Psychoanalytic Psychotherapy (1986) Vol 2 No 1, 45-52
THE INHIBITION OF MOURNING BY PREGNANCY
A CASE STUDY
EMANUEL LEWIS AND PA TR T!.K CASEMENT
SUMMARY
Pregnancy tends to inhibit the mourning process so that a
bereavement which occurs during pregnancy may be inadequately
mourned. When a bereavement occurs during the period of
"primary maternal preoccupation" (Winnicott) a woman has the
impossible task of making "an exclusive devotion" (Freud) to two
people. The bereaved woman usually opts for her live baby and
mourning is postponed. The complexities of this process are
discussed; and these are illustrated by a case of pathological
mourning, following a bereavement in pregnancy, that was
successfully treated by psychoanalytical psychotherapy.
INTRODUCTION
Pregnancy tends to inhibit mourning so that when a bereavement occurs during
pregnancy it is very difficult for the bereaved woman to initiate and carry on the
normal process of mourning (Lewis, 1978, 1979a). Bourne (1968) and Lewis
(1976) have shown that stillbirth, and to a lesser extent neo-natal deaths, are
difficult to mourn. It is particularly difficult for a mother to mourn her stillbirth
during a subsequent pregnancy. Bourne & Lewis (1984), and Lewis & Page (1978),
have discussed the failure of psychotherapeutic attempts to help women mourn
their stillborn during a subsequent pregnancy. As a result of this experience Lewis
investigated the difficulty of mourning all losses that have occurred during a
pregnancy, and made suggestions about the management of such a bereavement at
the time and subsequently (Lewis, 1979b). In this paper we discuss the relevance of
these ideas to the understanding of a case treated by Casement.
Freud (1917) describes how in normal mourning there is an incorporation of the
lost object - "the shadow of the lost object falls upon the ego." In comparing
mourning with melancholia he wrote, "Profound mourning, the reaction to the
loss of someone who is loved, contains the same painful frame of mind, the same
loss of interest in the outside world - in so far as it does not recall him - the
same loss of capacity to adopt any new object of love (which would mean replacing
him) and the same turning-away from any activity that is not connected with
45
EMANUEL LEWIS
&
PAT!l.ICK CASEMENT
thoughts of him. It is easy to see that this inhibition and circumscription of the ego
is the expression of an exclusive devotion to mourning which leaves nothing over
for other purposes or other interests. It is really only because we know so well
how to explain it that the attitude does not seem to us pathological.''
Winnicott (1956) describes pregnancy as a state of primary maternal preoccupation which "could be compared with a withdrawn state, or a dissociated
state, or a fugue, or even with a disturbance at a deeper level such as a schizoid
episode ...'' Strikingly similar to what Freud had said of mourning is Winnicott' s
account of primary maternal preoccupation as a condition "that would be an
illness were it not for the fact of the pregnancy." During pregnancy a normal
mother is so occupied with thoughts and feelings about the new life being created
within her that she finds it difficult to give serious consideration to other
emotional events. The onset of quickening focuses a mother's attention upon the
growing foetus inside her. Thoughts and feelings about the baby are intensified
during the third trimester of pregnancy and in the weeks following the birth.
There is little emotional time or space left for anyone else. A bereavement which
occurs during the period of primary maternal preoccupation confronts a woman
with the impossible need to make "an exclusive devotion" to two people. It is our
experience that the woman usually opts for her live baby and that mourning is
postponed. The reasons for this are complex.
Melanie Klein (1940) describes how a bereavement stirs up infantile anxieties
about the loss of the object. The denial of the guilt associated with the sense of
responsibility for this early loss can lead to a denial of the need for reparation,
thereby interfering with the working-through of these anxieties. Following the
incorporation of the dead object there can be manic elation associated with the
feelings of possessing the idealised loved object inside. Additionally Klein describes
the manic triumph of being alive after a bereavement due to unresolved infantile
feelings of manic triumph over the rival babies inside the bereaved's mother.
The identity of a foetus is necessarily vague. Like identical twins, until you
know them there is little to help distinguish between one foetus and the next. It
can therefore be difficult for a pregnant woman to separate her feelings for her
foetus from her feelings for her internal family (the internal object).
Expectant mothers have unconscious, if not conscious, ambivalent feelings
about their foetus. The discomforts of pregnancy, the expected impact of a baby
on the mother's work and her family, the anxiety about the well-being of the
baby, and the responsibilities of parenthood, all give rise to apprehension and
mixed feelings about the pregnancy. These concerns are a reason for the expectant
mother to have some unconscious hate even for the most wanted baby.
Bereavement re-awakens anxieties about the loss of the object. The work of
mourning requires the understanding and acceptance of ambivalence for the
incorporated dead person and the internal object. Because ideas about the foetus are
vague, reality testing is difficult and a mother can easily confuse her mixed feelings
for her foetus with those for the dead person and for the internal object. To protect
46
lNHIBITION OF MoURNING BY PREGNANCY
her foetus from a dangerous summation of hate from all these sources it can be
necessary for a pregnant woman to inhibit the working through of her
ambivalence for the dead person. This is an additional reason why she postpones
mourning.
Mourning an excessively idealised person tends in general to be difficult, but in
pregnancy there is an added danger. When an idealised person dies, a pregnant
woman can identify her loved but vague foetus with the incorporated idealised
dead person. Her loss is denied. This idealisation can continue for the rest of her
life. The baby may even be imagined to be the magical reincarnation of the dead
person. Furthermore, a loss during pregnancy can encourage idealisation of the
dead person to avoid ambivalence which is difficult to work through in pregnancy.
Another reason for the difficulty of mourning during pregnancy may be that
pregnancy can predispose to the manic elation and manic triumph which,
according to Klein, can impede the mourning process. The expectant mother has
the double triumph of her own and of her baby's survival.
Once mourning is inhibited during primary maternal preoccupation, it may
never be resumed. Although it is well-known that to become pregnant can be a
way of avoiding mourning, the catastrophic effect on the mother and her family of
a bereavement occuring during pregnancy is generally overlooked. The following
case was treated before the development of these ideas about pregnancy and
mourning.
THE CASE
Mr and Mrs T came because of the wife's frigidity and dyspareunia. (See also
Casement, 1985, 78-80). The husband had back-ache and dyspepsia.
Mrs T was aged thirty-three. Her father died when she was seventeen. She was
twenty and Mr T twenty-one when they married. After being married for five
years they had a son. He became ill with an hereditary brain disorder when he was
six months old and died nine months later. Two months after this, Mrs T gave
birth t.o a daughter. This baby appeared at first to be normal but died of the same
disord r aged ten months. Despite their being told the one-in-four genetic risk, an
ectopic pregnancy occurred in the following year and Mrs T then agreed to be
sterilised.
Mr T was the eldest of four children, his siblings coming in quick succession
after he had been the only child for the first five years. His father died when he was
fourteen.
At the initial joint interview, Mr Twas very anxious. He let his wife do mostof
the talking. Mrs T went over the painful details of the discovery that something
was 'wrong' with their first child. He screamed continuously unless sedated. She
nursed him until he died. She was then seven-months pregnant. After attending
the funeral she felt tearful but "held it in." She never cried, but felt numb.
)
47
EMANUEL LEWIS & PATRICK CASEMENT
Immediately after the child's funeral she was sent shopping "to take her mind off
things.'' She had wanted to be left alone with her husband, but her family made
her shop and cook before she had time for it to sink in that her baby had just been
buried. Mrs T continued to seek escape from the pain of bereavement in activity,
first fostering children and then adopting two children - a boy and a girl. Both
children were lively and demanding, but in addition to caring for them she helped
to run a club for mentally handicapped children. "It seemed to offer some kind of
link with the children we had lost.''
The sexual difficulty began after the first child had died. Mr T felt excluded and
retreated into night-work. His attempts at intercourse were rejected. Mrs T
explained: "Every time my husband approached me sexually I kept on seeing my
little boy's face;" What was most striking here was that her own face and tone of
voice remained wooden and lifeless. Even when she was talking of the children's
illness and slow dying she showed no feelings at all, whereas, my feelings on
listening to her were close to being overwhelming. I interpreted that while she
was telling me about these extremely painful experiences she did not seem to be
able to be in touch with her own feelings of distress, and that I felt as if she were
making me wish to cry her tears for her. She replied that others had made similar
comments. Sometimes she felt as if there were tears in her eyes but she did not
have any feelings to go with them. "It all feels too far down to be able to reach it
now." Mr T said that he found it hard to be reminded about the dead children, as
it made him face the fact that the adopted children were not his. He just thought
of them replacing the lost babies, as a help to his wife.
Mr and Mrs T' s physical symptoms were the somatic expression of the avoided
psychic pain of their several losses: the loss of two babies, the ectopic pregnancy
and then the loss of fertility after the subsequent sterilisation. I thought that if
Mrs T could be helped to get in touch with her feelings, if she could cry her own
tears rather than project her distress into others, then they would both be able to
forego their somatic symptoms.
When I saw Mr and Mrs T together they reenacted the pattern of the marriage,
with Mr T not allowing his wife to express feelings toward anybody but himself
- and Mrs T being inhibited in talking about the dead children in his presence. I
therefore saw them separately for a time.
What emerged in Mr T' s individual therapy was that his marriage had been an
attempt to replace the early exclusive relationship to his mother that he had lost
when he was five. He therefore experienced his children as rivals for his wifemother, intruders whom he unconsciously wished to 'eliminate'. He had then
reacted to the death of each child as if he were responsible; and his consequent need
to punish himself for the unconscious guilt found expression in his pqysical
ailments which developed when his first child was dying. Later he had felt that he,
rather than his wife, should have been sterilised. The stifling . of his wife's
expression ·of feelings about the dead children also reflected his need to repress the
murderous impulses he had felt toward them,. However,' as Mr T began to work
48
INJiiBITION OF MoURNING BY PREGNANCY
through his childhood jealousy, which he had been re-living in the marriage, he
became sensitive to his wife's needs and allowed her to begin to mourn. Her dead
children became psychically his children too, which helped him to share in the
mourning with his wife.
After her father's death Mrs T felt something "go dead" in her but found that
she could "lose" herself in sport and other activities, using activity as a defence
against mourning. After the children had died she found herself split between the
need to speak about them, to remember them, and the wish to forget. People
around her readily colluded with any avoidance of the mourning, because of needs
of their own. In the transference Mrs T could be seen to be trying to protect me
from feelings she assumed I would not tolerate, and similarly protecting herself
from my expected rejection or premature withdrawal in the event of her daring to
show her feelings. At one stage she tried to anticipate this by a temporary flight
into health, but returned for a slower and fuller period of working through.
Mrs T was able to recognise that her gynaecological pains were in part a form of
aggression towards her husband for not allowing her to grieve. After she had
found that she could be more direct with him about this she was able to begin to
allow intercourse. The first time she reached orgasm was crucial. She became
alarmed by its sequel, as she immediately found herself "crying from the deepest
depths" in herself. Previously she could only see the children as they had been
when they were alive. Now she could also see them at the moment she had last
held them, before giving them up to the hospital. The nurses had almost to drag
the first baby from her after he had died. By the time of the second death she had
lost her ability to feel anything. She had gone numb to the pain of nursing each
child, and coped with the second death "as a zombie." These memories poured
into her as she wept.
This breakthrough was so overwhelming that she reverted for a time to being
again afraid of intercourse, fearing to re-experience the pain in her crying.
However, having glimpsed her feelings of loss, after this orgasm, Mrs T began to
work through her fear of remembering. She faced the fear by active recall and soon
the physical pain disappeared.
There followed a honeymoon period during which husband and wife enjoyed
intercourse. Excited by this improvement they resumed joint sessions and
suggested that the problem was now cleared up. A date for stopping treatment
wa set, despite my concern that this' seemed premature. The night before the
'last' ses ion, Mrs T's frigidity returned. There followed a further five months of
work with this couple during which they were seen separately and together. Mrs
T continued to have intermittent, but tolerable, physical pains and she still
sometimes cried after orgasm. The treatment had lasted a year when they stopped.
They wrote a few months later to say that the improvement in the marriage had
continued: they were much less troubled by Mrs T' s gynaecological pains and Mr
T's indigestion pad cleared up. Their relationship felt easier and stronger.
49
EMANUEL LEWIS & PATRICK CASEMENT
THE MODE OF TREATMENT
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It is worth noting that this couple had been seen by the same therapist, separately
as well as together; Contrary to what many analysts might have expected, the
resulting pressures within the transference did not impede the treatment. Instead,
it was possible to use these difficulties to illustrate key problems which the couple
had not been able to resolve between them. I will give two brief examples.
The husband, being jealous of the therapist/wife relationship, clearly paralleled
his earlier jealousy of the relationship between his wife and their children, as with
that between his mother and her other children. The wife, expecting the therapist
to be defending himself from her psychic pain, sometimes assumed that he would
only see things through her husband's eyes rather than through hers. From
transferences such as these it became ,possible to work with Mr T' s difficulty in
being in touch with anyone else's feelings than his own, and Mrs T' s difficulty in
communicating feelings which others had formerly treated as unbearable. From
this separate work the couple began to be able to incorporate the growth from
their individual sessions into the shared work of the joint sessions - and into the
marriage.
What made it possible for this couple t use the same therapist in these difficult
ways was that they had, from the initial referral for therapy, presented together.
They knew that they had a shared problem, but they also sensed that their
individual difficulties had been preventing them from being able to deal with this.
The mode of treatment reflected the interplay between these different dimensions
to their relationship. Also, having been seen by so many other professionals before
being referred to me, it would have been quite unwarranted to have referred them
yet again (to two other therapists for individual therapy) unless it had been more
clearly necessary. The outcome of treatment here, in our OtJinion, iustifies this
decision.
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DISCUSSION
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Effective mourning for the dead children of our couple had been delayed for
several years before they came for treatment. The analyst was helped to a quick
perception that the failed mourning was a central issue in this couple, particularly
for Mrs T, through his awareness of his countertransference feelings. The
toleration and understanding of his countertransference experience enabled the
analyst to hold (be a container for) his patient's pain and fear of mourning, thereby
gradually enabling her to mourn.
During the treatment Mrs T became able to remember her dead children, m
particular her first child, with a 'plastic' sense, and this was important m
50
INHIBITION OF MOURNING BY PREGNANCY
facilitating her mourning. Her plastic remembering is similar to the case of the
failed mourning of a stillbirth described by Lewis & Page (1978). The parents
discussed in that paper had not seen their stillborn, but this impediment to their
mourning was overcome by asking the mother detailed questions about the
appearance of her unseen dead baby. This enabled the mother to build up an image
of her stillborn baby, forcing her into a helpful awareness of the reality of her dead
baby. In this way the unseen child was 'brought back to death' in her mind's eye.
The case described in our paper demonstrates how mourning was facilitated
when Mrs T was enabled to make intra-psychic, quasi-physical, contact with her
dead child. As a result of this contact, the 'corpse' was made more freely available
for psychic incorporation. During coitus and orgasm Mrs T was able to create a
concrete image of her children. She saw her children as they had been, when alive,
but then also in her fantasy she saw and 'held' the dead children. She also
remembered how at the time her first baby died he had almost to be dragged from
her arms. She then became able to cry from her deepest depths. Mrs T described
how before treatment she had kept seeing her little boy's face, when she was
sexually approached by her husband. Her mental 'conception' of the dead child
only occurred during treatment. It was only after this that her mourning, which
had previously been inhibited during pregnancy, and then postponed for several
years, was got under way. The ghosts, conceived from the unmourned deaths
during pregnancy, were psychotherapeutically laid.
As this case was seen before the Lewis's ideas had been formulated, it is of
particular interest to see how this patient led this analyst towards similar clinical
findings, particularly in relation to technique. It became an important part of this
therapy that Mrs T could describe in detail, in her sessions, the visual memories of
her dead children. The analyst felt it appropriate to be actively encouraging Mrs T
in her description of these details. It was thus that she was able to see and, as it
were, to hold once again her dead children as an essential step toward her eventual
ability to let them go. As she became able to experience, and to tolerate
experiencing, her psychic pain she became able to relinquish much of the
somatization of that pain which she had initially presented as needing treatment. It
is also interesting to see how this sequence was, in a different but similar way,
repeated in the husband. The inhibition of mourning had been collusively shared.
The working-through and recovery from this was mutual also.
REFERENCES
S. (1968). The psychological effects of stillbirths on women and their
doctors. J. Roy. Call. Gen. Practitioners 16, 103-112.
BoURNE, S. & LEWIS, E. (1984). Pregnancy after stillbirth or neonatal death. Lancet
2, 31-33.
BoURNE,
51
EMANUEL LEWIS & PATRICK CASEMENT
CASEMENT, P. (1985). On Learning from the Patient. London: Tavistock.
FREUD, S. (1917). Mourning and melancholia. S. E. 14, 243-258.
KLEIN, M. (1940). Mourning and its relation to manic-depressive states. In
Contributions to Psycho-Analysis. (1950) London: Hogarth.
LEWIS, E. (1976). The management of stillbirth - coping with an unreality.
Lancet 2, 619-920.
LEWIS, E. & PAGE, A. (1978). Failure to mourn a stillbirth: an overlooked
catastrophe. Brit.]. Med. Psych. 51, 237-241.
LEWIS, E. (1979a). Two hidden predisposing factors in child abuse.]. Child Abuse
& Neglect 3, 227-330.
LEWIS, E. (1979b). Inhibition of mourning by pregnancy: psychopathology and
management. Brit. Med. J. 2, 27-28.
WINNICOTT, D. (1956). Primary maternal preoccupation. In Collected Papers (1958)
London: Tavistock.
Dr Emanuel Lewis,
Tavistock Clinic,
120 Belsize Lane,
London NW3 SBA.
Mr Patrick Casement,
122 Mansfield Road,
London NW3 2JB.
52