PREGNANCY AND POSTNATAL DEPRESSION

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CHAPTER 2 THEORETICAL BACKGROUND

Orientation

In this chapter the theoretical background of this study is discussed. The chapter begins with a short introduction, followed by a brief overview of object relations theory and concepts as it pertains to this study. Thereafter the focus is on representations, maternal representations and Stern’s motherhood constellation. In closing, the link between maternal representations and depression, as well as the effect of postnatal depression on the infant’s representations, are discussed.

Introduction

The belief that a mother’s representations can influence how she acts with her baby is as old as folk psychology and still holds truth (Biringen, Matheny, Bretherton, Renouf & Sherman, 2000; Fonagy, 1999, 2001; Fonagy, Steele, Steele, Moran & Higgitt,1993; Rosenblum, McDonough, Muzik, Miller & Sameroff, 2002; Stern, 1995). Parents’ representations have played a key role in the history of parent-infant psychotherapies in the psychodynamic tradition. The mental world of both parents play an important role in determining the nature of their relationship with their baby (Fonagy, 1999, 2001; Fonagy et al., 1993; Lyons-Ruth & Zeanah, 1993; Raphael-Leff, 2001a; Stern, 1995). This will be illuminated in the discussion on representations. Babies evoke unconscious phantasies in their mothers, which shape the mother-child interaction (Haft & Slade, 1989; Raphael-Leff, 2001a). Object relations therapists were historically the first to describe some of the ways a mother’s inner life might influence her relationship with her infant and the infant’s development (Haft & Slade, 1989; Murray, 1991; O’Shaughnessy, 1988a; Scharff & Birtles, 1997). Seligman (1991) argues that psychoanalytic object relations theory is fundamentally a psychology of internal representations with core concepts such as introjection, projection, identification and transference describing the ways in which such representations can influence the personal experiences of self and others.
Object relations theory highlights two critical components in the relationship between a mother’s internal experience and the child’s developing sense of him-/herself and others, namely the role of the mother’s feelings, phantasies and expectations of the relationship, and her ability to provide a stable organisation which the child can ultimately incorporate as a part of his own psychic structure (Diamond & Blatt, 1994; Haft & Slade, 1989; O’Shaughnessy, 1988a; Waddell, 1998; Winnicott, 1965a, 1965b). Empirical confirmation of these notions has been provided by researchers working in the area of infant-mother attachment (Fonagy, 1999, 2001; Fonagy et al., 1993; Haft & Slade, 1989; Zeanah & Barton, 1991). Blatt and Ford (1994) emphasise the fact that the recent emphasis in psychoanalytic theory on the development of the representational world is consistent and convergent with recent trends in cognitive theory, developmental psychology and attachment theory and research.
This study is based on maternal representations as described by Stern in The Motherhood Constellation (Stern, 1995), and also the link between maternal representations and depression. Therefore, this chapter will focus on representations, especially maternal representations as described by Stern. Stern’s research and theoretical contributions are described by Haft and Slade (1989) as a bridge between the positions of classical psychoanalysis, object relations and attachment theory. Fonagy (2001) is of the opinion that Stern occupies a unique place in psychoanalysis and sees his work as a bridge between developmentalists and psychoanalysts. His unique contribution lies in the way he elaborated the representational world concept (Fonagy, 2001). Object relations theory provides a framework for understanding representations and stresses the modifications of the inner representational world (Meissner, 1991). This researcher values the emphasis of object relations theory on the complexity and unconscious processes of mental representations, but identifies more with Stern’s (1995) integrative approach. Object relations theory represents a diversity of perspectives (Fonagy, 2001; Gomez, 1998; Ivey, 1990; St. Clair, 2000), thus only the concepts relevant to this study are discussed briefly. The area of representations that has been the most widely researched, namely attachment, is briefly touched on. Finally the chapter is concluded by focusing on representations and postnatal depression.

Overview of object relations theory

Object relations theory has evolved over the past sixty years. It includes the work of several theorists such as Klein, Fairbairn, Winnicott, Bion, Kernberg, Mahler, Kohut, Bowlby, Balint, Sutherland and Guntrip, representing a diversity of perspectives (Blatt & Ford, 1994; Gomez, 1998; Ivey, 1990; St. Clair, 2000). As Melanie Klein is seen as the founder of object relations theory (Likierman, 2001), her concepts are used as a basic point of departure. Klein’s theory is seen as transitional from Freudian thinking to a full object relations theory, which was applied by other Kleinian-inspired thinkers such as Winnicott, Fairbairn and Balint (in Likierman, 2001; St. Clair, 2000). Object relations theory arose primarily from the psychoanalytic study and treatment of young children and psychotics (Bick, 1988; Celani, 1993; Ivey, 1990; Klein, 1997a, 1997d; O’Shaughnessy, 1988a; Scharff & Birtles, 1994; Winnicott, 1958a, 1965a, 1965c).
For Freud the term “object” was external and meant anything the infant directs or drives towards for instinctual gratification (Freud, 1971a). Object relation theorists argue that humans have an innate drive to form and maintain relationships (Gomez, 1998; Ivey, 1990; Klee, 2002; Scharff & Birtles, 1997). The term ‘object relations’ refers to an internal and external world of relationships, suggesting that an individual’s current interactions with people are shaped by the inner residues of past relationships (St. Clair, 2000). The objects and the relationship with the objects are internalised to form a self-structure. Ivey (1990) gives a useful definition of object relations theory: a psychoanalytic developmental account of how primary interpersonal relationships in the infant’s external world become internalized, represented and metabolized at the level of fantasy into a nucleus of personal identity which, whether healthy or deficient, determines subsequent personality development and deformation (Ivey, 1990, p.3).
Freud’s paper on “Little Hans” was one of the first and the most famous accounts of a child’s mental life (Daniel, 1992; Likierman, 2001). Although Freud did not work directly with Hans, his paper provided a working model for Klein’s work with children. Likierman (2001) points to the fact that Klein was revolutionary with her first paper on “The development of a child”, because she disregarded the importance of immediate symptoms, aiming at preventing future pathology. She had a need for a preventive use, and not a purely curative use, of psychoanalysis. Her view was also radical, because it suggested that psychoanalysis could be used routinely with children and that society should begin to think in terms of preventing neurosis from the early years via a different kind of upbringing (Daniel, 1992; Likierman, 2001). Winnicott and Bowlby developed that focus and inspired by them, child therapists began working in baby clinics and paediatric units in hospitals, to help mothers of distressed infants (Alvarez, 1992).
• Internal objects
One of Klein’s most important contributions is the concept of internal objects (Hinshelwood, 1989; Roth, 1999). The concept refers to an unconscious experience or phantasy of concrete objects located within the ego. It has its own motives and intentions towards the ego and other objects (Hinshelwood, 1989). According to Likierman (2001), Klein believed the first constructs in the psyche are not representations, ideas, words or symbols, but a less sophisticated form of thinking, namely what she called ‘internal objects’. Fairbairn on the other hand, believed that it is not merely objects that the child internalises, but object relationships (St. Clair, 2000). Hinshelwood (1989) notes that internal objects are not ‘representations’, as they might be in memories or in conscious fantasies (daydreams), but are felt to make up the substance of the body and of the mind. Other object relation theorists do not make this distinction. Framo (1992), in discussing Fairbairn’s theory, states that internal objects are retained as introjects, namely as psychological representations of external objects.Although the experience of an internal object is dependent on the experience of the
external object, it also contributes to the way the external object is perceived and experienced. Hinshelwood (1989) notes that our relations with objects comprise what we are. These objects can be people or things with which we form attachments (Klee, 2002). The importance of a good and secure internal object that can be identified with, is seen as the core of a stable personality, resulting in confidence in oneself (Bion, 1988; Klein, 1997a; St. Clair, 2000; Winnicott, 1965a).
Hinshelwood (1989) postulates that the concrete world of the internal object persists as a bedrock layer of the personality. In later development it is overlaid by the world of object- and self-representations, but it is never actually replaced (Hinshelwood, 1989). It takes on more progressive modes of experiencing, resulting in what is called “representations” in the mind of internal and external objects. For Freud (1971a) the only internal object is the superego, while all other objects are ‘represented’ in perception or memory. He argues that “…even in the unconscious, moreover, an instinct cannot be represented otherwise than by an idea ” (1971b, p. 177). Hinshelwood (1989) notes that representations for Freud had the function of personal symbols, but they were not confused with the actual external object. Hinshelwood (1989) distinguishes between an internal object and a representation by noting that the former is a concrete object experienced in phantasy, as active inside the personality. A representation on the other hand, symbolises an internal object to the ego, but is not confused with it. In the section on representations, the difference between internal objects and representations will be further discussed.
Klein was criticised because she did not always distinguish between theoretical  definitions and subjective descriptions (Jacobson, 1965; Likierman, 2001) and overemphasised the importance of the internal world of the infant without attending sufficiently to the influence of the parental objects in the environment (St. Clair, 2000). Klein’s concept of internal object was never clearly defined by her. She used the term ‘object’ without specifying whether she is referring to the actual object or an inner representation of an object (St Clair, 2000). She emphasised the subjective phantasy, specifically the subject’s experiencing of the introjected objects, as an actual being within the self (Likierman, 2001).
The internal object is thus, confusingly, both a subjective experience of an internal presence, initially based on an introjected breast, and at the same time, the theoretical designation of a process which takes on a relational pattern, treating or maltreating the individual in various ways, and by the same token, being moulded by the individual’s internal treatment of it (Likierman, 2001, p.110).
Ivey (1990) shed more light on how the term ‘object’ has been used by later object relations theorists. He describes an object as “(a) a person or psychological representation of that person, (b) coloured by unconscious fantasy and (c) invested with emotional energy by the subject, who (d) unconsciously experiences this object as an influential presence in his/her psychic life” (Ivey, 1990, p.6).
• Part objects and whole objects
Klein (1997a) postulates that the infant’s relation with his mother is at first (roughly during the first three or four months) a relation to a part-object, i.e. the mother’s breast in particular. In so far the breast is gratifying, it is loved and felt to be good and where it is a source of frustration, it is hated and felt to be bad. She argues further that this antithesis between the good and the bad breast is largely due to a lack of integration of the ego, as well as to splitting processes within the ego and in relation to the object. The infant projects his love impulses on the gratifying, good breast and his destructive impulses on the frustrating bad breast. Simultaneously, through introjection, a good breast and a bad breast and what they stand for, are established inside. As the infant grows and develops, he gradually realises that the good feeding breast and the frustrating bad breast are one single object. Thus love and hate are experienced towards the same object and his mother becomes a whole object which both satisfies and frustrates. Most of the object relations theorists agree with her conceptualization of part and whole objects. This splitting in part objects and integration that leads to realisation of whole objects, corresponds with the developmental stages described by Klein (1997a) as the paranoid-schizoid and depressive positions.

ACKNOWLEDGEMENTS 
SUMMARY 
OPSOMMING 
PREFACE 
CHAPTER INTRODUCTION
1.1 Aim of the study
1.2 Contextualising the research
1.3 An overview of the research method
1.4 Orientation
CHAPTER 2 THEORETICAL BACKGROUND
2.1 Orientation
2.2 Introduction
2.3 Overview of object relations theory
• Internal objects
• Part objects and whole objects
• Paranoid-schizoid and depressive positions
• The Oedipus complex
• Internal world
• Internalisation process
• The mother’s capacity for reflection
• True Self and False Self
2.4 Discussion
2.5 Representations
2.6 Maternal representations
• Schemas about the infant
• Schemas about herself
• Schemas about her partner
• Schemas about her own mother
• Schemas about her own father
• Schemas about the families of origin
• Schemas about substitute parental figures
• Schemas about family or cultural phenomena never actually experienced by the mother
• The father’s networks of schemas-of-being-with
2.7 Maternal representations in pregnancy: Stern’s motherhood constellation
2.8 The influence of maternal representations
2.9 Maternal representations and postnatal depression
2.10 The effect of depression on the infant’s representations
2.11 Conclusion
CHAPTER 3 PREGNANCY AND POSTNATAL DEPRESSION
3.1 Pregnancy and early parenthood
3.2 Psychological tasks of pregnancy and early parenthood
3.3 The impact of pregnancy on the woman’s partner and their relationship
3.4 The parents’ family of origin
3.5 Ante- and postnatal disorders
3.6 Conclusion
CHAPTER 4 METHODOLOGY
4.1 Orientation
4.2 Method of investigation
4.3 Ethical issues
4.4 Accountability
4.5 Conclusion
CHAPTER 5 DISCUSSION OF RESULTS
5.1 Introduction
5.2 Clinical background
5.3 Reflexive analysis
5.4 Analysis of interviews
5.5 Analysis of participant-observation
5.6 Analysis of documents
5.7 Discussion and triangulation with literature
5.8 Conclusion
CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS
6.1 Introduction
6.2 Conclusions
6.3 Critical evaluation of the study
6.4 Recommendations and future research
6.5 Concluding remarks
REFERENCES 
APPENDIX 
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