, we imply the psychotherapeutic conditions as described by Rothschild (2000) for trauma therapy in general. Of primary importance is that we do no harm; we do not want to overwhelm, re-traumatize babies, nor do we want them to decompensate. Safety is crucial; an “accurate empathetic relationship” (Terry 2005b) is a necessary condition for the healing process in babies. Baby psychotherapy is permission-based and containment-based. In baby psychotherapy, babies are allowed to express their pain through trauma-releasing crying. Emerson has called this trauma-crying (Emerson 2000). This is an intense crying by which babies express the pain that was stored in their body during the traumatic situation. Babies are allowed to express themselves through their crying, without being interrupted and within the safety of the psychotherapist and parents, who are present. Baby psychotherapy can lead babies to the edge of their birth memories, and the psychotherapist provides them with options to accept or to refuse their memories at any time. The babies give permission to work with their trauma or not. Babies do have defense mechanisms and these are respected by the psychotherapist. Resistance is seen as a survival

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strategy indicating that the released pain is overwhelming. That’s why it can be wise to slow down the expressive process and to reduce hyperarousal, when babies are expressing symptoms of being overwhelmed. As babies are very sensitive to our feelings and intentions, the psychotherapist must be clear in his intentions. This means that the therapist must have already worked through his personal prenatal and perinatal history. The deeper one has done personal regressive work, the purer our feelings intentions are. As baby psychotherapy can bring babies in contact with very painful memories, containment is crucial, so that within the safety of the relational field as set by the therapists and the parents, the baby can express his anger, sadness and anxiety. The mother must always be present at the treatment; the father can be present. During baby therapy, the therapist is continually monitoring for signs of resistance and refusal, as the work is permission based, meaning that the baby is in charge of the treatment. Emerson calls this baby-centered control. It can be compared with the non-directive attitude of the original client-­ centered psychotherapy (Verdult 2009). To access painful memories also means to strengthen the baby’s ability to maintain boundaries and control. Baby psychotherapy requires accurate empathy (Emerson 1989, 1994; Terry 2005b). As the entire body of the baby is a profoundly expressive instrument, the therapist has to be in empathy with the baby who is telling his story through his body language. In accurate empathy the parents and the therapist can agree on the fundamental emotions being expressed as well as on the nature of other subtleties and details. The psychotherapist is not only reflecting the feelings of the baby but also tries to establish a compassionate contact with the ongoing feelings in the baby. Deep and accurate empathy with the baby’s pain is very healing. With his sensitivity to the baby’s signals and his responsiveness to the expressed pain, the baby psychotherapist can support the baby to go deeper into his pain-releasing process. Empathy and containment go together. What is true with psychotherapy with adults is even more true to baby psychotherapy: the psychotherapist

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

must be in a process of resolving his own prenatal and perinatal traumas (Stroecken 1994; Terry 2005b; Verdult 2009), as babies are very sensitive and they can sense emotional activations in the psychotherapist very easily. In baby psychotherapy, it can be horrific to see the baby go through so much pain. The healing is saving them from a lifetime of pain or preventing dysfunctional behavior, from unresolved trauma emerging in later years. But it can easily activate unresolved trauma in the psychotherapist or parents. As babies are telling their stories about birth and prenatal life, their bodies are the expressive instrument. Structural signals (e.g. malformations of the skull), psychodynamic movements (e.g. restless movements in the legs), shock patterns (e.g. contracted body or hyperactivity), physical symptoms (e.g. breathing patterns), communication patterns (e.g. avoidance of eye contact), energetic symptoms (e.g. cold feed) and avoidance attachment patterns (e.g. the rejection of contact with the mother) can be observed. After the emotional release, schematic re-­ patterning is the next step. This is called the process of re-patterning. The movement patterns that babies use to get born are deeply embedded and retained in the nervous system and body. The psychotherapist offers babies the opportunity to reexperience their birth as it should have been from the perspective of his biological birth program. Babies can focus on body sensations and bodily felt feelings and work through the emotions of these new experiences, namely the releasing of his traumatic pain and the re-­experiencing of how their birth should have been. During this inner process, new neurological connections are being built in his brain changing his original traumatic experience for ever. Re-patterning can make other painful memories accessible. As the body psychotherapist Al Pesso has stated, when he spoke of impersonating ideal parents in his therapeutic work, re-patterning is not superficial role-playing for clients but it can really bring changes in the experiential world of clients (Pesso and Crandell 1991). This is also true for babies. Re-patterning their births as they should have been from the evolutionarily programmed process of being born is healing for babies.

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In the French tradition of baby therapy, giving words to the experience of the baby is considered to be extremely important. Francoise Dolto and her pupils Eliacheff (1995) and Szeyer (1997) stress the importance of giving words to what the baby has experienced (Verdult 2009; Verdult and Stroecken 2010). Babies can listen intently to what they are being told about their birth and prenatal history, if the psychotherapist is able to formulate the story in an empathetic way. It is not just talking, using words, but making an emotional contact with the baby through words. Dolto assumes that babies are able to understand language if the words used are related to their experiences and if the words are used in an empathetic way. In case of IVF/ICSI babies, the psychotherapist gives words to the anxiety that they have experienced, to their anger about being manipulated, about their loneliness felt in the womb, or about the very deep longing for an undivided Self. The psychotherapist is the advocate of the baby and gives words to the painful memories.

Baby Psychotherapy With IVF/ICSI Babies There is no such thing as the treatment for IVF/ ICSI babies. All the potential traumatic experiences can be addressed in PTPB. It depends on what the baby is telling us during the treatment sessions. There are many individual expressions through baby body language. We first address what is called the primary presentation. This is the more persistent and more frequently shown gesture of trauma in the baby, which is an indication of where in the body the trauma resides and what possible themes may be connected to these signals. The primary ­presentation can be regarded as a message or request from the baby’s psyche to work with these signals and themes. By repeating his signals, it seems as if the baby wants to underline what he wants the psychotherapist to work with. If there is no clear primary presentation, we work on the most recent traumas first and then go further back in time; for example, we first work on birth trauma, then in the next session perhaps on

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implantation, and sometimes a few sessions later on conception. In case of IVF/ICSI babies this often occurs, as they are confused about their body sensations and bodily felt feelings. This implies that we work from NICU admission to birth, to prenatal stress in the second and third trimester, to implantation, to conception and preconception. The psychotherapeutic process goes further and further back in the history of the baby and goes deeper into their feelings. As described earlier, according to Erikson, every major developmental crisis influences the next step in development. This implies that in the psychotherapeutic process of a developmentally later step (say, for example, birth), we can already see the influence of a developmentally earlier step (say, for example, implantation). If we work with a baby on the experience of its mother’s stress during pregnancy, then it might be possible to see and observe body signals that refer to conception trauma. As we work with the body language as shown by the baby’s gestures, movements, body postures, tensions, or facial expressions, a warning needs to be observed. Linear interpretation of baby body language can be dangerous. One-to-­ one interpretations of body language can overlook the deeper meaning of the bodily expressed emotions. Therefore, it is always important to keep looking at the coherence of several signals. As a psychotherapist we always work with hypotheses; we assume that the baby is expressing a certain theme and we look for confirmation by the baby to see if we have interpreted it correctly. The baby always guides us through the themes he wishes to work with. We use Carl Roger’s non-directive approach in which empathetically following the baby’s story telling is crucial. His emotional expressions tell us how deep in pain he or she is, and the body language gives us indication about the possible content of the theme. The psychotherapist uses his knowledge and experience of the prenatal child and baby within himself. Without having worked on the inner baby or inner prenatal child, the psychotherapist can easily be misled or he can easily project his own unresolved issues on the vulnerable baby.

NICU Admission As we have seen, NICU admission disturbs the attachment relation between baby and mother. We often see insecure-avoidant attachment patterns in IVF/ICSI babies. As they have been confronted with so many different adults, they find it difficult to differentiate between attachment figures. Also, the lack of boundaries can be seen, especially in premature NICU-admitted babies. They can become more attached to objects than to people. Pain evoking medical intervention makes the baby tactile defensive. In the course of the treatment, we pay a lot of attention to making contact with the baby. Sometimes it takes more than half of the session before we get permission from the baby for physical contact, especially when the baby has been on the NICU for a longer period. We first have to build basic trust. When we have the permission of the baby, we usually touch those body parts that seem most safe for the baby to touch. We avoid body parts that are related to painful experiences, like for example the hands where the infusion needle might have been, or the heels that can be a trauma site because of the frequent heel sticking. We want to reassure the baby that being touched can be safe. We advise parents to kangaroo their baby or to do baby massage, only if the baby can tolerate the intensity of such contact methods. Feelings of loneliness and abandonment have to be addressed too. We can see this in the eyes of the baby. This can be hard for the parents, but for the baby it is important that these feelings are recognized. Giving words to the baby’s feelings is important. In my opinion, the best way to restore attachment is by working through the baby’s trauma so that he can become more open for parental love and empathy. Trauma closes the baby for affection.

Birth Trauma As we already saw, IVF/ICSI babies are very frequently born premature, needing many medical interventions. For the therapeutic work on

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

birth trauma, I wish to refer to William Emerson (1998). More than 50% of IVF/ICSI babies are born by pre-labor cesarean delivery, like Louise Brown. In the treatment of cesarean or c-section babies, two aspects of the cesarean delivery experience are important: the sudden, unexpected and invasive interventions and the lack of the experience of a vaginal birth (Verdult 2009). Based on the Emerson-Terry model, we first make a reconstruction of the birth experience, followed by a re-patterning process. By observation of the baby’s gestures, movements, postural signs, skin reactions and facial expressions, we try to figure out how the baby was born. In the case of c-­section, what was the position of the baby before the c-section started, where did the obstetrician touch the baby after opening the womb and how was the conjunct pathway through the incision? By simply touching trauma sites, we can activate the trauma. Releasing the emotional pain within a safe and containing relation is important. C-section babies also need to experience a vaginal birth, as this was the biologically programmed way to leave the womb, and this energy must be dealt with (Verdult 2009).

Maternal Prenatal Stress The psychotherapeutic concept of maternal stress is called, after Mott and Lake, umbilical affect, which is the feeling state of the fetus as brought about by maternal blood reaching him through the umbilical vein. As the protection conferred by the placenta against toxic agents is not complete, the fetus needs to develop a defense mechanism to protect himself against toxic agents that pass the placenta. Nathanielsz (1999) called this mechanism shunting. Toxic agents such as maternal stress hormones can damage the developing brain or the heart. These crucial organs need to be protected. Therefore, toxic agents are shunted to the extremities, most often the legs. They are shunted caudally to the tail and feet. In IVF/ICSI babies, first-trimester umbilical affect can be observed. In the first trimester, women pregnant with an IVF/ICSI baby experi-

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ence more anxiety and they may find it difficult to connect to their baby. As the pregnancy develops, the mother is more reassured that she is not going to lose the baby. In IVF/ICSI babies we often see that their hearts are closed more often. The head over heart position in which the prenatal baby spends most of its life facilitates a natural defense gesture. Due to prenatal stress, head and tail contact more toward each other, pinching off the umbilical region to reduce the flow rate of incoming toxic placental blood (Terry 2011). Their breathing is short and superficial. The diaphragm can be tense, resulting in what we call umbilical breathing. The abdominal muscles, like the psoas muscles, are tense too, resulting in contractions in the legs. Later in pregnancy the fetus will arch to defend against toxic agents. After the baby has been born, symptoms of maternal stress in the baby are restless arms (“conducting”) and legs (“pedaling”). Especially during feeding the baby may arch. Also, the heart is more closed and the baby reacts strongly on interventions that cross his boundaries. As the psoas muscles can be polluted by toxic agents, the upper-lower body connectivity can be disturbed. By using specific trigger points on the muscle chain in which the psoas plays a key role, umbilical affect can be activated and released.

Twin Loss Twin loss can occur spontaneously or as the consequence of reductive abortion. In IVF/ICSI procedures, especially with women over 35 years of age, more often two embryos are transferred, thereby creating the more risky twin pregnancies. Twin loss can activate a mourning process in the surviving baby. When this process is not ­recognized, it leaves the baby with feelings of abandonment and loneliness. It is also important to be aware of the fact that the surviving baby has lived in the same conditions as did his deceased twin half. This implies that the surviving twin can have the imprint of a near-death experience. In PTPB we have to deal with bereavement feelings, like sorrow, anger, loneliness and with anxiety resulting from possible near death. These feel-

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ings can be activated by looking for the trauma site where the lost twin and the surviving twin have been connected to each other. This trauma site can be energetically observed. Sometimes we use a doll, symbolizing the lost twin. The accurate empathy and openness on the part of the psychotherapist are the crucial aspects of the twin loss treatment.

Implantation Implantation is a crucial biological and psychological process in every prenate’s life and, as we have seen, it certainly is in IVF/ICSI babies. In every baby psychotherapy this is an essential part of the treatment. As implantation can leave a near-death imprint, it certainly needs to be worked through carefully. Emerson has discovered that the forehead is a trauma site related to implantation (Emerson 2000). Typical movements can be observed. It seems as if the baby wants to creep into their mother’s endometrium again, whereby they dominantly make contact with her body with their forehead. Attachment patterns can be observed in this process: ambivalent, avoidant, and disorganized. The movements differ from birth movements where the baby wants to go through the birth canal; in implantation they want to go into their mother’s endometrium.

Embodiment The goal is to restore and/or to establish the connections in the baby’s body. This work needs to be combined with trauma treatment. If in IVF/ ICSI babies the trauma of conception is not worked through, then the body has the tendency to return to its old trauma postures and movements. Disembodiment is expressed in fragmented and rigid movements, gazing or vacant eyes, low energy as in a parasympathetic pattern, with little or no exploration, no deep breathing. To treat embodiment trauma in IVF/ICSI babies, we use techniques that can be compared with Bartenieff fundamentals (Hackney 2002).

R. Verdult

As described earlier, early embryonic growth starts with a “core,” from where further development is oriented around two crucial body axes, namely the dorsoventral axis (back/front) and the rostrocaudal (head/tail) axis. According to Bartenieff (Hackney 2002), a baby needs to have a sense of its own center or core, before it can move into the world. Core-distal connectivity, the connection between the center of the body and the six extremities (arms, legs, tail and head) is a deep pattern with the baby’s body that is there to support basic relationship in rhythms of coming into oneself and going out toward others in the world. Core-distal connectivity is associated with themes about the inner and outer world, like “me-­ not me,” “in-out,” “towards-away,” and “take in-­ take out.” In order to restore or achieve an inner connectedness, the baby needs to find core to distal relationships. This connection is also called “naval radiation.” It is a pattern of radial symmetry with the center of control in the middle of the body. The baby’s primitive, pre-vertebrate movements are oriented from this “naval radiation.” “Closing” and “opening,” or “condensing” and “expanding,” are body patterns associated with core-distal connectedness. Baby massage techniques can be used to restore the core-distal connectedness. Moving the baby’s body in closing/ opening positions can be helpful. We also concentrate on the head-tail connectivity. As the rostrocaudal axis or midline is almost coinciding with the spinal column, it is important to check the support and flexibility of the spine. The spine in IVF/ICSI babies can hold a lot of tension, for example, in the spinepelvis-­femur structures, this tension reduces the flexibility and support of the pelvis and spine. Movement patterns that are associated with “support” are “yield and push” patterns, which are linked to grounding. We often see IVF/ICSI babies that are not grounded. Through “yielding” or giving in to gravity, the baby is connected to the earth and to itself. Through “pushing,” the baby compresses the body, thus stimulating proprioceptive knowledge and a sense of bodily self. These movement patterns are disturbed in babies that are not embodied. Developmentally, “yield and push” patterns pre-

The Psychotherapeutic Treatment of IVF/ICSI Babies: A Clinical Report

cede “reach and pull” patterns. They are associated with the ability of going into the world and of moving into space. When the baby reaches out towards somebody or something, he is connecting to the world beyond its own kinesphere. His attention is focused outward and he is developing the capability to move into the environment as he is reaching and pulling. As a result of their embodiment problems, the head-tail connectedness is not well established in IVF/ICSI babies and this is expressed in disturbed reach-­ pull patterns. In general, to find inner connectedness in its body, we need to move the baby in such ways that he can find his core to distal relationship and his head-tail connectivity at a spinal level. These connections seem to me most fundamental for disconnected babies, like IVF/ ICSI babies often are.

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experience in IVF and ICSI conception. The IVF procedure forces the egg to leave the ovaries; in the ICSI procedure, the egg is raped. In the trauma confrontation stage, it is possible to observe body contractions in the baby that may refer to the egg’s rape. Special attention is required from the psychotherapist not to force the trauma confrontation. Paying attention to reactions that the baby shows by way of their body temperature is also important. As Emerson (2000) pointed out, shock is temperature. Being conceived in a non-affective, “cold” petri dish can be re-experienced as getting cold, in shivering all over the body. In the resourcing stage we use warm and tender body contact to overcome the trauma of the forced and cold conception.

Treatment Outcomes

Although it is hard to speak of results in psychotherapy, I can confirm that most of the IVF/ICSI In the trauma confrontation stage of the baby babies we have treated have improved. They psychotherapy, we explore the sperm’s and egg’s show less symptoms (e.g. fewer sleep disturhistory. Special body movements can be seen as bances or fewer eating problems) and seem less an expression of these traumas. If we look at the frustrated, more content. Mothers often report baby’s conception from a sperm perspective, that they can make an easier and deeper connecbeing able to move around and finding direction tion with their baby. The babies seem more are crucial characteristics of sperm. The move- expressive and seem to have a deeper connection ments of the sperm’s tail can be recapitulated in to their bodily felt feelings. This is a clinical the leg movements of the baby. Finding direction statement not based on research. William is recapitulated in being oriented both in the body Emerson (2000) did research on the treatment and in the environment. In IVF children more outcomes of baby therapy and compared these traumatic energy is expressed in restless legs, as outcomes with a control group. He found signifiin ICSI babies we see more constrained legs that cant positive effects of the treated babies comcan hardly be moved and are more disconnected pared with untreated children. There were fewer from the body. That is why we use more stress-­ psychological and somatic symptoms and more releasing techniques in IVF working from the personal growth towards the authentic self. The naval over the psoas muscles to the ankles. For treated babies showed more human qualities, like ICSI babies, activating techniques are used in more consciousness, more emotional expression, order to get their bodies moving. Activating leg more joy, more self-confidence, and more cremovements can release traumatic stress. In the ativity. Emerson was able to do a follow-up after resourcing stage of the treatment, we use restor- 13  years and the children still showed positive ing head-tail connectivity movements for both effects of the treatment. The research can be IVF and ICSI babies. questioned on methodological and statistical If we work from an egg perspective, being grounds, but it still gives an indication of potenforced into conceiving and the coldness of the tial possible outcomes of baby therapy. We have environment are the major characteristics of the the impression that IVF/ICSI babies show posi-

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tive changes after treatment, but not as much as do naturally conceived babies that have had prenatal and birth trauma. This seems to be in line with the idea that the earlier the trauma has taken place, the more difficult it is to heal. The IVF/ICSI babies need more sessions and the effects are often more limited. The fact that they have a traumatized connection to their body makes the process of emotional expression more difficult and makes the process of working through their pain also more difficult for them. To give bodily meaning to their deep pain is profoundly disturbing to the baby and to those who are watching. IVF/ICSI babies show a very deep longing, which Emerson would call “divine home sickness.” This deep existential longing is a longing for being undivided, a longing for an undivided consciousness. As the emotional split originates from a very existential moment in our life, namely pre-conception and conception, IVF and even more so, ICSI babies show a deep pain, reflected in their eyes, of disconnection to their inner selves, and by this to others. We observe more avoidant attachment patterns in the IVF/ICSI group than in the total group of the treated babies in our practice.

Conclusion Although on a psychosocial level no differences have been found in IVF/ICSI babies in comparison with naturally conceived babies with conventional research to date, in my clinical experience, with 40 IVF/ICSI babies I have found deep traumatization, mostly connected with conception, implantation and embodiment. With rising numbers of ART babies, we need to research the more deeply rooted traumas of these children and develop new psychotherapeutic methods to treat them. Therapeutic treatment is, in my experience, necessary as the IVF/ ICSI procedures imply potentially traumatic events. The authentic Self in IVF/ICSI babies has turned into a divided Self very early in prenatal life, disconnecting them from their soul and body.

Even, overlooking the potentially traumatic aspects of ART, I have the impression that ART can be considered to be a serious departure from the optimal “environment of evolutionary adaptedness.” Or, as Bruce Perry would say it: “We are now living in a world that is disconnected from the rhythms of nature and although this modern world is a product of the human brain’s capacities the human brain is not designed for the modern world” (Svalavitz and Perry 2010). To say it in another way: ART differs so much from our evolutionary history and is so alienated from our evolutionary biological programs of conception, implantation and birth that it may be considered as serious a threat to the health and well-being of the children involved as to mankind in general. This conclusion is not based on religious beliefs but on clinical experience. I would not go as far as some therapists who say that IVF/ICSI children and their offspring are developing a subspecies of mankind. At the same time, I would like to state that these children do need psychotherapeutic support to work through their deeply rooted traumas in order to heal their soul, psyche and body.

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Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy Rupert Linder

Introduction In the following contribution, practical experiences are reported from the daily work in a combined obstetrical and psychotherapeutical office. This is demonstrating how trans-generational aspects can profoundly influence the situation during pregnancy and birth. In doing so, it is illustrated how the observation of methodological levels (see Chap. 2) can be helpful in prenatal psychology. This also holds true for dealing with psychosomatically significant illness during pregnancy, about which is reported more extensively. To make understanding easier, it is necessary to know something about the situation of the described practice. I have been practicing in Birkenfeld, near Pforzheim, for more than 30  years and specialized in gynaecology and obstetrics as well as in psychosomatics and psychotherapy. I work on the basis of psychodynamic psychotherapy and I endeavour to fundamentally integrate these two sides in the daily work. Birkenfeld is a community with a population of 10,000, situated at the north of the Black Forest amidst woods with the small river Enz flowing through the valley below. The town of Pforzheim is just next to it. R. Linder (*) Gynecology, Obstetrics and Psychotherapy, Birkenfeld, Germany e-mail: [email protected]

In the course of psychotherapeutic training, I have gathered a lot of experience in single and group psychoanalysis and have also concerned myself intensively with body psychotherapy, in particular with ‘Funktionelle Entspannung’ (functional relaxation, according to Marianne Fuchs). Additionally, I have successfully completed a training to resolve pre- and perinatal trauma with Karlton and Kathryn Terry. Of particular interest to me are solution-oriented, salutogenetic and system-oriented approaches. Scientifically, I have worked principally with the psychosomatics and treatment of premature birth (Linder 1997, 2006, 2010). Supportive maternity care and assisting at home births have been further priorities in my work (Linder 1994, 1998; Linder and Klarck 1996). My understanding of the trans-generational aspects of problems during pregnancy and birth was increased by the conference ‘Liebe, Schwangerschaft, Konflikt und Lösung  – zur Psychodynamik des Schwangerschaftskonfliktes’ (‘Love, Pregnancy, Conflict and Solution – on the psychodynamics of conflict during pregnancy’), which was held in Heidelberg in 2006 (Linder 2008). This dealt with the deep-seated background sources of conflict during pregnancy, the survival of attempted abortion, ambivalence in contraception and the origins of these conflicts, which can make themselves felt over many generations. I wish to tell you about examples from my practical experience, of which none are sim-

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ple, as is often the case in reality; somewhere between black and white, as life mostly is. It will become clear how important the extended prior history is in evaluating the problems in the current pregnancy situation. Here, the observations in gynaecological practice correspond exactly with those of bonding analysis (Hidas and Raffaj 2006). What bonding analysis observes on the inside, as it were, reveals itself to the gynaecologist on the outside with all the complexities of a real-life situation. Due to this complexity, the conclusions of the ISPPM conference in 2007 on the methodological levels in prenatal psychology are helpful (see chapter “ Methodological Levels”). The starting point was the need or requirement that it is necessary to analyse which levels we are dealing with in prenatal psychology and at which level we are working. The clarification of the methodological levels is important not only for working with pregnant women but also for working with infants or adults regardless of whether in the field of psychotherapy, medical situations, the work of midwives or other socio-therapeutic or socio-medical fields. It was important to identify these levels and to consider their significance. There are five of these levels: 1 . The quantitative level 2. The qualitative level 3. The level of empathic insight 4. The level of practical knowledge of professional groups 5. The level of cultural psychological comparison In practice, it is of utmost importance for the unborn child’s interests that the carers take into account and balance all five of these essential levels in their work in order to do justice to the reality of the child’s life. The subsequent case histories will demonstrate how these levels are always present simultaneously and have to be newly balanced according to the situation. First, however, as background information I would like to identify the most important psychosomatic problem areas that the gynaecologist has to take into consideration.

R. Linder

 hysical Illnesses During Pregnancy P with Psychosomatic Aspects In the following psychosomatic problem areas, psychological aspects play a greater or lesser role in each case. It is necessary to clarify these individually in order to gauge the possibilities of psychotherapeutic/psychosomatic treatment: 1. Threatened miscarriage 2. Status after recurrent miscarriage 3. Morning sickness 4. Premature contractions/premature birth 5. Preeclampsia 6. HELLP syndrome 7. ‘Symphysial slackening’ pelvic pains 8. Breech presentation 9. Dealing with overdue delivery 10. Postpartum mastitis In dealing with women after recurrent miscarriages, I thank Dr. Zeeb for the following literature extracts, which show that the chances of a woman carrying the child to term increase by more intensive accompaniment/supportive care from 30% to over 70% (Stray-Pederson and Stray-Pederson 1984, Lidell et al. 1991, Clifford et al. 1997). Morning sickness, which is often difficult to access psychotherapeutically, is mostly alleviated by drip feeding and supportive care. Premature contractions and threatened premature birth are of particular interest due to their importance in health politics, as almost half of all perinatal complications and child deaths are due to premature birth. Consequent implementation of psychosomatic–psychotherapeutic possibilities of treatment, as outlined elsewhere (Linder 1997, 2006), could be of great significance here. Some aspects of this work are pointed out in the case histories II, III and IV. In this situation, it is necessary to bring together a profound medical and psychological judgement. A threatened premature birth should be regarded within the entirety of physical and emotional conditions. Medical intervention consists of reduction of strain (notification of sickness, home help, more bed rest), medication (home-

Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy

opathy, aroma therapy), rarely Arabin cerclage pessary (Abdel-­Aleen et al. 2013, Acharya et al. 2006, Alfirevic et al. 2013, Arabin and Alfirevic 2013, Quaas et al. 1990) or only very rarely hospitalization. Psychotherapy will help for relief from demands, better balance of tensions, overcome fears, increasing resources and improving security. In the end, it needs the consideration of all the five methodological levels. The diagnostic consideration of preeclampsia and HELLP syndrome as a psychosomatic illness is important because we are dealing here with life-threatening illnesses for mother and child that can only be treated by emergency caesarean section. However, in my experience there are strong indications pointing to psychosomatic factors for which a therapy can be considered in advance of a new pregnancy. They can be described in a synopsis of current knowledge about implantation time with psychological findings of patients affected by preeclampsia or HELLP syndrome. They show striking interrelations (see next chapter, Linder 2014a, b): “The lifelong fundamental question is: how is life in a relationship possible? Here a second-generation trauma is being dealt with, because the origin lies in the severe traumatization of the grandmother. She was apparently so unconsciously trapped in shock that the pregnant daughter remained so shocked in the areas of her motherliness that she could not enable the implantation and vascularization processes to take place adequately enough”. A new insight is the psychosomatic background to symphysial slackening or pain. Here, profound conflicts in the relationship between the pregnant woman and her mother, stemming from the embryonic and foetal stages, often seem to play a role. Dealing psychosomatically with overdue birth is a delicate subject and requires the integral consideration of psychological and physical aspects. The understanding of postpartum mastitis as a typical psychosomatic illness, resulting from the inability to cope with excessive psychological and physical demands, is now common to many obstetricians and midwives. When ascertaining psychosomatic interrelations in gynaecological consultation, it is impor-

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tant to have a particular attitude which is open for every methodological level and in particular for the dimension of pre-verbal life. Here is a short explanation of this.

Perceptive Attitude in Gynaecological Practice Prenatal psychology has taught us how important the early pre-speech stage is. Pre-verbal experience can express itself in dreams, emotions, moods, bodily sensations and feelings, as well as in scenic realization. Here, I want to expressly include associations and re-stimulation. We know from the experience of Balint groups (groups of physicians who meet regularly and present clinical cases in order to better understand the physician–patient relationship) that the background of a problematic situation can reveal itself in the group. And it is exactly these aspects, which are sometimes seen as chaotic and perhaps hard to digest, that are of psychodynamic importance. They are, therefore, an important diagnostic instrument. This can also be observed in the subsequent case histories. There are not always instant right answers; some questions remain open. Sometimes it is not possible to pigeonhole things. This is why openness, enduring not knowing and repeated appointments are so important. What might remain unclear in one session can be understood in a later one. What is not possible in one session can happen of its own accord in a later one. Gynaecological action can only arise from an understanding of the whole situation based on the interactions of the relationships in consultation. Here the fundamental setting of gynaecological practice is analogous to f­ree-­floating attention in psychoanalysis, although there the patient brings into the session the totality of a concrete life situation in free association with different levels of their communications and behaviour, including bodily expressions. As a result of the great responsibility in understanding and taking action, a special intensity develops in the diagnostic and therapeutic situation. This exceeds

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the bounds of the normal psychotherapeutic situation and requires the gynaecologist’s presence and the permanent re-evaluation of experiences and perceptions.

Case Histories Case histories deal with ongoing therapies, as interconnections can then be more vividly and authentically described. I would like to point out that I have to present the complexity of the cases as they exist so that you can comprehend how it is eventually possible to distinguish the important dynamically effective aspects that then facilitate sensible action. This happens in a kind of circular process. When one particular aspect becomes comprehensible, the therapist can then provide a stimulus relating to it, creating a new situation that facilitates new possibilities of understanding, and this in turn activates a further level. This process repeats itself several times. The whole thing has similarities with the mechanisms of a psychotherapeutic process, only all levels of reality are present. In addition, it could almost be said that the structure of this process is similar to the dialectic process described by Hegel with the progression from thesis to anti-thesis and then to synthesis, which in turn becomes the starting point for a new dialectic triple step.

 ase History I—Denial of Pregnancy C in the Prior History and its Repercussions Mrs. A., in the second half of her twenties, lived together with her friend. She came to me in the 24th week of pregnancy with severe morning sickness requiring a certificate of illness. She was in her third year of nursing training. It soon became obvious that she also had a drug problem. She had smoked a lot of marijuana. In passing, she said that she always had problems concluding things. This was a spontaneous statement, the significance of which would later become clear from her past history.

R. Linder

To begin with, I gave her a certificate of illness in order to take pressure off her. She was not able to give up smoking for the whole length of the pregnancy. We kept talking about it: sometimes it seemed as if she had managed to stop, then it was clear that she had not. Luckily, this point turned out to be not that important as the child was developing well. The ultrasound examinations never revealed any developmental deficits. I gave her an anamnesis questionnaire about her biography to fill in. These questions—among others— appeared on it: 1. Particularities during the pregnancy (your mother with you)? 2. How did the birth progress? 3. What about the months afterwards? 4. What do you know about your parents’ relationship at the time? The prior history of this patient is special because on the questionnaire she described how she had been conceived. Her mother had her first child at the age of 17. She was the second child, conceived during a chance encounter with a man at a summer festival 200 km away from her home. Her mother had denied the existence of the pregnancy, although she already had a child and must have been familiar with all the changes and the child’s movements within her. Apparently, no one around her had noticed anything. There must have been some awareness somewhere, but it had quickly vanished. In the end, she went to hospital with suspected appendicitis. This was the birth of the woman who was now herself pregnant. Therefore, it was fitting that she said “I can’t conclude things”. I find this very logical in view of the mother’s transference when seen from the trans-generational viewpoint. Now, this is how it continued: unfortunately, she developed severe gestational diabetes. I am not depicting this from a theoretical viewpoint, but from the practical viewpoint as things developed in my practice where all the background elements of the different levels are always present and significant: the quantitative, qualitative, empathetic, the level of practical knowledge of professional groups and the level of cultural psy-

Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy

chological comparison. Mrs. A. had in many respects, as could be expected from her prior history, a way of refusing to believe things. She visited the diabetes doctor irregularly (I worked together with an internist-diabetologist). She also had difficulties keeping agreements and missed appointments because “her mother or friend hadn’t given her a lift”. These are the kinds of things that frequently happen when there is a background problem with drugs. To begin with, she often did not have the sheets with her daily blood sugar measurements with her. She gradually managed to improve measuring and bringing the results with her. For a long time, she was undecided if she wanted to have a home birth or not. But in the end, the diabetes and the necessity of intensive monitoring of the child made delivery in the clinic advisable. The delivery date was 1 week overdue, which, in the case of diabetes, required greatly increased attention and patience. However, the delivery went well and Mrs. A. was very happy and contented. I have to add here that it was not possible for the patient to come to terms critically with her mother because she was too dependent in reality on her mother and her support. I did, however, keep bringing up the subject cautiously. I hope it has become clear that the whole situation of the patient and the supportive care during pregnancy was overshadowed by the denial situation in the time before her birth. Knowing about this well facilitated caring for her under the given circumstances. Without this holistic approach, there was a danger that individual aspects could cause one-sided interventions, which in their turn would cause a chain of further reactions, which could have had severe consequences.

 ase History II—Repercussions C of Being Unwanted in the Prior History Mrs. B. was 43 years old when she came under my treatment. It was her second pregnancy. Her first child, a daughter, was born 17 years earlier.

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She required prenatal diagnosis on account of her age. Due to anomalies in the region of the neck, I advised further clarification by standardised ultrasound screening with a colleague. He then calculated her risk factor. Going by age alone, this was 1:25 that the child had Down’s syndrome and after the examination 1:15, that is, even higher. We then discussed the matter, and after a detailed process of information, she wanted no further diagnosis carried out. It was noticeable that she always had a radiant smile on her face when she believed in the intactness of her child. Parallel to this, there was a serious crisis with her partner that led to a separation. She had to go through a lot during the process. In relation to this, premature contractions set in, which, however, disappeared after the strain had been relieved by the discussions and temporary certification of illness. She was always able to regain courage and bore the child normally. The collapse came 6 months after the birth. She then had a mental breakdown and I made an application for formal psychotherapy. In this context, it first became apparent to what extent the issue of being unwanted was important to her: she was the fourth child; the mother had got pregnant against her will by the child’s alcoholic father. She kept arriving at the point where her feeling of security threatened to breakdown, which resulted in her feeling that she simply was not able to look after her child. She said she sat in her flat and could do nothing—regardless of whether the child cried or not. She had also started smoking heavily again and was not eating regularly so that she finally weighed less than 50 kilos. This depressive psychosomatic reaction had been triggered by the fact that the father of her child had promised her a certain sum of money and not kept to it. She felt that she was just hanging in mid-air. The ­non-­appearance of the money had triggered her own prior history of being unwanted. Another impression was that when she railed against the father in her distress, often the child was with her and started to scream. We were then able to discuss this and she was able to understand it. Of course, she still has much to come to terms with and it went on in the continuing psychotherapy.

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 ase History III—Pregnancy After C Endometriosis Ms. C, 36 years of age, came for the first time to my gynaecological practice, on the recommendation of relatives, after missing a period. She was a very well-groomed, if somewhat emotionally reserved, woman who had worked for more than 12 years in a higher grade of the civil service. She complained of dizzy spells and nausea. While going for walks she had to stop over and over again, “It’s as if my feet were being pulled out from under me.” A sick line was issued for her. Her previous history: 5  years earlier she had undergone months’ long hormonal treatment (artificial change to the menopause) due to extreme endometriosis (dispersion of endometrial mucosa in the abdomen). During several operations in 1 year, the foci in and around the ovaries as well as part of the large intestine had been removed. It had even been necessary to give blood transfusions during the operation. In an earlier marriage, she had not become pregnant despite the wish to have children, especially on the partner’s side. Now, in a new partnership and marriage in which she feels very happy, the pregnancy had occurred without further treatment. After 1  week, bleeding had started. An ultrasound examination showed an intact pregnancy. Prescription of a homeopathic remedy (Crocus) was given. This recurrent bleeding remained a problem during the next weeks. Naturally, further sick lines were required (this remained so until the start of maternity protection). There was, however, reason for definite concern, calling for ascertainment of biographical history. This included again the anamnesis questionnaire with the aforementioned questions (see above—case I). Her past history was unique: her mother had also suffered from severe endometriosis 7 years before her birth. During the operation, one ovary was removed totally and the mother was told that a pregnancy was not possible after this operation as the rest ovary was only capable of a minimal hormonal function. Unexpectedly, she became pregnant with Ms. C.  There was also recurrent bleeding at the beginning of the pregnancy (threatened miscarriage). Inpatient treatment in

R. Linder

the hospital and hormone injections were necessary to maintain the pregnancy. Ms. C’s birth was absolutely normal although her mother had great problems in breathing through the contractions, due to the pains in her lower abdomen. Four months after her birth, a hip dysplasia was diagnosed, which required wearing a splint for a long time. Ms. C’s education and social development progressed well through her early years. From the past history, it should be mentioned that her father has, for a long time, been mentally affected by depression, which puts her under mental strain. Noteworthy, in her father’s past history is the very early loss of his father in the war as well as later the loss of his mother through suicide. To return to Ms. C’s pregnancy: the bleeding occurred on and off until the 13th week of pregnancy. At the same time, we were involved in discussion of her own situation as an embryo; her own endangerment during this time. Her mother’s astonishment at becoming pregnant so surprisingly similar to her own, adding to the anxiety about everything would go well. Later, in the 30th week of pregnancy she developed a much-­ shortened cervix: ultrasound length of cervix 26  mm. Therefore, an Arabin cerclage pessary was inserted, which she tolerated well. In a discussion with her husband, a prenatal and perinatal traumatic experience also emerged from his past history: his mother conceived him at a very early age. At the same time, a pregnancy among his relatives ended unhappily in the death of the child. He himself was born 6 weeks early weighing 1500 g (also small for the date) and lost a further 200 g after birth. Ms. C was introduced early to the chief physician of the obstetric clinic. This proceeding is particularly to be recommended in more complicated cases. The background personal history was mentioned candidly and the hospital colleague related in his very careful and empathic discussion report the plans to enable everything during the birth to proceed as normally as possible. Further progress was normal with removal of the Arabin cerclage pessary in the 36th week of pregnancy. However, a positive test for B. streptococcus in the vagina presented a complication. Ms. C reported many

Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy

dreams with birth scenes in which, although labour progressed rapidly, she would reach the clinic in time. The pregnancy exceeded the arithmetical birth date. At this time, a noticeable drop in the heart sounds (85 beats/min) in the cardiotocograph (CTG) caused some alarm. After delivering the data to the hospital colleagues, we came to the conclusion that this occurrence could be interpreted as being caused by a simultaneous continuous contraction of the womb. The next day, Ms. C was examined in the hospital thoroughly and in detail with ultrasound. The plan remained to continue close supervision, but no action. Three days later a healthy boy of over 3600 g was born spontaneously. However, due to an infection, he had to be transferred with his mother to a neighbouring hospital with a paediatric clinic. There the inflammation values went down within a few days and Ms. C was able to be discharged in good health within a week and went home with a healthy child. She was very happy about this outcome and was radiant at the first follow-up examination. The child had gained weight well and she obviously had good contact to him. Breast feeding had, however, not been greatly successful, only partial and for a total of 4 weeks. In reply to criticism on this point regarding the short duration of breast feeding, I would point out how many critical obstacles Ms. C., her son and her husband had been able to master well despite the very difficult past history. In order to lessen mental stress, I consider it counterproductive to turn the question of breastfeeding into a problem. Perhaps in the case of another pregnancy she can still achieve progress in this respect.

 ase History IV—The Effects of a Lost C Twin in Prior History Ms. D. was 27 and had got pregnant unexpectedly. She had not expected it because she suffers from Crohn’s disease and had 20 operations on her abdomen and intestines—including an anal extirpation—and lived with a stoma. She came in the 24th week of pregnancy, complaining of

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stomach pains and wanting a certificate of illness. This seemed to me to be a sensible way of relieving strain as she seemed to be overstressed and there was a suspicion of premature contractions despite her fundamentally marked commitment to her work. The emotional and/or physical overtaxing of women is a frequent cause of premature birth, and this is often underestimated. After 2 weeks, everything had calmed down. Ms. D’s record revealed that she had previously suffered from pronounced neurodermatitis and it transpired that her mother had assumed she had a miscarriage due to bleeding early in the pregnancy with Ms. D and thought the pregnancy was over. The mother had turned out to be wrong and in the end the patient had then been born. The situation of the lost twin and her own endangerment was discussed with her at length. She had made it but her twin had not. She was able to take in the interconnections. It appears the therapeutic efficacy of the psychosomatic work lies in the fact that people are enabled to talk about their traumas and can share the feelings. So, it was in this particular case and the further progress of the pregnancy went well. There was a question about the form of birth, that is, how she was going to deliver the child, was still unresolved. Her surgeon, in whom she has great confidence due to her years of illness, voted for a caesarean section due to the scarring caused by the operations for Crohn’s disease. On the other hand, the womb was the only undamaged organ, so there was the question if should it be subject to this operation? However, the patient decided to have a caesarean section due to the traumatization of the many operations, in the assumption that her maltreated pelvic floor would better be spared. And finally things went well. Another most helpful example is the case study Ms. O in chapter “ On the History of the Pregnancy Conflict.”

 ffects of the Application of this E Method First for the Cheek Memorial Lecture at the 2009 APPPAH Congress in Asilomar, it was possible to present own results (Linder 2010). This survey

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was further extended in cooperation with Dr. Simon Müller and Dr. Jürgen Dippon from the University of Stuttgart, Institute for Stochastics and Applications. The data of all 1189 pregnant women receiving prenatal care in the years 1987–2012 were collected prospectively.

R. Linder

Those were the results for the prematurity rates. They were changing between 0% and 15% per year Absolute frequencies

There was another opportunity to compare the data of Dr. Linder with the official data of the GeQiK (Society of Quality Control in the Hospital), where the medical records of more than 95% of all pregnancies and births of the whole Land BadenWueürttemberg (BW) are collected. Because of a restructuring of the system of the GeQiK, this was possible for the years from 2004 on. The hypothesis was that by the special treatment considering besides medical also psychological, social and biographical aspects a change of the outcomes could be possible. Existing stressors from actual life situations as well as from biographical and ancestral conditions

There was no detectable trend over the years Relative frequencies

should be alleviated by the special psychosomatic and psychotherapeutical treatment. So the question was can there be shown an improvement of less preterm births (PTB), more physiological

Results

Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy

births, possibly higher birthweight of the babies and a high lactation rate after birth? However, it is necessary to make two annotations: 1. It is not possible to proof a causality by these data, because the comparability of the groups of Dr. Linder and the comparison groups of the Pforzheim area and Baden-Württemberg cannot be assured. Significant results must be interpreted as correlation.

The prematurity rate in the office of Dr. Linder is about 2.2%; however, in Baden-

2. Because of the Huge Samples, Statistical Tests Are Already at Slight Deviations Showing Statistical Significance, which Means that Statistical Deviations Are most Important for the Interpretation In average, children are born in Pforzheim 6.6  days and in Baden-Württemberg 6.15  days earlier than at the office of Dr. Linder.

Württemberg it is 8.8% and in the Pforzheim area it is 9.4%.

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also true for the vaginally operative rate with 2.9% versus 9.15% with respect to 8.8% in Baden-­Württemberg and Pforzheim.

R. Linder

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From the first results, the impression was arising that within the own collective there have been less children with intrauterine growth retardation. The risk reduction by weight was much higher than by the pure duration of pregnancy. This could be a result of the same intervention measures, which could be effective against premature

labour and also possibly reduce impairment of placental perfusion and intrauterine growth retardation. In this examination, there could be signs to support this assumption, since the birth weight, at least compared to the Pforzheim group is higher (in average 66.95 g).

One remark shall be made here about the fact that the comparability of the groups of Dr. Linder and the groups of the Pforzheim area and Baden-­ Württemberg cannot be assured. One well-known risk factor for premature birth is the age of the

pregnant woman. This was looked at in the comparison of Dr. Linder and Baden-Württemberg (BW) and Pforzheim. In BW, the mothers were on average 1.25 years with respect to 1.93 years younger in Pforzheim.

Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy

Average SD

min

max

n

tpDifference Statistik Wert

BadenWürttemberg GeQiK

30,64

5,36

10

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31,89

5,50 17

45

239

GeQiK

29,97

5,48 14

51

18690 -1,93

Linder

31,89

5,50 17

45

239

Pforzheim

This means that in BW and Pforzheim, mothers are aged on average approximately 1.25 years with respect to 1.93  years younger than in the group of Dr. Linder. Since usually higher age is a factor increasing the risk of PTB, this would not resolve the question about the lower incidence of PTD in the group of Dr. Linder. The lactation rate 6 weeks after delivery was 78% (n = 925) (full lactation) and 6% (n = 73) (partial lactation).

Concluding Remarks There seems to be some evidence that a combined medical and psychotherapeutical treatment is able to reduce the rate of premature birth and increase the rate of spontaneous births. At the same time, obstetrical interventions (caesareans

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-3,51

0,00

-5,37

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and vaginal operative births) are considerably lowered. This corresponds very much with the findings of Tanzi Hoover and Gerlinde Metz in the chapter 6 (Transgenerational Consequences of Perinatal Experiences…), as well as David Olson et al. in the chapter 10 (Contemporary Environmental Stressors and Adverse Pregnancy Outcomes – OPERA). It is shown there that the occurrence of adverse childhood experiences (ACE) strongly determined poorer obstetrical and other outcomes. Obviously burdens in the prior history of the expectant mother and her mother are of far greater significance in the ongoing situation than is assumed in the normal view of maternity care, which is often so confined to the present situation. Similarly, like in bonding analysis, this observation can be fully confirmed from the

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clage for the management of cervical incompetence: viewpoint of the psychotherapeutic–psychosoA prospective study. Archives of Gynecology and matic gynaecological practice; only here, there is Obstetrics, 273(5), 283–287. even more complexity in the consequences of Alfirevic, Z., Owen, J., Carreras Moratonas, E., Sharp, A. N., Szychowski, J. M., & Goya, M. (2013). Vaginal burdens from the patient’s own prior history as progesterone, cerclage or cervical pessary for prewell as the mother’s, among others, in the preventing preterm birth in an asymptomatic singleton vailing corporeality. It is evident that the early pregnant women with a history of preterm birth and a burdens shape the whole life situation of the sonographic short cervix. Ultrasound in Obstetrics & Gynecology, 41, 146–151. expectant mother and the arrangement of her relationships. The awareness of the trans-­ Arabin, B., & Alfirevic, Z. (2013). Cervical pessaries for prevention of spontaneous preterm birth: Past, present generational depth of the prevailing situation and future. Ultrasound in Obstetrics & Gynecology, makes it possible for the gynaecologist to take 42, 390–399. into consideration the different existential and Clifford, K., Rai, R., & Regan, L. (1997). Future pregnancy outcome in unexplained recurrent first trimester methodological levels and so find a new balance miscarriage. Human Reproduction, 12(2), 387–389. between these levels. This is what makes possible Hidas, G., & Raffai, J. (2006). Nabelschnur der Seele  – an integrated understanding of the patient’s comPsychoanalytisch orientierte Förderung der vorgeburtlichen Bindung zwischen Mutter und Baby edition plex reality and so undertake appropriate action psychosozial. for the benefit of all persons involved (mother, Lidell, H.  S., Pattison, N.  S., & Zanderigo, A. (1991). father and child). Recurrent miscarriage  – Outcome after supportive To put it into five points: care in early pregnancy. Australian and New Zealand

• During pregnancy, there often is a reactivation of early emotional states from the individual’s earliest life history. • The mother gives home to a new person in her womb. Especially, in difficulties, it is very important that she herself gets support from her close or—alternatively—from her more distant social surrosunding. • The regard of the five methodological levels significantly reduces complications and allows many more options of treatment. • It may be suggested for caretakers in the psychotherapeutic and obstetrical field to recognize and work on self-activating personal backgrounds. • Implementing multidisciplinary teamwork and continuing education in these issues are strongly recommended.

References Abdel-Aleem, H., Shaaban, O.  M., & Abdel-Aleem, M. A. (2013). Cervical pessary for preventing preterm birth. Cochrane Database of Systematic Reviews, 5, CD007873. Acharya, G., Eschler, B., Grønberg, M., Hentemann, M., Ottersen, T., & Maltau, J. M. (2006). Noninvasive cer-

Journal of Obstetrics and Gynecology, 31, 320–322. Linder, R. (1994). Haus- und Praxisgeburten: Dokumentation der 1. Tagung für Haus- und Praxisgeburtshilfe Mabuse-Verlag, Frankfurt am Main. Linder, R. (1997). Psychosoziale Belastung und Frühgeburt -- Erfahrungen mit einem psychosomatischen Konzept in der Praxis. Archives of Gynecology and Obstetrics, 260(1–4), 71–78. Linder, R. (1998). Psychotherapeutische Schwangerschaftsbegleitung: Ermutigende Mutters chaftsvorsorge - ein Beispiel für die integrative Verbindung von Psychotherapie und Geburtshilfe, Int. J. Prental and Perinatal Psychology and Medicine 18, 71–81 Linder, R. (2006). How women can carry their unborn babies to term  - The prevention of premature birth through psychosomatic methods. Journal Prenatal Perinatal Psychology & Health, 20, 293–304. Linder, R. (Ed.). (2008). Liebe, Schwangerschaft, Konflikt und Lösung  – Erkundungen zur Psychodynamik des Schwangerschaftskonflikts. Heidelberg: Mattes Verlag. Linder, R. (2010). Overcoming somatic and psychological difficulties: New experiences from an integrated linkage of obstetrics and psychotherapy. Journal of Prenatal and Perinatal Psychology and Health, 24(4), 201–215. Linder, R. (2014a). Zur Psychosomatik bei Präeklampsie und HELLP-Syndrom. In K.  Evertz, L.  Janus, & R. Linder (Eds.), Lehrbuch der Pränatalen Psychologie (pp. 247–269). Heidelberg: Mattes-Verlag. Linder, R. (2014b). A new and unique synopsis of current knowledge about implantation with psychological findings of patients affected by preeclampsia or HELLP syndrome (hypertension, elevated liver enzymes, and low platelets) shows striking interrelations. Journal Prenatal Perinatal Psychology Health, 26, 105–130

Improving Pregnancy Outcomes: Effects of an Integrated Linkage of Obstetrics and Psychotherapy Linder, R., Klarck, S. (Ed.), (1996). Hausgeburten, Praxisgeburten, Geburtshäuser, Entbindungsheime: Dokumentation der 2. Deutschen Arbeitstagung Hausund Praxisgeburten Mabuse-Verlag, Frankfurt am Main. Quaas, L., Hillemanns, H. G., du Bois, A., & Schillinger, H. (1990). Das Arabin-Cerclage-Pessar  - Eine Alternative zur operativen Cerclage Geburtshilfe

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und Frauenheilkunde. Geburtshilfe Frauenheilkd, 50, 429–433. Stray-Pederson, B., & Stray-Pedersen, S. (1984). Etiologic factors and subsequent reproductive performance in 195 couples with a prior history of habitual abortion. American Journal of Obstetrics and Gynecology, 148, 140–146.

On the Psychodynamics of Preeclampsia and HELLP Syndrome Rupert Linder

Preeclampsia and the HELLP (hypertension, elevated liver enzymes and low platelets) syndrome are important clinical conditions because they are of great significance in health policies and the health of mothers of babies. For decades, a close link with conditions in early stages of pregnancy (i.e. bad placentation hypothesis) has been suspected by medical science as causal. The aim of this paper is to clarify the psychological relationships related to these conditions. There are three parts: • Knowledge about the manifold physiological processes during early pregnancy. • Findings from bodily therapeutic courses about mental processes during exactly this period. • Examples that give an impression of the early imprinting from this period in the lives of adults with appropriate case histories.

Knowledge of Early Pregnancy In scientific literature, the medical conditions preeclampsia and the more severe forms of eclampsia and HELLP syndrome are combined under the generic term pregnancy induced hyperR. Linder (*) Gynecology, Obstetrics and Psychotherapy, Birkenfeld, Germany e-mail: [email protected]

tension (PIH). Preeclampsia is characterized by increased blood pressure of the pregnant woman, proteinuria and the formation of oedema. The HELLP syndrome gets its name from H: hypertension, EL: elevated liver enzymes and LP: low platelets. Despite it being life threatening (bleeding disorder, liver failure), it is often only expressed clinically by light upper stomach pains. The diagnosis is made by means of characteristic blood values. The significance of health policies is very high: worldwide over 50,000 women die of PIH every year. In industrial countries, it occurs in 2–5% of pregnancies and is the second highest cause of maternal mortality in 12–18%. It is responsible for 25% of perinatal mortality in children. When occurring up to the 24th week of pregnancy, it is responsible for 65% of maternal complications and 82% of child mortality (Rath and Fischer 2009). Is it possible that such a serious illness can be related to psychological factors? I well remember a discussion with my esteemed colleague Susanne Bässler in a gynaecological working group in Karlsruhe in the mid-1990s. She replied at the time to my psychosomatic speculations, “That is impossible because medical science has just established that PIH is related to early placentation. It therefore can’t be caused psychologically”. On the other hand, medical science has increasingly accepted that early imprinting of people in many aspects (foetal programming) through the circumstances of the children before

© Springer Nature Switzerland AG 2021 K. Evertz et al. (eds.), Handbook of Prenatal and Perinatal Psychology, https://doi.org/10.1007/978-3-030-41716-1_17

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birth (Gluckman et  al. 2008; Nathanielsz 2006; Van den Bergh 2011). Foetal programming states that the roots of physical illness may be in the prenatal period and has increasingly included psychological attitudes and behaviours (Van den Bergh et  al. 2005 und Van den Bergh 2011, Räikkönen et al. 2011). Burkard Schauf (2008), previously senior physician of obstetrics at the University Gynaecological Clinic in Tübingen, now chief physician of the Gynaecological Clinic of the Sozialstiftung Bamberg, gave an unforgettable lecture on the topic, “Fetal programming, diabetes, hypertension, preeclampsia: What influence does the uterine environment have on later life?” Schauf’s noticeable empathy with the unborn child was remarkable. This was also expressed in his body language. During this early time of life (the implantation and early placental development), he described the early dialogue of the child’s cells with the mother’s immune cells, “Hallo T-helper cells, let us spread ourselves in the endometrium and keep the killer cells at bay”. This is then a good basis for successful placentation. As a matter of fact, implantation is prepared and modified by different influences: hormones, immune cells and peptides. The endometrium is prepared and thickened by the hormone estradiol during the woman’s monthly cycle. It can reach a thickness of 7–14 mm in ultrasound, whereby the doubled thickness, namely the front and back, is measured and appears with a delicate light centre line. The actual endometrium is relatively dark due to its high water content. At ovulation, the cells around the burst follicle change and the resulting corpus luteum produces the progesterone that alters the secretion of the uterus and prepares ideal conditions for the implantation of the embryo. When the embryo has migrated into the uterus and contact is made with the endometrium the fifth day after conception, some of the embryonic cells produce the human chorionic gonadotropin (HCG) that stimulates the corpus luteum to further activity, and the production of progesterone. The highest value is reached by about the 11th week of pregnancy, after which the placenta becomes increasingly capable of producing progesterone itself.

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This is scientifically spoken of as a mother– embryo crosstalk (the communication between mother and embryo). A google internet search for this keyword results in 135,000 hits. Fujiwara (2006) differentiates a “systemic crosstalk”, in which the substances or cells are transmitted by blood convey messages, and a “local crosstalk”, which occurs directly at the implantation site. Very complex processes play a role here. For instance, in the middle of the luteal phase the cells of the corpus luteum produce a particularly large numbers of receptors for chorionic gonadotropin, which the embryo produces in precisely this phase. The HCG is a characteristic of humans and primates. There is also an equine specific form, but other species of mammals have other mediators (prolactins, interferons). The HCG alone is not sufficient; however, there are additional mechanisms of combined crosstalk: Fujiwara discovered that in situ early contact develops between the embryonic cells and local immune cells at the implantation site. The human peripheral blood mononuclear cells (PBMCs) pick up the information that an embryo is present and, after migration, transmit this through the blood to many other tissues. This has a positive effect on the pregnancy as seen by the corpus luteum in the ovary. Therefore, the effect here together with the HCG was much greater than that with HCG alone. The fact that other substances soluble in blood plasma can perform this function in humans was excluded by Kratzer PG and Taylor (1990). Early immunological and other contacts are described by Fujiwara, as well as by Fazelli and Pewsey (2008). These contacts are important for all developmental stages from the gamete maturation to late pregnancy. They differentiate different signals. Messengers for long distances (long-range signals or LRS), such as progesterone, immobilize the musculature of the fallopian tube and reduce the movement rate of the cilia in the tube. They also affect growth hormones, growth factors and various lectins. Messengers for short distances (short-range signals, or SRS) do not yet display as uniform a picture as do LRS. At least it could be recently demonstrated (Georgiou et al. 2007) that the presence of an egg

On the Psychodynamics of Preeclampsia and HELLP Syndrome

cell or sperm cells in the fallopian tube in organ culture in vivo changed the nature of the protein secretion of the tube and in different ways depending on if and which gamete/s are present. These could even be divided into four different active categories: protein production and repair, antioxidants, metabolism and miscellaneous. Spermatozoa have influence on prostaglandin metabolism and thus apparently facilitate their migration to the fertilization site. Sperm cells are able to bond with local fibrinogen and thus are better protected against phagocytosis. The appropriate regulation of proteins for the egg cells is important, such as alpha-2-HS-glycoprotein, which prevents the spontaneous hardening of the zona pellucida, a problem that occasionally arises in in vitro fertilization. The conclusion is that the interaction between gametes, embryo and the female genital tract (FGT) forms a complex interactive network that leads to the creation and preservation of the pregnancy. The dysfunction of this network leads to the dysfunction of fertility, miscarriage or even the impairment of the state of health of offspring in adulthood. On the one hand, the immune defence in the FGT is essentially important for resisting pathogens. One only has to think of the open wound present at menstruation and after birth. As we know, the vagina is not a germ-free zone. There is a multitude of different microorganisms that are held in check at the threshold of the inner genital tract and the cervix. On the other hand, we have been previously able to learn that the immune system performs an important messenger function in early pregnancy. In this sense, certain “inflammatory responses” are even a prerequisite for a pregnancy. A local inflammatory response in the endometrium (in this case through a previous endometrium biopsy) may increase the rate of implantation (Dekel et al. 2006). Koga and Mor (2010) describes “toll-like receptors” (TLR) that perform important functions at the contact site between mother and child. They play a large role in the regulation of normal and pathological processes. Additionally, through immune cells recruited at the implantation site, high levels of pro-inflammatory T-helper cells (Th-1) and cyto-

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kines (IL-6, IL-8 and TNF-α) develop that are characteristic of the period of early implantation. Macrophages are important messengers. They present in large numbers during the entire pregnancy at the boundary point between mother and embryo. They are recruited from decidua and trophoblast cells (Renaud and Graham 2008). But uterine dendritic cells (uDC) are indispensable for the pregnancy (Pollard 2008; Plaks et  al. 2008). A macrophage colony stimulating factor-1 (CSF-1), which activates the formation and increase of monocytes and dendritic cells in all mammals, is established in the maternal decidua. The dendritic cells, which have a kind of morphological similarity with nerve cells because of their many appendages at the front and only one at the rear, are the antigen presenters for the other immune cells. Macrophages are important in deciding which antigens are tolerable and which have to be combated. On the other hand, they also have their own trophic functions, and they are necessary, in combination with the hormones estradiol and progesterone, to facilitate an effective decidual transformation of stromal cells into epithelioid cells at the implantation site. The decidual cells grow by means of rapid proliferation in an arc around the embryo. After complete implantation the embryo is totally surrounded by a primary decidual zone of polyploid cells and a secondary decidual zone of diploid cells. A further important growth-promoting function is the facilitation of vascularization, i.e. the formation and development of the vasculature supply. Capillaries grow from the uterine artery into the decidua. In this way, vessels are created with a large dilated lumen with maternal blood that bathes the decidual villi. As described by Plaks et  al. (2008), the uDCs partially regulate this vascularization by means of their synthesis of TGF-β1 and sFlt-1 (soluble fms-like tyrosine kinase-1, see also below). Implantation is not possible by elimination of the uDC in an animal model. These are therefore essential for a successful pregnancy. In a detailed summary, Furuya et  al. (2008) wrote about the pathophysiology of placental disorders in pregnancy-induced hypertension.

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Different life-threatening illnesses during pregnancy, such as pregnancy-induced hypertension, are closely related to a dysfunction of the placenta. Cumulative studies suggest that a hypoxic microenvironment at the site of implantation, the pure stress of the uterine placental blood flow and pro-inflammatory substances erroneously secreted into the maternal vascular system contribute synergistically to the progression of PIH.  So, for example, the soluble form of the receptor for the vascular endothelial growth factor (receptor-1, sVEGFR-1) and the soluble form of endoglin (CD105) are elevated in the circulating blood of PIH mothers. In the review, current knowledge about placenta development and the pathophysiology of the placenta in hypertension pregnancy disorders is exhaustively described. In addition, the latest results of vasoactive messengers in PIH and PIH rodent models are discussed. A variety of angiogenetic molecules and proteolytic enzymes play a decisive role in the bringing about of placentation and the development of the placental circulatory system. Adamson et al. (2002) describe two different ways in which the trophoblast cells penetrate into the uterus, namely.

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mentioned HCGs plays a role here (Zygmunt et al. 2003). In the later phases, trophoblast villi and on the foetal side vessels of terminal villi form a finely differentiated vascular network. The foetal weight almost doubles in the last trimester of pregnancy. On the other hand, the weight of the placenta hardly increases in this period. Instead the network of vessels in the terminal villi/the labyrinth becomes better differentiated and the functional capacity of the capillaries on the foetal side and of the maternal blood sinuses also increases (Furuya et al. 2008). In contrast to invasion by cancer cells, which is in some ways similar to the vascularization processes at the implantation of the embryo, the trophoblast invasion is finely regulated and controlled by the local pro-inflammatory microenvironment. This applies with respect to the immunological tolerance and the well-regulated development of the vasculature supply. By intrauterine growth retardation (IUGR), however, the differentiation of the terminal villi is often disturbed and the thickening of the distal villi becomes evident (Kraus et al. 2004). The placenta’s arterial circulation has no autonomous innervation and is therefore regu1. In the very early post-implantation period lated by local signals such as pressure and blood through the activation of the trophoblast giant flow (Myatt 1992). If the implantation process cell-specific gene Plf that regulates the pro- does not occur well enough the placenta suffers duction of proliferin and stimulates invasion from inadequate perfusion and secretes various closely associated with the spiral arterial types of pro-inflammatory molecules that damsystem. age the maternal endothelial cells (EC) and 2. Beginning from day 12.5 after fertilization increase vessel resistance as a result. This addi (p.c.), a more diffuse variation penetrating tionally damages the maternal organs and impairs interstitially into the decidua basalis that is not the foetal placental environment. regulated by PIf but by the spongioblast-­ The increase in the antiangiogen-effective specific gene Tpbp. The development of the sFlt-1 in proportion to the angiogen-effective plaplacental vascular network between days 10 cental growth factor (PlGF) and vascular endoand 17 p.c. is impressively represented three thelial growth factor (VEGF) plays a substantial dimensionally in this study by a plastic cast. role in the development of preeclampsia and growth retardation. The proportion can be deterThe vascular endothelial growth factor (VEGF), mined from the blood and is more and more the fibroblast growth factor (FGF) and the pla- developed as a relevant diagnostic test tool for centa growth factor (PlGF) are indispensable dur- the short-term outcome (Tallarek et  al. 2012; ing the entire pregnancy (Reynolds and Redmer Rana et  al. 2012; Akolekar et  al. 2013; Hund 2001); in addition, a proliferation-promoting and et  al. 2014; Zeisler et  al. 2016). Additionally, additional angiogenetic function of the above-­ there are studies that show a possible prolonga-

On the Psychodynamics of Preeclampsia and HELLP Syndrome

tion of the pregnancy by an extracorporeal apheresis (extraction of proteins from the blood) of the sFlt-1  in preeclamptic pregnancies (Thadhani et  al. 2011) and new findings from this method affecting the lipid metabolism (Contini et  al. 2018). In addition to these direct vasoactive mechanisms, the activation of the renin–angiotensin system (RAS) has recently been focused on in the pathogenesis of the conditions of preeclampsia and HELLP syndrome. Additionally, autoimmune reactions also come into play as autoimmune antibodies against the angiotensin II receptor type 1 (AT 1) have been found in the serum of preeclamptic women (Wallukat et al. 1999; Dechend et al. 2006). The relationships and clinical significance of these antibodies, the RAS and immune reactions are the subject of several investigations (Stepan et al. 2006; La Marca et al. 2011; Parrish et al. 2011; Freitag et al. 2013). As there are very few possibilities of examination of pregnant women the diagnosis of placental circulation depends primarily on Doppler sonography examination, more precisely ultrasound biometry, cardiotocographic examinations (CTGs) and the histological examination of the placental tissue after birth.

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“falls” into the lumen and “chooses” a place in the lumen, or rather on the uterine mucin layer, which is at this point greatly built up. It is then able to select a certain point by rolling. Finally, it attaches itself to a point on the uterine mucin layer (apposition) and adheres more tightly to the mucin layer (adhesion). Then connections grow, shoots from the embryo growing into the maternal mucin layer. Figure  1 shows schematically that different conditions are waiting here: the heart represents love and joyful expectation, the chef’s hat represents appetizing provisions; however, the dark stain represents all the mother’s wounds, perhaps a previously lost child, suppressed and side-lined emotions, the schnapps glass represents alcohol or other harmful substances. The conditions for the child can be very different: luxurious, satisfying, pleasantly warm, or else bare, arid or cool. The child can implant itself but gives up all its desires. About 40% of the children are able to implant themselves successfully in the uterine mucin layer, the other 60% not. How realistic these connections look is shown in the following illustration of the implantation site from Gray’s Anatomy ( 1918) (Fig. 2). After implantation, the mother discovers that she is pregnant. This moment regularly generates

Findings from Body Therapy I am grateful to the team from the Institute for Pre- and Perinatal Education (IPPE) for the following information, particularly Karlton Terry, Kathryn Kier and Max Peschek. In courses, they deal with the personal exploration of early phases of human development and the healing of wounds from this period. I am also grateful that I was able to take part in one of these courses. For the aspects that are discussed here, two periods of human development play a significant role: Implantation, the period in which the embryo adheres to the uterine mucin layer and grows into it, and Discovery, the point in time when the mother discovers that she is pregnant. According to teachings at IPPE, the early embryo migrates through the fallopian tube,

Fig. 1  Course material IPPE, see text for explanation

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Fig. 2  Section through ovum imbedded in the uterine decidua (Gray 1918). (Abbreviations: am. amniotic sac, b.c. blood clot, ect. embryonic ectoderm, ent. endoderm,

m.v. maternal vessels, mes. mesoderm, tr trophoblast villi, u.g. uterine glands, y.s. yolk sac)

a storm of emotions in her because her own internal feelings have also been activated. This moment is often short after the nonappearance of her period. Sometimes it is even earlier and some women even sense internal transformations immediately after conception. There is a rating of conceivable reactions of the mother to the child, listed here from spurning to the welcoming:

6. Child unwanted, but accepted 7. Child wanted, but not now 8. Child wanted, but should be of a specific sex 9. Child wanted, but for a reason that has nothing to do with the child 10. Child fully welcomed to be itself, relaxed

1. Unsuccessfully attempts abortion 2. Goes for an abortion but has second thoughts at the last minute 3. Child unwanted, disaster, thinks about “doing something to get rid of it” 4. Child unwanted, disaster, thinks about abortion 5. Child unwanted, negative thoughts, “maybe it’ll work”

Two further circumstances could also be significant, namely that children can be wanted too much (over wanted) or that the pregnancy is celebrated too much, both of which tend towards point 9, the child is wanted for a reason other than itself. These early emotional constellations are of extreme importance for the relationship between these two people (mother and child). For the mother, this is the first opportunity for awareness of the child to come into play. At this time during

On the Psychodynamics of Preeclampsia and HELLP Syndrome

pregnancy, every level of emotion resonates. These are often unconscious to the mother herself because they originate from her early and earliest existence, such as feelings from her own period of implantation and discovery, or even from unconscious (epigenetic) imprinting of her own forebears and family history. These run like a “golden thread” through all of the child’s life—sometimes spoken, often only implied, often silent. In my practice, I often meet with these questions when caring for pregnant women who are confronted in a new way with their own emotions during their new pregnancy. They are sometimes aware of the facts from previous generations, but the psychological significance and the internal relationships are not yet emotionally obvious to them. The development of this understanding is frequently associated with the sensation of considerable pain that is mourning previously missed emotional and concrete possibilities between these two people. The presence of people who are not easily shocked by these issues but can provide secure support is very helpful in this process. This can be done, for example, by means of art therapy (Evertz 2008), body therapy (Terry 2014; Emerson 2014; Peschek 2014), bonding analysis (Raffaj 2014; Schroth 2014) or by means of psychotherapeutic-oriented support during pregnancy (see Linder 2010). During pregnancy, these feelings are particularly strong and thus offer the chance of being better understood psychologically and cognitively. Sometimes great disappointment towards one’s own mother and/or father can be felt. In the long run, it is important to understand that the behaviour of the parents that was difficult to bear did not generally arise from their own conscious decision but that they themselves were similarly victims driven by their own family system. As a rule, the more unconsciously this occurred, the stronger the effect is on the descendants. Consistent with this is the fact that women who were themselves unborn children in unwanted pregnancies often get into the situation of having an unwanted pregnancy (Linder 2008a, b).

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The processing of such biographical backgrounds provides chances of relieving the children from such burdens. This is a comfort for the pregnant women who are often very concerned. They might say something like, “Well, if I’m feeling so terrible, how does that affect my child? I ought to be in the best possible condition. And now I keep on crying”. In reality these are tears of relief when suitable support and security are provided. And the comfort and gain is that the adults can set aside a part of their biographical burden and the children will be freed from the burdens of the past. This task is emotionally hard work, but for these reasons definitely worthwhile. In this context, the words of the English paediatrician and psychoanalyst Donald W. Winnicott, who spoke of the ordinarily “good enough mother”, are notable. He extended the trauma of birth as described by Rank to the entire period before birth and considered this to be formative of the whole person. The expression umbilical affects for this phenomenon was introduced into psychoanalytical terminology by the English psychoanalyst Francis Mott (Terry, Karlton and Team 2011). One of his basic convictions was: every psychological feeling derives from an older physical feeling. An extremely important topic in the umbilical period is: how can we get what we need? It is obvious that this is a question from the umbilical period, but it remains significant for every stage of life. We need: Food Money Love Intimacy Self-respect All these items are important requirements that already play a role in the implantation and discovery periods. But, as is evident, they have an indispensable lifelong function for every person. Therefore, different strategies are developed and practised early on, such as worming oneself in, cheating, stealing, bargaining, begging or sacrificing oneself.

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It is clear that not every one of these possibilities is particularly lifelong successful or socially acceptable. One purpose in life (and especially the work of psychotherapy) is to refine strategies that had possibly been of help in earlier periods, and also to acquire new ones. It is possible to be free to find out which possibilities are best suited to the prevailing situation in life. The umbilical affects correspond to precisely the period and the process of placentation. They represent the emotional side of the processes that have long been regarded by medical science as decisive in setting the course of the early relationship between mother and child, and vice versa. The roots of the problems that can later lead to preeclampsia or HELLP syndrome can be found here. Of course, men are also affected by emotional historical experiences. This was the case when these men were unborn children in the early phases of development and failed to receive nurturing from their fathers or mothers. Expectant fathers who are confronted with their own early emotional past can come to terms with paternity and accompany their pregnant wives. Strong negative emotional reactions to the woman’s pregnancy often have their own biographical background in this area.

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reaching insecurity can be felt, which was more or less passed on from the mother to the daughter. Ms. D. (Case History 4) had HELLP syndrome twice. Again her own deep insecurity is reflected in relation to her mother as well as in the relationship with her own oldest child. The intensive psychotherapeutic support during the second pregnancy could not, admittedly, prevent the renewed occurrence of a HELLP syndrome, however it did in an impressive way that allows much more understanding and sensitive relationship with the second child.

 ase History 1 C Thirty-eight-year-old Ms. A. came to my gynaecological psychotherapeutic practice. Her question was: “I want clarification with respect to further family planning for a second child or not. Four years ago I had severe eclampsia and my daughter was born prematurely by caesarean delivery in the 29th week of pregnancy”. The birth weight was 850 g (below the tenth weight percentile), the Apgar score was 3/4/6 (after 1, 5 and 10 min). From the hospital records, the medical emergency was evident: rising blood pressure despite attempted intravenous therapy using magnesium and Nepresol. The Doppler examination showed the child’s circulation to be already centralized, the cardiotocograph (CTG) was limited. The patient was already displaying neuroCase Histories logical abnormalities, the liver values were rising and the thrombocyte values were falling. “All the doctors advise me against a new pregThe following case histories depict experiences and life histories that have to do with preeclamp- nancy. It’s very deep-seated. It’s a very big issue sia or HELLP syndrome. Ms. A. (Case History 1) for me. My daughter is developing well so far”. She is a highly qualified professional in the suffered from preeclampsia (and a premature birth) with her own daughter, and her mother suf- field of early learning. “I’m also suffering from fered from it with her older sister. She was constantly recurring doubts about my marriage. strongly ambivalent toward her mother and her Fantasies about separation have almost always marriage. In the case of Ms. B. (Case History 2), been there, except during our first months her mother was badly affected by preeclampsia. together when I was very much in love. Other The situation and previous history was described men sometimes fascinate me”. She is the middle one of three children. The from her mother’s point of view. Here, it becomes immediately clear how life threatening the grand- birth of her older sister (+18  months) was very mother’s living situation was in her own prenatal confrontational and dramatic as an emergency period. Ms. C. (Case History 3) was affected as a caesarean delivery had to be carried out due to child by her mother’s preeclampsia at the end of preeclampsia. “I came into existence ‘by acciher pregnancy with her. Here again a deep-­ dent’”. In addition, the mother had reckoned with

On the Psychodynamics of Preeclampsia and HELLP Syndrome

having a boy and was absolutely convinced that she would. She herself was then delivered “completely without conflict” 2  weeks before the expected date by planned caesarean section. This was described by the mother as the most pleasant birth of all. She was not breast fed. The mother also described difficulties with bottle feeding. She fed very slowly and sometimes she unexpectedly spit up everything up again, especially when her older sister screamed. “My mother described me as difficult”. I experienced little real inner or physical closeness. Her own mother and the older sister were always interfering overbearingly, and she couldn’t stand up to it. She (the mother) felt that the father wasn’t “up to bringing children up”, so that she kept us mainly away from him and undertook the task of upbringing. He was then considered to be too authoritarian by the family and was not respected. In the course of therapy, the early relationship situation was also discussed many times. For example, in the form of a dream: she and several others were on a walk and came to a sort of filling station kiosk. They all wanted something to eat. The sales assistant said she had nothing to eat, we wouldn’t want anything. She made it very clear that she didn’t really want to sell us anything. However, on the counter in front of her there was food such as was in a bakery. She said she only had warm bread and butter. Everyone was delighted with that, as they all wanted something warm. The sales assistant had not reckoned with that. Here, eating and food are symbols relating to implantation, and so this dream could be seen as an example of “cross-talk” or when the early embryo is negotiating food supply and connection with the mother’s surrounding (uterine wall and lining). At one point, the early life situation of Ms. A.’s mother was talked about. She had been born during the war. Prior to this, there had been a furious quarrel between her parents. The father had volunteered out of conviction to serve as a soldier. She herself had been conceived during his home leave. Soon after, the father was reported

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missing in the Russian campaign and was later declared dead. Here it is easy to understand how the mother’s own earlier life situation had been reactivated by her pregnancies. After all, she herself had been conceived in a difficult relationship situation of the parents, had to do without her father from early on and her mother had doubtlessly found it very hard to cope with this loss. Ms. A.’s mother therefore was very anxious during the pregnancy with the sister as well as with her and still felt very insecure after her birth. Even during therapy, Ms. A. could still feel her mother’s anxiety when on the phone with her. She described how difficult it was for her as an adult to let her mother hug her and how close she came to tears then. She also related how she herself had felt unsure and never really comfortable during her pregnancy with her daughter. Time and again she describes her earlier life situation. It was, as described above, typical of and analogous to the early implantation phase by preeclampsia: “I know that my parents wanted to practice contraception, but I still came into being. I also came too early and moreover had the ‘wrong’ sex. I have never experienced being properly welcomed. I can never feel really at ease. Even inside me, I can’t really say yes. Inside me I’m running away. I always, even in a group, have the feeling of not belonging. I don’t like to be noticed, speak quietly and experience a feeling of oppression”. The early implantation and discovery periods came up again and again. Not only cognitively but above all from the viewpoint of emotional feelings. In some partner dialogues the relationship ambivalences were cautiously addressed. The internal doubts were expressed repeatedly. It was important for her to be able to understand that these doubts about herself and the r­ elationship were a part of her and could be explained on the grounds of her previous history. So she was able to experience the internal relationship to herself increasingly as “special” but ongoing. “They are just a part of me…”. After 25 sessions (spread over 3  years) therapy could be concluded. The question of having a

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child remained unresolved. The relationship with her husband however had succeeded in becoming much more trusting. She was able to venture gradually on a closer and more affectionate relationship with her husband. Holiday situations were much more relaxed than previously. She was able to tolerate her daughter becoming more independent. She could allow her husband to take responsibility as a partner in parenting. Professionally, she was able to involve herself successfully in the furthering of her career.

 ase History 2 C The next case history is special because it describes the situation of preeclampsia from the grandmother’s point of view. In my practice, I happened to hear that the daughter of a patient that I’ll call Ms. B. suffered from very severe preeclampsia during pregnancy. She is the younger of two sisters. While on holiday a doctor had to be called because of stomach pains in the 32nd week of pregnancy. She was already delirious (seeing evil faces, confusedness); emergency transport by helicopter to a specialist hospital was arranged; under way preparations already made for immediate delivery and emergency caesarean. The expectant father was told that it would be a miracle if you see your wife and child alive. Amazingly, the son, although only 1000 g heavy, was comparatively healthy and did not even require intubation. The mother had to remain in intensive care for 8 days with total kidney failure. Not until the fifth day did urinary excretion begin again. Extubation was completed 2 days later. Mother and son (and father, too) later made a complete recovery. About the grandmother’s previous history: In the second half of the 1930s, Ms. B.’s mother had a boyfriend who was studying and from a “good” family. The mother even supported him financially while he was studying. She became unintendedly pregnant. In her desperation, she went to her gynaecologist, Dr. Kuppenheim, in Pforzheim (see below). He encouraged her: You’ll manage it. You’ll have pleasure in your child in the future. She decided to keep the child, who turned out to be the very same as Ms. B. It was not possible, however, to get married. Her

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parents demanded that she move to another town and have the child there because of the “disgrace”. So she lived with an aunt in a neighbouring city. Ms. B. was prematurely born at 7 months gestation weighing 2250  g. She found the time spent with the aunt very enjoyable; the mother was very affectionate to her. She carried her in her arms for 2 years. “I still have this feeling of being cared for inside me”. She never got to know her father. The child maintenance was, however, always paid punctually. Ms. B. married and had two children. Her marriage, however, broke up after some years. She is extremely socially involved. The other daughter suffered for many years from depressive moods and had an unhappy first marriage. In the meantime, there has been a considerable improvement in her psychological state and a happy second marriage. As can be seen from this case history, the issue of eclampsia moves along a fine line between love, life and death. In this story, the gynaecologist also plays a special part. He himself had a special life history that was characterized by charitable work, commitment to life and in the end mortal danger. I believe at this point he should be remembered for playing a large role in the history of our town and being representative of our country. Therefore, his story will be briefly outlined here. Rudolf Kuppenheim, M.D., was born in 1865  in Pforzheim, studied medicine in Heidelberg and was the first gynaecologist to practise in Pforzheim. In 1893, he became chief physician of the Obstetric Clinic of the Protestant Siloah Hospital in Pforzheim. In the First World War, he received the title of medical consultant on account of his great services and various decorations due to his commitment and valour. His two sons also served, partly voluntarily, in the First World War and received prestigious awards. After his conversion from Judaism to Protestantism, he was also an elder of the church. On 1 April 1933, he and seven other doctors in Pforzheim had their medical licences revoked on the grounds of their Jewish descent. At this point, he was also forced to resign from the hospital. He was able to continue his private practice until September 1938. The meeting with Ms. B.’s mother had taken place the year before.

On the Psychodynamics of Preeclampsia and HELLP Syndrome

The persecution and harassment kept on getting worse. On 21 October 1940, the 50th anniversary of the day that the spouses Rudolf and his wife, Lily, met, SA men told them both to be ready to leave in an hour. They committed joint suicide and were found dying in their home, a cushion with the decorations won in the First World War on a table. The sons Hans and Felix managed to escape abroad.

 ase History 3 C Ms. C., 45  years old, began psychotherapy because of strong fears of being abandoned when there were disagreements in her marriage. “I have an exaggerated need for harmony”. She has suffered a great deal under this need, because it has been with her for many decades now. She describes her mother as “somewhat reserved”, but always correct and never loud. There had never been a real mother/daughter feeling. Ms. C. describes her father as temperamental, affectionate, “no matter what problem I had, he resolved it for me or with me”. He was a war exile and had to move to where the mother lived. The parents had got to know each other at the age of 15 in a dance course. The mother’s parents had wanted to prevent the liaison by all means, as being a refugee he was not of the same social class. The mother was beaten and she was sent to a job in a more northern city over 200 km away. The father then rode for 6  h there on his moped every weekend and visited her. Ms. C. had great difficulties in detaching herself from her parents during adolescence. She had severe depression and some suicide attempts. She ended up finally in inpatient psychotherapy in another town. As additional previous history, it must be noted that towards the end of the pregnancy with Ms. C. the mother developed preeclampsia with elevated blood pressure and severe fluid retention. She was born 4 weeks prematurely and the birth took place under a short-duration anaesthetic. She came directly after being discharged from hospital to her mother’s mother, who also brought her up for a long time. The mother had often had to suffer very much under the severity and harshness of her own mother and been able to develop very little self-esteem. Ms. C. worked

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initially at the reception of a charitable institution. Although dependable and friendly, she sometimes found it difficult when planning schedules to muster sufficient determination to reconcile differing interests. Sometime after having a baby, she went a bit strange: she imagined that she was erotically attracted to women. She told her friends this as a sort of coming out. Today she says that it was more of a notion than otherwise. Her husband then moved out of the home. When it seemed that he was going to start new relationship, she successfully did all she could to win him back. In the meantime, Ms. C. has successfully weathered the adolescent conflicts of her children. During the ongoing therapy, she has been able to increase her own self-security considerably. As a human being, she has managed to attain considerably more access to her inner authenticity and strength, which for some time had already been her professional assets in a successful career. Here the deep insecurity in being and in the early relationship is perceptible. This can be explained by the profound insecurity already present in the mother, probably from her own early trauma. This was certainly aggravated if not reactivated by the short-duration anaesthetic during delivery. The mental states and the circumstances of her earliest period of life (implantation, discovery, birth) and their underlying factors were gone over repeatedly; in this way, the emotional aspects were cautiously perceived and moderated in their impact on the present time, and a biographical sorting process and substantial breakthrough was made possible. So she was able to rediscover a deep emotional attachment and communication at first with her father, but afterwards also with her mother.

 ase Study 4 C A 30-year-old woman was being cared for during her second pregnancy. She had a neat and smart appearance but was reserved in utterance. The emotional vibrancy in her speech and body language reduced, her basic demeanour seemed apprehensive. At the end of her last pregnancy in the 38th week, the year before, Ms. D. had been admitted

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to the gynaecological department of a neighbouring hospital due to rising liver values and undetermined back problems after personal consultation with the senior physician. There she had a caesarean section a day later on account of further rising liver values and incipient HELLP syndrome; the boy (3080  g) had a good Apgar score (9/10/10) but was transferred to a paediatric clinic 2 days later after two convulsive seizures. “Our little boy had strange symptoms: since yesterday he’s twitched (minimally) for several minutes in the daytime, now he’s in the intensive care unit of the paediatric clinic with a lumbar puncture, antibiotic therapy and is getting anti-­ convulsants”. Several days later, she came to the practice with her husband who seemed supportive and loving. The child’s transfer to the (distant) paediatric clinic had certainly affected her. At this point, she was offered psychotherapeutic support to help her and her child come to terms with the stress and the events described. At the time, she did not take advantage of the offer. At the follow-up examination, she could partially breastfeed, the boy did not cry as much, everything was within reason. At some other appointments she continually talked of “a funny twitching and tingling” in her hands and feet. For this reason she had consulted various doctors for the last 6 months. A neurologist, found by her mother, had examined her thoroughly and had also found “nothing really wrong”. An MRI scan and other examinations had been carried out. She had the feeling that she had a serious illness. She had also thought about possibly suffering from multiple sclerosis; in the meantime, she would be happy at least to know what she did have. At the age of 5 months, her son had had an MRI scan due to suspected renal pelvis dilation, which was not confirmed. He was doing really well, he was starting to crawl and everything was developing age appropriately. One month later, she is again pregnant, in the seventh week. She still has the strange tingling as well as a peculiar pain in her leg. The neurologist is of the opinion that an anti-depressant could help and speaks of a depression affecting the body. Ms. D. now also agrees to preventive psychotherapy.

R. Linder

She came from a former German colony in Eastern Europe. At the time of her conception, her parents were living with the mother’s parents/foster parents in a small flat but “they got on well with each other”. After her birth, the father was allowed to move to Germany, but her mother and herself only 3 years later. She only saw her father twice during this period. She had a good relationship with her mother: she had been a “mummy’s girl”, very shy and lovingly cared for. The mother was not good at bringing discussions to a close, but withdrew at some stage. The father had managed to establish himself in industry in Germany, and had worked his way up and qualified as a master. Even though he was understanding, he was also strict, particularly when she could not do well enough in math. There had always been disagreements, and quite often quarrels, between the parents because of the father’s views about money, child upbringing and other things. He had just been an authoritarian man. The parents’ religious belief (protestant free church), which had been the basis of everyday life, was a support for them all. Her mother had been given to foster parents before she started school. She had, however, “already known” her birth parents. There is no longer any contact with a 2 years younger brother. Ms. D. can provide no other information on this point. Additionally, in regard to the course of her pregnancy, her husband was taking 2  months parental leave. A few times she missed appointments, especially when she was supposed to bring information about the history of her family. She complained of sleepless nights caused by her son’s teething problems. He cried every quarter of an hour and she had to give him a painkiller. The tingling problems, however, were getting less and the other complaints were practically gone. Nevertheless, she held her breath when saying this and she perceptibly lost contact to her base. “I’d rather have depression with crying fits”. During the last pregnancy: She had felt pretty well, there had only been the funny back pains. This was also the case at the last appointment before her referral to hospital. Then there suddenly came the time where something had to be done. “In the end we were powerless”. “Maybe I did hold back much of how I really felt”.

On the Psychodynamics of Preeclampsia and HELLP Syndrome

Whether it made sense to give her anti-­depressants during the pregnancy?—I argued for restraint in this respect. She said “I find my case somewhat odd”. Various complaints of her son continually played a role as well as (indirectly) the resulting demands or restrictions in her life. The back pains were successfully treated by gentle orthopaedic means. She lived in a flat above her parents-­in-law. Only sometimes things were said carefully, which suggested criticism of the relationship with her mother. She got on better with her mother-in-law than with her mother. The mother liked helping, also many other people, but never really listened properly. She continually talked about her son’s complaints and sickliness. In so doing, discussion of her own suffering and her state of mind took a back seat. Visits to the doctor’s and medication were talked about. Her own uncertainty, even reticence, was evident. On one occasion, her son cried audibly in the waiting room below without her visibly reacting to it (32nd week of pregnancy). She continued to suffer sleep disturbances on account of her son. But she also had her own ailments. She had a circulatory disorder, the feeling of not being able to breathe properly. In a CTG, a 3 min long continuous contraction of the uterus attracted notice. Regular measuring of the blood values was started. Elevated liver values were again evident. These were regularly checked. She had to continually clear her throat because of a little dry cough. Her state of mind and her results were patiently monitored. The child’s growth was good. In the 33rd week of pregnancy, the child’s size was calculated in an ultrasound examination to be a week further on, with an estimated weight of 2248 g, in the 36th week, 3415 g, in the 38th week 3589 g. She still had a series of slight complaints: itchiness of the arms and shoulders, restless legs that improved on walking around. No matter how she lay, nothing was right. Sometimes her bed was too warm and then it was too cold. On examination, the uterus was sometimes found to be relatively hard and sensitive. Once she was occupied by the question: how does the purification of the amniotic fluid work, how is the urea removed?

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The mother had doubtlessly been despondent after the births of two of her younger siblings. But it was difficult for Ms. D. to speak with her about it. The liver values continued to rise and thrombocyte values to fall. I consulted colleagues. I exchange views with a friend who is a senior physician (Dr. Deutsch, Karlsruhe): it is a chronic subclinical HELLP syndrome, which could remain stable for some time. It was important for the thrombocyte value not to fall below 100,000. Sometime later Prof. Schauf of the University Clinic in Tübingen advised inducing the birth especially as it was already at the beginning of the 39th week of pregnancy. A holiday was approaching. I asked the midwife if it were possible to do a blood test but she refused on the grounds of being too great a responsibility in this case. She was examined in the clinic where first a contraction stress test with oxytocin was carried out and it was normal. Ms. D. asked for a day to think it over. The next day she tried inducing the birth. The cervix did not dilate further so another caesarean section was carried out under epidural anaesthetic. The child was delivered at 9 p.m. in the evening of the holiday in a very good condition: 3490  g, an Apgar score of 9/10/10 and an umbilical artery pH of 7.34. On the day after, when I phoned the postnatal unit, the nurse in the unit said immediately “Oh, is that the woman who is looking after the child so touchingly? She’s already mobile on the 2nd day. The lowest thrombocyte value was 108,000. She says herself: she’s fine, everything is ok and she’s feeling much better than the last time”. A really long time was taken trying to achieve a normal birth. The child was very easy to look after, sleeps in the evenings, was breastfed twice each night then went on sleeping. He continued to develop well. This time, Ms. D. was quite sure of how she would be able to breastfeed properly and fully and also managed to do so. The first time she had not managed it. This is really quite astonishing considering how often she had felt unwell during pregnancy. All the toing and froing before the birth had been pretty difficult but the delay before the second induction had been very important for her. The older son was also doing relatively well. He was

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affectionate towards his brother. Occasionally, he also had infections but fewer problems than before the birth. After 3 months, she was worried that she might become depressed again. She had the tingling in her feet only occasionally. Once again the subject of the previous biography of her mother came up: she had a good relationship with her foster parents. Once again her dry little cough was to be heard. The birth grandfather’s wife had died from an embolism when the mother was 3  months old. There was also an older brother. The father took a new wife. She then said that there are too many children here. One of them has to go. The mother was almost put into a children’s home, which had a dreadful reputation in this country. Then the dead mother’s brother came and took her in. The interaction with her mother was really strange; she would ask how things were but did not really want to hear the answer. In this session, Ms. D. was able for the first time to begin to grasp how badly wounded her mother had been by her life history. In the following sessions, she was able to remember that her mother had apparently suffered from postpartum depression after the birth of her younger siblings. With regard to her children, she noticed how intensely her younger son had always looked at her from early on. Also, how he had smiled at 3 months. He had also much stronger muscles than the older son. He had always looked past her when breastfeeding. In the final session, she again describes how the family history, in this case her mother’s family, could have so great an impact. She could now better understand the interconnections. Up to then, they had been like holes, waiting to be discovered. Her mother was not aware of these holes, but she could not ask her about them. A great, hard to bear tension is tangible in the countertransference that is probably related to the mother’s life-threatening situation in her earlier lifetime.

preceding the second birth, there were extremely fierce disagreements. Strange differences suddenly arose between the carers, who normally associated with each other in a trusting and friendly fashion. The hospital doctors could not understand why the practising doctor had kept a woman with such pathological blood values in outpatient treatment for so long. The midwife, also a cooperative colleague for decades, was indignant about the impertinence of being asked to carry out a blood test. The practising gynaecologist “didn’t understand the world anymore” and wondered if they were all going crazy. Mutual anxieties were specified. The strong inner dynamic that had obviously transferred itself to the carers could be understood as the transfer of the inner conflict of the woman and the family history. It was therefore obviously important that the progress of the second birth greatly eased the undisturbed building of the relationship to her younger child. Such transfer phenomena have up to now not often been perceived in somatic medicine. It is, however, evident in this case how they can appear in the severe illnesses preeclampsia or HELLP syndrome and how the perception, comprehension and toleration of these phenomena are important for the deeper understanding of the dynamics of illness and the healing care of those affected. A further case study can be found in the story of Peter in chapt 26—Therapy stories for prenatal and perinatal experiences, children’s psychotherapist Antonia Stulz-Koller (2014), in which the mother at once realizes in the first conversation “that something between her and the child was wrong from the start”. The very empathetically written case history describes a similar disruption of the relationship from the very start and its partial dissolution.

Postscript

All of these life histories, which are enmeshed in various ways in the issue of preeclampsia or HELLP syndrome, impressively portray the very deep emotional insecurity of the people affected. During therapy the overcoming of this insecurity is clearly observable in some cases.

The deeper dynamics and background of the (grand)mother’s wounds could only be worked out in the months after the second birth. One aspect deserves closer description:

Summary

On the Psychodynamics of Preeclampsia and HELLP Syndrome

This account of the issue is intended to give very different perspectives on the background factors to preeclampsia and HELLP syndrome. The range is wide: from scientific knowledge about the earliest stage of life and the manifold interactions between mother and child, from the depiction of the realms of experience of the implantation and discovery periods in current body therapeutic self-experience and precise description of psychological phenomena from those most closely affected; in the process, the parallelism of the early phases of pregnancy and severe illness in later phases of life stands out. They all suffered from specific ramifications in the pivotal realms of relationships. This was obviously the issue in both illnesses that runs through all three levels. The lifelong fundamental question is: how is life in a relationship possible? Here a second generation trauma is being dealt with, because the origin lies in the severe traumatization of the grandmother. She was apparently so unconsciously trapped in shock that the pregnant daughter remained so shocked in the areas of her motherliness that she could not enable the implantation and vascularization processes to take place “adequately enough”. Of particular note, the processes observed in Case History 4 appeared of the fissuring situation transferred to the therapeutic teams, which in itself could be an important development for mother and child. This could even be revealed was only due to the trusting relationship between the somatic carers that had grown over many years. The inter-­ disciplinary working group was able to address this issue with precision and empathy.

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A Visual Exploration of Psychodynamics in Problematic Pregnancies: Case Studies in Analytic-Aesthetic Art Therapy Klaus Evertz

Introduction In undertakings such as psycho- and art therapy, the psychodynamic discords brought about by pregnancy reveal the close proximity of life and death. Might it be that the child “decides” to go because it feels overburdened or not accepted and loved, or perhaps because it senses that the mother is overburdened and struggling with inordinate amounts of inner stress. Or, maybe because the mother “decides” not to bear the child. Over the recent years of scientific prenatal research, the mutual interaction between mother and child has been increasingly documented and differentiated; for example, the continuous exchange of cells (pseudo-chimeras) and the neurobiology of prenatal brain activity (Chamberlain 1997; Roth 2003; Verny 2003). The empathic-intuitive research in prenatal psychology and trauma therapy regarding prenatal communication—as it occurs on all physiologic and psychic levels (Reiter 2004)—is now finding validation on a scientific level (Fedor-Freybergh and Janus 1989ff.). Whether external forces or inner motives determine conflict in a pregnancy, unconscious dynamics (that may even reach across generations into the past) can, by means of psychotherapy, be

K. Evertz (*) HfWU Nuertingen-Geislingen University, Institute for Art Therapy & Art Analysis, Köln, Germany

clarified and integrated within the discussion. Often enough, the gap between child bearing, miscarriage, preterm delivery, still birth, and abortion is not very wide. To finally obviate these unspeakable discussions about culpability with regard to problematic pregnancies, it is necessary to integrate the psychodynamic plane, and to consider the difficulties and beauties of the transfer of life in a broader and more humane context (Linder 2008). In contrast with conventional conflict counseling, psychotherapy allows us to address more far-­ reaching aspects of the conflict’s psycho dynamics with pregnant clients. However, few women and couples facing a problematic pregnancy decide to walk into a psychotherapist’s office, let alone men by themselves. In the course of developing a triad of pre- and periconceptional, pre- and perinatal psychology, and transgenerational systemic family therapy, we have devised a variety of therapeutic methods based on psychoanalysis and humanistic psychology. These methods are suited to the examination of a person’s entire biography, starting with conception, and encompass a psychodynamic context dating back as far as three generations (Janus 2000). Alongside focal therapy (Meistermann 1989) and other modern forms of psychoanalysis, these methods include: different types of body and art therapy—based on deep analysis (e.g., Analytisch-Ästhetische Kunsttherapie; Evertz  1998, 2001, 2003, 2007)—and conversa-

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tional psychotherapy, based on deep analysis and mother-child bond analysis (Hidas and Raffai 2006). They also include complementary and introductory means such as family constellations and other forms of experience-oriented group therapies designed to integrate transgenerational correlations. Conflicts in relation to pregnancy occur in many different ways and on many different levels. This chapter addresses some of the mostly subconscious, psychodynamic aspects that find expression in strong ambivalence regarding the pregnancy. Often, societal taboos against fear-­ provoking issues are overwhelming, and the framework for consultation and therapy is defined too narrowly, thus preventing the candid analysis of these aspects. In this chapter, I present family portraits created by: clients of my art and psychotherapeutic practice, participants of art psychotherapeutic workshops for cancer patients, and participants of vocational training in “psychooncological art therapy” at the Mildred-Scheel-Akademie in Cologne (Evertz 1997, 2007). These colors and shapes, subconsciously and spontaneously conceived, present more or less explicit depictions of abortive structures. The aim of these portraits was to symbolically capture difficult situations in one’s own family history where (new) children were unwelcome or could not be received with joyous anticipation. Subsequently, I will investigate different aspects of the situation of being unwelcome. My observations are based on experiences in my work with pregnant women, couples, and patients who used therapy to work through early childhood trauma; another source is the unpublished, yet fundamental, discourse held by the psychoanalyst Meistermann-Seeger in 1991: “Wie kommt es zur Abtreibung?  – Diagnose einer psychobiologischen Krise” (“How does an abortion come about? – Diagnosis of a psychobiologic Crisis”). Also, I am obliged to the psychologist Jürgen Vogel, of Cologne, for many insights resulting from our mutual collaboration. Often, transgenerational conflicts within the family or the expectant parents’ unsolved preand perinatal traumatization are a source for

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unconscious abortive tendencies. More often than not, abortion is the less-than-ideal resolution of unbearable subconscious pain, fear, and agony. The couple’s deeply buried fear of being forced to kill the child later on forces them to abort the embryo. The real child in the uterus is thus mistaken for the traumatized “inner child” of the father or mother. Generally, these processes happen subconsciously, but they have a strong impact on motivations; they are very complex and are therefore rarely discussed in public dialogue (Stern 1996; Verny 1981). Art psychotherapy can be a way to express these inner conflicts through the creation of spontaneous, very impressive, and deep images. By means of a case study (and a few case histories), I want to demonstrate the possibilities of therapeutic assistance during an initially unwanted pregnancy. Before therapy, the patient had already had three abortions; in the course of the therapy she arrives at the decision of keeping the child. The illumination of experiences during her own time as embryo and fetus brought her to a significant turning point regarding her fear of carrying the baby. By means of painting abstract and representational symbolizations in a spontaneous manner she was able, for the first time in her life, to connect with unconscious complexes rooted in her early development.

Abortion as a Problem of Society In Germany, the abortion rate is decreasing, but only very slowly. For many decades, it has remained virtually the same. Between 1996 and 2005, official numbers dropped from 131,000 to 124,000 (see Table  1). One reason for this decrease is better counseling services that, for example, focus on being more unbiased regarding the result. Another aspect is, of course, the decrease in the total number of pregnancies; while the absolute numbers seem to suggest a sustainable improvement, the change in percentage points is negligible. Similar developments can be observed in all European countries, that is, where regulations regarding a three-month window or generous

A Visual Exploration of Psychodynamics in Problematic Pregnancies: Case Studies in Analytic-Aesthetic… Table 1  Abortions in Germany 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

130,900 130,890 131,795 130,600 134,600 135,100 130,400 128,000 129,600 124,000 119,710 116,871 114,484 110,644 110,431 108,867 106,815 102,802 99,700 99,200 98,700 101,200 101,000

Note: Since 1996, the relationship between the number of abortions and births has remained between 16 and 18%. Therefore, the decreasing numbers of abortion are not indicators of a turning point. Source: Statistisches Bundesamt Destatis

social indicators were introduced in the course of the last decades. Either the number of abortions declined slightly, as in Germany, Denmark, and most Eastern European countries (as well as in the USA and Canada), or they stagnated with slight shifts, as in Italy, Norway, and Switzerland. Countries where numbers increased again after an initial decline are England, France, the Netherlands, and Sweden (Europarat 2004). It may be considered regrettable that the wealthiest societies in the world cannot provide their citizens with the necessary education and security of existence to make abortions unnecessary. However, it seems to be a consensus within society that abortions are declared illegal yet not subject to prosecution. Surveys in Germany revealed that while a majority of Germans would prefer that there were fewer or no abortions, they also consider the judiciary to be the wrong institution to deal with pregnancy conflicts

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(Meistermann 1991). The current social consensus with regard to abortion was established after decades of intense dialogue, and there is now a sort of truce. Everybody knows that this problem (and it is a problem for every society) cannot be solved within the foreseeable future, so, currently, there is not a lot of a discussion about it. A society seems to primarily engage in an argument when the solution is already conceivable. Quite a few voices consider abortions an unsolvable problem that should be treated with as much benevolence and empathy as possible; at least in the coming decades. Political, religious, feminist, and medical circles seem to agree that new solutions can only be fueled by improved services with regard to education and consultation. However, this approach does not get to the root of the problem. Why have abortion rates remained relatively unchanged for decades? A first psychocultural answer could be that there is a psychohistorical momentum that cannot be solved individually, but can only be understood by looking at individual cases. This would mean to assume an unconscious collective momentum within every society of the world that makes a certain number of abortions “necessary” because there are no better solutions available for the specific, deeply ingrained complexes underlying these conflicts. It is hard to explain why the risk of pregnancy is often taken on despite a fairly extensive sexual education and the availability of a wide range of contraceptive measures. Trivial explanations may include the lack of education of sexual partners; however, this would mean that unwanted pregnancies occur more often among the lower social classes, and that is just not the case. Here is an example taken from the author’s environment: An artist and colleague, age 45, highly educated, middle-class, could not fathom having any responsibility for a child that had been conceived during a one-night stand. It is still quite common for many men to show this kind of childish, defiant arrogance and to burden women with the exclusive liability for contraception. Another argument is that sexual contact without any means of contraception leads to higher sensual intensity. Nobody would seriously deny

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that, but it seems unlikely that it would be more difficult if not unbearable for a couple to refrain from unprotected sexual intercourse for a few days every month, as opposed to having to deal with an unwanted pregnancy. And the notion that contraception inhibits all spontaneity in short-­ term sexual encounters seems rather short-sighted. On the other hand, one of the most intense sensual aspects of sexual intercourse is, indeed, the inherent possibility of conceiving a new human being—the consummate symbol of the love between a man and a woman. This very issue may touch an unconscious complex of unresolved trauma woven into the history of a man and a woman, and it may lead them to take the risk of unwanted pregnancy in order to find themselves in a position where they can decide over life and death. Or, as one couple stated in therapy: “We really only conceived it to later abort it…somehow it was very exciting.” Effectively, there is no stronger negative arousal than to take the life of another human being. These sadomasochistic complexes usually have their origin in the parents’ unresolved childhood experience, or in abortive structures within their family history. Every person carries such complexes. These abortive structures —destructive, traumatic, and possibly life-extinguishing tendencies—are present in every family. An impressive example is the extremely high number of artificial fertilizations in Israel: the horrific trauma of the Holocaust along with a state of war that has been maintained for more than 60 years—this imposes a heavy burden on nascent life. Naturally, past and present traumata are the maximum credible stress for expectant couples. It is essential to realize that abortive tendencies always result from the experience of distress and real fears and survival in specific traumatizing situations; it is not just a “fictional” and accidental inclination to torture. The liberalization of abortion law that took place in many democratic countries in the last decades—long overdue in the interest of education and women’s emancipation —finally terminated the horrific and unspeakable predicament that women of earlier generations were forced to

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deal with. However, less well-informed contemporaries could come to the conclusion that abortion was a simple medical procedure; one that could be easily endured several times without any serious consequences for body or soul. That is not the case, at least with regard to the consequences for the souls of men and women. They may suffer from an abortion for years and decades, and only find peace in their lives after an elaborate process of grieving—and this includes not just women and men who allegedly are “too sensitive” or “weak” or of catholic denomination. Many couples who come to my practice because of an “unwanted” pregnancy, first unburden themselves of all their fearful fantasies about their future life as parents; only then do they realize that they either feel too immature to take on the responsibility of parenthood or that they have not yet mutually committed to being a couple, or they immediately encounter memories of what they missed out on as children and how it would be unfair to burden a child with parents like themselves. Often this is a good entrance into a longer process of accepting the pregnancy and preparing for parenthood. Sometimes, however, the consultations are aborted—last, but not least, because our society still prefers to be blinded by fear-induced fantasies of power and grandeur and has little appreciation for allowing individual fears to emerge in therapy or counseling. A climate of critical self-reflection usually requires a hermetic-­ intimate constellation and is rarely possible in a public setting. Of course, an open-ended process is the necessary precondition for any kind of therapy and counseling regarding problematic pregnancies. Many couples who decide against the child are influenced by inner, mostly unconscious factors, in addition to outer reasons such as lack of financial security, life plans, or partnership conflicts. These unconscious motivations usually result from pre- and perinatal experiences, childhood trauma, and transgenerational conflicts within the family. The couple is not aware of these motivations, but they wield a strong affective power that creates an urge to act them out,

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with no framework to ever address the deeper causes. This seems to be one of the underlying reasons why the number of abortions remains so consistent in Germany and other countries: At a specific level of psychohistorical social maturity, a collective dynamic is required to act out deep-­ seated fears and agonies by means of abortion, at least to some extent. There seems to be no other way to resolve this psychodynamic complex, either individually or collectively. Moreover, these correlations are little-known and barely discussed beyond small circles of scientists and therapists. In a best-case scenario, the abortion rate could be reduced significantly through improved counseling practices. These would include the integration of psychotherapeutic services capable of addressing deeper fears and complexes, as well as fact-based education of the public that is, significantly different from the extremely polarized positions of the former discussion (“Abortion is Homicide” vs. “My body belongs to me”). This also includes educational services in schools to better prepare students for future parenthood. Dass man der Mutter die Schwangerschaft als einen Übergang zu einem reicheren Dasein beschreibt, ist nur möglich, wenn man das Parasitäre der Schwangerschaft akzeptiert, es ihr offenlegt und ihr zeigt, was es bedeutet, dass keine Macht der Welt ihr mehr für den Rest des Lebens die Chance gibt, für sich alleine zu sein. (Meistermann 1991, p. 3) Telling the mother that pregnancy is a transition towards a more bountiful life can only be justified if we accept the parasitical aspect of pregnancy. This must be disclosed to her. She needs to know what it means: that never again in her life will any power in the world give her the opportunity to be all by herself.

It is of no use—and only increases the resistance against the argument—to condemn human conduct if we have not attempted to really understand, not just why couples have an abortion, but why they do not dare to raise children or do not believe they can create a loving home for them. Just the sheer force of numbers reflecting the ubiquitous presence of problematic pregnancies should set every sensible witness of the debate

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thinking about what is going on here, and why it must happen so consistently, on such a large scale and over such a long period of time. With good reason, Meistermann points out that there is almost no research into the reasons why women resort to abortion. Apparently, there is an inadvertent consensus: on the one hand, conservative-patriarchal structures refuse to address their own part and responsibility with regard to pregnancy dilemmas and prefer to condemn rather than support; on the other hand, feminist structures, in their rightful fight for a liberalization of abortion laws, are forced to abnegate that pregnancy termination has an emotional-psychological dimension, even though it is considered “clean” and physiologically without consequences in a medical-technical sense. People tend to repeatedly recreate specific states of excitement in their lives, even though these states are dangerous, damaging, or destructive for them and others. In psychoanalysis, this behavior is called compulsive repetition. Modern brain research confirms the existence of corresponding neurobiological patterns that prompt repetition, for example: when it is not possible to undergo the grief that is necessary to resolve a trauma (Hochauf 2003). Abortion is a matter of life and death. Many abortions that seem necessary may be ascribed to larger-than-life fears—the parents’ fear of not being able to really love a child or of being forced to kill the child later on, all because of their grief, for example, about their own adverse pregnancy or childhood, which has not been allowed to surface. From a psychohistorical point of view, it seems vital to discover the real reasons for abortion in order to promote the process of democratization and development in modern society. Vast excesses in human history seem to be conditioned by a collective abortion complex, and, simultaneously, may condition these complexes. It is imperative to break this vicious circle. A society that still requires a high number of abortions cannot be considered safe for the individual person. For example, besides Romania, Russia is the only European country where the number of abortions is higher than the number of births (see Table 2).

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314 Table 2  Abortions in Europe and North America: Legal abortions per 1000 women (between age 15 and 44) Belgium (2003): Bulgaria (2003): Denmark (2006): Germany (2006): England and Wales (2006): Finnland (2003): France (2004): The Netherlands (2005): Italy (2004): Canada (2003): Lithuania (2003): Norway (2006): Romania (2003): Russian Federation (2003): Sweden (2006): Switzerland (2005): Spain (2005): Hungary (2003): USA (2003):

7.9 29.9 14.3 7.2 8.3 10.7 17.3 8.6 11.6 15.2 15.0 15.0 46.8 55.3 20.6 6.6 9.6 25.8 20.8

Source: Evolution démographique récente en Europe 2004 [European Council], National Statistics/BFS/Alan Guttmacher Institute 2005

After decades (and centuries) of inner terror, nobody can deny that Russian society finds itself in a state of maturation where a single human life does not count too much. It will still require a few decades of educational advertising and democratization efforts before this can change. The reverse projection of the practice of abortion is indeed that the individual citizen cannot feel safe regarding his or her own life; this creates strong, unconscious, paranoid fears that, in return, further antisocial structures and an authoritarian strive for power: There is a need for toughness. Empathy is a sign of weakness. In truth, the reverse applies: the greater the fear, the tougher and more ruthlessly a person behaves; the stronger he is, the more empathically he can react toward other people. It is appropriate to consider the abortion rate as an indicator among many others for the psychic maturation of a society, as long as it is not abused in a projective way. The paranoid is antisocial and averse to family (J. Vogt, n.d., oral communication). The extreme facets of capitalism—as opposed to more moderate forms (such as social market economy)—bear an aspect of abortion: there can only be one win-

ner (survivor)—in contrast to having all citizens with their individual talents contributing to the general welfare, as is possible in a healthy and fair competitive society. Even the world’s largest democratic nation with its paranoid fears and resulting politics of deception and violence, the USA, cannot be understood without the deep analysis of pre- and perinatal psychology. Concerning the history of civilization, abortion means: allegedly, one must destroy the other in order to secure one’s own survival. Islamic fundamentalism also shows significant signs of pathologic fear that can only be eliminated at the price of one’s own or the other’s life, just like any totalitarian and authoritarian system. You or me, rather than let us join forces. This is the dangerous delusion that arises from an unresolved complex of being unwanted, and it cannot be resolved or healed with all the catalogues of virtue in the world. The mother can only accept a child, can only allow a new being to grow in her body for nine months, if she is empathic, if she can empathize with this new being and its situation. A priori, it is impossible for her to carry a child when her parasitical fantasies are too strong. She knows that there will be a lifelong commitment to the child and no powers in the world could unburden her from this responsibility, that is, when she is on her own. Parasitical fantasies arise from unbearable feelings of stress and excessive demands, reverberating the mother’s own complexes of being unwanted that cannot be made conscious or mourned. It is legitimate to question whether there are always unrecognized deep psychologic motivations that make an abortion necessary. If we assume that adults are informed that every unprotected sexual intercourse may lead to conception, both sexual partners are accountable for conceiving a child even if they do not want to have one. In the last few decades, most Western countries have recognized the need for more liberal legislation with regard to abortion. Having accomplished this, it is now possible to scientifically explore the deeper reasons behind abortions rather than overexert ourselves in polarized, hysterical discussions. Of course, this tendency

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toward rapid polarization common to debates on abortion was brought about by the implicit situation of conflict: life or death and the unbearably lopsided hierarchy between the all-too-small and the way-too-big. Nowhere else is the actual ratio and mutual dependency between two human beings as extreme and tremendous as between blastocyst/embryo and mother/father. All human beings have either had such borderline experiences in the course of their life, especially in their earliest times, or felt these fears in their parents. (After all, our parents and grandparents lived through, or were in some way involved in, the greatest human massacre of all times.) These repressed traumatic experiences of the collective are immediately triggered; as a result, the abortion debate was mostly dominated by views of survival, justification, and destruction that barely ever allowed for a constructive discussion. Rather than polarized debates— either-or, you or me—we need a conversation that sheds light preferably on all motivations and origins of certain behaviors during pregnancy. This form of debate would allow us to provide real answers to couples in doubt, offer more accessible perspectives to women who are left to their own devices, including support in the case of abortion, and, finally, open up public discussion. Many women and men who were involved in an abortion will later become loving parents. Many men who ran from their responsibility are able to admit this later on. Some women who already are loving mothers are later forced to end a new pregnancy for many different reasons. Of course, these incidents remain tragic; unresolved conflict prevents one from fully loving one’s own life as well as the life of others. And there are many life paths where people manifest their love of life and being human in many forms of social and cultural activities, but not in the transfer of life onto children of their own. The main concern is to move out of the paranoid planes of discussion toward a level of greater empathy. We need an answer to why, while birth rates are decreasing, our society is still not able to offer a loving environment to those children who are born—and if not with their own parents, then at least with adoptive or foster parents. We need

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this greater empathy and sensitivity as a deeper foundation to build a stronger affirmation of life—this is the next step of growth for our society—rather than choosing to hide behind a biological discussion about the point in time when human life really begins. Life does not start with conception, it is only transferred. Individual life is always just one link in a phylogenetic chain, bound to another level of family history, and therefore even the fertilized egg is already a human being. The biologic-psychic-social spheres of conception are very complex. Usually, they start long before the actual act of conception, that is, when the parents themselves were still children and played “parents.” Up till now, our culture has processed them in “occult” ways or, highly coded, as religious and artistic symbols (Evertz and Janus 2002), restricts them to esoteric circles, or it treats them as a merely biochemical and medical-­ technical complex. As of now, prenatal psychology integrates solely incipient stages of pre- and periconceptional psychology, and these are implicitly assumed in a transgenerational, systemic family therapy (Evertz 1999; Janus 2000). Anyone who considers these previous deliberations unworthy of discussion might need to be reminded that at the end of the nineteenth century, the death rate among babies in Germany was much higher than in other industrialized countries. Only after growing protests and embarrassment about the scandalous fact that the weakest human beings were not given enough attention, politics, medicine, and science consolidated their efforts and, within a period of 15 years, Germany became a worldwide leader in obstetrics and baby care in accordance with contemporary standards. Many German citizens are only alive today because their grandparents and great-grandparents benefitted from these new measures when they were babies. They survived, whereas under the previous circumstances of neglect, they could not have. As I said before, in order to eliminate aspects of guilt, accusation, and justification from the current debate and to reach constructive conclusions, we need to initiate a discussion that considers the underlying causes and is able to offer

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more empathic and specific counseling, education, and support. As one pillar of support for potential parents, we need to integrate psychological aspects alongside political, social, and psychohistorical dimensions, particularly the new insights of prenatal psychology. We can conclude that abortion and the aborted child have a psychic function within the process of a human being’s path to maturity. For father and mother, at least, it is a lost chance to give something back to the life that they have been given; a human existence. It is necessary to grieve this loss—rather than to conceal, deny, suppress, or veil it as something that was carried out on nothing but a heap of cells—so that its psychic function can be consciously integrated. Life offers many possibilities to give back and show gratefulness, although one cannot act on every possibility and it must be said: there are good reasons to have an abortion. However, we would be well advised to stand by our actions, especially men; too often, they do not appear to play a part in problematic pregnancies or they withdraw from the situation. If we allow ourselves to be aware of chances missed, it will be easier for us to find our place in the world.

Parenthood and Passing on the Unresolved Parenthood facilitates man and woman in developing new self-conceptions. With regard to the child’s future development, one can anticipate two opposing directions: –– Self-enhancement, self-realization—one’s own “good” self continues to grow –– The child is a rival—possibilities are constrained In either case, the child is, inevitably, a projection surface for the unresolved problems of its parents. Additionally, fantasies of abortion are part of the identification process with one’s “own child.” These fantasies are “normal” and, in a certain way, even necessary to create a real object

relationship with the child. Indeed, the child is completely dependent on its parents’ devotion or aversion: just as they can let it die during the pregnancy, they can also prepare it for life in a better or worse way, depending on their degree of empathy during the pregnancy. A deep and distinct object relationship with the child is the best way to support it in establishing contact with the emotional, social, and material world. Even in the womb, the child is better equipped to deal with its parents’ ambivalences than with a facade of: “pregnancy has to be absolutely wonderful.” The parents’ basic imbalances lead to privation and gaps in the child’s potential, whereas “basic imperfection” and “incompatibility of parents” provide it with vital creativity (Meistermann 1989). For everyone, it is and remains a life’s work—maybe the deepest work of all—to “merge the parents inside one’s self” in order to create a completely new human being from both the paternal and the maternal halves. The merging of sperm and egg (easy to describe on the level of biologic language) as well as the psychobiological process resulting from it are and remain a challenge throughout our entire life. Thus, we seek to unite what is rather incompatible, especially at the intuitive, affective, and cognitive levels that we reach as adults. Couples can match, more or less, but no couple forms a perfect union. When a child is conceived, two genetic strands meet that never before had anything to do with each other (in a more narrow apprehension). Modern biochemical research claims that the more diverse two genotypes, the stronger and more resilient is the life they can create. Indeed, the strength of a love relationship is also determined by the way two partners are able to accept, allow, and empathize with the completely alien aspect of the other.

First Case-Story Female client, age 55, 1 year after being diagnosed with cervical cancer presents with panic attacks, recurring states of confusion, and states of anxiety. Among other things, her anamnesis shows that, being in conflict with some of her

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s­ iblings, she is unable to recount her family in the order of her siblings’ birth dates. She confuses names and birth dates. Only after she arrays her family members in a session, and after setting up her family constellation with real people during a three-day workshop, does she regain clarity in her perception of herself.

ing them—and resulting in great relief and relaxation. In this conversation, the client learned about the parents’, and especially the father’s, fears: the family learned during the pregnancy that they might be dispossessed and have to give up their farm in the former GDR.  This threat became a reality, which also is a thorough expla-

The client (symbol with star) had eight siblings. All in all, there were nine children in her family of origin: the first (born in 1940) is alive, the second died at the age of one month, the third is alive, the fourth is the client, the fifth was a miscarriage. The sixth was aborted, the seventh died of a brain tumor at age eight, the eighth is alive and psychotic, and the ninth died of a brain tumor at age 40. She discovered that, on the one hand, the three siblings who followed her directly died early, and, on the other hand, the two siblings who followed her—the first one was a miscarriage, followed by an abortion—were never named or given a place in the family progression. She gives them names, and it makes her feel safer and more rooted. In another art therapy workshop, she paints a long succession of images about her own pregnancy. While painting one of these images, she feels a belly ache and persistent feelings of discomfort. She decides to visit her 80-year-old mother and ask her whether she was meant to be aborted. Her mother is surprised by her question, but spontaneously answers that she wanted the pregnancy, revealing, however, that the father did not. The client is very happy about her mother’s spontaneous answer; she feels her mother’s acceptance and welcome in a new way. She had always fantasized that it had been the other way around; that her father had loved her more than her mother. A productive conversation unfolded that had apparently been desired by both, covering the family dynamics—as well as some taboos regard-

nation for the breach that happened in the client’s row of siblings after her own birth. In very short form, this example shows how fateful turns in a couple’s lives create periods during which they can welcome and accept children, and also phases in which they are forced to consider additional children as an overwhelming threat, that is, because the extraneous circumstances already are very perilous.

Second Case-Story A female client, age 55, after having been diagnosed with uterine cancer paints images in which she constantly confuses the depiction of her tumor and a child that she aborted when she was 25 years old. It becomes clear that, as a 25-year-­ old, she perceived the child as a parasite with the capacity to swallow her life, to devour her from the inside. It was completely clear to her at the time that she could not have the child that was conceived in a short relationship with an Arab man, and she went to an obscure surgery to have an abortion. The way that she told her story made very clear that it had been a traumatic experience: the doctor lacked competence and the environment was horrible. She was on her own and very afraid, and then had to undergo clinical follow-up treatment because her bleeding did not stop after the surgery. Even afterwards, she remained completely on her own with her decision and never talked about it or told anyone. It all happened in a traumatic fog. The image shows a tumor and/or

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Only then is she able to grieve both experiences. In the logic of trauma, both traumata are gummed up and require careful and cautious differentiation by means of many images and sessions in order to resolve an unbearable feeling of guilt and replace it with genuine grief.

Third Case-Story

Fig. 1  Mix-up of embryo and tumor (acrylics on paper, 85 × 61 cm)

embryo (as little monster) that threatens the client from the inside (Fig. 1). Twenty-five years later, she experienced her cancer as a similar trauma. Only now, during the therapy following the diagnosis, is she able to grieve her abortion. It becomes obvious at this point in her life that her aborted child—whom she felt to have been a boy—would not only have been her only child, but also the only child of a possible new generation of her family, as none of her three siblings have children of their own. She names the child and creates a painting that shows a boy at age 10, and only now can she tearfully realize just how painful an experience her ambivalence had been for her and how haunting was the trauma of her abortion. Only then could something inside her be reconciled. This example shows a differentiated subconscious dynamic: the trauma of uterine cancer is interwoven with her earlier trauma—an abortion that was executed poorly and endured without any emotional support.

A 50-year-old client is empowered for the first time to express her experience of being unwanted as an embryo/fetus with a series of paintings (Figs. 2, 3, and 4). By means of aesthetic expression, she cautiously approaches a complex of repressed emotions that has been encumbering her entire life and, up until then, could only be expressed in autoaggressive ways such as physical illness and depression. After a whole series of black-and-gray paintings (Figs. 2, 3, 4, and 5) that evoke associations with death and destruction, ashes, severed body parts, and “scorched earth” (survival of an attempted abortion), a different kind of image is beginning to emerge, showing at first the color red followed by the unscathed body. Dismemberment is transformed into the split between two body shapes (Figs. 5, 6, and 7). Then she can perceive the traumatized “inner child” in her paintings (Fig. 8). Finally, images emerge that symbolize the acceptance of this traumatized “inner child” for the first time (Fig. 9). During her pregnancy, the client’s mother faced severe psychosocial stress and did not want to bear the baby. The paintings depict inner images of destruction that a rejected child must overcome in order to develop a feeling for itself and a fairly stable self-image (vgl. Levend and Janus 2000).

 he Psychodynamics of Problematic T Pregnancies In the psychodynamic complexes of problematic pregnancies, we can discern the following aspects of conflict: On a conscious level:

Figs. 2, 3, 4, 5, 6, 7, 8, and 9  From “black” triangulation to the acceptance of the “inner child” and its intrauterine trauma (acrylics on paper, 65 × 81 cm)

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1. Excessive demands (life situation, partner ship, work, financial situation, etc.) 2. Apprehension to transfer life (painful childhood experiences, the catastrophes of the world) On an unconscious level: 3. Traumatic stress during one’s own pregnancy: for example, highly ambivalent parents, illness, severe psychosocial stress during preand perinatal periods, dreading to be forced to kill (unresolved suicidal aspect) 4. Transgenerational trauma: for example, the experience of a death during childhood or during an attempted abortion, severe psychosocial stress during pre- and perinatal periods With regard to 1 and 2, there are good and responsible, conscious reasons not to continue a pregnancy. On the other hand, there is also subterfuge based on neurotic complexes. The most crucial conscious reason is usually the unmitigated feeling that one lacks maturity, along with the lack of means and resources to provide a child (or an additional child) with a good home at a specific point in time. The feeling is that it is too soon, I have not finished my education, this partner is not the right one or he is trying to abdicate his responsibility, there are no financial reserves, the apartment is too small, etc. Considering the common standard of living, some of these reasons seem unrealistic and the expectations for a(n even) better life are too grand. This means that some of these arguments are based on neurotic complexes and not in accord with reality, but there are also deeply felt and comprehensible reasons rooted in genuine distress. Overall, 71% of all abortions registered in Germany (almost 88,000 abortions per year) are carried out by women (and their partners) between 18 and 34 years of age. Six percent of these pregnant women are younger than 18, 16% are between 35 and 39 years of age, and 7% are older than age 40. For 40% of all women/couples who have an abortion, the aborted child is their first (Statistisches Bundesamt 2018).

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Based on observations made in his practice, the author thinks that a certain number of couples choose to have an abortion simply because they refuse to grow up. Others barely reflect on what they are doing. As a society we accept the free decision to abort, however reasonable or superficial the motives. It is not up to society to evaluate or judge this decision. However, it should be considered a social task to provide a broad spectrum of counseling services and support in order to reduce the number of abortions, or even make them redundant. As a serious sociopolitical endeavor of the future, the preparation for parenthood needs to be advanced with a clear focus on pedagogic and therapeutic aspects. It is not acceptable that girls and women, boys and men are still given the impression that any citizen can take on parenthood without preparation, and even by accident; or that society faces enormous difficulties and costs when completely derailed, dissocial lives emerge from accidental or ill-reflected parenthood. Every Euro invested in the teaching of how to be a mother or father will save thousands of Euro that need to be put into police work, the justice system, and rehabilitation later on. In this context, it is not irrelevant to mention that since the United States liberalized their abortion law, the rate of very serious crime has gone down (House 2002). In society, completely unwanted children have no choice but to behave unwantedly. They do everything to be punished—for a guilt that originally was not theirs. One could call this a law of nature. These developmental-psychological aspects need to be taken into consideration when we speak about left-wing and right-wing radicalism as well. Instead, we talk about extreme “political powers,” as if these ideological extremes were not simply another refuge for particularly unwanted and traumatized children who, as adults, turn their logic of trauma into a doctrine. But the aspect of the entire society’s emancipation is much more important: For the sake of advancing democratization and human development, the conception of a child is not a trivial or accidental incident that can be undone just as succinctly. Each conception, and the way society handles it, is an expression of the value of each

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single person in this society. And we can probably all agree that we are a long way from the complete implementation of human rights—even in the Western countries. A child can only be well if the parents are well. Severe psychosocial stress limits the possibilities for mutual empathy leading to increased misunderstanding in the everyday reality of raising the child. Parents-to-be often cherish exaggerated expectations of happiness. They are surprised when they find themselves confronted with their own early childhood experiences, and find it hard to grasp. Nonetheless, the immeasurable happiness many couples experience through their parenthood is one of the great experiences of bliss for mankind: a new human being really has come into existence through the love between two people. Life can continue and increase, as each generation has the possibility to improve on the solutions of the previous generation. Undoubtedly, recent centuries have brought about real ethical progress; however, the stratum of culture is still fragile, and there is a continuous threat of archaic regression. No pregnancy is free of ambivalences, doubts, fears, skeptical considerations, and one’s own childhood memories. No pregnancy is entirely blissful. Men tend to project their own (infantile) longings onto the pregnant woman and believe that she and the child should be the happiest beings in the world. As a wistful projection of hope, the image of the child as a happy baby towers over concrete apprehension and (self-)critical reflection. Thus, it is all the more important for pregnancy counseling to differentiate between real and more neurotic apprehensions. Some people leave the counseling session with a completely different attitude toward the child, just because—to their surprise—they were invited to voice their seemingly bad and negative feelings about the pregnancy. They are amazed that these feelings are normal and permitted, and do not automatically imply an abortion. Due to the mutual biological-psychological interaction between mother and child, and the father in the background, the following emotional environments may be prevalent within the uterus: Maternal forces (death pole):

–– –– –– –– ––

–– –– –– –– –– –– ––

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Overprotective-dominating Repelling and abandoning Depressive Fearful Overexpectant (longing as suppression): still in the uterus, the child is already the object of narcissist projections, thus being used to fill in for parental deficits. Maternal forces (life pole): Loving and with relish Curious and full of expectation Confident and secure Open for bonding Lust for triangulation Transgenerationally connected

In his article “Das unwillkommene Kind und sein Todestrieb” (“The unwelcome child and its death wish”) in 1929, Sándor Ferenczi wrote about pre- and perinatal traumata: …beide Patienten kamen sozusagen als unwillkommene Gäste der Familie zur Welt. Der eine als zehntes Kind der offenbar stark überlasteten Mutter, der andere als Nachkomme des todkranken, bald darauf wirklich verstorbenen Vaters. Alle Anzeichen sprechen dafür, dass diese Kinder die bewussten und unbewussten Merkmale der Abneigung und Ungeduld der Mutter wohl bemerkt und durch sie in ihrem Lebenwollen geknickt wurden. Im späteren Leben genügten dann verhältnismäßig geringe Anlässe zum Sterbenwollen, auch wenn dieses durch starke Willensanspannung kompensiert wurde… (Ferenczi 1982, p. 251). …one could say that both clients came into this world as unasked-for guests of the family. One as the tenth child of a mother who was obviously overwhelmed, the other as the offspring of a mortally ill father who died soon afterwards. It seems quite obvious that these children were very aware of their mothers’ conscious or unconscious signs of aversion and impatience, and that this impaired them in their desire to live. Later in their lives, even seemingly minor incidents were enough for them to experience the wish to die, though compensated by a strong act of will….

During pregnancy, life’s tension between life and death becomes very obvious and fragile; here is where the foundations for future vitality and the death wish are constituted. There is a fluent spectrum between early miscarriage (sometimes

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unnoticed by the mother), tendencies toward premature delivery, premature birth, abortion, still birth, and sudden infant death. An unconscious dynamic seems to turn the balance! And there is also the possibility of “natural abortion.” Forty to seventy percent of all implantations are not successful. Immunotolerance cannot be established; mutual resistance cannot be overcome by empathy. This tells us that the mother’s ambivalence is often much greater than what men are ready to acknowledge. “Natural abortion” is therefore not unusual, but rather an occurrence as natural as non-abortion. However, memories and grieving still require space and time and resonance. A woman who absolutely does not want to have a child will not get pregnant, but she may not even be completely aware of these nuances (Meistermann 1991). In rough outline, couples decide for or against one of the following six possibilities regarding the transfer of life: –– Couples consciously decide not to have children and do not have any. –– Couples are infertile (usually one of the two partners takes on this function), but usually do not reflect the family dynamics and psychodynamic factors of their infertility; in their distress, they almost exclusively rely on the technical means of artificial fertilization with all its abusive implications; psychotherapeutic counseling may provide a solution, but this possibility is too rarely considered. –– Couples conceive children, but they are miscarried (“natural abortion”). –– Couples conceive children only to abort them. –– Couples conceive children to abort them or carry them to full term. (For the first time, during a workshop on family constellations, a couple was able to become conscious of the fact that they not only had three living children, but also five aborted children. This analysis brought considerable progress to their stagnating, painful relationship.) –– Couples conceive children and are determined to carry them to full term. Throughout the different phases of their lives, most people shift through several of these catego-

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ries, but the more they can reflect upon them, the more likely they will be able to fulfill their wishes and dreams. The efforts people make to compensate for their unfulfilled wish to have children is immense. As I mentioned earlier, for each generation the transfer of life does not only happen through procreation, but also through all cultural efforts to support and enhance life on this planet in a constructive way. It is particularly moving to work with couples who have lost a child during the first months of pregnancy and are now willing to go through a conscious process of grieving to assure that the next child (the next pregnancy) will not be burdened by bereavement and unfulfilled hopes regarding the first child. Within the intimate space provided by couple’s counseling or therapy, the couple can develop a way to assign meaning to what happened, such as: We were not ready, and the child we lost helped us to mature. We have never been able to talk about what we expect of ourselves as parents, but now we can. We had ‘too many’ expectations of the child, and we might have run away if we were overcome by such forceful powers. Now we can look forward to the second child, but it is less subject to our expectations and we can see it more as an independent, new human being.

These examples illustrate how children who died early, be it a miscarriage or abortion, certainly have a systemic function within the dynamic of the family or couple. Every conscious and emotional reflection about what happened leads to inner maturation of the personality and can help to better understand and negotiate future processes. A painting like in Fig.  10 mirrors the psychotic fears of pregnant couples. Inner images depicting a person surrounded by a hostile object without any means of escape can create the need to have an abortion. The subconscious background of a consciously and intentionally executed abortion may, among others, include the following aspects: –– Subconscious motive: to avoid a threatening destruction through merger with the object; if another human being attempts to establish closer contact, it creates a threat of loss of

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Fig. 10 Psychotic intrauterine fears (acrylics on paper, 61 × 85 cm)

identity—in a pregnancy, the child requires potentially unlimited contact from the beginning. –– Subconscious dynamic: reenactment of one’s own early traumatization—the desire to have control over death. –– Subconscious hope: abortion as a means to pierce through the unconscious cycle of trauma, to cast off the inner child of fear.

rightly, Meistermann points out that the problem of abortion only occurs because a being that is half alien and new, grows in the belly of the mother. This new being creates itself and ruthlessly claims its space, and just through this unconditional claim it triggers the mother’s self-defensive reactions against endoparasitic fantasies.

Psychotic fears in pregnant couples are reflected in such an image. With such inner images, in which one feels surrounded by the enemy object and there is no escape, an abortion may be necessary. On a psychodynamic level, only couples can have an abortion. The role of the father is rarely discussed in the debate on problematic pregnancies. And yet, triangulation starts with conception rather than at birth or with the beginnings of the oedipal period! Therefore, the current debate does not sufficiently include the role of the father: men shirk their responsibility, participate in, or even require the abortion; they never hear about it (i.e., do not want to hear about it), and in the discussion they hold very rigid opinions (toward both sides) or appear pathetic. But the father and his early history are part of the decision: they participate 50%. Quite

Fourth Case-Story A 28-year-old female client, student, had abortion at age 18. She describes her life during the last ten years as an almost unconscious succession of situations, thus as traumatic. She now recognizes the rage she feels against the strong ambivalence that she adopted for herself during her time as a child in the womb. She expresses her archaic-destructive impulses in a painting of her mother. The fetus is a parasite that devours the mother (Fig. 11). This image expresses very clearly the reciprocity of prenatal emotional deprivation and hate against the mother. With such an internal image of motherhood, the first child “must” be aborted. It is literally unbearable. However, most couples are not aware of these underlying complexes.

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devour her and her life—it is the identical fantasy the (grand)mother had during her (3rd, 6th, 10th, or 13th) pregnancy. These fantasies make it almost impossible to carry a child. The images painted in an art-­ therapeutic context are symbols of physical experiences that had been completely unconscious up until then. They demonstrate the actual fears behind problematic pregnancy and abortion in a very powerful way.

Fifth Case-Story The following images came into being over the course of one year during weekly sessions (90 min) of art psychotherapy. The client, age 33, diagnosed with borderline syndrome, is the fourth child in an upper middle-class family. Her three older sisters were born at a distance of one to two years. The client has had three abortions and is going through a phase of separation from a violent man. She wants to go through this therapy Fig. 11  The intrauterine representation of the mother: the to address certain aspects that she has not been mother as a devil, the fetus as a parasite (acrylics on paper, able to not work through during her six years of 140 × 90 cm) conversational therapy. These aspects regard her pre- and perinatal experiences, something she has This leads to the conclusion that the most not been able to address with her previous theracommon psychodynamic in problematic preg- pist. She has a notion that the artistic work would nancies is to confuse the inner “traumatized” help her to get in touch with certain emotions that child (pre- and perinatal aspects and aspects of have been suppressed up until now. Besides, she early childhood contained in the mother’s and hopes for more support from a male therapist in father’s history) with the real child growing in the her attempt to break away from her sexually very arousing, but violent, sadomasochistic uterus. Abortion is the attempt at an emergency solu- relationship. The question regarding the strong arousal tion. At that point, the situation cannot be solved in any other way, because rather than being aware resulting from these cruelties quickly leads to of the unconscious dynamics, they are acted out. unconscious pre- and perinatal traumatization and Most clients who seek counseling or therapy in strong ambivalence of the mother. Being the fourth case of a problematic pregnancy cannot see any child, she meant a significant overextension for her other solution; the emotional conflict is too mother. Yet in deference to her husband and her strong. And time is too short to resolve the confu- own religious beliefs, the mother could not have sion between their own unconscious experience an abortion. After three daughters, her husband and the real pregnancy. In these cases, expected her to finally bear him a son. During the therapy, after a short encounter Meistermann calls abortion the woman’s self-­ defense in the face of an (unconscious) imagina- with a new man, the client enters her fourth pregtion of a monster (parasite) growing inside her nancy, but she does not know yet whether she that relentlessly claims its space and threatens to wants to keep the child. In our sessions, she

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clearly perceives, and emotionally relives, the ambivalence her mother felt during her pregnancy, and she can relate that to her own aggression. She has had one abortion to account for each of her three older siblings. Now she can have her child. Figure 12 shows a colored figure of the devil framed by the smaller figures of a man and a woman—a couple that cannot get together because something terribly frightening stands between them. The client can accept the interpretation of an intrauterine mother representation that has always interfered with her relationships, has made cruelty seem desirable, and necessitated three abortions. This leads to the final separation from her last partner. Figure 13 came about when the client became pregnant, but was not yet aware of it. At this point, she had already been in therapy for a few months. The image thus presents an unconscious depiction of a conception. It looks like a heat lamp in a dark cave that illuminates and warms

something hidden inside—a white form resembling a cotton ball. In Fig.  14, she can express all her fears of having to abort the new pregnancy and leave her new partner because he is much less violent and much more loving than her former partner; at the same time, this is the turning point for this conflict. An embryo dismembers a fetus or vice versa. This large-size image led her to the insight that her traumatic prenatal experience (her mother not wanting a fourth child), symbolized by the large fetus, will also eat up her fourth child if she cannot accept this deepest and smallest inner child in herself and thus alleviate the confusion between her traumatized inner child and the real new embryo inside her womb. The client projected her mother’s introjected anger and fear of the new child (the client) onto the “perpetrator fetus.” It can only express its own loneliness through aggression, and has already devoured three embryos—one for each older sister.

Fig. 12  The intrauterine mother representation (acrylics on paper, 160 × 110 cm)

Fig. 13  Conception (acrylics on paper, 160 × 110 cm)

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Fig. 14  Embryo eats fetus (acrylics on paper, 160 × 110 cm)

Such “extreme” images explain the undercurrents of a pregnancy crisis in an extremely honest and direct way, and show how powerfully the mother’s (the father’s) early experience still affect the present. Once these strongest affects had been processed, the client could realize that despite all resistance and ambivalence, her mother gave birth to her child and was able to raise her as best she could, and how this was an act of love in its own right. Very often, this latter aspect cannot come into view at first because the hostile feelings toward the mother are so strong that they supersede almost all other emotions. However, notions of reconciliation are only allowed and possible after an examination of the entire psychic spectrum has been facilitated. If reconciliation occurs too early, it only leads to further stagnation and destruction. In this case, the client could only become a mother herself once she had comprehended the powerful negative mother representation and thus, overcome or integrated it to some extent.

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These complexes are of such force and size that once it has been decided upon, it is almost impossible to prevent an abortion. Most outsiders do not even realize the power behind these dynamics, thus, usually, they remain unconscious. In addition, the resistance of society in general against the disclosure of these planes— even the acceptance of the scientific discoveries of prenatal psychology—is still much too strong at this point. (Instead, night after night, the TV and movie industry entertains us with crime- and horror-movies about the fictional, yet quite ingenious disposal of vast numbers of people to, at least superficially, balance our inner scenarios of fear and horror. They also serve the collective psychic function of cathartic-projective identification (“…thank God I survived again….”); however, this has not really been illuminated yet.) In this case, therapeutic counseling could help the client to see, understand, and overcome her mother’s terrible feelings of rejection (which of course resulted from her mother’s distress and overextension, and probably also from her own very ambivalent prenatal experience) that she had suffered during her time in the womb as an embryo and fetus, and carried inside her ever since in the form of self-damnation, self-­ denigration, and masochism. I could add many other case stories of therapies where pregnant women were only able to accept the child after they could show and process their own early fears through images. Nonverbal media are particularly helpful to symbolize repressed and repudiated complexes for the first time. One of the core aspects of therapy was the clients’ surprise; they were astonished that it was possible to understand and explain these horrible images emerging from their souls, that they were “logical” and “normal,” given their biography; astonished also about the fact that these images could be honored and respected and did not force their counterpart to run away. The occult energy contained in this entire layer of our unconscious indeed turns into something sinister unless it is resolved by means of therapy. The conclusions that can be drawn from the images of these clients dealing with problematic pregnancies can go even further. Many of these

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images urge us to reconsider the origins of humanity’s horror fantasies and even its horror scenarios enacted in reality. I imagine that there can be no more powerful origin of human violence than the experience of being unwanted and the resulting consequences such as neglect, abuse, and violence. As an adult, the person will express the experience of nonacceptance it has undergone through many forms of aggression against itself and others. These psychohistorical and psychocultural aspects still require their own intense reprocessing (Kurth and Janus 2002). Another aspect of this form of therapy: in cases of severe ambivalence toward pregnancy, countertransference can bring up extreme experiences of abdominal pain, desire for abortion, paralysis, resignation, and the impression that if nothing incisive happens, only one person can survive the therapy.

What Leads to an Abortion? The lecture of the psychoanalyst, Meistermann, “Wodurch kommt es zur Abtreibung?” (“What leads to an abortion?,” 1991), so far unpublished, is one of the deepest, most concrete statements about the crisis situation of unwanted pregnancy that we know. Unlike most publications on abortion that look at the external reasons, Meistermann investigates the hidden, yet lastly, most determinative motivations for having an abortion. In the next few paragraphs, I will present some quotes and conclusions from this lecture: Wir verstehen, eine Mutter muss unbedingt zu ihrem Fötus nicht nur eine positive, idealistische, sondern eine realistische Objektbeziehung haben. Diese mag negativ sein, aber die Mutter muss den Föt wahrnehmen, ihn fühlen. Sie muss wissen, was er will und tut. Sie muss alle Aggressionen, die er gegen sie ausführt, reflektieren – dann erst kann sie ihn akzeptieren, auch wenn er noch so sehr ihre eigene Gesundheit schädigt und ihren eigenen Interessen widerspricht. Sie muss den Kampf kennen, der sich zwischen ihr und dem Föt abspielt. Und sie muss den Mut haben, sich diese Kämpfe so lebendig und hart wie möglich vorzustellen p. 3. We understand, it is very necessary that a mother have not just a positive, idealistic object relation-

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ship with her fetus, but also a realistic one. It (the relationship, translator’s note) may be negative, but the mother must appreciate the fetus, feel it. She must know what it wants and does. She must reflect all aggression against her that it expresses— only then can she accept it even though it harms her health and foils her own interests. She must be aware of this battle between her and the fetus. And she must have the courage to imagine these battles as vividly and as forcefully as possible (Meistermann 1991).

Therefore, what leads to an abortion? If we disregard the external reasons, the following aspects have an effect: 1. Destructivity and/or transmarginal stress during the pre- and perinatal existence of father and mother (abortive structures within the family history). 2. Missing experience of a distinct object relationship in the early history of a parent. 3. Acute psychosocial charges increase these unconscious and repressed fears in one’s own history. The lack of intrauterine bonding experience, the resulting deficient self-confidence of the fetus, and missing body boundaries collide with the desire for life of the new embryo. A mother representation that acts in a hostile manner is a firm obstacle to the woman’s own fantasies on how to be a mother. Instead of coming to an acceptance of one’s own mortality (and thus also of one’s own experience of trauma), an infantile desire to reproduce and perpetuate one’s own life continuously creates new unwanted pregnancies. Die beiden genetischen Gaben der Eltern müssen vom Kind ohne Widerspruch vereinigt werden. Diese entsetzliche Bürde ist jedem von uns auferlegt. Das Kind wird bei seiner Zeugung in das Beziehungsgeflecht der Partnerschaft der Eltern geworfen mit all seiner Lust, Gier, Trauer, Angst, Erregung, Ekstase. Von seiner Mitgift her ist das Kind mit dem Vater genauso identifiziert wie mit der Mutter. Die Mutter kann nur über den verinnerlichten Vater eine Objektbeziehung mit dem Kind aufbauen. Geschieht dies nicht, so muss das Kind in diesem vergrabenden, sich in die Mutter hereinbohrenden Zustand verbleiben. Es gerät in unauflösliche Abhängigkeit zu ihr p. 3.

328 The child has to unite the genetic gifts of both parents without contradiction. This is the terrible burden that was imposed on each of us. With its conception, the child is thrown into the web of relationships that is characteristic of its parents’ union, with all its passion, greed, grief, fear, arousal, ecstasy. With regard to its dowry, the child is just as identified with its father as with its mother. Only by means of the internalized father, can the mother build an object relationship with the child. If that does not happen, the child is forced to remain in this state of burying itself, boring into the mother. It is drawn into an unresolvable dependency (Meistermann 1991).

The archaic-primitive mother-fetus relationship is pitted against the singularity of the child, and is another aspect of the conflict between conception and abortion. Among others, the archaic-­primitive is the desire for one’s own individual immortality created by neurosis that is counteracted by the individuality of the child. The cultural achievement of each person is to acknowledge the evolutionary drive to insure the immortality of the species, not that of the individual. Each person is just one link in an endless chain of living beings. Each child reminds its parents strongly of the fact that they are mortal, while it embodies their immortality for the species. In a certain sense, the child creates itself—it is responsible for its own conception and for itself, it is autopoietic. The biopsychological powers express themselves spectacularly through the rapid and incredibly complex development from one to 100 billion cells within a period of nine months. The habitat of parental relationship and, in the narrower sense, the habitat of the maternal womb allow for a more or less successful autopoiesis. At best, all three cooperate. A particular source of tension for a pregnancy is the minuteness of the seed that necessitates implantation, in some circumstances ruthlessly causing injury to the mucosa of the womb. Simultaneous tolerance is only possible in contention with the other (immune tolerance). The embryo’s incredible drive for development meets up against the already advanced mortification of the adults as mother and father. Case-story  A 35-year-old woman, mother of two daughters age 10 and 12, has seven abor-

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tions after her births! In her case, an aggression that had long gone unsatisfied expressed itself. She was the only child of a widow. Her father was missing in action. She had fantasies of suffocating, being crushed, dying of thirst. “She always sat on my face,” was a central image the client had of her mother. The imagination the client suffered from most was to die of thirst and dry out. This deadly idea can occur in cases of oligohydramnios (the regular flow and volume of amniotic fluid is decreased) causing the embryo’s/fetus’s sustenance with fluids to be significantly threatened. This can be caused, for example, by the psychosocial stress of a mother who loses her husband. The client reenacted her continuous proximity to death during her time in the womb in her abortions. The strong destructive aggression expressed in these seven abortions can be understood as a subsequent self-defense against these real prenatal death threats. Abortion, therefore, is hard to prevent: An existing tendency toward aggression is increased and nourished by the “parasitic guest.” This destructivity usually originates from one’s own prenatal existence. Das Wichtigste ist, die Idealisierung aufzuheben, die dem Fötus gilt. Schon vor seiner Geburt wird er verwechselt mit dem begehrenswerten und entzückenden Wesen, das wir erwarten und nach der Geburt im Allgemeinen sehen. Mit dieser Vorstellung sind wir alle identifiziert; aber wir müssen verstehen, dass es sich beim Fötus um ein Lebewesen handelt, das noch nicht den Geburtsakt hinter sich hat, also keine selbständige Handlung kennt, die zum Leiden führt p. 5. The most important thing is to let go of the idealization of the fetus. Even before its birth it is already being confused with the desirable and lovely being that we expect and usually see after birth. We all are identified with this expectation; but we have to understand that the fetus is a living being that has not gone through the act of birth, and it does not know about autonomous action that leads to suffering (Meistermann 1991). Der Zusammenhang von Ursache und Wirkung, der Gegensatz zwischen Mutter und Fötus ist viel zu groß, viel zu mächtig, um von der Mutter auf eine einfache Weise ertragen zu werden. Daher die

A Visual Exploration of Psychodynamics in Problematic Pregnancies: Case Studies in Analytic-Aesthetic… Ideologien oder auch die Forderung nach der Tendenz zur Unterwerfung p. 6. The context of cause and effect is the fear, the antithesis between mother and fetus is far too large, far too powerful to be easily suffered by the mother. This is the origin of these ideologies or also of the demand for a tendency towards submission (Meistermann 1991).

The biggest fear during a pregnancy is the fear of exposing one’s own child to death or being forced to kill it. Unconscious suicidal tendencies resulting from early trauma express themselves in this fear. This results in a paradox: in order to not have to kill the child later on, it cannot be carried. But it has to be conceived, because the crisis must intensify out of the compulsion for repetition. Therefore, each abortion also contains an attempt to eliminate the losses from early childhood for which neither father nor mother have thus far been able to find symbolization; so, usually, they are not aware of them and do not reflect upon them as a couple. If we assume that man as a natural being is subjected to very complex laws, none of his actions are accidental, but result necessarily from his entire biography and the underlying family history. The psychic totals of these complexes are what we call the unconscious, which, compared to our conscious decisions, motivates some 90% of our actions (vgl. Roth 2003). Factors that remained relatively constant:

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1 . It is called on voluntarily 2. The counselor does not impose any particular value orientation 3. It is confidential and independent of third parties 4. It does not lead to predetermined results 5. It supports the person seeking counseling in the decision-making process 6. Opportunity for deeper psychological correlations can be provided if desired (after Meistermann 1991) About 110,000 abortions per year express, among other things, the collective need and desire to resolve early childhood trauma, which, at this point, can only succeed through emergency solutions. We find ourselves in the midst of a psychocultural dynamic that so far is nowhere near its conclusion. Those children who have died represent a potential gift to their parents: if they can be mourned, that mourning leads to greater maturity.

Postnatal Abortion

50% unmarried/married, 40% one child 6% under 18 years of age 71% 18–34 years of age 16% 35–39 years of age 7% over 39 years of age 3% medical/criminological indications 80% vacuum aspiration 8% Mifegyne (RU-486) (+)

The following cases of child abuse and infanticide quoted from the daily press demonstrate what can happen when a pregnancy conflict could not be solved and was suppressed instead. Kölner Stadtanzeiger, October 17, 2006: “The Land court of Würzburg sentenced a 24-year-old woman to five years in prison because she admitted to dashing her 12-weekold baby’s head against a crib several times, and killing it. The boy had been crying incessantly until it became unbearable for her. The defendant was declared to have diminished criminal responsibility.”

By means of increased possibilities for counseling and therapy, as well as a more liberal level of discussion, problematic pregnancies should be increasingly seen for what they are; situations of existential crisis with real, reenacted motivations and future potential. There is no family without abortive structures. Counseling is considered satisfactory if:

Comment  The infant’s crying becomes unbearable if mother or father were never able to express and reflect their own inner crying and wailing from their own infancy. This leads to an increasing mutual dynamic between the parents’ absolute denial and the crying and wailing of the infant that, in consequence, is inconsolable. In reality, the child only reflects what is inconsol-

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able inside the parents (Janus 1997; Renggli 2004).

a background of migration are often not able to deal with a problematic pregnancy in a “reasonable” way, find counseling and help, or even just Kölner Stadtanzeiger, October 17, 2006: “A talk about it with partners, friends, parents. These 31-year-old man, accused of attempted murder, cases can lead, at worst, to “belated abortions,” as confessed to the Land court of Hildesheim that he in a case in Brandenburg in 2006, where a mother, severely abused his infant. He admitted to have over the course of several years, killed each of violently shaken and repeatedly hit his three-­ her nine children right after their birth. From our week-­old son Nico. The baby suffered life threat- perspective, such an act can only be explained by ening injuries to the head. The son was crying taking into account the mother’s experiences of even though the father had changed his diapers her own gestation, her extreme ambivalence and and bottle-fed him. As a consequence, he had (often also) traumatization that later followed. snapped. The verdict is expected on Wednesday. According to her own words, the baby’s mother has forgiven the defendant, and married him dur- Infant Mortality in North-Rhine Westphalia (NRW) ing custody.” Comment  The mutually enhanced feelings of suppression and expression can finally result in murderous anger that one of the parents can no longer control and thus unloads upon the child in an act of projection. Kölner Stadtanzeiger, October 31, 2006: “Four years of prison for killing a baby. Verena P., the 22-year-old mother of two children, was convicted by the Land court of Cologne for a lesser case of manslaughter. The judge pointed out that the court could find no explanation for a deed that seemed ‘alien to the personality’ of the defendant. The young woman had given birth to her child in a café and then suffocated it in a garbage can. She had concealed the pregnancy as well as her two previous ones for a long time.” Comment  German courts cannot find an explanation in many cases of murder and manslaughter because court psychiatrists and consultants have yet to consider the deeper psychological levels of insight; derived from pre- and perinatal research. Dare it be said aloud? Self-confident and educated women who carry hate against their mothers, consciously or unconsciously, will either not become pregnant or will eventually abort their pregnancy (and can later, indeed, be good mothers for their eventual, future children). For many reasons, women from lower social classes or with

2005: 298 girls and 406 boys died before reaching their first birthday. This means 3.98 girls and 5.11 boys per 1000 live births. In 1970, the death rate was five times as high! Today, there are 14 prenatal centers in NRW (4500 premature babies per year) specializing in pre- and perinatal problems. For women with a migrant background, the rate of infant mortality is particularly high. (Source: Landesamt für Datenverarbeitung/ Statistik Nordrhein-Westfalen.)

Psychohistory of Violence Men and women are equal, even in regard to their destructive aggression. While men must resort to arms in order to kill someone, women can end life within themselves. Men, being afraid of this power, compensated their fears with exaggerated fantasies of manhood. Before the connection between sexual act and conception became culturally conscious fact, women were the only masters of life. This led to destructive male behavior and non-empathy toward women, which, again, resulted in further female destruction. We should have slowly overcome this spiral by now, that is, man and woman cooperating in a good and sensual way, and couples learning to resolve aggression against each other constructively/with therapy instead of acting them out on the chil-

A Visual Exploration of Psychodynamics in Problematic Pregnancies: Case Studies in Analytic-Aesthetic…

dren. (Even during many divorces, the child is abused by and for parental feelings, because the parents refuse to reflect on their own share of responsibility for the separation. It is always the other who is to blame. However, the number of sensible separations is increasing.) A precondition is the recognition of the deep reasons for this spiral of violence between man, woman, and child that has been going on throughout the last millennia.

Psychohistory of Love There have always been couples who, based on intuition and experience, have birthed and raised their children in a warmer, more empathic and loving way than others. There is no doubt that this results in an evolutionary advantage that will eventually prevail, when the thrilling lust for destruction that results from traumatization (basically forms of disappointed love) can be increasingly replaced by therapeutic reflection. Only then can we (and are allowed to) feel that, in reality, there is nothing more thrilling than love.

References Chamberlain, D. (1997). Neue Forschungsergebnisse aus der Beobachtung vorgeburtlichen Verhaltens. In L. Janus & S. Haibach (Eds.), Seelisches Erleben vor und während der Geburt. Neu-Isenburg: LinguaMed. Europarat. (2004). Evolution démographique récente en Europe. Evertz, K. (1997). Kunsttherapie und Geburtserfahrung. In L. Janus & S. Haibach (Eds.), Seelisches Erleben vor und während der Geburt. Neu-Isenburg: LinguaMed. Evertz, K. (1998). Der Ursprung der Bilder  – Pränatale Wahrnehmung, Ästhetik und Kunst. International Journal of Prenatal and Perinatal Psychology and Medicine, 10(3), 365–392. Evertz, K. (1999). Rezension zu “Sphären, Band I, Blasen, von Peter Sloterdijk”. International Journal of Prenatal and Perinatal Psychology and Medicine, 11(1), 140–145. Evertz, K. (2001). Analytisch-ästhetische Kunsttherapie in der Arbeit mit frühtraumatisierten Patienten. In Y. Bertolaso (Ed.), Musik-, Kunst- und Tanztherapie – Qualitätsanforderungen in den künstlerischen Therapien. Münster: Paroli. Evertz, K. (2003). Pränatale Traumata im kunsttherapeutischen Ausdruck. In R. Hampe et al. (Eds.), Trauma und Kreativität. Bremen: Universität Bremen.

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Evertz, K. (2007). Bilder als Lebenszeichen  – Psychoonkologische Kunsttherapie. In E.  Aulbert, F.  Nauck, & L.  Radbruch (Eds.), Lehrbuch der Palliativmedizin. Stuttgart: Schattauer. Evertz, K., & Janus, L. (Eds.). (2002). Kunstanalyse. Heidelberg: Mattes. Fedor-Freybergh P., & Janus, L. (Eds.) (1989 et  seq.) International Journal of Prenatal and Perinatal Psychology and Medicine. Heidelberg: Mattes. Ferenczi, S. (1982). Schriften zur Psychoanalyse. Frankfurt: Fischer. Hidas, G., & Raffai, J. (2006). Nabelschnur der Seele. Gießen: Psychosozial-Verlag. Hochauf, R. (2003). Trauma und Strukturdefizit. In R. Hampe et al. (Eds.), Trauma und Kreativität. Universität Bremen, Bremen. House, S. (2002). Lecture, Congress of the International Society of Pre- and Perinatal Psychology and Medicine. Heidelberg. Janus, L. (1997). Affektive Lernvorgänge vor und während der Geburt. In L. Janus & S. Haibach (Eds.), Seelisches Erleben vor und während der Geburt. Neu-­ Isenburg: LinguaMed. Janus, L. (2000). Die Psychoanalyse der vorgeburtlichen Lebenszeit und der Geburt. Gießen: Psycho-sozial-Verlag. Kurth, W., & Janus, L. (2002). Psychohistorie und Persönlichkeitsstruktur. Heidelberg: Mattes, (Jahrbuch fu ̈r psychohistorische Forschung, Band 2). Levend, H., & Janus, L. (Eds.). (2000). Drum hab ich kein Gesicht. Würzburg: Echter. Linder, R. (Ed.). (2008). Liebe, Schwangerschaft, Konflikt und Lösung. Erkundungen zur Psychodynamik des Schwangerschaftskonflikts. Heidelberg: Mattes. Meistermann-Seeger, E. (1989). Kurztherapie Fokaltraining – Die Rückkehr zum Lieben. München: Verlag für Angewandte Wissenschaften. Meistermann-Seeger E. (1991). Wodurch kommt es zur Abtreibung?  – Diagnose einer psycho-biologischen Krise. Unpublished talk held at ErftstadtLechnich, Katholisches Bildungswerk im Erftkreis, 25.6.1991 Reiter, A. (2004). Introspektiver Zugang zum vorgeburtlichen Erleben. In L.  Janus (Ed.), Pränatale Psychologie und Psychotherapie (pp.  21–36). Heidelberg: Mattes. (Ergebnisse der pränatalen Psychologie, Band 1). Renggli, F. (2004). Babytherapie. In L.  Janus (Ed.), Pränatale Psychologie und Psychotherapie (pp. 159– 173). Heidelberg: Mattes. (Ergebnisse der pränatalen Psychologie, Band 1). Roth, G. (2003). Fühlen, Denken, Handeln. Frankfurt: Suhrkamp. Statistisches Bundesamt (Destatis), Germany, 2018. Stern, D. (1996). Die Lebenserfahrung des Säuglings. Stuttgart: Klett-Cotta. Verny, T. (1981). Das Seelenleben des Ungeborenen. München: Rogner & Bernhard. Verny, T. (2003). Das Baby von Morgen. Hamburg: Rogner & Bernhard.

Erik: Case Study of an Experienced One Twin Loss Britta Dilcher

Introduction In child psychotherapy, many playful media are used and are methodically generally recognised (Lukash 2002; Trueg and Kersten 2002). This also includes children’s drawings and paintings (Schuster 2001). Children use the media both for emotional expression and for symbolic communication and interaction. Especially small children between the ages of 2 and 5, who are not yet fully proficient in the language, communicate through drawings, paintings, sculptures, scenic stagings, puppetry and playful interactions with the therapist experiences and feelings from conflicts and problems of the family system. This also includes symbolic processing of one’s own feelings and emotional positions towards one’s parents and siblings in one’s own family system. Unprocessed traumata in the family system as well as secret, taboo and excluded family members, including aborted or prematurely deceased siblings, are often unconsciously addressed by the children in the pictures or the scenic productions. In the course of the treatment of a child, the therapist must find out what significance and reality the symbolic representations contain. Central questions here are: do the aesthetic dynamics of the representations contain recurring

criteria (number, form, colour, meaning of objects) and are they real representations of ties and relationships in the family system, or are random and fictitious symbols also used to suggest something behind them? In the perspective of the therapeutic phenomenological-hermeneutic method, the aesthetic expressions of the children show both the one and the other, as well as mixed forms. Just as it is in adult dreams and in art. Through empathic relationship building in child psychotherapy, the therapist succeeds in clarifying these levels and using them for healing in the knowledge of family relationships and with the involvement of parents. The unconscious knowledge of children about serious constellations in the family system, which they have never been told on a cognitive level, is astonishing. This has been proven in hundreds of thousands of documented cases of child psychotherapy (Evertz et al. 2014; von Spreti et al. 2005; Hiller et al. 2009). This chapter describes a child psychotherapy and a sociopedagogical look at a prenatal trauma that reveals the background of the child’s behaviour: a twin loss during pregnancy. The methodological levels of prenatal psychology and medicine also include the phenomenological-­ hermeneutic approach in low-threshold therapeutic settings, as described in this chapter.

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Case Study Erik is a 4-year-old boy who deals with the loss of his twin brother in the 16th week of pregnancy. The twin died because of a spontaneous abortion, but the reason for the miscarriage has not been clear. Erik, being the surviving twin, was born via caesarean section. The mother feels sad about the loss, but at the same time relieved, as she had been afraid of not being able to cope with the demands of two children at once. As his mother is a paediatric physical therapist, Erik receives adequate support growing up. For the most part, his childhood developments are unobtrusive. The only exception is that he has difficulties with situations of separation. For example, he cannot fall asleep alone and has huge problems with saying goodbye to his parents, for example, in kindergarten. Erik requires a lot of physical contact to certain important reference people. If this closeness could not be given, he becomes scared, sad, tearful and hysterical. The mother describes their living together as harmonic; however, she was not able to explain the separation anxiety her child suffered. The existence of the passed twin brother and the early loss had never been discussed in the family, as the parents did not want to burden their son Erik with the topic. Moreover, they did not believe that he remembered the incident. As I ask Erik’s mother to show me current pictures of what he had drawn, she is more than certain that there are no hints of the experienced death in her son’s drawings. She is very sceptical and assures me that he draws quite normal and there are no unusual features to be seen. The next day she brings along 14 randomly picked pictures from his kindergarten-box. Thirteen of these show two people; two of them show a face. They are age-appropriate human depictions, containing the commencing differentiation of limbs and faces. The drawn figures vary

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in the degree of their contours, have got different sizes and are partly characterised by stars or circles. Especially striking is the placement of the figures in accordance with the positioning of twins in the womb. This type of drawing is not at all common or customary for a 4-year-old, but it complies with the experience Erik underwent during pregnancy.

Most of the drawings are framed at least on one or more edges. Within the emerging space one can often see a little yellow shape, probably a sun-symbol (= intrauterine contact to the mother).

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When asked about the content of the images, who the drawn people are, Erik answers, that they show him and his preferred superhero. Due to our preliminary discussion, the mother can recognise the meaning of the pictured as depictions of Erik and the lost twin. She is very surprised, as she did not expect any deeper meaning behind his drawings (especially as she thought that he was not aware of the loss). According to the mother’s later statements, after being made aware of the situation, she realised that most of Erik’s drawings showed the twins.

One of the pictures strikes out especially. It shows a paper-filling face with eyes without pupils. Regarding the reverse side of the paper one can see another large face with little circles, representing the pupils. The facial expressions convey the impression of fear or shock.

By developing his artistic and creative abilities, Erik found a way to visualise and uncover the diffuse but vivid feeling of loss. Being able to draw the lost brother as a superhero was his method to convert his fear and the horror of his twin brother’s death into a healing illusion. The mother, being very shocked by the fact that Erik remembered losing his twin brother emotionally, is now capable of understanding his

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separation anxiety. The separating situations functioned as a trigger for the sustained loss of his brother and made him panic.

Discovering the source of Erik’s fear makes his mother feel the urge to talk to her surviving son. As she is quite distressed by this discovery herself, she wants to wait until she can handle the knowledge gained. In the end, it is not her, who initiates their conversation, but Erik himself. He asks her at the next best cuddling time, when the “other baby” will be born. Obviously, he intuitively felt something had changed within his mother and he finally could ask her about his brother. After mother and son have talked about the twin loss, the topic was made a subject of discus-

sion within the whole family. This led to a huge relieve in separation situations, which from now on pass much more relaxed.

References Evertz, et  al. (2014). Lehrbuch der Pränatalen Psychologie. Heidelberg: Mattes. Hiller, et  al. (2009). Lehrbuch der Psychotherapie. München: CIP-Medien. Lukash, F. N. (2002). Children’s art as a helpful index of anxiety and self-esteem with plastic surgery. Plastic and Reconstructive Surgery, 5, 1777–1788. Schuster, M. (2001). Kinderzeichnungen. München: Reinhardt. Trueg, E., & Kersten, M. (2002). Praxis der Kunsttherapie. Stuttgart: Schattauer. Von Spreti, F., et al. (2005). Kunsttherapie bei psychischen Störungen. München: Urban&Fischer.

Love, Pregnancy, Conflict, and Solution: On the Way to an Understanding of Conflicted Pregnancy Rupert Linder

Early lifetime may be threatened. The beginning consists of three key periods in every person’s life. I propose to call this period of time “The Early Triade: Conception, Implantation and Discovery.” Each of these will remain as basic patterns in the unconscious of the individuals. Conception – or, if you want to look at it from the male viewpoint, procreation  – will form and influence all ideas in the field of sexual attraction and desire. Implantation will lead to resonances in the fields of trust, supply, feeling safe, and being in good hands (see Linder 2014 – On the Psychodynamics of Preeclampsia and HELLP Syndrome). Discovery refers to the moment when the woman consciously realizes that she is pregnant, which later reflects as conscious recognition of and relating to others. The period of life when these three developmental steps are happening is actually quite short. It consists of 3 weeks. Conception takes place at about the 14th day of the mother’s menstrual cycle, implantation occurs 3 to 5 days later, and discovery is usually within the first week after missing the menstruation. Discovery can be understood as conscious perception by the mother. However, besides that R. Linder (*) Gynecology, Obstetrics and Psychotherapy, Birkenfeld, Germany e-mail: [email protected]

recognition, there are many layers of body functions, body sensations, and subtle changes of mood going on within her. Everything is adapting to the new goal. Biology is going on her way, not necessarily asking for consciousness or gray matter brain function. It can be the questioning for the mother – will she be able to have this child? This is a common situation in a gynecological office. Many women are happy to become pregnant. But some are not. There is a wide range from some discomfort to total devastation and alienation. This may look like a total lack of empathy. In 2005, my colleagues and I began this discussion of conflicted pregnancy and were compelled to find a way to deal with it. In that year the Charter of the Rights of the Child Before, During and After Birth was formulated and approved (see Appendix). That document was based on the 1989 UN Convention of the Rights of the Child. The purpose was to extend rights to the time before birth and also to focus on relation oriented and low intervention birth and deep support for bonding processes after birth. During the membership assembly of the International Society for Prenatal and Perinatal Psychology and Medicine (ISPPM), there was wide and vigorous discussion. Deep and strong objections were made concerned that these new rights could be used to criminalize women or doctors who ask for or performed abortions. So it

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was decided an addition was needed: “Clearly these rights are subject to the relative rights of others, particularly of the mother and family. Those with responsibility need to balance the relative rights with understanding of the issues involved, including those of the child.” At this same membership assembly, I had the honor to be elected as president of ISPPM.  It appeared obvious to face these essential and fundamentally contradictions regarding the rights of women and the rights of the unborn. It was time to organize a meeting focusing just on these questions. This meeting occurred in 2006 and a comprehensive booklet was edited (Linder 2008): Delving into this delicate topic, it is necessary to acknowledge that many different attitudes can

occur in life and show up in a gynecological office. This topic touches upon all aspects of psychosexual development, personal past histories, the current situation as a couple, social ties, one’s own early experiences, self-image, and trans-­generational factors that are the significant forces. You will find a range of personal aspects more extensively described in the chapter “Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice.” However, it is helpful to keep the following numbers in mind:

of the remaining 360, 15% (54) of the embryos die as a result of abortion; 306 are born live.

Here you can see the development within the last 15  years in Germany (from the Federal Statistical Office of Germany):

Every year in Germany around 100,000 fetuses are aborted, compared to more than 700,000 births.

A gradual decrease of the number of abortions can be seen in relation to the live births and as well a decrease in relation to the total number of women between 10 and 55. Possible reasons of

Of

1000 pregnancies, only 400 implant successfully; of the 400, about 10% (40) end in miscarriage;

Year Live births All induced abortions Abortions per 100 live births Abortions per 100 live and stillbirths Abortions per 1000 women aged 15–45 Abortions per 1000 women

2001 734,475 134,964 18.38

18.3

8

2000 766,999 134,609 17.55

17.48

8

Induced abortions in Germany

7.8

18.06

2002 719,250 130,387 18.13

7.6

18.05

2003 706,721 128,030 18.12

7.8

18.3

2004 705,622 129,650 18.37

7.5

18.02

2005 685,795 124,023 18.08

7.3

17.73

2006 672,724 119,710 17.79

7.2 5.8

6

16.71

2003 682,514 114,484 16.77

7.3

17.01

2007 684,862 116,871 17.06

5.8

7.1

16.58

2009 665,126 110,694 16.64

5.9

7.1

16.23

2010 677,945 110,431 16.28

5.9

16.37

2011 662,685 108,867 16.43

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15.8

2012 673,544 106,815 15.86

5.7

15.02

2013 682,069 102,802 15.07

5.5

13.9

2014 714,927 99,715 13.95

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the decline might be good access for women to 5 . Pregnancy just came when she has finished contraception at any age; a functioning system of family planning. counseling for pregnant women, which is open-­ 6. Pregnancy in total cleavage/conflict about minded and accepting of the woman’s decision; whether to have the child or not. and possibly a growing public attitude to accept 7. Pregnancy was originally accepted, but then the value of prenatal life. severe disability was discovered. 8. Discovery of a life-threatening disease of the baby was discovered.

 hat About the History W of the Abortion Issue?

Dr. Ludwig Janus addresses the history of abortion. Dr. Janus shows that there is a link between a patriarchal structure of society and the women’s ability to make decisions about her life and her generative issues. Rights of the unborn hardly existed in early times and gradually evolved with social developments of legal structures and women’s rights. Deep changes of people’s consciousness and time-dependent agreements have been ongoing. However, over time, humanizing of conditions can be recognized and gradual acceptance into social understanding observed (see article On the Psycho-History of Pregnancy Conflict in this issue). Sven Hildebrandt (2008) described severe ambivalence already one step earlier: dealing with contraceptive devices. Reliable contraception is possible today. Why do some women not accept or effectively use family planning? And later not feel able to have the baby? This leads us to believe that the ambivalence must be positioned much deeper in personal history and structure. (See the example of Mrs. C in my chapter Conflict of Pregnancy- Experiences from a Gynaecological and Psychotherapeutic Practice.) Justine Buechler (2008) endeavored to describe different life situations of women in pregnancy conflict: 1 . Pregnancy does not fit into her life plan. 2. Pregnancy does not fit into an involved person’s life plan. 3. Pregnancy has arisen from a secret love affair. 4. Pregnancy has arisen while separating from the partner.

In contrast with post-traumatic stress disorder, where a severe extrinsic derangement brings one out of balance, in these situations more silent embitterment is going on, resulting from severe conflicts that violate rather inner moral attitudes or basic assumptions. It is evident (see example below) that early influences have deep effects on the patterns of intimate relations. Subtle therapeutic work with couples is done by Franz Renggli from Basel. He and his colleague Carmen Ehinger and Renggli (2008) have reported how they began to realize more and more the impact of unresolved early prenatal and birth trauma on conflicts in partnership. The earlier and the more unconscious they are, the more deeply they influence our behavior toward our partners: We observed that many of our clients had chosen partners whose early life traumas were often the exact opposite of their own. For example a person who was the long awaited and overprotected child after a miscarriage might choose a partner who was a survivor of attempted abortion. These complementary traumas seem to fit like a key into a keyhole and are on one side causes for mutual attraction and potential on the other hand, carries of immense conflict potential. While working with couples, we began to consider their conflicts in the light of each partner’s prenatal traumas especially their earliest existence. Whenever we could successfully trace back an actual pressing conflict to the clients’ mutual prenatal wounds, the couple was often able to find a way back to respectful and loving understanding of each other. On the basis of these experiences we assume that emotional outbursts and tensions in a partnership need to be traced back into early prenatal times. The partner may become the trigger for current conflict. The way out is to teach couples strategies how they can see and deal with their mutual prenatal wounds.

Love, Pregnancy, Conflict, and Solution: On the Way to an Understanding of Conflicted Pregnancy

To illustrate these backgrounds, Franz and Carmen choose this poem of Erich Fried, a master describing also the dark side of love: To a nerve saw

An eine Nervensäge

With your problems, it is said, you are like a nerve saw

Mit deinen Problemen heißt es bist du eine Nervensäge

I love the pointed end and cutting edge of every single tooth of this saw and its shining blade and its round handle, too

Ich liebe die Spitze und Schneide von jedem Zahn dieser Säge und ihr blankes Sägeblatt und auch ihren runden Griff Erich Fried

From German: Renate Meyer and Thomas Verny

Erich Fried, An eine Nervensäge aus: Erich Fried, Es ist was es ist. Liebesgedichte Angstgedichte Zorngedichte ©1983, 1994, 1996 Verlag Klaus Wagenbach, Berlin

Many of these shadow side aspects of love can be found in the example Mrs. O below, as well in the chapter On the Psychodynamics of Preeclampsia and HELLP Syndrome (Linder 2014). In 2007, another key moment in this field occurred in Moscow. It was a session during the Joint Congress of ISPPM and Russian Association for Pre- and Perinatal Development (RAPPD) with the title, “THE PRENATAL CHILD AND SOCIETY: The Role of Prenatal Psychology in Obstetrics, Neonatology, Psychology & Sociology.” Because of some difficulties, we were employing consecutive translation. In a smaller auditory, people were listening to a lecture of Klaus Evertz titled Psychodynamic aspects of problematic pregnancies expressed in images (see the related chapter in this issue). The auditory session was crowded and so people needed to sit closer together. Because of the slower pace of translation (English and Russian passages following each other), the reaction of all participants could become much more obvious. The pictures – as you can see in Evertz’ article – show very clearly the emotional feeling of men, having undergone the thread of abortion attempts. Elena Tonetti, who is well acquainted with the

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Russian society, gave a remark on Russian contraceptive behavior: “we know that a woman in Russia with age 45 had had an average of 7.5 abortions in her life? And it can be up to 22.” A continuing and affected murmur was going through the hall. It brought up the serious question and that continues to echo: What effects does this way of family planning have on the inner (and outer) peace of a society and on the estimated value of human life in general? What influence can it have on the people and society that has experienced so many losses of children, siblings, cousins, uncles, and aunts? To illustrate this I want to share an example with you:

Case Study: Ms. O Ms. O was, when she first came into my care a 31-year-old woman, just recently pregnant (in the sixth week). At the age of 4 years, she has moved with her parents to Germany from an East European country. Two years ago she has breast amplification. She is a dynamic, well-groomed and superficially extroverted person. “For seven years I have had a strong wish to become pregnant. Now I have pain and aches everywhere. I could reduce my smoke habits from 20 to 12 every day.” She has been living together with her boyfriend for 1 year. Physical findings were positive. A little later she reported that her eating habits ranged between nausea and eating attacks and said, “All my friends are having either extrauterines (ectopic) pregnancies or spontaneous abortions….” In the 12th week, she had a little bleeding; the fetus was much too small without any heartbeat visible by ultrasound. Curettage was performed a few days later. After that she felt very bad. She hardly was able to sleep and to handle daily needs. In addition to psychotherapy, even a little dose of amitriptyline was necessary for some weeks. She was questioning her relation with her boyfriend, even though a marriage has been planned. She said, “Whatever he is doing, it bothers me.” She was eating badly, smoking, and drinking a lot of coffee. All people in her surrounding were say-

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ing: “Don’t worry; you will get the next baby soon.” She remembered that her mother has had some abortions. A twin of her brother had been miscarried. Her boyfriend already has a son, who was not wanted. He has little contact with his son. After a month of treatment, she said: “I am pulling myself together. Things go better. I have better feelings to my boyfriend than ever.” Five months later she was pregnant again. Her emotions were like riding a rollercoaster. She has nausea and withdrawal from nicotine, having stopped smoking from 30 cigarettes to zero just 2 days before. Three days later she reported that she is haunted by nightmares, but she has things “well in hand”: She also quit coffee and cola drinks. I gave her frequent appointments. At the next appointment, she reported that once she had not slept and everything has become blurred. In a dream she saw a corridor in an operation theatre, including chopped limps. She reported, “My

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mother had quite a few abortions: There were only three children from 10 pregnancies. Most were after me.” She remembered waiting in a car while mother went for an abortion to be done. Mother did it because father was treating her badly. At this appointment a gestational sac was visible, the heart action not yet. Two weeks later a friend had lost her child in month 5 of her pregnancy. However, there was heart action visible at this appointment. I offer weekly controls in endangered pregnancies, since it dramatically enhances their chances. Often Mrs. O comes in panic before the checks, but shows considerable relief after them. This time there was the chance to show her the teddy bear appearance around the ninth or tenth week. Teddy Picture below (they certainly can be positioned side by side…). Mrs. O wanted an ultrasound every check, until she could feel the motions of her baby. Before the check she had a kind of exam anxiety. Once she had

Love, Pregnancy, Conflict, and Solution: On the Way to an Understanding of Conflicted Pregnancy

dreams of premature birth. The baby needed to be in a glass box with bandages on it. In the 27th week, the cervix was dramatically shortened to 25  mm and the head of the baby pressing on it. She was prescribed medication (progesterone, Tokolytikum oil, magnesium, and bryophyllum), but vigorously was refusing an Arabin cerclage pessary. Her mother has had a pessary with her sister’s pregnancy and experienced a 7-month premature birth just 3 days after having one inserted. Mrs. O had her marriage at the weekend. There was labor pain every 3 min and the cervical os elapsed. Now she could agree to the insertion of an Arabin cerclage pessary. She also got my personal mobile number for emergency calling. After a few days adapting to it, the pain relieved and things got significantly calmed down. In the 36th week, the pessary could be removed. For a while she was considering a caesarean and had even made an appointment with the hospital for the procedure. Finally she could agree to labor’s induction 1 day after the estimated date of delivery. A daughter with 2820 grams (6.22 lbs.) and good Apgar scores was born. The baby was fine, although she was crying more during the day and was hospitalized once together with the mother for 2  days because of threat of sudden infant death syndrome (SIDS).

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Half a year later, she came pregnant again. “It happened unexpectedly for me. I was shocked the first two days. But my husband is so happy.” She does not feel very much being pregnant. Her mother was encouraging her to go for an abortion  – “it’s not a baby yet.” She also said: “Grandchildren are loved more than personal children.” Again we talked a bit about the abortions that her mother has had. The legal regulation in Germany that compulsory counseling and a 3-day waiting period to think things over are required was explained to her. These considerations never came up again. She was losing some weight because of nausea. Regarding her husband, his father emigrated from Asia Minor; his mother was from southern Germany and was 17 when she got him. During his gestation his mother had smoked and drunk alcohol. He almost was given to adoption, but his grandmother intervened, saying “he shall stay.” The husband already has a 12-year-old daughter, conceived from an earlier relationship. He has had little contact after a very destructive conflict with her mother. Once Mrs. O came for an intravenous infusion because of nausea. In a very impatient manner, she suddenly left and could not wait any longer. But the visit relieved the morning sickness.

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This pregnancy went on. She described pain like twitches and lightning in her belly. Because of a cervical dilation with a funnel syndrome, it was necessary to administer a cerclage pessary again, which she tolerated much better. It led to a dramatic recovery of the cervix. She was able to relax for a week’s vacation together with her husband for his birthday. This case shall demonstrate how serious attempts of abortions in the previous generation can influence the life of this woman. The serious complaints and her acting out may indicate that she herself has been threatened at least by abortion thoughts. She has lost many siblings, even being witness of mother’s abortion waiting in a car. She has lost her first child by a spontaneous abortion, throwing her into severe grief. She still gets a recommendation to do an abortion by her mother during her third child. Her husband also comes out of a confrontational relation and himself got an unwanted child. The way she acts things out shows how much she is imprinted by this tension-filled way of relation. Her smoking habits show selfdestructiveness in a repetitive matter. However, although she even has refused to formally apply for psychotherapy, her slow but gradual relaxation is obvious. She repeatedly could share her early living conditions and her early threat – in a way that was tolerable to her. Inevitably it is necessary to share such insights to another person being empathetic and not falling into shock himself. Only this can relieve the tension and gives?? a chance to develop other and better choices of life.

The Work of John Sonne John C. Sonne, a pioneer of merit in studies of the consequences of abortion ideation, has diligently described severe prenatal trauma issues in his article Interpreting the Dread of Being Aborted in Therapy (Sonne 1996). He illustrates “how the sequelae of prenatal trauma can be transferentially expressed in a variety of pathological symptoms in postnatal life.” Certain characteristics are pointed out:

R. Linder Although abortion survivors may have a variety of obvious symptoms, it is important to also note the presence of a variety of more subtle but pervasive unusual characteristics; they are clues which can help in making the diagnosis. They will ultimately be seen as transferential derivatives from prenatal trauma, even though the abortion survivor initially has little awareness of their repressed traumatic origin. …. Abortion survivors have a sense that they are not present, do not feel real and that life has little meaning for them. … They often describe themselves as incurable, often on the basis that they consider themselves genetically flawed.

However, for good reason Sonne emphasizes the knowledge of Kandel (1989) that genetic programming is reversible. “Abortion survivors can only make limited use of poetic metaphors and metonyms in their speech, and have little sense of humor. … They have extreme difficulty trusting. They are not thankful, grateful or appreciative.” There is a danger of suicidal thoughts or even committing suicide, potentially also homicide. “The meaning of the messages communicated by the traumatized unborn are ‘known but unthought’ by the patient until the associated links are interpreted in therapy”. But: “Such interpretations require the therapist to think in terms of prenatal mentation and communication, and to consider the dread of being aborted as a possible component in the transference…” “Once the therapist has become more open to the prenatal dread of his patients and at least partially convinced, he will begin to understand more and more, and his work will become easier. He will feel a tremendous sense of liberation, a clarification of his own thinking about human life, and he will be rewarded by vicariously enjoying the resultant gratitude and happiness of his patient.” Another diligent article by Sonne (2002), On Tyrants as Abortion Survivors, describes the personal history of well-known historical figures as Adolf Hitler, Joseph Stalin, Saddam Hussein, and Osama bin Laden. In all of these, he finds a background of abortion survivorhood. And another observation, which we can see also in present time: Tyrants often act out their tyranny in the name of religion. The work of Sonne was an outstanding achievement within prenatal psychology. It has

Love, Pregnancy, Conflict, and Solution: On the Way to an Understanding of Conflicted Pregnancy

put a new site on serious aspects of early human life. Luckily, in more recent times, things can even be further differentiated. There are many fine-tuned gradiations of mother’s respectively parent’s reaction during the discovery phase (Terry 2009; Linder 2014), listed here: 1. Unsuccessfully attempts at abortion 2. Goes for an abortion but has second thoughts at the last minute 3. Child unwanted, disaster, thinks about “doing something to get rid of it” 4. Child unwanted, disaster, thinks about abortion 5. Child unwanted, negative thoughts, “maybe it’ll work” 6. Child unwanted, but accepted 7. Child wanted, but not now 8. Child wanted, but should be of a specific sex 9. Child wanted, but for a reason that has nothing to do with the child 10. Child fully welcomed to be itself, relaxed So these are obviously different choices. Some of them can even be acting parallel. And for the treatment it is important to know: one thing is the definite version having happened at the time of discovery. Were there differences between the parents? How did things develop over the next and further years? How openly could it be handled from the parents’ and kids’ side? One side is looking at it from the fact of information and another from the emotional side. What possibility did the emotional aspects have to develop? What chances did the involved persons have to work on their relation? And how can we work in therapy to bring things forward.

Conclusion The deep influences of very early life experiences have been underestimated, especially life events during The Early Triade: Conception, Implantation and Discovery. The imprints of this time can last for the rest of the life. In case of unhappy events during this time, there is a tendency to re-enactment of the dynam-

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ics either in personal and intimate relationships, especially when becoming pregnant (which certainly is another intimate relationship) or general in the attitudes to the further surroundings, work or politics. Since couples becoming pregnant inevitably get into touch with their own early feelings, it is necessary for all caregivers to keep these dynamics in mind for giving them appropriate support. It will help in difficult situations to either stand them through or to get to necessary decisions. For governing bodies it is important to find wise regulations, which honor both sides: the situation of the woman and the dignity of the unborn. Well-balanced legal procedures are necessary to guide all relevant parties: women, doctors, counseling agencies, and others. The agreement of wide segments of the population is helpful, as it will exclude parts of the destructive psychodynamic energy originating from the key questions regarding abortion into the political discussions. When counseling pregnant women and their partners, it is vital to understand their underlying dynamics. Continuity of caregivers in these fields is definitely needed. It is crucial for the resolution of conflicting situations in this field. Here it cannot matter what the decision finally will be. However, this necessary tolerance is a hard issue for all the people involved. But this kind of support will enable people in conflict to move forward in their personal development and come to more balanced decisions.

References Buechler, J. (2008). Hypnotherapy for Avoiding and Coping of Pregnancy Conflict (Der Stellenwert der Hypnotherapie bei der Vermeidung und Bewältigung von Schwangerschaftskonflikten). In R.  Linder (Ed.), Liebe, Schwangerschaft, Konflikt und Lösung, Erkundungen zur Psychodynamik des Schwangerschaftskonflikts (pp.  41–52). Heidelberg: Mattes Verlag. Ehinger, C., & Renggli, F. (2008). The Prenatal Roots of Conflicts in Partnership (Die pränatale Wurzel von Konflikten in der Partnerschaft). In R.  Linder (Ed.), Liebe, Schwangerschaft, Konflikt und Lösung, Erkundungen zur Psychodynamik des Schwangerschaftskonflikts (pp. 153–174). Heidelberg: Mattes Verlag.

346 Hildebrandt, S. (2008). Ambivalence in Dealing with Contraception (Ambivalenz im Umgang mit Schwangerschaftsverhütung). In R. Linder (Ed.), Liebe, Schwangerschaft, Konflikt und Lösung, Erkundungen zur Psychodynamik des Schwangerschaftskonflikts (pp. 29–40). Heidelberg: Mattes Verlag. Kandel, E. R. (1989). Genes, nerve cells and the remembrance of things past. The Journal of Neuropsychiatry and Clinical Neurosciences, 1(2), 103–125. Linder, R. (2008). Liebe, Schwangerschaft, Konflikt und Lösung  – Erkundungen zur Psychodynamik des Schwangerschaftskonflikts. Heidelberg: Mattes Verlag.

R. Linder Linder, R. (2014). On the psychodynamics of preeclampsia and HELLP Syndrome, recent advances in treatment. Journal of Prenatal and Perinatal Psychology and Health, 29(2), 105–131. Sonne, J. C. (1996). Interpreting the dread of being aborted in therapy. International Journal of Prenatal and Perinatal Psychology and Medicine, 8(3), 317–339. Sonne, J.  C. (2002). On tyrants as abortion survivors. International Journal of Prenatal and Perinatal Psychology and Medicine, 14(3–4), 261–276. Terry, K., & Team. (2009). Institute for Pre- and Perinatal Education. Umbilical Affect, Booklet http://www. ippe.info/publications/booklets.html

Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice Rupert Linder

Introduction

says: “Dumb German” before they both land on his bed. In a second scene, on the morning after, Pregnancies result, hopefully for the main part, they are both lying on his bed contentedly from love. When one considers the wider concept relaxed. of Eros, which includes desire, its different facets Almost all of the questions that are dealt with become even clearer, as the following paragraph in gynaecological practices have to do with relawill demonstrate. tionships: of the woman to herself and her body, In two scenes from the first series of the ARD to a partner or to the coming generation. In these serial “Turkish for Beginners”, the two young- areas belong many different questions about the sters Lena and Cem demonstrate impressively the functions of the female body: the different phases inner chaos and the feelings of happiness that of the monthly cycle, the changes at the beginprevail where love is concerned. ning of sexual maturity (the development of the Lena, the daughter of a psychotherapist, and breasts, pubic hair, menstrual cycle, the strong Cem, the son of a Turkish policeman, end up psychic disturbances during this time, etc.), contogether in one household as a result of the love traception or the reverse side of this, desire for a affair between their parents. In the course of time, child or preparation for a pregnancy. erotic tension builds up between them. In gynaecological consultation various dimenUnexpectedly they are standing together in the sions of life are focused on: the situation in life of hall as she discovers that he is in love with her. At the woman with its opportunities and contradicfirst she is shocked and swears at him: “You ass-­ tions, the influence of the partner relationship, hole!”, slaps him and escapes into Cem’s room. her life story, the family situation of the woman You can see in her facial expression what she is and her partner, her work situation, etc. These feeling. She is caught between different tensions realities of life reveal themselves simultaneously (“I’m going to faint”) as she realises that he at different levels: in what she relates (verbally desires her and she has been latently attracted to and non-verbally, i.e. in words, in fluency, in senhim for some time. She says: “Don’t look at me tence melody, in pitch, with open or forced voice, like that!” – “I can’t help it”. As they approach in the accompanying body movements and facial their first kiss, she says, “Bloody Turk”, and he expression), in the psychosomatic dimension of her complaints and in the overall state of her health. It is therefore necessary to take into conR. Linder (*) Gynecology, Obstetrics and Psychotherapy, Private sideration the overall situation at every level, that Praxis, Birkenfeld, Germany is, psychologically, socially, biographically, e-mail: [email protected]

© Springer Nature Switzerland AG 2021 K. Evertz et al. (eds.), Handbook of Prenatal and Perinatal Psychology, https://doi.org/10.1007/978-3-030-41716-1_21

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somatically and biologically. In order to achieve an integrated starting point for work during consultation, all these levels have to be considered, not selected or segmented but in total and all encompassing. This means that in order to describe this process in writing, it is necessary to reproduce in concrete terms each overall situation as it became known to me. This requires the reader to really think about the individual case studies and to become emotionally involved with them in order to understand the often very dramatic reality of life and the multi-layered personal situations. A further difficulty arises from the fact that in our patriarchal culture, the reality of mother and child is often hardly considered and not given its due importance in public discourse. Therefore, behind a (supposedly) simple statement such as “the man doesn’t want children”, there exists a large and complex reality, which is not easy to set forth and understood. It may have to do with partner conflict, as in examples B or E that follow. There could be financial difficulties, the woman could appear to be unable to cope with the children or feel as in example D, it could be the existence of an individual or trauma problem in the man’s case (also E), etc. Despite this complexity, which can only partially be grasped, extremely significant decisions have to be formulated and resolved, as the examples make clear. In this respect, the dimension of time is significant as it can be helpful in providing an impulse for taking needed steps. Sometimes women are relieved when the first 12 weeks have passed because at that point, they cannot choose to terminate the pregnancy without severe medical indication. The time factor is often crucial during pregnancy because of the deadlines that have to be met. Particularly short is the time frame for using the abortion pill which can only be used during some weeks after the period is overdue.

Case Histories Using the following five examples, I would like to describe  some of the wide spectrum of challenges that can present themselves. These are five

very different personal situations in exceptional threshold circumstances. If you can become involved emotionally, which isn’t easy due to the emotional density, you will more likely comprehend the diversity of social, emotional, relationship-­related and cross-generation facets.

Case Study A Mrs. A, who works in a technical profession at the computer, first came to my practice at the end of her twenties 10 years ago. At the age of 16, she had undergone an abortion. Her mother and grandmother had both had breast cancer. “I reckon with having some kind of cancer in my life”, she said during her first appointment. Some years later, she said: “I’d like an anonymous artificial insemination, as I don’t have a partner”. She had already been in contact with a gynaecologist colleague and had been artificially inseminated four times, without, however, having become pregnant. One year later, this was her statement, “Something has happened in my private life, my partner also wants a child. How can I get pregnant?” She quickly learned to understand her bodily functions, including mucus production in the middle of her cycle. With this knowledge, she sensed her fertile days and 2  months later was pregnant. She suffered occasionally from circulatory trouble, saying “I feel like my batteries are totally empty and I sleep 12 to 14 hours a day”. An amniocentesis was carried out in the 16th week of pregnancy on grounds of age. In the course of the pregnancy, she had occasional problems with premature contractions. However, she was able to balance this by looking after herself when necessary and paying more attention to her body signals. At term a normal birth produced a healthy child. Two years after this, she reported, “It’s about time for a second child”. One year later she was pregnant. During the ultrasound (US) examination, it turned out to be with non-identical twins. She was extremely shocked and said “I didn’t want three children. My boyfriend lives several hundred kilometres away. I know from a friend

Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice

how exhausting life with twins can be. My parents are both no longer alive and I have no support”. She told my assistant that she was considering having one child adopted and had already been in touch with the youth welfare department. At her next appointment, she also spoke to me about these considerations. Two weeks later one of the foetuses showed some abnormality during the ultrasound. Did it want to die of its own accord? An amniocentesis showed that one child had a trisomy 21; the other was normal. Two weeks later the child with trisomy 21 was dead; the second child continued to develop normally. There was no desire for lengthy (more intensive) psychotherapy. There was an improvement of the emotional and social condition, thanks to more support from the partner. Despite a lot of work (job, in addition the purchase and conversion of a house and finally moving), her pregnancy went well.

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markedly shortened with a crater formation revealed in ultrasound examination. Using Tokolytikum oil to relax the uterus musculature and with rest, she carried the child in the end over the calculated date of birth. During this pregnancy she gained only 15 kilos (33.1 pounds) in weight. I dealt with the clinic registration, explaining by phone the particular circumstances to the senior physician responsible for the delivery room. One week before the birth, she smiled tentatively for the first time, “I’m quite all right, I’m just waiting day by day”. The child was born normally 11  days after the calculated date and she breastfed for a long while.

Case Study C

Mrs. C, a 33  year-old woman from a southern East European country, had previously had four abortions. She has been living for a long time in Germany, speaks accent-free German, and is Case Study B extremely well-groomed, if somewhat mask-like. Her dealings with contraception have always Mrs. B is in the second half of her twenties, from been contradictory; she had each time taken the a near East European country. She has a 3-year-­ pill for only a short time and had given up quickly old son who was given away a few weeks after because she had forgotten to take it. She had been birth to the parents of her partner in yet another repeatedly informed about other methods of concountry. She had gained 30 kg in weight during traception and wanted “to think it over”. Once the her  first  pregnancy and commented  now “I again she was pregnant and said: “A child isn’t want an abortion”. On being asked about her situ- convenient now”. The consultation didn’t last ation in life, she revealed that her partner had left very long. the decision to her. She stated “Sometimes there A few years later, she said spontaneously durare fights in the relationship, about trifles”. I sug- ing a cancer check-up: “I prefer riding a motorgested a partner dialogue. bike to having children”. Five days later she came alone and said: “It was foolish to think of that (an abortion)”. All through the pregnancy, however, she seemed to Case Study D be very serious and her face never showed the least trace of a smile. She suffered some of the Mrs. D, a warm-hearted, emotionally receptive time from nausea and was once off work sick due and motherly looking woman, had two children, to an influenza infection. She felt the child’s ages 2 and 3. An intra-uterine pessary had been movements relatively early (17th week of preg- fitted elsewhere and was positioned deeper than nancy). In the 25th week of pregnancy, she was optimal, i.e. in a less effective position in the fetched her son and shortly after went for uterus. She was informed of this but didn’t want 2  weeks’ holiday with her parents in her home to have any adjustment made. country. She occasionally suffered from premaSix months later she came to my practice ture contractions; the ektocervix was at times with her period 3 weeks overdue. She was very

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c­ onfused. She already had two children; she and her husband had just built a house and wanted to move in 4 weeks’ time. She felt she was “not far away from the madhouse”. She was also thinking about it and how she would find a job later. The examination showed an enlarged uterus corresponding to the time elapsed, and the ultrasound showed an amniotic sac with an intact embryo lying next to the spiral. She asked about the formalities of getting an abortion. She refused offers of further discussion. Three weeks later she came again, 1  week after the abortion had been carried out. Physically she was healthy; mentally she was not. She had already known in the recovery room that it had been the wrong decision. (The physical findings were in order.) She could only think of the fact that it had been the wrong decision. She wanted to have another child soon. They would have managed after all. The objections seemed to her to have disappeared. When she saw children at friends’ or in the street, it was very painful for her. She decided to have psychotherapeutic sessions in short-term therapy. A few weeks after, she said that some days it was better but that she still thinks every day about having done the wrong thing: “The head thinks but the heart doesn’t understand”. Her husband was also not very enthusiastic and thought that she was already unable to cope with the two children who were there and didn’t have enough time for him. What was awful was that there were so many pregnant women around her and that she couldn’t talk about her abortion; it had to remain secret. She said “I feel so alone”. With regard to her husband’s attitude, when he found out about the pregnancy, he had said: “It’s inside you, I have no say in the matter”. On the evening before the operation, she had thought: if he said anything about it I wouldn’t have it done. After the operation he had said: “I thought you wouldn’t have had it done anyway”. After the ultrasound in my practice, she thought that she would prefer to have the child. He said afterwards: “but we did talk about it”. It is easy to understand how they both “just missed each other” in this respect.

During the time after the abortion and in therapy, she talked a lot with her husband about the difficulties in their communication. Both had made mistakes. Both had to take responsibility for that. She mentioned feelings of guilt in connection with the deaths of other family members. She had bought the figure of an angel before Christmas and put in the kitchen. She had in the meantime been able to talk to her mother about her third pregnancy. The intervals between the therapy sessions got longer. One week before the calculated date of birth, which she expressly mentioned, she said she was going to return to work. She felt better and that she no longer needed therapy sessions.

Case Study E Mrs. E, in her early thirties, was already mother of two children, ages 7 and 5, from a first marriage. My colleague diagnosed an early pregnancy. At the second examination in the seventh week of pregnancy, she reported she was suffering from stress and had, since the day before, had abdominal pains on the right side. Her partner had said: “Either me or the child”. The ultrasound examination showed two amniotic sacs. Three days later the partner came along to the session. He said accusingly that he was being neglected: “The lives of four people are being destroyed – mine, hers and those of the children already there… I don’t want more children. I dreamed of a holiday every year in peace and being spoiled. My job is very strenuous …” One week later she came alone. She had separated from her partner. He had accused her of getting pregnant intentionally and with twins at that. A few days later, I saw her myself: she was completely stressed; the day before she had a total emotional meltdown. The partner insisted on termination. She had ditched him. He was an only child. One or two friends were standing by her. Her son wanted to support her; the daughter was inquisitive. The examination results were all normal; the ultrasound showed positive heart activity twice. I told her the story of a woman who had her best experience of pregnancy in her third

Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice

pregnancy despite separating from her husband, a lot of work and other pressures. In the 22nd week of pregnancy, she was under stress from the father. His parents had phoned: They wanted to obtain a court order from the youth welfare department to make her undergo an amniotic fluid examination. She came herself from a large family; however, her mother lived a few hundred kilometres away. As a result of abdominal pains paired with a relatively intact ektocervix, I prescribed a household help for 4 hours twice a week and Tokolytikum oil. A week later she told me that this relief was doing her good. She had some time to herself, could occasionally read, and also read to the children. She had been able to give up smoking 2 days previously. A few weeks later, she told me her mother had a miscarriage of twins at 6  months. Her mother and father had each had children from previous marriages. She had been very attached to her father, who had died when she was 17. She talked every day with the children in her womb and told them “stay where you are”. In the 29th week of pregnancy, the findings deteriorated in that the ektocervix had shortened and was more sensitive. It was debatable as to whether the insertion of an Arabin cerclage pessary was necessary. The stress became no less. Her own divorce (from the father of the first children) was imminent. There were very unpleasant altercations before a psychologist and the youth welfare department. It was unclear whether the son was going to move to his father. She found some support in (distant) relatives of the child’s father. A certain amount of cautious contact to the father of the twins came about (“he brings mineral water, leaves the car on loan in front of the door …”). She remained constantly in internal contact to the two children in her womb. There were further legal arguments about custody of the older child. Obstetrically the clinic was considering whether the breech presentation of the foremost child would make it necessary to perform a caesarean operation. I therefore contacted the senior physician responsible. The patient developed severe water retention and had difficulties dealing with everyday tasks with such a large abdomen (cir-

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cumference 108  cm [42.5  inches]). Ultimately the first child moved into a cephalic presentation, and she was able to give birth normally in the 36th week of pregnancy, both children weighing almost 2550  grams (4.96  lbs.). They were both discharged from the children’s clinic and went home 2 weeks after birth. The relationship to the children’s father became more stable in the course of time, even if she retained a degree of uncertainty due to the conflict during the pregnancy. They later moved into a house together and got married.

Reflections on the Case Histories These examples are representative of the spectrum of different situations. The diagnosis and with it the growing awareness of pregnancy touches the deepest conscious and unconscious attitudes and opinions of both adults. In the process, resources are mobilised, sometimes, however, also memories of one’s own old, often prenatal, injuries. The experiences of previous generations can also be significant and unconsciously influential. Different facets, backgrounds and possible solutions will be demonstrated in the following contributions. In the first example (A), a woman, who had a somewhat troubled relationship with herself (she reckoned with getting cancer at some stage in life), had made various attempts to get pregnant through artificial insemination – without success. She finally had her first child when her situation in life had so changed that she got pregnant normally as the result of a love relationship and, with support, mastered all the phases of pregnancy well. In her second pregnancy, she had unwanted twins and was shocked for so long and so deeply that she actually thought about giving one child for adoption. This measure seems very extreme and might be shocking to the reader. However, it probably reflects the attitude of her own parents to their unborn children. Finally, one of the children, already recognised as chromosome damaged in a prenatal examination, gave up and died in the womb. The other twin went through the pregnancy, apart from this occurrence, normally.

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In her case it was always impressive how she managed to cope on her own energetically with every external circumstance. Her independence is very important to her. The relationship to her partner always has a large (safety) margin. She was expressly told of the necessity of making her younger son aware of the existence of his twin. The second woman (B) appeared from the start to be inhibited, depressed and not really at home in herself, her surroundings and the country (now Germany) in which she lived. So it was not surprising that she gave up her first child (no doubt under external pressure) shortly after birth to the parents of her partner and could maintain very little contact. Her decision to have this second child nonetheless also enabled her to create a new relationship to herself. She finds some security in the journey to her parents and her native country in this situation of a new pregnancy. At the same time, she was able to decide to fetch her son to her. Nonetheless her emotional state is depressed during the whole pregnancy. Not until its end when all the interdisciplinary arrangements have been made for as uncomplicated a birth as possible and relationships have been established through the special efforts of all the caretakers is she able to smile for the first time. Mrs. C keeps getting unintentionally pregnant. She has never managed to permanently solve the problem of contraception. It almost seems as if internal factors are responsible for always getting her into the situation of unintentional pregnancy. However, this point cannot be directly touched upon but seems to lie deep in her unconscious. She is only able to deal with these painful factors by means of repeated abortions. This situation can perhaps be explained by the greater frequency of abortions that exists in her cultural environment. This can also include her family or forebears. Perhaps she herself as an unborn child had been threatened with thoughts of termination. Riding a motorbike could be interpreted as a confirmation of her own physical existence in the face of such a threat. Mrs. D is aware that she runs the risk of getting pregnant. This also displays the high degree of ambivalence towards the child that cannot be born. She fluctuates between empathetic compas-

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sion and the great fear of not being able to cope with the demands. This is mirrored in the ambivalence towards her husband. She feels her husband expects too much from her. They both just fail to find each other like the king’s children in the well-known Grimm’s fairy tale. She is capable of expressing her manifold emotional anguish clearly and candidly in the subsequent psychotherapy. She concerns herself intensively with the question of death and the end. She finds room during the process of mourning for love and closeness to the child (figure of an angel on the kitchen shelf). Finally, openness and opportunity help her to be able to discuss this difficult problem with her mother. By the calculated date of birth, of which she is consciously aware, she can bring the development to a certain end. Mrs. E shows a highly complex situation at different levels. Once again the great burden of being pregnant with twins becomes obvious. Especially striking is the vehement reaction of the father, which indicates personal traumatic experiences probably at his prenatal level. In addition, there is the fact of personal instability in and due to living in a multiple patchwork situation. There also exist major burdens from the personal family of origin. This made the effort of letting her find a safe bolster in the therapeutic situation all the more important. Such difficult circumstances often demand intensive and interdisciplinary cooperation between many caregivers (practice staff members, gynaecologist, therapist, clinic, advisory centre, psychologist, lawyer, etc.). In this example and within this framework, she was able to continually find resources (even in the distant relatives of the child’s father). Mrs. E’s good emotional ties to both her unborn children were decisive in this situation. Finally such an example can show how narrow the line sometimes is between good, successful development in a healthy physical and psychological range, and severe, possibly life-­ threatening complications. Here can be seen how important the emotional openness and solicitude of caregivers is when dealing with pregnant women, particularly in conflicted situations. This is required immediately and in sufficient measure. In situations such

Conflict of Pregnancy: Experiences from a Gynaecological and Psychotherapeutic Practice

as those described in this case, this cannot be restricted to the mere measuring of apparently inconspicuous physical findings but has to include other facets of the qualitative condition of the pregnant woman, the development of her life history and cultural and social background. The openness of the caregivers for the underlying unconscious facets of the woman concerned, as illustrated by the examples given above, can help support them in finding the best possible solution for themselves and perhaps the unborn children

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as well. It is precisely the time during pregnancy and after that, with relationship-oriented accompaniment as well as an increase in value of actual relationships, which affords great potential for development of the prospective parents at every level. It becomes clear from the examples that the concrete fates of the women and their children reflect all the opportunities and contradictions of our time as well as from the time of our parents and grandparents.

On the History of the Pregnancy Conflict Ludwig Janus

Introduction The characteristic that man is both a biological and a cultural being means that elementary life processes can lead to conflict. This applies in particular to a life process as the creation and development of a new person and the associated transformation of biological parents into psychological and social parents. Historically, this conflict has assumed different forms depending on the differing social and cultural contexts. For practical reasons, I will confine myself to the historical area of ​​Western Europe and follow to a great extent the historical background of Robert Jüttemanns presentation in his book The History of Abortion: From Antiquity to the Present (1993). It is a peculiarity of human culture to fundamentally transform the biologically predetermined relationship of the sexes and thereby essentially determine the inner structure of the personality of man and woman. The pregnancy conflict is in turn determined by these rules and exists in very variable historical contexts. We can assume that pregnancy conflict may have existed from time immemorial and that there have always been traditions of abortive remedies in societies. However, conflicts of this nature have always been below the level of offi-

L. Janus (*) St. Elizabeth University Bratislava, Dossenheim, Germany

cial information, so that we can only record actual pregnancy conflict indirectly through the social arrangements for terminating pregnancies. It is significant that European history is predominantly patriarchal in nature, so that termination of pregnancy was regulated by paternity law: “Theologians, moralists, writers, politicians and medical practitioners agreed from the outset that the woman, and therefore her body, had to be subject to male authority” (Jüttemann, 1993, p. 13). A pregnancy conflict in the modern sense of a conflict within the woman is linked to the emancipation of women and the qualification of patriarchal attitudes. To provide orientation, I will first of all summarize the historical information.

Abortion in Early Civilizations The harsh relations between the sexes in the early civilizations are evident in their penal codes. The laws of Hammurabi from the seventeenth century BC state as follows: “Whoever kills the fruit of a (free) woman’s womb by mistreatment will be punished by a fine of 10 shekels” (Jüttemann, 1993, p.  27). The conflict thus exists between men or with the paternal deities. There are relatively detailed reports on abortive remedies from Egypt. Nothing is known about legal restrictions of their use.

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In Greece, abortion was seen as a means of regulating population growth. Thus, Plato advised in The Republic: “… the best thing is to ensure that the fruit should not see the light of day after it has been created, but if this cannot be avoided to behave as if there was no food for one such” (see Jüttemann, 1993, p.  30). From this advice, the complete lack of empathy for the prenatal child becomes clear, which to a great extent was also the case with the postnatal child. This was partly due to the deprived living conditions of women and children. At most, one third of children born reached adult age, the marriage age was extremely early at between 14 and 18 years, and women usually did not become older than 35 years. In ancient Greece, however, there was variable speculation about the prenatal child: on the one hand, the assumption was that the fetus was not a living being but a part of the mother’s intestines; on the other hand, however, a degree of vitality was assumed. Historically influential was Aristotle’s doctrine of the “successive ensoulment,” according to which the male embryo was ensouled on the 40th day after conception and the female embryo on the 80th day after conception. This is the philosophical background of deadlines which already existed in ancient medical authors, who recommended abortion between the second and third month of gestation. In Rome, abortions were probably relatively common, not only in the upper classes but also in the lower classes. There were numerous remedies, and the fetus was not regarded as a living being but as part of the woman’s intestines. Thus the incarnation or ensoulment began only with the first breath. Abortion only became criminally relevant when the patriarchal law of “atria potestas” was affected. This aspect gained importance in the late Roman Empire with the introduction of Christianity as a state religion, inasmuch as the “patria potestas” now lays with God the Father. Just as the earthly father had had the right over life and death of the offspring, this right now passed to the Christian father-god with the claim of universal validity. As a result, abortion, child exposure, or infanticide, which had been custom-

ary in the Roman Empire for getting rid of unwanted offspring, became a criminal offense. In so doing, parts of Aristotle’s concept of “successive ensoulment” and information from the Septuagint (Greek Old Testament) were used to prove that only the formed fetus possessed a soul. With this in mind, there existed a deadline for carrying out abortions in the Roman Catholic Church until the last nineteenth century, but this was progressively abolished by papal edicts during the nineteenth century. Up to this day, this Christian rejection of abortion is not, however, based on empathy but on theological reasoning which is based on the abstract evaluation of a soul that originates from the divine father and is therefore subject to his rightful claim.

Development of Dealing with the Pregnancy Conflict in Modern Times The more powerful structuring and organization of the Western European states and societies at the beginning of modern times also led to harsher punishment of abortion or aiding abortion, as formulated in Emperor Charles V’s “scrupulous justice order” of 1532. In this “order” an abortion is punished by the death penalty by execution or drowning. If the child was not yet living, fines, beatings, or exile is possible. However, the practice was not as rigorous as the statutory regulations. For example, a midwife from the time of Louis XIV was executed for 2500 abortions in 1680. However, the trials relating to abortions were much less frequent than those relating to infanticide. The Enlightenment qualified the power of the divine father and his earthly deputies, and the purely punitive aspect of the legal regulations on abortion also lost its absolute importance. “The main goal was the prevention of abortions” (Jüttemann 1993, p. 91). Abortion and infanticide were no longer regarded as actions against God but against the state. The following point was important: “The purpose of punishment was no longer the reconciliation with God but the improvement and safe-

On the History of the Pregnancy Conflict

guarding of each individual and of society” (Jüttemann 1993, p. 95). It is only in the context of this transformed mindset that the pregnant woman’s conflict becomes evident. Well-documented is the court case of Eleonora Schulzen from the year 1768. She became unintentionally pregnant by a manservant and endeavored to obtain an abortive remedy from the midwife (Jüttemann 1993, p.  97). Abortions were typical among maids and servants. Due to the efforts of modern criminal law, in 1871 the Reichsstrafgesetzbuch (German Penal Code) was produced, which dealt with “Crimes and Offenses Against Life” in § 218. However, this did not mention killing but “the abortion of the fruit of the womb.” This allowed for a medical indication for the well-being of the woman. The notable thing about this paragraph was that despite the strict regulations, with a 5-year jail sentence, or under mitigating circumstances a term of 6 months, between 300,000 and 500,000 abortions were carried out in Germany at this time. This was particularly dangerous for women of the lower classes. Compared to the frequency of abortions, judicial proceedings were minimal. In the 1920s, there was very intense discussion about § 218, which was loaded with political polarization. The communists advocated its complete abolition because it had criminal consequences, especially for working women, and abortion was safer than before as a result of growing medical knowledge. Despite the legal regulations with their high moral demands, the “practical” aspects seemed to prevail in the reality of life. Any empathy for the prenatal child was little developed: “… for many women, a pregnancy of two or three months was not much more than a bloating, an irregularity that could be eliminated” (Jüttemann 1993, p. 143). From a somewhat different perspective, women’s emancipation questioned § 218 in the sense of a consequent self-determination of woman. This also meant that contraception became more and more a matter of course. Abortion was “a self-evident alternative to contraception” (Jüttemann 1993, p. 143). Birth control became more a self-evident part of personal life plans. If abortions had earlier

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been mainly among unmarried women, now abortions were more likely among married women with several children, who often wished to prevent further births for economic reasons. The increased knowledge of anatomy also enabled women to bring about abortion with knitting needles and infusions of soapy water or even vinegar. Informative books like Bilz sold millions of copies. From the lively discussion about § 218, the deadline regulation for carrying out abortions had already crystallized in the 1920s, which was later enacted in the Federal Republic of Germany. On the right, the tendency was toward tightening § 218, and from the left came the plea for abolition. At an international congress on sexual reform, the following was formulated: “§ 218 is a representative, and the most visible representative, of the authoritative procreation, a representative of a vanquished epoch, a remnant from the time of the sovereign state, a pillar which is only a witness of vanished splendor. Whoever supports the state of today must be against them” (Jüttemann 1993, p. 158). At that time, leaving the responsibility entirely in the hands of the woman was still a minority opinion. As the feminist Helene Stöcker expressed in 1922: “Only when this paragraph, which is meant to protect a growing life from its own mother, is abolished, only then, when every compulsion is removed, when every pregnancy termination takes place freely and under personal responsibility, can the maternal sense of responsibility develop completely” (Jüttemann 1993, p. 162). Overall, the discussion about § 218  in Germany had an enormous public impact. There were plays titled “Paragraph 218: Tortured People” and “Cyanide.” The former was filmed and was seen by millions. Therefore, it came about that the pregnancy conflict was shifted from the level of legal, theological, and political discussion to the level of the people’s responsibility. However, empathy for the prenatal child and its situation still played virtually no role: “Compared to today’s discussion, it is striking that abortion was barely treated as a question of conscience. It was not about the right to life of

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the embryo but was about the existence and strength of the nation” (Jüttemann 1993, p. 167). A certain degree of practical clarification was brought by a court ruling on March 11, 1927, which ruled that the “physically indicated pregnancy termination” by the pregnant woman herself or with the consent of the pregnant woman was not “unlawful” “if it was the only means of releasing the pregnant woman from an existing danger of death or serious health damage” (Jüttemann 1993, p. 169). This qualified § 218 in the sense of an indication regulation. Under National Socialism, the regulations regarding pregnancy termination were tightened again, because “the vigor of the German people” would be impaired. The liberal spirit of the 1960s as well as the 1970s permitted a new and critical discussion of social politics in Germany and the revision of § 218 in terms of a deadline regulation with obligatory counseling, which has been the case since 1976. In this way, the responsibility of the woman and the parents is now acknowledged as being largely as important as the interests of the state and ecclesiastical values. It was only at this stage that the empathy for the actuality of the prenatal child became increasingly felt, and for the first time, in 2005 the “rights of the unborn child” were described in qualitative and differentiated terms in a corresponding charter of the ISPPM (see website www.isppm.de). Based on these new framework ideas and the resulting extended responsibility, the problem of “pregnancy conflict” can now be discussed at a new level. It is evident to me that all legal, moral, and theological arguments remain relative compared with the reality of 130,000 pregnancy terminations per year in the Federal Republic of Germany, the background to which is largely an

insufficient preparation for the realities of adult life. For a long time, the project of a “parenting license” has been considered by the ISPPM.  However, this parental preparation would have to go much further in the sense of “learning for life” in our schools, which should not only prepare for professional competencies but also social and psychological competencies such as responsible relationship, ability to resolve conflict, dynamics of couples, father identity, mother identity, life plans, etc. (see the contribution of Ludwig Janus “On the Fundamentals and Necessities of Promoting Parental Competence” in this volume). The present preparation for parenting is exceedingly insufficient, as a glance at the given statistics of pregnancy terminations shows. If a driving school qualification led to every fifth participant causing a fatal accident, this would not only be a catastrophe in itself but would also leave considerable reservations with regard to the qualities of the driving skills of the other four. This must provide the impulse for a real change in our school education. In the present state of lack of preparation, parenthood becomes an overwhelming situation for a large proportion of those affected, which shows itself not only in the high number of pregnancy terminations but also in the failings of parenting competencies. With regard to pregnancy conflict, there can only ever be era-related solutions, which must be further developed according to the understanding of the causes and the background.

Reference Jüttemann, R. (1993). Geschichte der Abtreibung (History of Abortion). München: C.H. Beck.

Part IV Neonatology

Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care W. E. Freud

Introduction After teaching infant observation for many years at the Hampstead Child Therapy Clinic and the Institute of Psychoanalysis in London, the author, a nonmedical psychoanalyst, had the unique opportunity of observing for extended periods of time in a great many neonatal intensive care units (NICUs) in England, North America, Canada, and in the German-speaking countries of central Europe. His overall impression is one of superb medical technology in these units, of devoted intensive care for the tiny babies by nursing and medical stuff, and of ample room for improvement of the psychological side of neonatal intensive care (NIC). As in other hospital departments, The author “W. E. Freud” is deceased at the time of publication of this chapter. This article is one of the historic documents of the Prenatal Psychology (1988) Source: Prenatal Attachment, the Perinatal Continuum and the Psychological Side of Neonatal Intensive Care. Lecture on the 8th International Congress of the‚ Internationale Studiengemeinschaft für pränatale und perinatale Psychologie und Medizin’, Bad Gastein, Germany, 21.–28. September 1986. Published in: P. G. Fedor-Freybergh und M. L. V. Vogel (eds) Prenatal and Perinatal Psychology and Medicine. Encounter with the Unborn. Parthenon, Carnforth, Lancester, 1988, S217–234. Translation: Hans von Lüpke. and in: Evertz K et  al. Lehrbuch der Pränatalen Psychologie, Mattes, Heidelberg, 2014, S313–333. W. E. Freud (Deceased) (*) Heidelberg, Germany

established routines, schedules, and procedures, which have proved themselves in the past, have become firmly rooted in the practice and in the minds of those who have been there for a long time. Therefore, it is not always easy to kindle enthusiasm for hitherto untried approaches, especially when it can be argued that the rapid and impressive advances on the medical-­technological side have enabled us to save ever more and ever lighter babies, even when separated from their mothers. It is my contention, however, that premature babies and premature mothers usually need each other more than healthy newborns and their mothers need each other (Anderson 1977). By separating them, we are approaching the limits of human adaptability (Lozoff et  al. 1977). The togetherness of mother and newborn will be the leitmotif of this presentation. The trailblazing observations by James Robertson (Bowlby et  al. 1952), who went into the children’s wards of hospitals with a cine camera, showed that an independent, unattached, and psychoanalytically trained observer (with a flair for viewing events from a slightly different perspective) is in a particularly favorable position to spot flaws and drawbacks in the system. These are flaws and drawbacks which can otherwise remain unnoticed in the course of habituation or are scotomized by hospital staff who have to work there day and night. The kind of mother–infant observation developed for the training of psychoanalytic candi-

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dates in London (Bick 1964; Freud 1975) proved, in slightly modified form, suitable for observing in NICUs. All the observer then had to do was to make himself as inconspicuous as possible while identifying and empathizing in turn with everyone he encountered there. This includes everyone from the premature baby, the parent, and other visitors to midwives, nurses, physicians, and ancillary staff (cf. Freud 1980)  (Freud 1989, 1991; Freud and Freud 1974; Sanabria and Gomez, 1984). Such a method is in keeping with the use of free-floating (evenly distributed) attention employed by the psychoanalyst. In the following, I will convey some of the impressions that led me to suggest charges in order to bring the psychological side of NIC more in line with the achievements of present-­ day computerized medical technology. The opinions expressed here are mine, though they were not infrequently shared (albeit sometimes secretly) by parents of prematures, nurses, midwives, and physicians alike. NIC makes sense only when seen in the wider context of a developmental perinatal continuum that takes full account of prenatal experience. I am aware that whenever it comes to attempt at describing prenatal psychological events, we are up against the problem of having to conceptualize prenatal phenomenology in postnatal language, which may not always be the best way to understand the intricacies of prenatal manifestations. However, it proved too tempting not to extend Klaus and Kennell’s (1982) concepts of attachment and bonding to the prenatal. The term “attachment” is used here in the sense of “forming a bond,” the term “bonding” to denote a more intense attachment. Sometimes I use the flexible psychoanalytic term “cathexis,” in the sense of emotional investment (cf. Ornston 1985). Prematurity presents us with a unique “experiment of nature,” in which we can observe a bit of prenatality postnatally – a circumstance that also has a bearing on our therapeutic efforts in NIC: We want to make the premie feel as much “at home” as we can. When we try to simulate intrauterine conditions (e.g., by rocking the incubator at regular intervals), our efforts appear crude and remain noncontingent (i.e., not necessarily ful-

filling the premature’s needs just when they arise). Such crude approximations also highlight what Als (1984) has called “the mismatch of organism and the neonatal intensive caregiving environment.” Against the background of a perinatal continuum, one can select certain “constants” of fetal experience to signpost the route which NIC should take. In this sense, one can think of prenatal aspects, like host togetherness (togetherness with mother), contact (body contact by touch), continuity, contingency, movement, interaction, feedback, and rhythm. One can then ask to what extent currently practiced NIC meets such prenatal criteria. So let us first look at prenatal attachment.

Prenatal Attachment The Mother The emotional investment (cathexis) in the idea of having a baby begins in the parents’ own childhood with childhood interest in where babies come from and how they are made (Freud 1908). The fact that boys also have wishes for a baby (Brunswick 1940) should make us give more thought to how we can help fathers of newborns. A wish for offspring comes up in many guises and can express itself consciously as well as unconsciously. It is always intriguing to note what is spontaneously mentioned by the parents and then to compare it with what we think are the really important underlying motivations for a pregnancy (1). There are usually quite definite expectations and hopes (the mother is “expecting”). The wish for a child may be predominantly positively or negatively cathected and is in any case ambivalent. Not infrequently we find a conscious positive wish for a child, but underlying it is a stronger unconscious rejection. It is widely assumed that a strong emotional cathexis decisively influences prenatal fetal development and has a bearing on outcome. By contrast, there is widespread evidence that if a woman wants to get rid of a child, her most ardent wishes remain inef-

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fective, and one cannot help wondering to what extent an even stronger unconscious wish to keep the child is not a stronger one. Though the area of prenatal influences is a fascinating one, I do not want to enter it here. Once the mother is pregnant, she often has a vivid fantasy relationship with the fetus (von Lüpke 1984) that is characterized by projections of her wishes. Just as the later real relationship with her child, the fantasy relationship will already be influenced by the unconscious meaning this particular pregnancy has for the mother, i.e., whom the fetus represents (e.g., a sibling, parent or other family member, or herself). What gender this person is also plays a role.

The Fetus Albert Liley’s (1972) charming paper dispelled the last doubts, if there had been any, that the fetus can be regarded as a lively and active personality. Additionally, Graves (1980) speaks of the fetus as sentient and competent. He is growing up in the environment of his mother’s biological rhythms, which is of cardinal relevance for NIC. Through the early maturation of hearing and of the labyrinth (Clauser 1971; Korner and Thoman 1972), he is particularly receptive to sound and movement. There is the constant background rhythm of his mother’s heartbeat (perceived by his ears or by conduction via the more solid structures of his body), and he may be aware of “the rhythmical whooshing sound of her blood flow” (MacFarlane 1977) “punctuated by the tummy rumbles of air passing through his mother’s stomach” and the noise and rhythm of her breathing, just as he may be aware of her wake-­ sleep pattern and her general style of functioning (lethargic, smooth, hectic, abrupt). Rice (1979) quotes Salk (1962) when she wonders about “imprinting” to intrauterine sound. In any case, rhythm itself provides the most reassuring “cradle” through its promise of repetition and continuity. Last, but not the least, there is his mother’s voice, which he can distinguish from the voice of others (DeCasper and Spence 1982), and there

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are suggestions that he may also be aware of the emotional under- and overtones of peoples’ voices (Verny and Kelly 1981). Clauser (1971) regards the mother’s movements and the rhythmic rocking of her gait as the most frequent stimulation which the fetus experiences and speaks of the prenatal experience of the mother as an acoustic-rhythmic happening. John Lind regarded movement as so important that he thought cessation of movement is experienced as severe deprivation (personal communication, 1981). Graves (1980) quotes Dawes (1973) as stating that the fetal need for activity is recognized and connected with the need to practice and to exercise. Such practice is considered a necessary prerequisite to normal functional development and morphological maturation  – a view also held by Milani Comparetti (1981). The exercising aspect of fetal movement reminds one of Bühler’s “Funktionslust” (pleasure of functioning). Maybe, the fetus has to be so active during certain periods of his maturation because, with his increasing size, there will later be less space for him in which to frisk about. Milani Comparetti (1981) pointed to the embryonic need to change contact with the surface of the uterine cavity. Kulka et al. (1960) take motion to be the first means of tension discharge and state that contact needs are probably fully gratified in intrauterine life. Blechschmidt regards the amnion (the innermost membrane enveloping the fetus and enclosing the liquor amnii) as a swing (personal communication, 1983). Platon (1970 edition) was of the opinion that: all young children, especially very tiny infants, benefit both physically and mentally from being nursed and kept in motion, as far as practicable, throughout the day and night; indeed, if only it could be managed they ought to live as though they were permanently on board ship. But as that’s impossible, we must aim to provide our newborn infants with the closest possible approximation to this idea.

One wonders to what extent movement serves communication. Verny and Kelly (1982), who elaborate on behavioral, sympathetic, and physiological channels of communication, think that

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mother-child communication is an important part of bonding, especially during the last 2 months of pregnancy. Mothers often take kicking as a message. Veldman (1982) found that if the fetus is “rocked” regularly at a certain time through laying hands on the sides of the mother’s body, he will “knock” if the practice is discontinued. This presupposes some kind of memory. How are we to imagine this? Feher (1980) thinks that bodily sensation is the medium of expression most accessible to the infant and that body movements in the womb are also significant in that they may affect later emotional states and mental development. She writes: “According to Corliss (1976) movements create sensations which have patterns. These patterns are actually imposed on the musculature, and then on the cortex itself, as imprints or memories, which remain like a permanent ‘motion picture’ to influence our consciousness and future reactions.” When we observe a premature pressing hands or feet against the wall of his incubator, we wonder whether a “body memory” is at the back of it. Greenacre (1945) speaks of unique somatic memory traces. To what extent does the fetus “cathect” his mother in terms of body memories? Verny and Kelly  (1981)  hypothesize an “organismic memory” that would allow even a single cell, like an ovum or a sperm, to carry “memories” and link it to the Jungian concept of the collective unconscious. There are other communication systems, like the one by which the mother becomes aware of the moment of conception (Petersen 1983) or the coenesthetic organization (Spitz 1945a) (2). Before we ask what is important for the fetus to remember, one other aspect should be mentioned: the fetus has a much larger number and a much wider distribution of taste buds in his oral cavity than the child or adult (Liley 1972). Graves (1989) quotes a suggestion from Bradley and Mistretta (1975) that the shifting ratios of fluid and urine contribute to the stimulation of taste buds in utero. Taste buds are already developing between the 11th and 20th week, and one wonders to what extent the fetus may be monitoring his liquid surrounding and whether some

parameters (like chemical composition, pressure, temperature, or other fluctuations) are more important to him than others. Could one hypothesize that the fetus “bonds” to tangibles (i.e., to that which he can touch), like parts of his own body and parts of his environment (such as the amniotic fluid, the placenta, the uterine wall, etc.)? Likewise might the same idea be extended to “intangibles,” like togetherness with his mother, his mother’s voice, or certain affective intonations of it (cf. Lind and Hardgrove 1978), continuity, rhythm(s), movement, and other forms of intangible stimulation? All aspects of psychological prenatal bonding may serve as stepping stones that facilitate moving along the prenatal sector of the perinatal continuum.

The Perinatal Continuum For our purposes and in order to emphasize the importance of togetherness, I will widen the concept of the perinatal continuum, extending it from conception to the end of exterogestation, i.e., until the child can crawl (Portmann 1944; Bostock 1958; Kovacs 1960; Montagu 1961). The sensitive period (Klaus and Kennell 1982) is at the beginning of exterogestation, when after the brief interruption through delivery, mother and newborn are reunited again. A long stretch of this continuum, from the pregnancy test to postnatal care, has, in Western-industrialized societies, become institutionalized, which is in sharp contrast to the so-called underdeveloped countries and the societies of traditional peoples (cf. Liedloff 1976; Montagu 1978; Kitzinger and Davis 1978). Institutionalization tends to crowd out the humane aspects, which means that constant efforts are needed to reinstate them. There are striking and intriguing “parallels” between intra- and extrauterine life. To name a few, Milakovic (1967) thinks that the drinking of amniotic fluid by the fetus represents the consummatory act of a prenatal stage of libidinal development and stresses the great importance of fetal oral experiences. Hoffer (1949) pointed out that already in intrauterine life, the hand becomes closely allied to the mouth for the sake of reliev-

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ing tension. He saw in this alliance the first achievement of the primitive ego. Kulka et  al. (1960) postulate a kinesthetic phase, which predates the oral and has its own primacy and specific modality of expression (3). Greenacre (1953) stresses that intrauterine life and early infancy form a continuum and that “the fetus reacts to discomfort with an acceleration of the life movements at its disposal,” stating that these responses represent an earlier form of anxiety-­like response. She further postulates that the fetus derives some pleasure from moving and from contact with the maternal body. Graves (1989) thinks that, given the level of auditory responsiveness and the repertoire of fetal movements, it is not impossible that already in utero some synchronization between fetal movements and intrauterine sound variations may occur. Truby (1971) holds that the fetus moves his body in rhythm to his mother’s speech, reminiscent of the synchrony between the neonate and his mother (Condon and Sander 1974). How can the essential ingredients of maternal-­ fetal interaction be pinpointed? Does the mother’s contribution always have to be contingent? Could it be that in the absence of one or more essential part-interaction components, the fetus reacts like Tronick and Adamson’s (1980) “still-­ face” infants whose mothers had been instructed to withhold feedback? Would the fetus, after being exposed to certain amounts of the mother’s ambivalent cathexis, become entrapped between contradictory messages, so that eventually his cooperation is impaired when it comes to labor and delivery (cf. Hau’s 1973 concept of “intrauterine hospitalism”)? Or, if the mother’s unconscious negative cathexis of the pregnancy becomes too strong and unpleasant, might he be thought to refuse nourishment or make an unexpected premature getaway? The question also arises under what conditions and at what point in time fetal activity contributes to the onset of labor. Milani Comparetti (1981) stated that “the fetus himself triggers parturition when his humoral message makes the womb responsive to the stimulus of his thrusting. Propulsion then is not only mechanical collaboration in labor, but also a fetal timing mechanism

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for the saccate rhythm of delivery.” The fetus sometimes confronts us with dilemmas by the way he chooses to lie, especially when he shows no inclination to conform to our attempts at turning him – or perhaps we are not going about it in the right way. There are reports of inducing him to assume a position which we think is the best for delivery by talking to him or to his mother (Groddeck 1923). There is probably something in Veldman’s view (personal communication, 1985) that the intentions of the fetus should be respected if, after the second attempt at turning, he reverts to the position from which he does not want to be dislodged. The principle of “following” a person’s natural inclinations reflected in the psychoanalytic model of therapy, where observing and listening have pride of place. It has found ample expression in the Hampstead Well-Baby Clinic where this approach is one of the cornerstones of the service (Freud and Freud 1976) (4). Such a model differs from the medical model which requires that something should be “done” most of the time (5). This is not to underrate the merits of the medical model, only to suggest that it should be suitably complemented by the analytic one. On another part of the perinatal continuum, Sosa et  al. (1980) followed the same principle when they demonstrated the importance of a supportive companion during labor. The mere presence of the “doula” favorably influences the mother’s interaction with the fetus resulting in shorter labor, fewer obstetric complications, and less maternal anxiety. Leboyer (1975) had already prepared the way for a smoother transition, and Odent’s (1984) flair for capturing the spirit of being in tune with parent and fetus at a crucial point along the continuum is exemplified in the communal singing and dancing in his unit. Mixed groups of prospective parents, and parents who have already had their babies, are joined by doctors and nurses in the merrymaking. I can personally testify to the warm emotional climate and the feelings of support and friendship this creates. It goes a long way toward creating and strengthening the parents’ confidence in themselves and the feeling of belonging. Meeting familiar persons again along the continuum is reassuring. We

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would be well advised to beat this in mind when selecting teachers for antenatal classes as well as for follow-up visits and ultimately for home visits in the course of long-term follow-ups. “Following” also has a bearing on the design of antenatal preparation. The term antenatal “class” reveals the emphasis on “teaching,” in which the parental share of anxieties and attendant questions usually get an insufficient hearing. As a colleague mother once put it to me: In the whole course of antenatal classes I was really only optimally interested when problems were discussed that corresponded to my prevailing state of pregnancy. It meant that a certain topic would already have been dealt with when it was still comparatively meaningless to me; or that I had to wait, sometimes for a long time, until my own particular problem could be aired. By then it was usually no longer topical. In short, my anxieties could hardly ever be discussed when they were most acute.

It should make us think again whether antenatal preparation is best done, as it is now, in groups of mothers in different stages of pregnancy or whether better ways can be found. Field (1979), in her studies of imitation vs. stimulation of the premature, also followed the principle of taking cues primarily from the baby, by “following” his signs and signals in order to be in tune with what he needs and wants at any given time. Only in this way can truly contingent caregiving be assured. The “amazing newborn” (Klaus and Klaus 1985) is programmed to interact with his mother from the beginning, and it is important not to deprive him of this opportunity. As DeChateau and Wiberg (1984) said: “The alertness of the newborn is highly significant and complements parental receptivity, thus preparing for a sensitive synchrony of responsiveness of infant and caretaker. In fact, the early parent-infant interaction is felt to determine the amount and quality of sensory stimulation received by the newborn later on.” Klaus and Kennell (1976) had already laid the foundations, and the kangaroo method more recently brought the whole issue into the limelight again (Sanabria and Gomez).

 reliminary Summing Up: P Relevance to NICU By placing the newborn on his mother’s body immediately after delivery, he is “plugged in again” into the familiar environment of his mother’s biological rhythms. This may well be the decisive ingredient in the soothing effect of maternal holding and in the kangaroo method of carrying the premature between the mother’s breasts. Other things being equal, optimal conditions for transition from the intrauterine to the extrauterine state are thereby given, and least demands are made on the newborn’s integrative capacities. Skin-to-skin contact between mother and newborn is a vital component. Feher (1980) supports her statement that touch epitomizes continuity by referring to Spitz’s (1945b, 1946) studies on hospitalism, and Kitzinger (1978) stresses that it is not only the sight or sound of the baby which provides clear signals in the bonding process between mother and newborn but also the physical contact through touch that initiates an onrush of feelings, which is “perhaps the most significant element in attachment to the neonate.” Touching, holding, and stroking play a major role. Optimal entrainment, reciprocal interaction, dialog, feedback, synchrony, and mutual caregiving can only occur in the context of mother-baby togetherness, which confers psychological immunity (cf. Freud 1980). The mother is not only the best incubator, but, if given half a chance, also the best monitor of her baby’s well-being.

 he Psychological Side of Neonatal T Intensive Care Psychologically, the premature can, like his “premature” parents, be regarded as traumatized. After delivery, he is “plugged out” of the biological rhythms of his mother and is, unlike the healthy newborn, not immediately “plugged back in again” into his familiar environment. On the contrary, he is whisked away to the NICU or to a

Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care

specialized perinatal center, i.e., to the pediatricians and to the nurses. He is no longer regarded as belonging to his family. The perinatal continuum has thus become a discontinuum. Uterogestation has been shortened by prematurity, and exterogestation has been lengthened. By radically separating the at-risk newborn, we are making exterogestation longer still. It seems as if we took the wrong turning at the fork in the road (see Fig. 1) instead of continuing along the road of togetherness. The premature parents feel they have failed and lose their self-confidence. Within an achievement-­oriented society, they feel that they have not “produced” as expected. They have lost face within their wider family and are shunned by their friends, who do not know how to cope with such situations except by embarrassment, pity, and avoidance. Hospital and NICU staff subconsciously also do not trust them, because they have not produced a healthy newborn, and they take over the baby. Traditionally, psychoanalysis has always stressed the importance of keeping mother and infant together (cf. especially Bowlby 1969, 1973, 1980; Robertson 1953; Winnicot 1958, 1965). In the light of what we now know about

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intrauterine existence and in view of the importance of safeguarding the perinatal continuum, it is my contention that if mother and premie were kept together from the outset, many pathological conditions in the at-risk newborn that now seem almost inevitable might simply not arise, while other problems which do arise may be more benign. The separation issue has not only been on the minds of the parents but very much on the minds of the caregivers too. Jonxis (1967) thought of using the whole NICU as an incubator so that the mothers could stay together with their sick newborns. This worked well until we became too adept at saving ever lighter babies, who in turn required ever higher temperatures for their well-­ being. The NICU then became too warm for the personnel (Okken, personal communication). Kahn et  al. (1954) and Bell (1969) tried to do something similar in Johannesburg. Garrow’s NICU in High Wycombe, England, which is built like a wheel with the NICU at the hub and the mothers’ bedrooms, like spokes, right next to it, has become a model for NICU design (personal communication). In Pithiviers incubators are kept alongside the mothers’ beds (Odent 1984), but these are the exceptions.

Delivery

I I I I I Psychological I immunity I -----------------------------------+-------------------------------------------------------------------------> Pregnancy

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Togetherness

I I I I I I I I Fig. 1

NICU Computerized technology (iatrogenic hazards)

Separation

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Separation means additional stress for the parents, premies, and caregiving personnel. Not infrequently the premie remains “plugged out” for weeks. In the absence of close contact with him, the mother’s fantasies tend to get out of hand: she worries and expects the worst. Uncertainty about their baby’s further development and possible permanent handicap is never far from the parents’ minds. Trying to strengthen the invisible bond by providing the parents with a polaroid photo helps but does not go far enough. A hospital in Grand Rapids, Michigan, has a film of the NICU, which is shown to the mother while her baby is stabilized for transport to the perinatal center, and in future there may be closed-circuit television for those who want it, but these are only palliatives. The road along separation has been buttressed and consolidated by medical technology. Now we need a new technology in the service of togetherness. A start has been made in a maternity unit in W.  Germany, where the newborn can enjoy receiving phototherapy on his mother’s tummy (6). Consequently there are no longer crying babies nor anxious mothers during phototherapy in this unit. One way to approach the issue is from the side of basic needs. The first task here is to identity the psychological needs of those concerned. In trying to do this for the mothers and for the prematures (Freud 1980), it became evident that the whole issue of visiting needs reappraisal. It is not surprising that if mother and newborn belong together so much, parents of prematures don’t visit more often, and when they do, they don’t stay for very long. The real question is why don’t we let the babies belong more to their parents, especially to their mothers? The “whose baby?” syndrome goes some way toward explaining it. One reason is that we do not really want visitors in the NICU, where they are subconsciously regarded as being in the way. Another reason has to do with our reticence to consider and accept change (cf. below). Until Barnett et  al. (1970) showed that the bacterial hospital flora constituted a greater threat to the baby’s health than that of the visiting mother and that the mother’s presence did not appear to increase the risk or the occurrence of

infection, visiting parents were held at bay behind the glass walls of the corridors. NICUs were not designed for the comfort of visitors, and this message is brought home to them by the lack of basic provisions which would make them welcome. While many NICUs display notices to the effect that no responsibility is taken for valuables, few units provide lockers for the mothers’ handbags. There are usually no facilities for making visitors physically more comfortable in the well-­ heated units. There are neither changing rooms nor shower facilities, let alone lockers for the parents’ clothes. There are also still too few high stools in the units to enable the parents to get a comfortable view of their baby in the incubator, and in middle Europe, the rocking chair in the NICU is conspicuous by its absence. The parents still have no “territory” within the unit and feel themselves as guest who can be asked to leave at any time. The greatest drawback, however, is that they do not have a well-­ defined role which would enable them to participate more actively in their baby’s care. A start has been made since it became clear that premies benefit from being touched, stroked, held, and talked to, and the more progressive units also allow the parents a slightly bigger share in the cleaning and tube-feeding of their baby (Baum and Howat 1978), but to my knowledge, no unit has as yet integrated one or both parents into the caregiving team. It should never be forgotten that active participation is still the best form of occupational therapy!

The Needs of the Premature The needs of the premature, like the needs of infants, clamor for immediate gratification. Because he is so small and light and lonely, the premie needs his mother all the more. In the context of prenatal togetherness, I assume his basic needs to be for continuity (e.g., of the mother’s biological rhythms), contiguity (body contact), contingency, interaction, and feedback, and we have to ask ourselves to what extent they are adequately met. In a NICU, togetherness is primarily with inanimate objects, i.e., with machines, like the ventilator and

Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care

the monitors, and in an abstract sense with routine procedures, schedules (e.g., feeding, cleaning, temperature taking), and interventions (many of them painful). The rhythm of the ventilator and the background sounds of the monitors do not readily lend themselves to adequate feedback. Attachment then is in the first place, to the machine, with the tendency to hold on to the familiar problems of weaning from the machine(s) which may subsequently arise. Marton et  al. (1980) have pointed to the human interaction deficit, and what human interaction there is usually unpleasant. This is in stark contrast to the analytic view that maximal pleasure should be experienced at each developmental stage before the infant moves on to the next one. Additionally, NIC requires intervening steps, which have to be negotiated (e.g., from parenteral feeding to tube-feeding to bottle-feeding before he gets to his mother’s breast). Too many intervening steps may overtax the premie’s capacity for integration, especially when transition from one step to another is not smooth. Another stress imposed on the immature organism is that of having too many different caregivers. Minde et al. (1975) observed 70 different nurses during a period of approximately 7 weeks, and of course, each nurse has her own individual style of caregiving. On top of it all, we may unwittingly delay integrative processes by not providing enough opportunities, for example, for unlimited nonnutritive sucking and for exploring the mother’s skin (especially the breast) with lips and tongue (Bonnard 1960). In spite of individually tailored stimulation programs (e.g., Brown and Helper 1976), it is difficult to discern the cues the premie may be giving us, which is partly due to our inexperience in clearly understanding his signs and signals. There are, furthermore, wide individual differences in the premies’ abilities to communicate. Communication could be via one, several, or all sensory modalities. But in view of the separation from his mother, the vital channel of bodily communication is usually not at his disposal, with the kangaroo method of nursing it is. All the “vehicles” for facilitating, promoting, and consolidating mother-infant interaction presuppose togetherness. Traditionally, breastfeed-

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ing and skin-to-skin contact have been the most effective ones. The kangaroo method, whereby the baby is carried between the mother’s breasts (Rey and Martinez 1983; Anderson et al. 1986), combines many of the essentials, notably closeness, continuity, movement, and unlimited sucking time, which is the best preparation for breastfeeding. For the mother of a premature, avoidance of a second “failure” assumes special importance and needs extra encouragement (Lowen 1982).

 he Psychological Needs T of the Nurses This somewhat isolated elite group of specially trained nurses, who are attending the at-risk newborns round the clock, has in essence been given an impossible task. The nurses provide substitute mothering of a kind that requires constant over-­ cathexis of their charges, whose lives they repeatedly save. And yet, they are not usually accepted as “family.” On the other hand, they are doomed to lose “their” babies in any case, if not to the family when the baby gets well, then to death. Mortality in NICUs is usually higher than in other units of the hospital. Their medical and technical competence puts them on a level with the physicians, who often rely on their superior skill and experience. Most of their time is taken up by routine ministrations to babies and machines, leaving little scope for creative activity in connection with their work. In addition they often have to give psychological support to the parents, usually without having received formal training in this. Little wonder then that the cumulate emotional stresses expose them to the burnout syndrome (Marshall and Kasman 1980; Marshall et al. 1982; Duxbury and Thiessen 1979). Their own need for ongoing emotional support is only just beginning to be recognized, but as yet far too little provision exists for regular support groups (Bender 1981) or for individual support. Their impressive potential for instruction and supervision, for which their experience amply qualifies them, remains largely untapped.

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The Risks of Change

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the beginning of evaluation of the advantages of the kangaroo method (Whitelaw and Sleath The challenge to save lives in the face of the well-­ 1985), preliminary studies sound most encouragnigh impossible and the attendant need to develop ing. A start has been made with developing appliand perfect defenses, which enable one to cope ances that allow mother and sick newborns to with that task, may explain why suggestions for remain together, such as with phototherapy and change seem to meet special opposition in the cots that hinge on to the mother’s bed. Another NICU. Understandably, there is great reticence to area awaiting development is the more active parexchange the precious footholds that have been ticipation by the premie himself. Mary Neal gained in the fight against death and disease and (1968) made a promising start by putting little replace them with new and unproven ones. It is, hammocks inside the incubator in which the pretherefore, not surprising that suggestions for even mie could push himself off from the incubator minor alterations usually meet with firm resis- wall whenever he needed more motion. tance. Resistances are usually easily “rational- Surprisingly, this method has not been developed ized,” i.e., supported by convincing-sounding further. The sick premature is isolated in an incujustifications for holding onto the known and pre- bator (“incubator prem,” for short), but, as Kulka dictable. The most frequently met rationaliza- et al. noted in 1960: tions are lack of space, lack of time, lack of staff, Premature infants are particularly vulnerable to and lack of resources – with medical safety often increased muscular tension. It may be postulated that for their particular state of neuromuscular thrown in for good measure (“Can it be proved development, close cuddling and rocking should statistically?”). Not infrequently the need for furbe as constant as in the mother’s womb. If this is ther research is put forward before anything new so, the modern incubator falls far short of a good is accepted. Closer scrutiny, however, often environment for a premature infant. reveals that these rationalizations are neither convincing nor valid. For example, it may be argued Prematures, whose condition is sufficiently stathat there is really no space, but at the same time, bilized to allow for graduation to an open cot, a room nearby is cluttered with rarely used appa- where they can breathe room air unassisted ratus. It should not be beyond the ingenuity of (“cot prems,” for short), pose a similar chalthose concerned to find a quiet area for mothers lenge. They spend most of their time sleeping, who want to breastfeed and to relegate the rarely and with some of them, one wonders whether so used appliances to other quarters. Once the much sleep is really necessary. It is an intriguing underlying anxieties, which are at the bottom of question to what extent their long periods of many resistances to change, have become more sleep are due to physiological needs and to what accessible to conscious consideration by discus- extent they are an expression of conservation sion, the way is open to consider even seemingly withdrawal (Engel and Schmale 1972). After unacceptable proposals for improvement with all, neglected children and adults, who are greater equanimity. A patient, analytically trained deprived of human contact and attention, also outside observer, can often act as a catalyst, if not spend long periods of the day sleeping, if only because there is not much else that life can offer as a midwife to new ideas. them (cf. also Spitz, op. cit. 1945b, 1946). The cot prems’ relative isolation from human contact (apart from being taken up for schedule The Ideal NICU: A Reality feeds and ministrations or when their parents I submit that the future of NIC lies in the direc- come visiting for short periods of time) should tion of keeping mother and premie together from give cause for concern. Be that as it may, if the cot prem must sleep, the outset, however unconventional that may sound in view of the specialized care the sick at-­ he should sleep on his mother’s body in order to risk baby should receive. Though we are only at be “plugged in again” to her biological rhythms.

Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care

The perinatal continuum would thereby be safeguarded again. In view of caregiving, as well as of holding, being a mutuality (Anderson 1977; Kestenberg 1977), there should really not be any valid objections to creating conditions that allow the mother to be together with her newborn as long as she wishes. I envisage a nursery where mothers sit in rocking chairs (preferably in skin-­ to-­skin contact for those who want it) with their premature babies or carry them in kangaroo method between their breasts. Then mother and premie would have unlimited opportunities for getting to know each other, and the premie would have ample leisure for exploring his mother’s skin with tongue and lips by touch, smell, and taste besides enjoying endless sucking time. Instead of being fed at regular intervals, topped up to imbibe the “required” amount of fluid, and then put back into the loneliness of his cot to sleep some more, the premie would doze off satiated in his mother’s arms or in her lap. It would have the added advantage of experiencing his maturational spurts during sleep within an environment he has been used to during his prenatal existence. When he is sufficiently rested, he will wake up again, and if hungry again, he will communicate his need for more. Even if he takes less than the prescribed amount at any one feed, there are suggestions that over a cycle of 24 hours, he will take as much food as he needs without being forced to do so (Ounsted, personal communication). An interesting research area beckons: do world prematures who have unlimited nonnutritive sucking and exploring time on their mothers’ bodies achieve an earlier integration of breathing, sucking, and swallowing, enabling them to breastfeed sooner? A mother is probably the best observer of her infant, being intuitively in touch with them. Bender (1981) describes how the mother of a 30-week-old premie noticed her daughter in the incubator sucking the corner of the sheet. She showed the nurse, who simply suggested putting the baby to the breast, and it turned out that the baby could fully breastfeed. We could encourage observation of prematures as part of NIC, perhaps with an interdisciplinary team composed of a pediatrician, a nurse, a psychologist, child psy-

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chiatrist or psychoanalyst, and at least one parent. If this team sat around the incubator for a period of half an hour or an hour at a stretch and then discussed their observations, we would soon know with which parents we could work together as a team apart from learning a lot from the pooled observations. It would not only cement the relationship between family, nurses, and physicians but would also make it easier for the nurses to let the mothers do a good part of the routine ministrations themselves. Initial bonding would be enhanced, and the mother’s confidence in handling her baby after discharge from the NICU would be strengthened. At the same time, the nurses would be freed for more creative activities. The role of the NICU nurse would change to being advisor to the parents. Nurses would thus have more time to supervise the parent’s acquisition of necessary skills and to give them more emotional support. As nurse consultants, they would have a different status and could more easily be drawn into independent research. One of the maternity hospitals to which I was attached in London had a nurse who specialized in advising mothers about breastfeeding. Fittingly, she was known as the “milk lady.” Even so, there were always more questions than she could answer in the available time, especially from primiparas without previous experience of how to breastfeed. There is no reason why different nurses should not, according to their special interests and skills, become “experts” for certain aspects of NIC over and above their general competence of NIC nursing. I can think of several such specialized aspects, like visiting, communication of mother and premie, nonnutritive sucking, baby massage (Rice 1977, 1979), father bonding, parent participation in NIC, discharge problems, follow-up, etc. Such drastic changes would require a reassessment of the training syllabus for midwives and nurses. Lest it be thought that these changes could be brought about without extra effort, let me hasten to add that such transformations require well-­ thought-­ out preparation and probably ongoing nurse and physician support apart from the feedback needed from parent’s self-help groups. Obviously, what matters most in all this is that we

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can create the right “climate” for such an undertaking. Spitz (1950) regarded affective perception, emotional development, as the trail breaker for all other development of the personality in the first year of life. This has been amply borne out in the psychoanalytic treatment of children, where we can observe how, for example, learning disturbances disappear once emotional conflicts have been resolved. The emotional aspect is the main carrier. In the Hampstead War Nurseries, Anna Freud and Dorothy Burlingham (1942, p.  76) observed that regression occurred while children who were separated from their mothers passed through the “no-man’s land” of affection, i.e., during the time after the old love object had been given up and before a new one had been found. One of the children, John, aged 5, expressed his own state of mind in words which have since become famous: “I am nobody’s nothing.” We do not know how many of the infants who went through NICU and especially through an incubator experience for any length of time encounter serious difficulties in their further emotional development and what the quality of their adult relationships will be like. We can only hope that they will feel better about themselves than little John. Unfortunately, a certain number of them end up needing therapy, either as children or as adults. It would be interesting to know whether they develop characteristics that are specific for their NICU experience and especially their incubator experience (7). Remarks: 1. The wish to have a child before one gets too old; perpetuating the family; competition with siblings, friends, relatives, or with one’s own mother; to keep a marriage together; to have a “live doll” on whom one can lavish affection; to recreate a childhood that is better than the childhood one experienced oneself; to get away from the parental home; to have someone “who really cares for me and will look after me,” etc. 2. Perhaps the key to the kind of affective prenatal attachment, in which we are most interested, lies in these regions, but to the best of

my knowledge, this has not been systematically researched further. 3. By kinesthetic they mean “all incoming sensory modalities: light, touch, pressure, temperature, visceral afferent, and also their central representations.” 4. The Hampstead Well-Baby Clinic is attached to the Hampstead Child Therapy Clinic, now called “The Anna Freud Centre.” 5. For a striking illustration in connection with sewing up episiotomies, cf. Jordan (1980), p. 44. 6. This is a device jointly developed by Dr. G. Eldering, his engineer, and the author. 7. I will close with a request that those of you who have treated or are treating such cases acquaint me with what you have found.

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374 Kitzinger, S., & Davis, J. A. (Eds.). (1978). The place of birth. Oxford, New  York, Toronto: Oxford Medical Publications, Oxford Univversity Press. Klaus, M.  H., & Kennell, J.  H. (1976). Maternal-infant bonding: The impact of early separation or loss on family development. St. Louis: Mosby. (German: Mutter-Kind-Bindung: über die Folgen einer frühen Trennung. Kösel, München 1983). Klaus, M.  H., & Kennell, J.  H. (1982). Parent-infant bonding. St. Louis: Mosby. Klaus, M.  H., & Klaus, P.  H. (1985). The amazing newborn. Reading: Addison-Wesley. (German: Neugeboren. Kösel, München 1988). Korner, A. F., & Thoman, E. B. (1972). The relative efficacy of contact and vestibular-proprioceptive stimulation in soothing neonates. Child Development, 43, 443–453. Kovacs, F. (1960). Biological interpretation of the nine-­ month duration of human pregnancy. Acta Biologica Academiae Scientiarum Hungaricae, 10, 331–336. Kulka, A., Fry, C., & Goldstein, F. J. (1960). Kinesthetic needs in infancy. American Journal of Orthopsychiatry, 30, 562–571. Leboyer, F. (1975). Birth without violence. London: Wildwood House. (deutsch: Der sanfte Wegins Leben. Deub, München 1974). Liedloff, J. (1976). The continuum concept. London: Futura Publications. Liley, A. W. (1972). The foetus as a personality. Australian and New Zealand Journal of Psychiatry, 6, 99–105. Lind, J., & Hardgrove, C.  B. (1978). Lullaby bonding. Keeping abreast. Journal of Human Nurturing, 3(3), 184–190. Lowen, L. (1982). Breastfeeding when your baby is premature. The Mother, 22, 68–70. Lozoff, B., et  al. (1977). The mother-newborn relationship: Limits of adaptability. Journal of Pediatrics, 91(1), 1–12. Macfarlane, A. (1977). The psychology of childbirth. London: Fontana/Open Books. Marshall, R.  E., & Kasman, C. (1980). Burnout in the neonatal intensive care unit. Pediatrics, 65(6), 1161–1165. Marshall, R. E., et al. (Eds.). (1982). Coping with caring for sick newborns. Philadelphia: Saunders. Marton, P., et al. (1980). The lnteraction of ward personnel with infants in the premature nursery. Journal of Infant Behaviour and Development, 3, 307–313. Milakovic, I. (1967). The hypothesis of a deglutitive (prenatal) stage in libidinal development. International Journal of Psychoanalysis, 48(1), 76–82. Milani Comparetti, A. (1981). The neurophysiologic and clinical implications of studies on fetal motor behavior. Seminars in Perinatology, 5(2), 183–189. Minde, K., et al. (1975). Interaction of mothers and nurses with premature infants. Canadian Medical Journal, 113, 741–745. Montagu, A. (1961). The origin and significance of neonatal and infant immaturity. Journal of the American Medical Association, 178, 156.

W. E. Freud Montagu, A. (1978). Touching: The human significance of the skin. New  York: Harper & Row. (German: Körperkontakt. Die Bedeutung der Haut für die Entwicklung des Menschen. Klett-Cotta, Stuttgart 1995). Neal, M.  V. (1968). Vestibular stimulation and developmental behavior of the small premature infant. Nursing Research Reports, 3(1), 2–4. Odent, M. (1984). Birth reborn. London: Souvenir Press. Ornston, D. (1985). The invention of “cathexis” and strachey’s strategy. International Review of Psychoanalysis, 12(4), 391–399. Petersen, P. (1983). Empfängnis und Zeugung: Phänomene der Kindesankunft. Vortrag auf der 7. ISPP-Konferenz, Düsseldorf, Mai 1983. Platon (4. Jh. v. Chr.). (1970). The laws, Buch VII: Education (pp.  271–277). Harmondsworth: Penguin Classics. (German: Die Gesetze. Artemis, München Zürich 1974). Portmann, A. (1944). Biologische Fragmente zu einer Lehre von Menschen. Basel: Benno Schwabe. Rey, E.  S., & Martinez, H.  G. (1983, March). Manejo rational de Nino Prematuro. Proceedings of the Conferences I.  Curso de Medicina Fetal y Neonatal. Bogota/Kolumbien, S 137–151. Rice, R. (1977). Neurophysiological development in premature infants following stimulation. Developmental Psychology, 13, 69–76. Rice, R. (1979). The effects of the rice infant sensori-­ motor stimulation treatment on the development of high-risk infants. The National Foundation, Birth Defects: Original Article Series, 15(7), 7–26. Robertson, J. (1953). Young children in hospital. London: Tavistock Institute of Human Relations. 1958/1970 (German: Kinder im Krankenhaus. Reinhardt, München 1974). Salk, L. (1962). Mother’s heart beat as an imprinting stimulus. The New York Academy of Science, 24, 753–763. Sanabria, E.  R., & Gomez, H.  M. (1984). The rational management of the premature baby. Bogota: Maternal and Infant Institute. (unpublished). Sosa, R., et al. (1980). The effect of a supportive companion on perinatal problems, length of labor and mother-­ infant lnteraction. New England Journal of Medicine, 303(11), 597–600. Spitz, R. A. (1945a). Diacritic and coenesthetic organisations. Psychoanalytic Review, 32, 146. Spitz, R.  A. (1945b). Hospitalism: An inquiry into the genesis of psychiatrie conditions in early childhood. Psychoanalytic Study Child, 1, 53–74. Spitz, R.  A. (1946). Hospitalism: A follow-up report. Psychoanalytic Study Child, 2, 113–117. Spitz, R.  A. (1950). Relevancy of direct infant observation. Psychoanalytic Study Child, 5, 66–73. Tronick, E., & Adamson, L. (1980). Babies as people: New findings on our social beginnings. New  York: Collier Books. Truby, H. M. (1971). Prenatal and neonatal speech, “pre-­ speech”, and an infantile-speech lexicon. Word, 27, 57–101.

Prenatal Bonding, the Perinatal Continuum and the Psychology of Newborn Intensive Care Veldman, F. (1982). Life welcomed and affirmed. The St. Cloud Visitor, Newspaper of the Catholic Diocese of St. Cloud, Minnesota, 71/2, 11.11.1982. Verny, T., & Kelly, J. (1981). The secret life of the unborn child: A remarkable and controversial look at life before birth. New  York: Summit Books. (German: Das Seelenleben des Ungebo-renen. Ullstein, Berlin 1983). von Lüpke, H. (1984). Prophylaxe und Therapie bei frühen Formen auffälligen Verhaltens: Risiko und Regulation in Entwicklungsprozessen. In R.  Voss (Ed.), Helfen – aber nicht auf Rezept (pp. S 54–S 74). München Basel: Hoheneck, Hamm und Reinhardt.

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Whitelaw, A., & Sleath, K. (1985). Myth of the marsupial mother: Home care of very low birth weight babies in Bogota/Columbia. Lancet, 25, 1206–1208. Winnicott, D. W. (1958). Through paediatrics to psycho-­ analysis. London: Hogarth/Institute of Psycho-­ Analysis. 1982 (German: Von der Kinderheilkunde zur Psychoanalyse. Kindler, München 1976). Winnicott, D. W. (1965). The family and individual development. London: Tavistock Publications. (German: Familie und individuelle Entwicklung. Fischer, Frankfurt 1984).

Family-Centered Individualized Developmental Care of the Preterm Baby Otwin Linderkamp

Introduction The transition from intrauterine to extrauterine life is the most complex adaptation that occurs in human experience (Hillman et  al. 2012). Although the entire prenatal development is in preparation for this transition, many specific anatomic and physiologic changes take place in the last weeks and days before birth preparing the baby for a healthy transition. The preparation includes the ability to start regular breathing, to establish mature cardiovascular connections, to achieve independent thermoregulation, and to drink independently with little help of the mother. The maturely born baby expects the mother’s protecting body, her warmth, her voice, and her milk. The mother is usually physically and psychologically prepared to meet the needs of her baby at full-term. Actually, the entire family, friends, neighbors, and work colleagues are prepared for a full-term baby. The premature baby does not expect to leave the protective body of the mother and is not as yet prepared for the transition from intrauterine to

O. Linderkamp (*) Institute for Prenatal Psychology and Medicine, Heidelberg, Germany

extrauterine life (Freud 1981). Extremely prematurely born infants are often not as yet able to breathe sufficiently, to adapt their circulation, to regulate their temperature, and to swallow milk. Neither the preterm baby nor the mother is ready for the physical separation. Although mother and infant are less prepared for the separation, the preterm baby is usually taken away from the mother to a neonatal intensive care unit (NICU) that is with luck located in the obstetric hospital. Early birth, separation from the mother, and intensive care often lead to lifelong traumatization of the child and the mother. Formerly, hospital care of the prematurely born infant has concentrated on the stabilization of physiological parameters using artificial ventilation, cardiovascular support, temperature maintenance, parenteral nutrition, infection control, and general nursing care. The expectation prevailed that maturation will happen automatically as long as predefined parameters such as oxygenation, blood pressure, and laboratory variables are maintained in the normal range. Although some authors early recommended to consider psychosocial needs of premature babies and their families in the NICU (Klaus and Kennel 1977; Freud 1981, 1995; Als et  al. 1986; Winnicott 1987), very few neonatologists paid attention to the long-term psychological development.

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Marina Marcovich, an Austrian neonatologist, started to care for preterm infants with gentle and minimized technical care in 1992 (Marcovich 1995). We have used her care principles and were surprised to see that even very tiny babies are capable to breathe by themselves and swallow small quantities of their mothers’ breast milk. Marcovich and our group (Linderkamp et  al. 1995; Linderkamp 1995, 1996) found that her care principles of minimization of intensive care and maximization of personal attentiveness to the infants and their families resulted in much better outcome of the babies when compared with conventional care. In Heidelberg we have introduced the neonatal care program “Family-centered Individualized Developmental Care (FIDC)” based on methods published by Als et al. (1986, 2004, 2009, 2011), Freud (1981, 1995), Ludington-Hoe and Golant (1993), Marcovich (1995) and Westrup (2015). Our Heidelberg group has studied the effectivenes of several elements of this care program including light reduction (Seiberth et al. 1994), minimization of intensive care (Linderkamp 1995, 1996), kangaroo care (Fischer et al. 1998), music (Linderkamp et al. 2004), mothers’ voice (Djordjevic et al. 2007; Nöcker-Ribaupierre et al. 2015), pain management (Gharavi et al. 2007) and electronic documentation (Kohl et al. 2007). This chapter addresses some important aspects of psychological and developmental care of preterm infants and their families during the hospital stay.

General Aspects

O. Linderkamp

between 37 and 42 weeks of gestation, and 11% of the babies are born before 37  weeks (Chawanpaiboon et al. 2019). In 2010, 15 million children were born prematurely. Fifteen percent of all newborn infants weigh less than 2,500  g (Blancowe et  al. 2019) (normal range 2,500– 4,500 g). In most countries, preterm births appear to increase for a variety of reasons (Table 1). In the USA, the rate of preterm deliveries increased steadily from 1990 to 2013 but declined from 2014 to 2016 in relation to a decrease in the number of young mothers with age below 20  years (Martin et  al. 2018). However, since 2014 the preterm rate is on the rise again. The preterm birth rate in the USA (11%) agrees with the global average but is higher than in other developed countries. This is in part because more US women are exposed to the stresses of racism and low income, thereby increasing the risks to young age and unintended pregnancies, obesity, heart disease, and poor health status compared with women in other countries (Bronstein et al. 2018). The “epidemic” rise of cesarean sections from approximately 10% to more than 30% during the last 20 years (Visser et al. 2018) plays an important role in the worldwide increase in the numbers of the so-called “late” premature babies (34–36 weeks, approximately 10% of births) and “early term”(37–38  weeks, 25–30%). Cesarean sections are performed prior to full-term before the onset of natural labor. Late preterm and even early term infants are at greater risk for respiratory, temperature, and feeding problems, hypoglycemia, and jaundice than full-term babies Table 1  Causes of the increase in preterm birth

A preterm or premature baby is born before 37 weeks of gestational age. The gestational age begins from the first day of the last menstrual period (postmenstrual age), although the conception actually takes place approximately 2 weeks later (postconceptional age). Full-term babies born at a gestational age of 40 weeks have thus an actual age of 38 weeks. The proportion of premature babies has been steadily rising for years in most countries. Worldwide, 89% of the deliveries take place

Cesarean section increased (32% in Germany and the USA) Relatively more first-born babies Increase in the number of pregnant women over 35 years Reproductive medicine, multiple births Increasing stress (job, leisure) Social problems (poverty, lack of support from partner, family) Smoking, drugs in some countries Care of extremely immature infants, who were formerly considered nonviable

Family-Centered Individualized Developmental Care of the Preterm Baby

(Glavind and Uldbjerg 2015; Huff et  al. 2019). Breastfeeding is more difficult for these babies. Birth by cesarean section aggravates these risks. Of the late preterm infants 10–15% and about 8% of the early term babies are transferred to a neonatal unit. Thus, many of these apparently mature babies are separated from their mothers for neonatal care, thereby impeding the transition to a healthy mother-infant relationship.

Developmental Disorders of Premature Babies In premature babies, vital organs such as the lungs, intestines, liver, and kidneys are not yet mature, and their functions should be exercised by their mothers. Nevertheless, 60% of premature babies survive after 24 weeks of pregnancy and 85% after 26  weeks thanks to extremely intensive treatment in specialized perinatal centers. The limit of medical care for premature babies is 23–24 weeks in Western countries and 22 weeks in Japan (Linderkamp 2017). The chances of healthy survival of premature babies have also improved significantly, due to new drugs, improved medical techniques, delayed cord clamping (Linderkamp 1982; Katheria et al. 2017), organizational changes (establishment of perinatal centers, specialization of nurses and doctors on neonatology), and the introduction of “gentle” developmental care in many neonatal centers. However, the risk for lifelong problems resulting from dysfunctions of the brain is still high (Kubli et al. 2011). Brain damage visible in ultrasound and magnetic resonance imaging (bleeding, leukomalacia, hydrocephalus) exposes the infants to a high risk of severe motor and mental disabilities. These severe impairments have become less frequent during the last decades. However, the frequency of brain dysfunctions with no visible damage in brain images appears to increase. These dysfunctions include cognitive (Liebhardt and Sontheimer 2000; Jaekel et  al. 2013; Wolke et  al. 2013), motor (Greene et  al. 2018), behavioral, attention (Lindström et  al. 2011), and autistic (Lagercrantz 2017) disorders. These impairments are in part the result of dis-

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turbed development of the premature brain during the weeks of intensive care (Kubli et al. 2011; Wolke et al. 2013; Greene et al. 2018).

 rain Development in the Fetus B and Premature Baby The majority of neonatologists and most recommendations by national and professional authorities consider a gestational age of 23  weeks the limit of viability (Linderkamp 2017). At 20 weeks of gestation, the proliferation and migration of nerve cells (neurons) in the cerebral cortex are largely completed, and the cells start to differentiate into the specific type of cell appropriate in that location. During the following weeks, nerve fibers (axons and dendrites) grow out of the neurons in the direction of other neurons (guided by neurotransmitters) and form innumerable connections among neurons, both within and across regions. At 23 weeks, each neuron is on average connected with one other neuron only; at 40  weeks each cortical neuron is linked with approximately 2500 other neurons (Linderkamp et al. 2009; Rogers et al. 2018; Linderkamp and Linderkamp-Skoruppa 2020). Between 24 and 27 weeks, initial electrical activity (EEG) can be noted (van de Pol et al. 2018) as a sign of neural connectivity. Lagercrantz (2014) suggests that consciousness localized in the cortex commences at the earliest at 24 weeks with the establishment of thalamocortical connections from sensory organs. Myelination of the cortex begins very slowly at 14  weeks but catches up at 35  weeks and continues for several years. Between 24 and 38 weeks of gestation, about 50% of the neurons and neural connections are eliminated and rebuilt according to the apparent individual demands of the fetus. Adjustment of neurons and connections to the individual environment (i.e., neuroplasticity) usually makes sense but can result in severe impairments of sensory, behavioral, and cognitive functions, if the fetus or young infant is deprived from normal sensory input or exposed to severe stress (Trachtenberg et  al. 2016). The hippocampus (stores memory!) is particularly sensitive to the

380 Table 2  Development of the nervous system in the fetus and the premature baby Significant steps in the maturation of the child’s nervous system take place during the gestational age of 23–38 weeks: Formation of nerve fibers and synapses, myelin formation, elimination of about 50% of neurons, and development of the frontal brain and other brain centers. Formation and elimination of nerve fibers, synapses, and neurons depend on the use and expected usefulness, derived from external stimuli (plasticity of the brain). The prematurely born infant lives in an unexpected and inappropriate environment, but tries to continue the prenatal development paths. Abruptly changed and unexpected external stimuli after early birth can lead to aberrant development of the neuronal network. Pain, stress, and sedatives promote the death of neurons (apoptosis). Long-term consequences include risks of cognitive, psychosocial, and behavioral/developmental problems and learning and behavioral disorders (ADHS, autism). Development-promoting care can prevent or alleviate the undesirable development of the preterm brain.

apoptotic actions of corticosteroids transmitted to the fetus as a result of maternal stress (Van den Bergh et al. 2018). Thus, important steps of brain development take place while the preterm baby is cared for in an NICU (Table 2). Because the conditions in the NICU deviate considerably from the intrauterine conditions, the abnormal sensory experience in the NICU may contribute to the high risk of preterm infants to disturbed long-term development. The frontal brain is considered the brain region that “makes us human beings.” Skills such as attention, decision-making, planning actions, and dealing with feelings, emotions, and rules are important tasks of the frontal brain. The synapse formation in the frontal brain begins as in other brain regions at about 24 weeks of gestation and reaches the maximum at 15 months of birth. The first weeks of development are particularly critical for the frontal brain. This explains that preterm infants are at high risk to develop functional deficits of the neural conduction in the frontal brain and that these abnormalities can be pre-

O. Linderkamp

vented by development-promoting care (Als et al. 2004, Westrup 2015). The premature baby is physically, neurologically, sensorily, and psychologically adapted to the intrauterine world of the mother. The preterm infant is abruptly separated from this adequate environment and thrown into an absurd world with loud and unfamiliar noise, bright light, and insensitive touching by strange people. The preterm infant is just as competent as prior to birth and continues to build the sensory experience into the neural network. The stimuli that the premature baby receives are, however, completely different from those in the intrauterine world. The brain does not receive the anticipated stimuli that promote the normal development of the nervous system but the stimuli of an intensive care unit. Because expected stimuli (e.g., mother’s voice, intrauterine sounds) are suddenly interrupted, the development of the brain continues to an unfavorable direction. Sensory isolation of preterm infants has been blamed as risk factor for the pathogenesis of autism in extremely preterm infants (Lagercrantz 2017). A particularly high risk for the brain development is caused by repeated stress in early life. Repeated or long-term stress is associated with increased elimination of nerve cells and neural connections. In premature babies, several risk factors for increased apoptosis of neurons have been reported (Bhutta and Anand 2002): (1) increased elimination of neurons due to recurrent or persistent pain; (2) increase of natural apoptosis of neurons due to stress or lack of social stimulation; and (3) degradation of nerve cells by sedatives such as phenobarbital, diazepam, and chloral hydrate. The dependence of normal brain development on external stimuli explains that even in the absence of medical complications and in spite of normal brain imaging, premature babies are at high risk for subsequent cognitive, psychosocial, or behavioral problems. These late complications can be alleviated by avoiding stress (development-­ promoting care, minimization of intensive care) but not by early intervention programs after discharge of the infant from the intensive care unit.

Family-Centered Individualized Developmental Care of the Preterm Baby

This suggests that the weeks of intensive care for premature babies lead to an altered functional and structural organization of the brain. Developmental care is, therefore, as important as technical care for the brain and long-term development of the premature infant (Linderkamp 1996).

 tress and Emotional Problems S of the Parents During pregnancy, the expectant mother develops significant psychological and physical adaptations. Already prior to birth, a strong bond between the mother and her child develops. The mentally healthy mother communicates in many ways with her unborn child. From the beginning of pregnancy, mother and father adjust to the birth of their baby at a gestational age of 40 weeks and develop an image of a mature newborn girl or boy. The premature birth leads to an unexpected and sudden separation of mother and child. The mother has the feeling of unfinished, interrupted pregnancy. She is no longer pregnant but does not as yet feel like a mother. She carries her baby neither in her belly nor in her arms. She has feelings of failure as she was not able to carry her child to full term. She feels guilty and looks for self-­ inflicted causes for her preterm delivery. She does not experience the expected social recognition through her mother role but experiences the birth of her premature baby as a devaluation of her person. She fears the reactions of the family, friends, and work colleagues, who expect a well-­ nourished mature baby. Her premature baby is small, lean, fragile, and dependent on apparatus (Table 3). The child is not only separated from the mother’s body but also moved away from her to a neonatal intensive care unit. If mother and baby are lucky, the NICU is located in the women’s hospital. If they are less fortunate, the baby is transported to another building or to a children’s hospital in another city. Not the parents are responsible for the care and the life of the baby but unknown physicians and nurses work-

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Table 3  Parental stress 1. Stress during pregnancy:  Personal, family, and work stressors  Stress due to pregnancy complications 2. Stress of the premature baby after birth:  Hospital-related stress  No private atmosphere with the baby  Fears of suffering, disability, or death of the child  Feelings of guilt and failure  Grief over the lost dream of a mature healthy baby  Separation of the parents from the child  Disagreement of expected and real image of the child  Fear to harm the vulnerable baby by touching, disturbing, and transmission of infections  Loneliness in the NICU environment and toward the staff  Loss of personal autonomy, parenting, and responsibility for their child  Lack of time of the staff and incomprehensible information  Unfriendliness, commanding tone, and rejection by the staff  Poor communication with the hospital staff  Worries about physical and emotional demands after hospital discharge of the child 3. After hospital discharge of the preterm infant:  Lasting strangeness of the child and attachment disorder  Inability to understand the specific signals of the premature baby  Overload and loneliness due to chronic impairments of the child  Unwanted renunciation of professional activity  Partner and family conflicts  Long-term sequelae of the mother as a result of a posttraumatic stress disorder

ing in the strange world of an intensive care unit. The parents cannot fulfill their role as protective and supportive institution. Parents have to accept the environment, medical, and nursing care of their baby with little influence. The parents cannot influence the emergence of permanent disabilities, and they are helpless if medicine cannot help their baby anymore. The heteronomy and paternalism from the staff reinforce the sense of incompetence and failure. The loss of autonomy, which began with the uncontrollable premature labor, frequently leads to feelings of personal guilt and self-reproaches, allegations against the partner, mistrust, and

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allegations against the nursing and medical staff. At the worst, a severe posttraumatic syndrome develops (Jotzo and Poets 2005). Fathers of premature babies can also be significantly traumatized (Freud 1995).

Attachment and Bonding of the Premature Baby and the Parents The bond between mother and child begins at the latest with the knowledge of the pregnancy (Levend and Janus 2011). The unborn baby communicates through movements; the mother communicates by stroking her abdomen and speaking to her child. Maternal emotions are transmitted to the unborn child via hormones, respiration, heart activity, and body movements. During the first hours after the birth of a healthy, mature child, the mother-infant attachment is strengthened by physical contact and first breastfeeding attempts. The mother speaks to her newborn baby for the first time with visual contact. The newborn remembers and recognizes the voice, rhythm, and melody of her speech and feels immediately safe. The mother’s heart rate and respiration patterns are also familiar to the newborn baby. There are even indications that the heart rate pattern of the fetus is influenced by cardiac activity of the mother (Weller and Linderkamp 2012). Involuntarily, the mother places her child on the left side of the chest immediately after birth so that the baby can hear and feel her heart rhythm. Even short-term separation of mother and child after birth can lead to attachment disorders (Kästner et al. 1995). Oxytocin is an important promoter for the development of parent-infant attachment (Vittner et  al. 2018). Oxytocin is considered a love, sex, loyalty, and trust hormone and is therefore the essential hormone of partnership and social relationships (Feldman 2012). Oxytocin has a number of important functions during and after birth: It causes contractions, reduces the pain of the mother and probably also of the child, and promotes lactation and the bond between mother and child. Oxytocin is also produced by parents and their children as a result of touch and of strong feelings for the child.

O. Linderkamp

Lack of skin contact, negative emotions (such as anxiety and depression), and lack of breastfeeding reduce the formation of oxytocin, thereby impeding bonding of the parents and babies. These inborn mechanisms promoting mother-­ child attachment are largely absent in immature premature babies. At the worst, mother and preterm baby cannot see each other if the infant is transferred to a remote pediatric hospital. At the best, the mother can visit her baby after a few hours if mother and baby are cared for in the same building. She can stroke but not hug or breastfeed her baby. The noise in the NICU, the distance from the child, and the lack of privacy make it difficult for the mother to talk to her baby. In the environment of an NICU, it is difficult to build a relationship. The mother has hardly any chance to convey her love to her baby and receives little or no response from her child (Table 4). Even a healthy mature newborn infant causes stress in many families. About 15% of mothers and 15% of fathers consider their mature newborn baby a burden and have difficulties to forge a bond with their baby. The premature birth is perceived by many parents not only as stress but as a crisis or even a disaster (Vonderlin and Linderkamp 1996). The security of attachment of mothers and their premature infants has been studied by several groups by means of the Ainsworth model at a corrected age of 12–18  months. Most authors reported less secure mother-preterm infant attachment (Korja et  al. 2012). Moreover, the susceptibility to insecure attachment appears to increase with the preterm baby’s age. Wolke et  al. (2014) observed that most healthy babies born at full-term (72%) and preterm infants (61%) show secure bonding. 17% and 32%, respectively, showed disorganized attachment. Disorganized bonding has been attributed to unpleasant early interaction experiences. Attachment problems of fathers to their premature infants have also been reported (Chen et al. 2019). Secure attachment is strongly dependent on the parents’ sensitivity to the signals of their child. Parents of preterm babies are not less sensitive than parents of mature infants (Bilgin and

Family-Centered Individualized Developmental Care of the Preterm Baby Table 4  Risk factors for impaired attachment of premature babies Preterm birth is often preceded by chronic stress and hospitalization of the mother that can interfere with prenatal attachment. Prenatal attachment development is suddenly interrupted at an early stage and must continue under extreme conditions. Many mothers experience the sudden and usually operative delivery by cesarean section as traumatic. An essential part of the mother-infant bonding takes place in a critical phase after the birth, when the mother and her premature baby are separated. From the beginning of pregnancy, mother and father prepare for the birth at full-term and expect a well-nourished, vital baby. The premature baby is small, lean, fragile, and often dependent on apparatus. Intensive care leads to enormous physical and emotional strain on the preterm baby. Instead of the family’s emotional and physical warmth anticipated by the baby, the preterm infant experiences unpleasant external stimuli such as bright light and noise, repeated pain, and touch by strangers. Bonding may be difficult to develop in this hostile environment. The signals of premature children are different and more difficult to understand than the behavior of full-term infants. The sensitivity of the parents for their child becomes impossible if they are denied access to their baby in the NICU. The reaction of the mother to her premature baby is often more passive and less sensitive or overly stimulatory and intrusive. Touch is a central part of the interaction and development of a secure parent-infant bonding. The restriction of touch, which is still common in many NICUs (due to concern about the transmission of infection or inadequate monitoring), has an unfavorable effect on parent-child attachment. Premature babies may suffer from chronic physical illnesses and behavioral and psychological disorders after discharge from the hospital. Increased irritability, shrill crying, or passive, anxious-avoidant behavior of the preterm baby may inhibit the development of a secure relationship.

Wolke 2015), but many parents of preterm babies are more anxious and tend to overstimulate and control their children. Measures to promote a secure attachment of prematurely born families include child-parent togetherness, physical and emotional contact, and parental training to identify the special signals of premature babies. Kangaroo care in addition to development-promoting and family-centered care is particularly effective in

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improving attachment (Als and McAnulty 2011). The importance of early mother-infant contact has been demonstrated by a study from Cologne. 76% of preterm infants (