Perinatal Depression, Prevention Strategies ...

Rorschachiana 29, xxx–xxx © 2008 Hogrefe Huber Publishers S. Garnier Perinatal Depression, et&al. Prevention

Strategies, Personality

Perinatal Depression, Prevention Strategies, Personality, and the Importance of Therapy Acceptance Salomé Garnier1, Claude De Tychey1, Joelle Lighezzolo1, Philippe Claudon1, Christine Rebourg-Roesler1, and Isabelle Flach2 1

Groupe de recherches en Psychologie clinique et pathologique de la santé (Grepsa), Université Nancy, 2Centre Hospitalier Universitaire Régional Bonsecours de Metz, Nancy, all France

Abstract. This comparative, short-term, longitudinal clinical study evaluated two depressed women during the prenatal period using multiple methodologies (interview, Rorschach, and measures of depression, coping, and quality of life). The results provide evidence for the interest and efficacy of a preventive therapeutic approach during this period. The study demonstrates that masochistic personality organization is a significant obstacle to patients’ acceptance of therapy and that a neurotic personality facilitates therapeutic acceptation. Possibilities for future research are discussed. Keywords: perinatal period, depression, prevention, therapy acceptance, personality organization

Introduction – Objectives and Hypotheses Over the last 10 years, clinicians working in the field of perinatal psychology have called attention to the growing problem of pre- and postnatal depression (Cramer, 2000; de Tychey, 2001, 2004; Beck 2006). These authors, along with Anglo-Saxon authors working in the same field (Wheatley, Culverwell, Brugha, & Shapiro, 2000; Matthey, Kavanagh, Howie, Barnett, & Charles, 2004; Mallikarjun & Oyebode, 2005), suggest the existence of a growing malaise regarding parenthood rendering the perinatal period subject to anxiety and depression. Recent 1

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studies in Western Europe estimate the frequency of prenatal depression at 20% (e.g., Manzano, Righetti, & Conne Perreard, 1997; Lighezzolo et al., 2004). Although there is a decrease in the postnatal period in France (11% on average), it remains at a disquieting level. This trend represents a serious concern for public mental health. Other areas of the world show significantly higher levels of perinatal depression. Studies in Australia show frequencies of 18% (Maloney, 1998) and 14% (Buist, 2002[not in refs, or Buist et al.?]). In Canada, Da Costa (2000[not in refs, or Da Costa, Larouche, Dritsa, & Bender?]) found a level of 16%, similar to the level of 13% found in the US (Beck, 2002, 2006). The levels rise significantly, however, in Turkey at 40% (Budgayci, Sasmar, Tezcan, Kurt, & Öner, 2004). Research in perinatal psychology shows that skilled individual support offered immediately reduces not only the risk for depression (Hertz, 1992; Matthey, Barnett, & Ungerer, 2000; Zlotnik, Johnson, Miller, Pearlstein, & Howard, 2001, Zlotnick, Miller, Pearlstein, Howard, & Sweeney, 2006) but also lowers the risk for obstetric complications (Miller, 2002). Service delivery and therapy efficacy during the perinatal period are the subject of current controversy as suggested by Ogrodniczuk & Piper (2003). Some studies advocate for an aggressive approach of providing psychotherapy during the prenatal period (Spinelli & Endicott, 2003; Cooper, Murray, Wilson & Romaniuk, 2003); others feel that prevention is far more effective if service delivery is initiated in the postnatal period (Dennis, 2005). Some authors (Boath, Bradley & Henshaw, 2005) suggest that the contradictory viewpoints are a consequence of methodological differences rendering true comparison difficult. Manzano et al. (1997) stress that two-thirds of prenatal depressions resolve spontaneously without any postpartum intervention, particularly when the baby is categorized as having an ‘easy’ temperament (positive mother-baby interactions, sleeping well, eating and growing according to growth curves, few somatic complaints, and little crying). A major problem confronting clinicians attempting a preventative approach in dealing with depressive individuals is the rejection of proposed therapy. Indeed, according to studies carried out in psychopathology (Chabrol, Teissedre, Saint Jean, Teisseyre, & Rogé, 2003), 25% to 30% of patients refuse psychological support (independent of psychopathological disorder). This rejection of therapy is equivalent to a failure in establishing the first phase of therapeutic alliance. Therapy rejection for mothers presenting prenatal depression is quite common (Carter et 2

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al., 2005); given the utility of preventive interventions it can form a major obstacle to improving maternal mental health. Rejection of psychological support is a complex issue with numerous determinants (Garnier & de Tychey, 2007). Ackerman & Hilsenroth (2003) showed that the therapist’s personal characteristics, such as f lexibility, honesty, respect, confidence, warmth, and sincere interest in the patient were positively correlated with therapeutic acceptance and alliance. However, the objective of the current study is patient characteristics that can impede therapeutic engagement. A number of these characteristics have been identified but rarely empirically studied including: a priori negative representations of the therapist (Garnier & de Tychey, 2007), inability to introspect and provide mental exploration as manifested by patients stuck in operative thought (Marty, 1991), the existence of certain defense mechanisms (Chabrol & Callahan, 2004), feelings of omnipotence (Modell, 1975), and counter dependency (Kernberg, 1979, 1998; Bergeret, 1986). Paranoid traits or personality organization can also negatively impact the relationship in such a way as to generate excessive suspicion, thus, rendering therapeutic engagement impossible (Schafer, 1954, 1992; Garnier & de Tychey, 2007). More recently, some researchers (Zuroff, et al., 2000, Zuroff & Blatt, 2006) have underlined the invalidating role of certain personality traits, such as perfectionism, in the scope of brief therapeutic approaches to depression. In their review of patient personality characteristics, Petrie, Tennen, and Aff leck (2000) conclude that our understanding of these individual factors remains inadequate. Staying in the realm of personality, the fundamental question behind the current study is: Given similar psychopathological complaints (prenatal depression), what would prevent one woman from accepting therapy when another agrees to it? This study specifically addresses one personality characteristic that appears to be linked to therapy rejection: masochism. From a psychoanalytic perspective, Freud (1924) suggested that this characteristic constituted a major resistance to therapy acceptance and developing a therapeutic alliance. His point of view has been affirmed by a large number of contemporary psychoanalytical clinicians both French (Nacht, 1965; Assoun, 2003; Chabert, 2003; Chagnon, 2003[not in refs, or 2006?]) and American (Fenichel, 1949[not in refs, or 1945?]; Kernberg, 1998). Within this perspective, moral masochism characterizes patients through their unconscious feeling of guilt obliging them to seek suffer3

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ing in diverse life circumstances (Chabert, 2003). Assoun (2003) uses the term “self-destructing life” to define moral masochism. Nacht (1965) emphasized that moral masochism resists cure by adding to the patient’s symptoms. Fenichel (1945) stressed the torture that the subject unconsciously inf licts on himself. Kernberg (1998) pointed out how borderline masochistic patients were particularly difficult to treat. A masochistic personality trait (e.g., suffering through a situation) is not equivalent to masochistic personality or moral masochism where the personality and all the relationships created with others are dominated by a quest for suffering. Whereas both the American (Kernberg, 1979; 1988) and French (Bergeret, 1974[not in refs]) schools of psychoanalysis recognize the link between masochism and borderline personality, along with the DSM-IV, Freud did not make this connection as the term did not exist at the time. For both Kernberg (1979; 1988) and Bergeret (1974[not in refs]) the organization or structure of the masochistic personality is inextricably linked to a borderline personality organization. In contrast to an isolated masochistic character trait that can coexist with any personality structure, the masochistic personality or structure manifests itself through moral masochism and/or object relationships that are fundamentally (sado-) masochistic with an accompanying eroticization of suffering and complacency with the morbid. The two clinical cases presented in this study provide insight on the evolution of the same clinical complaint given two strikingly different personality organizations. The analysis of these two cases will aid in answering the question posed earlier and here reformulated with its logical corollary: Can the lack of a masochistic personality structure, associated with the presence of a neurotic personality structure, facilitate therapeutic acceptance in a depressed pregnant woman?

Method Subjects This study is an exploratory investigation of a phenomenon not previously studied in the literature; the nature of the innovative research question justifies the use of a comparative case study using qualitative comparative methodology (Widlöcher, 1990, 1999). The two women 4


selected for the study were part of a larger sample of women participating in an ongoing longitudinal study on perinatal depression and its prevention*. At the initial meeting, the women were asked to sign informed consent papers after having been informed of the study’s goals, objectives, and constraints. The women agreed to participate during the 5th and 6th month of pregnancy (Time 1[T1]). The initial meeting consisted of a taped semistructured interview; completion of scales evaluating clinical depression, quality of life and coping; and a projective test (Rorschach). About 2 weeks after the initial interview, once the diagnosis of prenatal depression had been confirmed, a brief intervention of psychoanalytic psychotherapy was proposed to these two women, composed of one meeting every 3 weeks up until the second month postpartum (T2), at which time a second psychological evaluation would be carried out. One woman (Ms. N) accepted the full psychotherapy and evaluation program; the other woman (Ms. M) agreed to two psychological evaluations but refused to engage in psychotherapy at either T1 or T2.

Measures Pre- and postnatal depression were measured using two scales: the Edinburgh Postnatal Depression Survey (EPDS; Cox, Holden, & Sagovsky, 1987; French validation: Guedeney, Fermanian, Guelfi, & Delour, 1995; Adouard, Glandeaud-Freudenthal, & Golse, 2005), and the General Health Questionnaire (GHQ-12; Lépine, 1996[not in refs]). During the first postevaluation interview, the women were asked whether they could provide a reason (or reasons) for their depressed affect. If the presence of an easy baby can help reduce depressive symptoms as suggested by Manzano et al. (1997), it seemed important to control for this factor. It would be expected that the scores on these two scales would be below threshold levels at T2. Two additional indicators of improved psychological well-being were studied: quality of life as measured by the SF36 scale (Ware, Kosinski, & Keller, 1994; French validation by Leplege, Ecosse, Verdier, & Perneger, 1998, Leplege, Ecosse, Poucho, *

These women were met during a routine medical consult in the Maternity Department of the Centre Hospitalier de Bonsecours de Metz (57); the current study was presented and participation elicited during their appointment.

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Coste, & Perneger, 2001) and coping was measured by the Brief COPE (Carver, 1997; French validation by Muller & Spitz, 2003). Infant temperament was evaluated during the postnatal interview with the following questions: Q1: Do you find your baby is difficult?

Yes

No

Q2: Do you have the impression that your baby cries a lot? Q3: Do you feel your baby sleeps well?

Yes Yes

No No

Q4: Do you feel your baby is in good health?

Yes

No

Q5: Do you find that your baby is easy to understand? Q6: Do you find that your baby calms himself easily?

Yes Yes

No No

Q7: Do you feel that your baby feeds well?

Yes

No

Q8: Is your baby’s gender that which you had hoped for?

Yes

No

The baby is considered well-accepted and easy if the mother responds “No” to Questions 1 and 2 and “Yes” to Questions 3 through 8. The presence of a masochistic trait or personality structure was evaluated by both interview and Rorschach using indicators provided by Chabert (1987) and the dynamic affect scale (Rausch de Traubenberg et al., 1990) listing content identified as linked to passive and experienced aggression. In order to examine the specific hypotheses of the current study, only pertinent indicators were considered; an exhaustive Rorschach analysis was not performed. The content under study included: – Interactions characterized by masochistic tendencies using kinesthetic responses. – Morbid, deteriorated content showing experienced aggression using the dynamic affect scale; frequency of the projected response indicating the subject’s complacency when confronted with suffering. The interview questions examined both masochism constructs and clinical behavioral indicators using current French psychoanalytic theoretical propositions (André, 2000; Maidi, 2003[not in refs]; Assoun, 2003; Chabert, 2003; Chagnon, 2006): Q9

Do you know if your mother hoped for a girl or a boy when she was pregnant with you?

Q10

Did you have experiences of failure during adolescence?

Q11

Do you remember your parents (or parental figures) having difficult experiences during your childhood; experiences that may have left you feeling powerless? Have you experienced painful bodily sensations since your childhood, which may or may not have required hospitalization?

Q12

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Perinatal Depression, Prevention Strategies, Personality Q13

Do you believe in fate or do you believe your accomplishments can be attributed to your own abilities?

Q14

Do you have the impression that you sacrifice yourself?

Q15 Q16

Do you often reproach yourself? Do you find that you complain?

Q17

Do you believe it is necessary to experience great suffering during childbirth?

Q18 Q19

When something bad happens to you, do you shake it off quickly? If you feel significant discomfort do you refrain from visiting your doctor?

The clinical data was the object of an analysis by two psychologists working in the perinatal field. The analysis was performed on all data gathered through interview, psychological scales, and the Rorschach by two clinicians who were not present during the psychological evaluation at either T1 or T2. Rorschach protocols were analyzed using the Parisian School method. The Rorschach is considered to be one of the most sensitive tools for differential diagnosis for both Anglo-Saxon psychoanalytic clinicians (Schafer 1954; Lerner-Kwawer & Sugarman 1980[in refs as Lerner, Kwawer, & Sugerman?]; Lerner 1998, 2006) as well as French clinicians from the same orientation (Chabert 1987; de Tychey 1994; Emmanuelli & Azoulay, 2001). Aside from the interview indications for masochistic personality as described above, the Rorschach can provide specific data regarding this personality structure: – An accumulation of dynamic affect scale content relative to the experience of passive aggression, which invades the representation of both the self and other (this would normally be rare in nonmasochistic structures). – Indications of sadomasochistic object relationships apparent in the M projections. – Object loss anxiety as seen in the remarks about relationships (as noted in the qualitative interpretation column). – The importance of the struggle against depression as seen in the contents with depressive valences (for a detailed list see Endicott & Jortner 1966). – A failure to repress anxiety and increased use of more primitive defenses altering the relationship with reality (e.g., F% and F+% decreasing as test progresses) – Significant narcissistic fragility seen in the self-representation through a higher number of deteriorated and fragmented contents (e.g., re7

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sponses scored as “defect” in the qualitative column and an increase in fragmented contents Hd = Anat + Bl + Sex increasing beyond norm levels). Conversely, a neurotic personality organization would be characterized by: – A lack of experienced passive/aggressive indicators as would be expected by someone who tends toward depression. – A “whole” self-representation as seen in contents that are not deteriorated (in particular, a lack of fragments and defects). – A clear capacity for sexual identification along with participation in object relationships as seen in M responses where positive interaction is portrayed. – Efficient use of repression resulting in less reality distortion (e.g., adaptive levels of F% and F+%) and a lack of nonmetabolized anxiety.

Results Presentation and Analysis of Clinical Data for Ms. M. Ms. M. is 24 years old, the second oldest of four children, and the only girl in her family of origin. She renounced her secondary education at 16 years of age to help out at home as, according to her, her mother was depressed and she was needed to help care for her younger brothers, prepare meals, and do general housekeeping. She met her husband, who is 8 years her senior, at age 18 and they were married immediately so that she “could leave home as quickly as possible.” According to Ms. M., she receives no emotional support from her husband, who can be quite violent. She is frequently the victim of her husband’s verbal and physical abuse; he hits her, humiliates her, and resorts to psychological manipulation. Ms. M.’s current situation mirrors that of her situation in her family of origin, as she was often the victim of her father’s abuse starting at age 2. Ms. M. indicates that her father’s violence was also directed at her mother and brothers who “often looked on without doing anything . . . I wondered if they weren’t somehow happy to see that, particularly my older brother, who could have defended me and my mother but never lifted a finger to do so . . .” Ms. M. feels quite isolated and it is for this reason she expressed a desire to have children. Her pregnancy was 8


marked by several complications, including blood loss and intrauterine bruises that varied in severity. The reasons for her depression are multiple; the depression was clearly identified by her scores at T1 on the EPDS (26) and on the GHQ-12 (10 for Items 9, 10, 11, and 12, which measure depression; 9 for Items 2, 4, 6, and 9, which measure anxiety and sleep problems). Some elements leading to this patient’s depressive affect include: – The depressive symptoms may be inherent to the patient’s difficult past, including many traumas related to a problematic family situation filled with both physical and psychological violence toward both herself and her mother; Ms. M. indicates that she witnessed violence to her mother on a nearly daily basis. – Depression appears to be part of the family history both within and across generations: “no woman in our family has been happy, they were all depressed as they say . . .” – The apparent continuity between her experience in her family of origin and her current family experience. Indeed, Ms. M explains that she “is sick of being beaten up,” citing this as the main reason for her current depression. She is reliving with her husband the same relationship her father had with her mother based on physical brutality. – The nondesire of her husband to have children because “he never wanted a child, I think when I was pregnant he hit me more often so that I would lose the babies.” – Ms. M. indicates that she is depressed because she fears she cannot take care of her child; moreover, her husband often tells her that she will never be able to take care of the baby. – Finding out her child’s sex (a girl) also has a depressive impact. This information resonates with her personal life experience. Indeed, the simple fact that the future baby is a girl only accentuates her apprehension as she says, “at any rate, she’s a girl so she is off to a bad start, girls suffer a lot in our family, it has always been that way, girls suffer no matter what . . . we must have done something to deserve it . . .” Ms. M. shows masochistic traits through both her “yes” responses to questions Q11-Q18 as well as on the qualitative analysis of Q9 and Q10. Ms. M. accumulates all the risk factors for the early stages of a masochistic component: – Her own mother did not want a girl (Maidi, 2001[not in refs]) as she responds to Q9 that her mother preferred boys, “a boy, I wish I had never had a girl.” 9

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– The strong sense of ascendancy and sacrifice that she has interiorized in her maternal imago (André, 2000): “Yes, my mother directed the whole household . . . well, especially us kids, she managed everything, but she was always saying how tired she was and how she was always sacrificing everything for us and that she was sick of it.” – The fact that she was often confronted with situations leaving her feeling completely powerless (Assoun, 2003). She responds to Q11 by saying, “Yes, when my father hit my mother . . . I watched and I couldn’t do anything about it” and to Q12, “Well, yeah . . . my father went too far with his hitting sometimes, uhm . . ..” – The investment in a clearly fatalist attitude as she responds to Q13: “Oh, well, there are people who are lucky and others who aren’t, that’s all . . . I am not lucky and there is nothing I can do about it.” – Her complacency in her obvious masochistic distress when she is asked at the end of her interview for the reasons she is refusing any psychological support once she has heard the results of her different tests. She says, “A ‘shrink’ can’t do anything for me, as long I am stuck in this shit . . . Because suffer a bit more or less . . . depression on top of all that isn’t any big deal.” Ms. M’s masochistic borderline personality organization is clearly confirmed in the analysis of the Rorschach factors that were evident in both the initial and follow-up evaluations (Appendix 1). The profoundly masochistic dimension of the object relationship is evidenced by the interactions of kinesthetic responses is present on both protocols. Only the most salient features will be presented here in the interest of expediency:

Content Provided at T1 – The amusement associated with suffering and destruction (R20: “Those are funny, those two little things there . . . they look like, uh . . . dead embryos . . .”). – The complacency of self-image in terms of morbid suffering (R12, R25). – The investment of fundamentally masochistic relationships (R1, R7) within scenarios of sadomasochistic kinesthetic responses (R5, R6, R7, R8, R17). – A recurring theme of experienced passive-aggression using the dynamic affect scale (Rausch de Traubenberg et al., 1990): 10 responses 10


out of 25 (40%), which provides a theme-dominant orientation to the protocol.

Similar Results at T2 – Complacency in the face of masochistic suffering is presented again (R1, R10, R12, R14, R16). – The same kinesthetic scenarios are projected, thus, translating into an object relationship marked by sadomasochism (R2, R5, R6, R7, R9, R13, R14, R19). – The regularity of experienced passive aggression is worsened as it infiltrates 63% of the responses (12/19). In addition, Ms. M also manifests all the other borderline characteristics, which we will not enumerate here (see above as well as the structural summaries in Appendix 1). The interview and Rorschach data converge and emphasize the dominant masochistic personality organization that is likely responsible for the patient’s rejection of the proposed therapy. The severe narcissistic assault on Ms. M., attested to by the large amount of Rorschach content that is either deteriorated or fragmented, pushes her into a borderline organization where she is fighting against depression. Moreover, a large amount of projected content in both of her protocols could also be scored on Endicott and Jortner’s depression scale (1966). Similarly, it should be noted that the potential therapeutic utility of an easy baby remains unconfirmed. Although Ms. M responded positively to Questions 1 and 2 and negatively to Questions 3 through 8 (all indicative of an easy baby), the severe depression manifested at T1 did not spontaneously resolve at T2. On the contrary, the depression appears to have accentuated; her scores on the EPDS went from 26 at T1 to 27 at T2. Similarly, the GHQ scores showed more serious indications of pathology at T2: the global score went from 30 to 35 points, the depression score from 10 to 12, and the anxiety/sleep difficulties score from 11 to 12. Her SF-36 scores for 6 of the 8 dimensions follow the same progression (Appendix 2). The scores on quality of life, which can normally oscillate between 0 and 100 were already strikingly low at T1 for Ms. M on all dimensions and were even lower at T2 for all but two dimensions (physical function and physical role); the lack of negative change in these two areas can easily be attributed to the improvement of her phys11

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ical state as a result of the birth of her child liberating her from the physical challenges of pregnancy. The analysis and evolution of Ms. M.’s coping strategies follows a similar path (Appendix 3). During pregnancy, Ms. M. showed a preference for denial, self-blame, substance use, and behavioral disengagement. These results are not surprising given the poor adaptive quality of these strategies (Chabrol & Callahan, 2004) and which have been correlated to perinatal depression (de Tychey et al., 2005). It should be noted that self-blame is not only a dominant coping strategy identified by the Brief COPE (maximum score at T1 of 8 out of 8) but that Ms. M. showed a strong tendency for self-reproach during the interview with her response to the question Q15, “Do you often reproach yourself ?” to which she responded, “Always.” This tendency is again confirmed on the EPDS for the question “I have blamed myself unnecessarily when things went wrong” to which she responded “Yes, most of the time.” Unconscious and unelaborated feelings of guilt are at the heart of Ms. M.’s difficulty; these feelings are the driving force of masochistic actions (Chabert, 2003) and masochistic feelings (Nacht, 1965). Ms. M. excessively uses emotional expression coping strategies, showing to what extent Ms. M. feels the need to express her suffering. During the postnatal period (T2), Ms. M. continues to show a preference for poorly adaptive coping strategies (avoidance through the use of substance use and behavioral disengagement) while coping focused on negative emotional aspects are her dominant strategies (denial, self-blame, expressing feelings). Conversely, her scores on adaptive strategies (active coping and problem-focused coping), which were low at T1, are even lower at T2. Thus, it appears that the arrival of an easy baby is not necessarily effective as psychotherapeutic support for resolving the prenatal depressive state, modifying behavioral strategies, or ameliorating certain aspects psychological functioning.

Presentation and Analysis of Clinical Data for Ms. N. Ms. N. was 24 years of age at the time of her first psychological evaluation (T1). The younger of two children in her family of origin, she has some postsecondary education (2 years of college) and expresses frustration about her work, which she finds unfulfilling, anticipating career reorientation a few years in the future. Ms. N. feels that she has “sufficiently good” support from her husband and indicates that his presence 12


is, for her, indispensable. In terms of her family of origin, Ms. N. appears to have a conf licted relationship with her father, who she feels was regularly absent during her childhood. With regard to her mother, the current relationship is also conf licted and she remembers her childhood relationship with her mother being “difficult.” This is Ms. N.’s first pregnancy, which was particularly desired and anticipated by both parents, and their reactions to this pregnancy have been extremely positive. Ms. N. had difficulty becoming pregnant, and it was necessary to wait 4 years between their original desire for a child and achieving conception. In addition, the pregnancy has been troubled by different complications, rendering it necessary for Ms. N. to be confined to bed for the last 6 months of the pregnancy. She expresses negative feelings regarding this pregnancy, in particularly she feels bad about her body, describing herself as “fat and ugly.” Given the analysis of her interview and test scores, her depressive symptoms at 6 months of pregnancy (T1) appear to be as follows: – The weight of an intergenerational mandate, given that Ms. N.’s mother was depressed during her pregnancies with Ms. N. and her sister. – The reactivation of a previous depression linked to her difficulties in conceiving a child propelling Ms. N. to seek psychiatric help for 3 years before becoming pregnant; she stopped seeing this psychiatrist because her symptoms had subsided. – The guilt she felt when confronted by negative attitudes coming from health care providers because she chose not to breastfeed her baby. – Despite her manifestly supportive husband, Ms. N. expressed fear that her husband would become quite distant as her own father had done with her mother when they had children. – The overriding anxiety about losing this baby or having a premature birth given the complications she has experienced during pregnancy. The objectives of the short-term psychotherapy (1-h sessions every 3 weeks undertaken at 6 months of pregnancy) were derived from both cognitive-behavioral and psychodynamic orientations. With regards to the CBT objectives, this includes: – Create goals for change at T2 using all the data from the interview and the psychological tests at T1. In terms of the psychodynamic-oriented goals these include: – Allow Ms. N. to better understand past events that may be operating in the present and inf luencing her anxiety and depression. – Help Ms. N. to identify and to elaborate her feelings of guilt as well as 13

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relationship conf licts in her own life, within her marital relationship, and other relationships. Ms. N.’s psychological evaluation at T1 indicated the presence of depressive symptoms comparable to those of Ms. M. at T1. Indeed, Ms. N. scored 21 on the EPDS, 25 on the GHQ-12 global scale, 10 on the GHQ depression scale, 9 on the GHQ anxiety/sleep scale, and 6 on the GHQ social impact scale. Quality of life scores showed significant difficulties, with an exception for the vitality scale; none of the other dimensions went beyond scores of 50 (Appendix 2). The second evaluation carried out at T2 showed a significant and positive change. It should be noted that Ms. N. had a baby similarly easy to that of Ms. M, as evidenced by positive responses to Questions 1 and 2 and negative responses to Questions 3 through 8. Her depression scores indicated either full remission (going from 21 to 0 on the EPDS) or dropped drastically to nonpathological levels (Global GHQ went from 25 to 5, GHQ depression from 10 to 2, GHQ anxiety/sleep from 9 to 3, and social impact from 6 to 0). Seven out of eight quality of life dimensions showed improvement; surprisingly, only the vitality scale showed a minor regression going from 70 to 50. The interview following the second evaluation brought to light several elements explaining this slight regression, including her feelings of overwhelming fatigue upon leaving the hospital and the large number of visits she received once she returned home. The psychotherapy sessions seem to have had a significant impact on Ms. N.’s coping strategies (Appendix 3). Her initial evaluation at T1 showed that Ms. N. had feelings of isolation and called upon strategies similar to Ms. M. Ms. N. showed higher scores in instrumental supportseeking and emotional support-seeking along with high scores in less adaptive strategies (expressing feelings, self-blame, substance use, and behavioral disengagement). Her adaptive coping scores during this period are quite low (active coping, planning, and acceptance). The brief psychotherapeutic intervention had the effect of fully reversing this double tendency of Ms. N. pushing her to adopt more adaptive strategies and relinquish less positive strategies. Not only does her guilt appear to be well-elaborated (her self-blame score went from 5/8 to 2/8) but other ineffective strategies appear to have dropped significantly (scores of avoidance and emotions as well as denial, substance abuse, and behavioral disengagement). The adaptive problem-focused coping 14


score showed significant improvement with particularly strong improvement in active coping and planning. The comparison of the two Rorschach protocols for Ms. N. is interesting when also compared with the protocols of Ms. M. The evolution for Ms. N. confirms the already noted improvement in her symptoms. The first element of note is that Ms. N.’s personality structure differs greatly from Ms. M.’s borderline masochistic organization. Indeed, Ms. N’s Rorschach protocol fulfills all the neurotic diagnostic criteria presented above. Ms. N.’s projected content is more often based on whole and unitary responses, suggestive of more solid narcissistic bases. Clear sexual identification and positive interaction with others can be observed with her kinesthetic responses to the third card for both tests. Aggressive symbolization is both more positive and fully present in both protocols (R12, R13 at T1, R7,R12, R13 at T2). The aggressive symbolization is also improved at T2 as shown when Ms. N. provides the response “A baby rhinoceros” (T1) and then “A rhinoceros” (T2). The projection of deteriorated responses suggestive of experienced aggression is quite rare for Ms. N. with only 3 out of 25 responses (12%) at T1 and nonexistent at T2. Recognition of phallic potency is evidenced in Ms. N’s protocol (e.g., responses to Card IV). The overriding sense of these elements indicates a neurotic personality organization. Depression is clearly evident in the first Rorschach protocol (e.g., the C’ determinant and deteriorated content on R8, R15, and R19) as well as a distressed self-image on Card V that is overly indicative of suffering and the inability to remain unified (e.g., deterioration dynamic between R14 and R15). At T2 the frequency of deteriorated responses is even lower. The selfimage is much more stable and unified in large part because of an operant repression, which is highly visible through the responses to Card V for both tests. In the first protocol, Ms. N. starts with a banal response (R14) indicative of repression (Schafer, 1954) yet this repression doesn’t take hold. It is immediately rendered inadequate by the following response (R15) projecting a highly deteriorated response that can be translated into a poor body image because of to suffering. At the second testing, the repression put into place at Card V resists this disorganization of the self-image. The therapy also provided the possibility for reworking the maternal image. At T1, the responses to Card VII with symbolic maternal content are particularly shattering. After providing two fragmented contents (R17, R18), Ms. N. projects a particularly deteriorated response (R19) 15

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saturated with depressive connotations (C’F determinant), which can be understood as a particularly insecure and poorly-containing maternal image: “That could also be a house in ruins, for a long time, it’s weird, like it burned, it is so black . . .” This imagined projection is completely in keeping with Ms. N.’s conscious representation of her mother as indicated in the interview, when she was asked to describe her mother. Ms. N. responded by saying, “distant, insecurity-provoking, guilt-inducing, and selfish.” At T2, while she again initiates her projections with the same content (R19, R20) the noncontaining and insecure dimensions of the maternal image are no longer present. Ms. N. appears to have established effective defense mechanisms for this card in terms of her ability to repress the anxiety-provoking maternal representations. Unlike her responses to Card X at T1, Ms. N. is capable at T2 of evoking both feminine and maternal qualities (R28, R29), even if these contents are too heavily loaded with castration anxiety and cannot maintain formal elaboration in her responses. The psychotherapy sessions have clearly eradicated the depressive symptoms present at T1, improved her quality of life and helped her deal with old feelings of aggression toward her parents, particularly toward her mother. Indeed, at her termination interview when asked what she feels has been most beneficial in her therapy she responds, “Getting out of the tunnel where I was stuck . . . I risked missing out on the happiness I share with my daughter. I feel better, I am under the impression that I have forgiven my father and mother and have started over again with my new family.”

Discussion This study has shown the potential for positive modification, in both psychological and behavioral domains, through a brief psychotherapeutic intervention. Moreover, the study has demonstrated the utility and pertinence for using divergent methodology, from both psychoanalytic and health psychology orientations, toward the common goal of objectively following the psychotherapeutic process and precisely evaluating the benefits of a psychotherapeutic intervention. Several noteworthy results merit discussion: – The presence of a borderline-linked masochistic personality, as op16


posed to a neurotic-based structure, appears to be an obstacle to therapeutic acceptance and, additionally, seems to either perpetuate and/or aggravate depression originally manifesting during the prenatal period, thus, having a significant negative effect on maternal quality of life. Both women had depressive antecedents, and for Ms. N these would appear to be more significant given her history of psychiatric support. Yet, whereas Ms. M has more objectively clear reasons for experiencing depression (history of and current abuse) she did not seek nor accept psychological support either before or currently. At T1, the clinical interviews for both women provided no evidence for major chronic depressive episodes in that neither fulfilled the minimum DSM-IV criteria. Thus, it seems plausible and legitimate to attribute both the improvement in Ms N.’s psychological well-being to therapy acceptance and follow-up as well as the aggravation in Ms. M.’s state to her psychological organization and her related staunch refusal to accept therapy. – The possibility of engaging in a brief psychotherapy for prenatal depression at 6 months gestation has a profound and significant remediation effect. This type of prevention is particularly effective in both economic and temporal terms. Therapy allows for significant change in the mother by eradicating depressive symptoms, improving quality of life and behavioral strategies, all positively contributing to her psychological functioning. These results provide empirical confirmation for the theoretical position held by numerous contemporary French psychoanalysts. Prevention is of particular utility during this period given the notion of a “critical period” which Bydlowski (1997) likens to the notion of “psychological transparency,” a psychological state present in the gestating woman, as well as in the weeks immediately following delivery, allowing her to be more open to her own repressed unconscious and subconscious feelings, thus, leading to identity reconstruction. Certain inherent limits to the present study must be discussed. Although significant and notable differences were noted in the two individuals followed in this study, in terms of the evolution of depressive symptoms, quality of life, and behavioral and psychological changes, the approach remains too limited in terms of time to suggest that the psychological states of these two women will remain stable over time. Only a longer longitudinal study could overcome this limitation. These wom17

S. Garnier et al.

en will be evaluated at 1-year postpartum as part of an ongoing longitudinal study. The current study is clearly an exploratory qualitative and clinical endeavor providing a rich body of results. Despite this, a two-case study cannot sanction generalization. In order to fully examine this effect, it would be preferable to study a group of women presenting depression in the prenatal period who do end up having an easy baby according to whether or not they agree to engage in therapy. It was suggested above that a neurotic personality may facilitate therapeutic acceptance whereas the presentation of a masochistic/borderline personality has a less favorable prognosis. Again, however, it is important to note that generalizing this result requires longitudinal study of depressed mothers presenting both personality organizations, to whom therapy would be proposed. From a more general perspective, this qualitative clinical study has another limitation. Only two situations were compared in the current study: agreement to participate in therapy versus therapeutic refusal. Clinical experience would suggest that a second stage for potential failure in establishing therapeutic alliance could exist for a mother who did agree to the intervention and might take the form of terminating therapy after a few sessions or the form of stagnation with little improvement in important domains. It would be both useful and interesting to undertake an exploratory comparative clinical study of these four situations, further examining any subgroups that may subsequently materialize. This type of study would allow for a more comprehensive model of the general factors implicated in success or failure of therapeutic acceptance and alliance in treating perinatal depression. Moreover, this type of study could provide valuable insight in other contexts of treating depressed individuals, by establishing which factors are responsible for achieving successful therapeutic acceptance and alliance. Only two parameters were examined in the current study: subject personality (masochistic or not) and therapeutic acceptance. Other determining factors in establishing therapeutic acceptance and subsequent alliance, in particular other personality components indicated in the introduction, could also have a negative effect. A study composed of a large number of pregnant, depressed women refusing either therapeutic engagement or therapeutic alliance could identify and weigh potential risk factors as a function of their frequency, for example.

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Conclusion The results of this comparative clinical study suggest that the maternal personality structure, in particular the presence of a masochistic organization, is an important factor behind the refusal to accept therapy leading to ongoing depressive symptoms in the postpartum even in the presence of an easy baby. The latter factor appears to have less of an impact on the depressive symptoms than the personality characteristics of the mother. In conclusion, the results of this study provide both enriching subject matter and form the basis for future comparative studies in perinatal depression. Future research as outlined above will provide even more substantive data, thus, permitting generalization of the discussed results.

Acknowledgments The authors wish to thank American Professor Stacey Callahan for her helpful translation and pertinent remarks on earlier versions of this article.

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Appendix 1: Rorschach Protocols*

*

AA The scorings “M,” “FM” and “m” do not belong to the “French school.” They should be coded “K,” “kan” and “kob,” respectively.

24


25

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27

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29

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31

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Appendix 2: Quality of Life Scores for Both Subjects at T1 and T2 Quality of Life Dimensions (Total score possible for each scale = 100)

Ms. N (Intervention)

Ms. M (No intervention)

T1

T1

T2

33

62

T2

Physical Components Physical Function (PF) Role Physical (RP)

15

95

0

100

20

75

Bodily Pain (BP)

20

100

10

0

General Health (GH)

50

55

23

7

Mental Health (MH)

0

100

15

6

Role Emotional (RE)

36

64

42

12

Social Function (SF)

50

100

9

0

Vitality (VT)

70

50

19

4

Mental Components

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Appendix 3: Brief COPE Scores for Both Subjects at T1 and T2 Coping Style (Possible score)

Ms. N (Intervention)

Ms. M (No intervention)

T1 13

T2 23

T1 11

T2 6

Active Coping (8)

3

8

4

2

Planning (8) Seeking Instrumental Support (8)

2 8

8 8

2 5

2 2

Problem-Centered Coping (24)

Emotion-Centered Coping

29

28

32

34

Positive Reframing (8) Acceptance (8)

5 2

8 7

2 2

2 2

Seeking Emotional Support (8)

7

5

6

6

Denial (8) Expressing Feelings (8)

4 6

2 4

8 6

8 8

Self-Blame (8)

5

2

8

8

Avoidance (40) Humor (8)

25 4

14 4

22 2

24 2

Religion (8)

2

2

2

4

Self-Distraction (8) Substance Use (8)

4 8

3 2

2 8

2 8

Behavioral Disengagement (8)

7

3

8

8

Address missing! Summaries missing!

35