a. piontelli from fetus to child an observational and psychoanalytic study new library of...

From Fetus to Child

There is much more continuity between intra-uterine lifeand earliest infancy than the impressive caesura of the actof birth would have us believe.

Sigmund Freud, Inhibitions, Symptoms and Anxiety

The use of ultrasonic scans in pregnancy makes it possible to observethe fetus undisturbed in the womb. Dr Alessandra Piontelli has donewhat no one has done before: she observed eleven fetuses (threesingletons and four sets of twins) in the womb using ultrasound scans,and then observed their development at home from birth up to the ageof four years. She includes a description of the psychoanalyticpsychotherapy of one of the research children, and the psychoanalysisof five other very young children whose behaviour in analysis suggestedthat they were deeply preoccupied with their experience in the womb.

Dr Piontelli has discovered what many parents have always thoughtthat each fetus, like each newborn baby, is a highly individualcreature. By drawing on her experience as a child psychotherapist andpsychoanalyst as well as on her observational research, she is able toinvestigate issues relating to individuality, psychological birth and theinfluence of maternal emotions during pregnancy. Her findingsdemonstrate clearly how psychoanalytical evidence enhances, deepensand supports observational data on the remarkable behavioural andpsychological continuities between pre-natal and post-natal life.

From Fetus to Child is a pioneering work which will raise manyquestions in the readers mind. It will be of great relevance and interestnot only to psychoanalysts, psychologists and ethologists, but to allthose working professionally with young children. Its descriptions ofbehaviour in embryo, with which all human beings can identify, makeit a fascinating book for a much wider audience.

Dr Alessandra Piontelli is an Associate Member of the ItalianPsychoanalytical Society. She trained in medicine and neuropsychiatryin Italy and as a child psychotherapist in England where she becamepart of the teaching staff of the Tavistock Clinic in London. She is now

Visiting Professor at the Department of Child Psychiatry, Universityof Twin and has a private practice in Milan.

The New Library of Psychoanalysis was launched in 1987 inassociation with the Institute of Psycho-Analysis, London. Its purposeis to facilitate a greater and more widespread appreciation of whatpsychoanalysis is really about and to provide a forum for increasingmutual understanding between psychoanalysts and those working inother disciplines such as history, linguistics, literature, medicine,philosophy, psychology, and the social sciences. It is intended that thetitles selected for publication in the series should deepen and developpsychoanalytic thinking and technique, contribute to psychoanalysisfrom outside, or contribute to other disciplines from a psychoanalyticalperspective.

The Institute, together with the British Psycho-Analytical Society,runs a low-fee psychoanalytic clinic, organizes lectures and scientificevents concerned with psychoanalysis, publishes the InternationalJournal of PsychoAnalysis and the International Review of Psycho-Analysis, and runs the only training course in the UK in psychoanalysisleading to membership of the International PsychoanalyticalAssociationthe body which preserves internationally agreedstandards of training, of professional entry, and of professional ethicsand practice for psychoanalysis as initiated and developed by SigmundFreud. Distinguished members of the Institute have included MichaelBalint, Wilfred Bion, Ronald Fairbairn, Anna Freud, Ernest Jones,Melanie Klein, John Rickman, and Donald Winnicott.

Volumes 111 in the series have been prepared under the generaleditorship of David Tuckett, with Ronald Britton and Egl Laufer asassociate editors. Subsequent volumes are under the general editorshipof Elizabeth Bott Spillius, with Christopher Bollas, David Taylor, andRosine Jozef Perelberg as associate editors.

ii

NEW LIBRARY OF PSYCHOANALYSIS15

General editor: Elizabeth Bott Spillius

From Fetus to ChildAn Observational andPsychoanalytic Study

ALESSANDRA PIONTELLI

First published in 1992by Routledge

11 New Fetter Lane, London EC4P 4EEThis edition published in the Taylor & Francis e-Library, 2005.

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1992 Alessandra PiontelliAll rights reserved. No part of this book may be reprinted

or reproduced or utilized in any form or by any electronic, mechanical, or othermeans, now known or hereafter invented, including photocopying andrecording, or in any information storage or retrieval system, without

permission in writing from the publishers.British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.Library of Congress Cataloging in Publication Data

Piontelli, Alessandra, 1945From fetus to child: an observational andpsychoanalytic study/Alessandra Piontelli. p. cm. (New library of

psychoanalysis: 15) Includes bibliographical references and index. 1. ChildanalysisCase studies. 2. Behavioral embryologyCase studies. 3. Child

psychologyLongitudinal studies. I. Title. II. Series.[DNLM: 1. Child Behavior. 2. Child Psychology. 3. Fetus. 4. Prenatal ExposureDelayed Effects. 5. Psychoanalytic Interpretation. 6. Psychoanalytic Therapyin infancy & childhood. 7. Twinspsychology. W1 NE455F v. 15/WS 105

P662f] RJ504.2P56 1992155.4dc20 DNLM/DLCfor Library of Congress

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ALSO IN THIS SERIES1 Impasse and Interpretation Herbert Rosenfeld2 Psychoanalysis and Discourse Patrick Mahoney3 The Suppressed Madness of Sane Men Marion Milner4 The Riddle of Freud Estelle Roith5 Thinking, Feeling, and Being Ignacio Matte Blanco6 The Theatre of the Dream Salomon Resnik7 Melanie Klein Today: Volume 1, Mainly Theory Edited by Elizabeth

Bott Spillius8 Melanie Klein Today: Volume 2, Mainly Practice Edited by Elizabeth

Bott Spillius9 Psychic Equilibrium and Psychic Change: Selected Papers of Betty

Joseph Edited by Michael Feldman and Elizabeth Bott Spillius10 About Children and Children-No-Longer: Collected Papers 194280

Paula Heimann. Edited by Margaret Tonnesmann11 The Freud-Klein Controversies 194145 Edited by Pearl King and

Riccardo Steiner12 Dream, Phantasy and Art Hanna Segal13 Psychic Experience and Problems of Technique Harold Stewart14 Clinical Lectures on Klein & Bion Edited by Robin Anderson15 From Fetus to Child Alessandra Piontelli16 A Psychoanalytic Theory of Infantile Experience: Conceptual and

Clinical Reflections E.Gaddini. Edited by Adam Limentani17 The Dream Discourse Today Edited and introduced by Sara Flanders18 The Gender Conundrum: Contemporary Psychoanalytic Perspectives

on Femininity and Masculinity Edited and introduced by Dana Breen19 Psychic Retreats John Steiner20 The Taming of Solitude: Separation Anxiety in Psychoanalysis Jean-

Michel Quinodoz21 Unconscious Logic: An Introduction to Matte Blancos Bi-logic and its

Uses Eric Rayner22 Understanding Mental Objects Meir Perlow

23 Life, Sex and Death: Selected Writings of William Gillespie Edited andintroduced by Michael Sinason

24 What Do Psychoanalysts Want?:The Problems of Aims inPsychoanalytic Therapy Joseph Sandler and Anna Ursula Dreher

25 Michael Balint: Object Relations, Pure and Applied Harold Stewart26 Hope: A Shield in the Economy of Borderline States Anna Potamianou

vi

To Filippo and Roberto

There is much more continuity between intra-uterine life andearliest infancy than the impressive caesura of the act of birthwould have us believe.

Sigmund Freud, Inhibitions, Symptoms and Anxiety, SE 20:138

Contents

Editors preface x Acknowledgements xii

Introduction 11 Fetal behaviour and fetal environment 252 Singleton pregnancies 37

Observation no. 1Giulia 38Observation no. 2Gianni 66Observation no. 3Pina 87

3 Twin pregnancies 105Observation no. 1Delia and Marco 109Observation no. 2Alice and Luca 125Observation no. 3Marisa and Beatrice 143Observation no. 4Giorgio and Fabrizio 159

4 Child analysis 177Case no. 1Giulia 178Case no. 2Tina-Vera 192Case no. 3Tilda 197Case no. 4Alexander 204Case no. 5Thomas 212Case no. 6Peter 219

5 Concluding remarks 229

Postscript 239

Bibliography 241 Name index 253 Subject index 255

ix

Editors preface

Dr Alessandra Piontelli, a medical practitioner, child psychotherapist,and psychoanalyst, has written an original and controversial book. Init she does something no one has done before. She observes elevenfetuses (three singletons and four sets of twins) in the womb usingultrasound scans, and she then observes their development at homefrom birth up to the age of four years. She includes a description of thepsychoanalytic psychotherapy of one of the research children, and thepsychoanalysis of five other very young children whose behaviour inanalysis suggested to Dr Piontelli that they were deeply preoccupiedwith their experiences in the womb.

The study is, as she says, ethological, preliminary, and descriptive.It cannot prove or disprove hypotheses. Her central finding is that thereis a remarkable continuity of behaviour before and after birth. Thisfinding is at once striking and obviousobvious, that is, once one hashad such clear descriptions of it. Like Freud, who said that it was hisfate to discover what every nursemaid knew (infantile sexuality), DrPiontelli has discovered what many parents have always thoughtthat each fetus, like each newborn baby, is a highly individual creature.The newborn baby is not nature waiting for nurture to interact withhim. In Dr Piontellis view, nature and nurture have been interactingfor so long in the womb that it is impossible to disentangle them; eventhe idea of nature and nurture as separate entities comes to seem muchtoo crude to be useful.

Dr Piontelli describes the fetal observations, the ensuing post-natalobservations, and the analysis of the small children in meticulousdetail. It makes fascinating reading. The twins Marisa and Beatricehit each other in the womb and continued to do so after birth as soonas their motor development allowed it. The twins Alice and Lucastroked each other in the womb through the dividing membrane, andat the age of one year a favourite game of theirs was to stroke eachother from either side of a curtain. Marco, who buried his face in theplacenta as if it were a pillow, four years later insisted that his motherget him a pencil case shaped like a pillow. Pina, the most adventurous

fetus until a near miscarriage, showed a similar pattern after birthgreat adventurousness soon followed by claustrophobia and near panic.Dr Piontelli is not claiming, however, that all the behaviour of theresearch children can be attributed to their pre-natal experiences; shemakes clear that much also depends on their interaction with theirparents.

Dr Piontellis study may well raise many questions and doubts in thereaders mind. Are ultrasounds really safe, psychologically as well asmedically? Did she find what she wanted to find, and would it not havebeen more scientific to have had a different observer doing the post-natal observations? Does not the fact that the parents saw anddiscussed the scans seriously affect their behaviour towards theirchildren, and therefore contaminate the findings about continuity ofbehaviour? One is very struck, as Dr Piontelli notes, by the way theobserving obstetricians ascribed adult meanings to fetal behaviourshe is using the placenta as a pillow, look how badly he treats thecord, definitely this one doesnt like to be disturbed. But how can onebe sure that such attributions are meaningful when they occur in anenvironment that is not yet truly social? Is it likely, as Dr Piontelli (andone of the fathers) suggests, that fetuses may have some awareness ofme/not me sensations? And what, overall, are the implications of thesefindings for psychoanalysis, both its theory and its therapy?

Nearly all these questions Dr Piontelli anticipates and answers inher own way, but, as with any radically new work that upsetsestablished ways of thinking, doubt and disturbance will remain. Asshe says, she hopes the findings of this work will form the subject offurther research both descriptive and experimental.

Elizabeth Bott Spillius

xi

Acknowledgements

Amongst the many people who have helped me throughout my studiesand the final version of this book my deepest thanks are due to thefollowing: to all the families who so generously let me share such animportant part of their lives and to all the parents who have entrustedtheir children to my care; to my editor, Elizabeth Bott Spillius, whosereading of the manuscript and whose advice, comments, patience,intelligence, and respect have made the publication of this bookaltogether possible; to Mario Cornali, Silvano Ponzi, ProfessorGiuseppe Accinelli, Alessandra Kustermann, Alessandro Zorzoli,Professor Costantino Mangioni, Patrizia Vergani, Silvana Mariani,Nadia Roncaglia, who have all been of invaluable help in various ways;to Hanna Segal, Betty Joseph, Ruth Riesenberg-Malcolm, forsupporting and encouraging me through various stages of my work; toPeter Fonagy and Nicholas Temple for their helpful comments andimportant advice; to Alicia Etchegoyen for helping me find somebibliography which was not available in my country; to Chris Bentonfor so patiently and skilfully revising my English; to Laura Matteinifor assisting me with the difficulties of computer work; and finally tomy husband for his unfailing support. I also want to thank theInternational Journal of Psycho-Analysis and The InternationalReview of Psycho-Analysis for their kind permission to reproducecopyright material. Ultimately all the responsibility for what I say inthis book remains mine only.

Introduction

My aim in this book is to describe a preliminary study of pre-natal lifeand its impact on the future development of the individual. Throughultrasound scans I observed eleven fetuses (three singletonpregnancies and four sets of twins) monthly five or six times, usuallyfrom about the sixteenth week of pregnancy until just before theirbirth. I then observed the infants after they were born, using themethod of infant/mother observation developed by Esther Bick (1964).These observations took place weekly until the infant was a year old,then monthly until the age of two, and then two or three times a yearuntil the age of four. In one case I was asked by the parents toundertake psychotherapy of the child when she was three years old. Iwill also briefly report the analyses of several very young children (agedtwo to three years) in whom experiences of their fetal past seemed toplay an important part in their current pathology, although thesechildren had not been included in my pre-natal observations.

My findings suggest a remarkable continuity in aspects of pre-nataland post-natal life. Each fetus had characteristic ways of behavingwhich were to some extent and in some form or other continued in post-natal life. Such continuity occurred in spite of the vast changes of birthand the nature of the containing environment. I do not want to assert,however, that nature is more important than nurture. What I thinkmy findings do suggest is that the interplay between nature andnurture begins much earlier than is usually thought, and that certainpre-natal experiences may have a profound emotional effect on thechild, especially if these pre-natal events are reinforced by post-natalexperiences.

Essentially this study is exploratory and descriptive, a preliminaryexamination out of which I hope that hypotheses will emerge that canbe tested by further observations and perhaps more rigorous methods.

The study combines certain aspects of fetal behaviouraldevelopment, ethology, and psychoanalysis. As this combination ofinterests is somewhat unusual, I think it may help the reader to knowthe circuitous path by which I came to it.

My interest in fetal life and in the origins of mental and biologicallife is longstanding, dating back to a time even before I began to workin the psychoanalytic field some twenty years ago. It was mainly thisinterest in fetal life that prompted me to study medicine in the firstplace. Although obstetrics and embryology continued to be a centralinterest throughout my medical career, neurology, psychiatry, andfinally psychoanalysis seemed to offer other and even more fascinatingstandpoints from which I could attempt to explore what lay in the depthof our minds.

In 1971 in Italy I met Mrs Martha Harris from the Tavistock Clinicof London. She was lecturing on, among other things, the method ofInfant Observation as described by Esther Bick (1964). She encouragedme to continue my observational and psychoanalytical studies and,with her invaluable support, I then moved to London during the early1970s in order to widen and deepen my psychoanalytical education.

During my English years I had the opportunity of coming into contactwith and being supervised by many leading psychoanalysts, all ofwhom have left a deep mark on my thinking. Amongst them was EstherBick herself, who supervised my psychoanalytic work with a youngchild for several years and who then also encouraged me to observeanother infant under her direct supervision. While living in London Ialso worked in and taught child psychotherapy at the Tavistock Clinic.Infant Observation is central to the Tavistock Child PsychotherapyTraining and, together with child analysis, increasingly became mymain interest.

Other parallel interests during these and the following years weredirected, albeit in a rather amateurish fashion, towards ethology andanthropology. Only somewhat later was I in fact to realize that the sortof naturalistic observations of infants I was taught to conduct in thefield first by Martha Harris and then by Esther Bick had much incommon with the methodology of observation used in ethology andanthropology.

I will mention here only some of the main features of Bicks methodof Infant Observation as many other psychoanalysts have writtenthoroughly about it after Bicks original paper in 1964. (See amongothers: M.Harris 1969, 1975, 1979, 1982; W.E.Freud 1975; Miller et al.1989; Prez-Snchez 1990). As in much ethological, ecological, andanthropological research, infants are observed weekly from birth in thenatural surroundings of their homes by a participant observer tryingto fit in as much as possible with the routine and the sub-culture ofthe household. The main subjects of the observation (usually the motherinfant pair) are left free as much as possible to interact in theirordinary way, with the observer refraining from giving expert advice,directions, and unsolicited comments. At the same time the observer

2 FROM FETUS TO CHILD

tries to be sympathetic and receptive to all the members of the familyand is always aware that they have allowed the observer into theprivacy of their home. Central to this kind of observation of infants isthe assumption that their behaviour has a meaning within the contextof the nascent relationships with the people populating their worlds.As in ethological research, which usually deals with non-verbalbehaviour, the observer assumes that a vast repertoire of behaviouralpatterns common to the entire human species underlies and isexpressed in the pre-verbal behaviour of the infant.

As in ethological research, inferences about observed behaviour canlater be more systematically checked against cumulative data collectedfrom a series of subsequent observations.

Bick is not of course the only person to have observed infants,although the combination of naturalism of the setting and thepsychoanalytic slant in interpreting the observations is peculiar to herapproach. Anna Freud (1953, 1965), Isaacs (1933), Mahler et al. (1975),Middlemore (1941), Spitz (1955, 1957, 1965), and Winnicott (1958),amongst others, though with different methods and varied settingshave all made fundamental contributions to our understanding of earlyinfancy through observation. Meanwhile the field of infant and childobservation has been further enriched by the rapid development ofmore structured observations and experiments on infant and infant-maternal behaviour by developmental psychologists, although thehypotheses that have been examined in these studies have not beenbased on the sort of naturalistic observations of Bick, Harris, and otherpsychoanalysts. Piaget is the pioneer in this field (1936) but Brazeltons(1962, 1974) and Emdes (1980, 1989) work is of special relevance forpsychoanalysis, as is the work of Daniel Stern (1977, 1985), who givesan especially important discussion of the relation of thesedevelopmental studies to psychoanalysis.

The first ethological observations were initiated by Darwin with hisfamous The Expression of the Emotions in Man and Animals publishedin 1872, and with the study of his son Doddy, published in 1877,reporting the first careful observation of an infant. Another studysimilarly conducted on his son was published a few years later in 1882by Preyer, who is generally regarded as the initiator of fetal studies.These observations are regarded as having started a long tradition ofobservational studies of infants.

Bicks method, though closely related to the kind of naturalisticobservation and fieldwork used in anthropological and ethologicaldisciplines, is generally little known outside British psychoanalyticalcircles. Much more famous are the ethological researches conducted onthe human infant by John Bowlby and Mary Ainsworth at theTavistock Clinic in London. John Bowlby himself had appointed Bick

INTRODUCTION 3

as head of the Child Psychotherapy Training which began at theTavistock Clinic in 1948. From the very beginning Infant Observation,although not yet in the manner in which it would be finally formalized,began to be practised in this course. It is probably no coincidence thatBick had also studied and obtained her Ph.D. in Vienna underCharlotte Buhler at the same time that Konrad Lorenz was studyingthere and coming in touch, through Karl Buhler, with Americanbehaviourist psychology. This was prior to Freuds flight from Vienna.Though Bick had no opportunity of meeting Freud while she wasstudying in Vienna after herself fleeing from Poland, she was greatlyinfluenced by his thought and subsequently, after moving to England,trained in psychoanalysis with Melanie Klein. Klein also exerted aninfluence on Bowlby as he himself, while refuting Kleins (or Freuds)views on instincts and drives, often acknowledged in his early works.

The name of Konrad Lorenz is well known in the field of ethologyand he has had a profound effect on its development (1939, 1949, 1978).Perhaps less known in psychoanalytic circles is the work ofH.F.R.Prechtl, one of the leading authorities on fetal behaviour (as wellas on neonatal neurology). He began his first studies with Lorenzstarting with the study of an obscure lizard before moving on to theobservation and the examination of the human infant (see Chapter 1for references and description of his work). Thus a thread of continuitylinks the figures whom I regard as major inspirations for my work: fromFreud to Klein to Bick and Bowlby; from Darwin and Preyer to Lorenz;from Lorenz to Bowlby; from Lorenz to Prechtl.

Unfortunately the various sciences related to man have now becomehighly compartmentalized as well as specialized, rendering it verydifficult to maintain a truly interdisciplinary approach. Suchcompartmentalization, although probably enhancing our knowledge bydeepening each single and specific field, has also brought with it anunfortunate closure towards different areas of investigation. Anethologist, a behavioural neurologist, or an ecologically orientedpsychologist, for example, could easily frown at the non-scientificconclusions reached by an observer trained in the psychoanalyticalfield, while a psychoanalyst might dismiss much of the evidence comingfrom ethological studies as being too unemotional and superficial forsomeone used to speculating about the depths of the human mind. Yetcareful observation is fundamental in each of these disciplines.

It was in fact, as I have said, with Infant Observation that I firstbegan my training in the field of psychoanalysis, and the first babies Iobserved are now twenty years old. As I have kept in touch with mostof them I am always struck by the degree of continuity, evenpredictability, in some of their behaviours since birth. The longitudinalstudy of two such infants was written in book form in the late 1970s


and was finally published a few years later (Piontelli 1986). Its title,Backwards in Time, clearly indicates my growing interest in what layback in our pre-natal past.

For a very long time, however, my interest in fetal life was mainlyretrospective, focusing as I was on the apparent regressions to it thatI observed in some of my patients. While working intensively withyounger children, in particular, I met daily with very vivid phantasiesand representations of life inside the womb and of birth. The sameapplied to dreams and phantasies reported by some of my adultpatients. Some of my most regressed patients seemed to live as if theywere still in an unborn state, closed inside a mental womb whichrendered them almost totally impervious to life in the outside world.This sort of regression was particularly striking in one of my adultpatients whom I used to think of as the big fetus, as, among manyother manifestations, tall and strongly built though he was, he used tocurl up like an enormous fetus on my couch while declaringemphatically his wish and intention to enter inside me with all hisbody. His intentions at times seemed so serious that I had to arrangefor someone equally strong to be present in a room next door should Ihave needed help. It was actually while trying to treat this patient thatI began to think of engaging actively in some kind of direct study of pre-natal life. This same patient, however, also made me realize howdistant he or any other adult patient actually was from the concretereality of our pre-natal past.

Through inferences from the re-living in the transference of whatmight have been the emotions, defences, and mechanisms operative ina patients past, even the pre-natal past, one can certainly gather manyideas for the formation of hypotheses about pre-natal life. Suchreconstructions, however, are always very much coloured by theaccretions and distortions of later life and cannot be considered faithfulaccounts of the events and the emotions felt in a more or less distantpast. In treating severely regressed patients, though dealing with moreprimitive fnctioning, one is also only apparently closer to early life, aseach severe regression carries with it something fundamentallydifferent from the original non-pathological stages one is referring to.

As Hanna Segal, whose direct supervision and teaching has also beenfundamental for my work, says in her Introduction to the Work ofMelanie Klein:

The psychopathology of the earliest phase of development is, notsurprisingly, the most obscure and difficult problem inpsychoanalytical research. It is the phase of development the mostremote in time from the actual age at which we see our patients,when their earliest experiences are certain to be modified,

INTRODUCTION 5

distorted and confused with later ones. Furthermore, whenobserving the behaviour of infants, the younger they are the moredifficult it is to interpret. Difficulties encountered in the study ofthe earliest phases in normal development are very muchincreased in the presence of pathological phenomena; the moredisturbed the infant is, the more remote is his experience fromthe observing adults introspective experiences.

Nevertheless the study of this phase is of paramountimportance. We know that the fixation points of psychoses lie inthe earliest months of infancy. Furthermore, we know that inpsychological illness regression occurs, not to a phase ofdevelopment that was in itself normal, but to one in whichpathological disturbances were present, creating blocks todevelopment and constituting fixation points. We are entitled,therefore, to assume, and our clinical experiences have amplyconfirmed this assumption, that, in so far as the psychoticregresses to the earliest months of infancy, he regresses to a phasein development which already possessed pathological features inhis infancy.

(Segal 1964:54)

Working with adult patients made me feel that one could not aim toachieve a faithful picture of the happenings and the possible emotionsof pre-natal life just through clinical work and the tools of transferenceand counter-transference. Though deep down we can probably all stillfeel in our bones some of the sensations of or the emotions pertainingto fetal life, it is certainly not possible to derive much exact informationfrom such sensations alone.

Reconstruction in analysis of babyhood (as well as its directobservation and testing) was and is certainly rendered much easier bythe fact that we have all been babies once, and also by the fact thatbabies, with their reactions, development, and behaviour, are easilyand constantly available for observation in everybodys everyday life.Whilst the fact of having all been babies once helps us to understandbetter the emotional impact that real babies or infantile aspects in ourpatients elicit in us, the direct observation of babies in daily life helpsus to confirm and reinforce, as well as to correct or reject, ourintuitions. But just as psychoanalysis without observation can lead tosterile speculation, observation without the fundamental tools offeredby introspective analysis can easily lead to false beliefs and superficialtheories. Though babies have been available for our observation sincethe origins of mankind, it was mainly with the advent of psychoanalysisthat we began to look at early infancy in a different light, and onlylately in the history of mankind have babies been given the dignity of


human beings with already complex feelings and emotions. Some of thepsychoanalytic theories about babyhood may in the end prove to bewrong, but nobody would deny they have at least had the fundamentalrole of awakening ordinary people as well as researchers to the largelyignored world of early childhood.

As Anna Freud remarks:

In recent years direct observation has added much to the analystsknowledge concerning the mother-child relationship, and theimpact of environmental influences during the first year of life.Moreover, the various forms of early separation anxiety becamevisible for the first time in residential institutions, creches,hospitals etc., not in analysis. Such insights are on the credit sideof direct observation. [On the other hand she added that] None ofthe discoveries were made before the observers werepsychoanalytically trained, and that the most vital factsremained unnoticed by direct observation until they werereconstrued from analytic work.

(A.Freud 1965:24)

Freud himself drew attention to the limits of observation and the needto combine it with psychoanalysis. He states in the Three Essays onSexuality:

The direct observation of children has the disadvantage ofworking upon data which are easily misunderstandable;psychoanalysis is made difficult by the fact that it can only reachits data, as well as its conclusions, after long detours. But bycooperation the two methods can attain a satisfactory degree ofcertainty in their findings.

(Freud 1905:201)

Until quite recently we knew very little about intrauterine life and thedirect observation of it seemed to belong to the realm of voyeuristicphantasy. Fetal life, because of its sheltered nature, was often regardedeither as a totally separate world, as if life only really began with theact of birth, if not even much later (the fetus in this case was seen asa complete Lockian tabula rasa) or else, at the other extreme, fetalmental life was subjected to the wildest adultomorphic speculationssuch as attributing to it very complex phantasies and foresights intoits future life. In any case the fetus was always compared to the adultand any reconstruction of its life and functioning took a retrogressivepathway using adulthood as the reference point and reaching the fetusbackwards from it.

INTRODUCTION 7

Medical sciences and technological advances have recently helped usgreatly in shedding light on fetal life and, thanks to ultrasounds, wenow know much more about fetal behaviour and development. When Idecided to study fetal life more closely, I knew of course that what Iwould observe would basically be motor and somatic manifestations. Idecided that it was only through observing how a fetus then developsas an infant and child that I could have a basis for developinghypotheses about the role of fetal life. Through the already establishedlinks of infant observation and child observation with psychoanalytictheory, I hoped to understand something of what the childs fetalexperience might have meant to it. And, unlike the usual situation inordinary infant observation, child analysis, and adult analysis, I wouldknow a good deal about the material reality of the individual pre-natalexperience. In other words, I hoped to link a new field of observation(the fetus) with a familiar field of observation (the infant and child) andwith psychoanalytic thinking.

I had no specific hypotheses. As this was such a preliminary study Ihad little idea of what I was looking for. I only had in mind that Iwanted to extend the method of Infant Observation to life before birthand to follow some fetuses and their mothers before and after birth. Iwanted to see if it was possible to detect some kind of continuity ordiscontinuity between the two stages and what sort of continuity ordiscontinuity it would be. But I had no idea of what one could actuallyobserve and expect to find. A preliminary descriptive and observationalphase is central to and characteristic of ethological and anthropologicaldisciplines, and the formation of hypotheses usually only takes placeduring the course of this preliminary phase. Hypothesis formationrather than testing was therefore and still largely is my aim.

Preliminary stagesWhen I decided to engage in some kind of study of fetal life I beganreading the currently available literature on fetal life brought about bythe recent advent of ultrasounds; with such a non-invasive, non-damaging technique, albeit with some limitations, it had now becomepossible actually to see and observe the undisturbed fetus in its naturalenvironment. Chapter 1 of this book consists of a brief review of thisliterature.

Though this reading gave me a fundamental basis for my knowledgeof the milestones of fetal development and an essential view of itsphysiology and pathology, the fetus seemed to emerge from theliterature as an absolutely anonymous, though highly skilled andsophisticated, creature: I learned what a fetus was capable of doing at


a certain age and stage of development, but still could only picture itas a rather amorphous being.

Soon I decided to try to observe fetal life personally with ultrasounds.Other research on fetal movement was being carried out at the hospitalI had contacted at the time. Very much following the lines of Prechtlswork and that of his co-workers, a team of obstetricians was trying torepeat and thus check his observations. I spent about a year watchingultrasound scans and learning how to interpret them.

At first it took me quite a while to get used to the images on the screenand to acquire confidence in my capacity to decode what was beingshown on it. At the same time, following mostly ethological concepts, Iwas trying to form in my mind a kind of ethogram of the fetus withinits natural environment. Therefore for a while I sat through manyobservations as a simple onlooker in order both to get accustomed tothe visual images and to form a better idea of what one could aim tolook for. What struck me during this time (about one year of almostweekly observations of several pregnancies) was the richness and thecomplexity of movements one could observe right from the early stages.Long before mothers could perceive any of these movements, theirbabies could suck, stretch, scratch, yawn, rub their hands and theirfeet. I was also struck, particularly in the earlier stages, by the freedomof movement each fetus could enjoy in the amniotic fluid. With the fullimpact of gravity at birth this freedom is lost at least for a while, andin this respect a baby may seem a much more impotent creature thanits predecessor.

I realized almost immediately that my previous stereotyped visionof fetuses was changing into one of increasing differentiation andpersonalization. As my experience developed I was more and morestruck by the individuality of movement of each fetus and by theirpreferred postures and reactions. I could no longer regard the fetusesI was watching as non-persons, as each of them seemed already to bean individual with its own personality, preferences, and reactions.Each fetus also seemed to relate differently to its own environment andthe various components that went to make it up. This was evident notonly from what I would observe on the screen, but also from thefrequent comments made by the obstetricians and the mothers andtheir companions. Everybody ascribed motives to the behaviour of eachfetus, very much as is done with animals or with babies in ordinarylife. All the observations were also interspersed with remarks like heis a nervous type, this one will become a dancer, he is very calm, sheis a sort of reflective type, she has a good character, or he is using theplacenta as a pillow or look how badly he treats the cord. All theobservers seemed to take it for granted that some kind of motive couldbe ascribed to each single action of each single fetus and that one could

INTRODUCTION 9

also read from the different types of attitude and activity someindication of the childs future temperament. More or less the samecomments were repeated for each fetus each time.

This tendency to anthropomorphize or to adultomorphize the fetusis so strong and so universal among the observers of fetuses (and ofbabies as well) that it may be dismissed as unscientific and unreliable.In the case of a single observation such judgments and attributions ofmeaning carry little conviction. When the behaviour is repeated inobservation after observation, however, one becomes increasinglyconvinced that the behaviour has a consistency and meaning whichneeds to be understood, even if the meaning may not be that which isso readily attributed to the behaviour by the initial observers.Longitudinality cannot tell what the fetus or the infant feelshypotheses only become more plausible if they can be checked againstrepeated future observations.

At this stage I decided to focus on a few mothers and their fetusesand to follow them throughout pregnancy and during the first years ofthe babys life to see if what had been an impression of some earlymarkers of temperament could then find confirmation or disproof inthe subsequent development of the child after birth. Having made thisdecision, I found that many unforeseen problems still lay ahead andhad to be considered and overcome step by step.

The first and fundamental question was of course that of the safetyof ultrasonographic observations in general both for the mothers andtheir unborn children. Again a thorough review of the most up-to-dateliterature on this topic was required. From all such publications itemerged that no ill effects have so far been attributed toultrasonographic examinations of the fetus with the intensitiescommonly used for such observations, and, indeed, generally theabsolute safety of this procedure has been underlined. Quite recentlythe American Institute of Ultrasound in Medicine (AIUM 1988) statedofficially that There are no confirmed biologic effects on patients orinstrument operators caused by exposure of intensities typical ofpresent ultrasound instruments.

All the principal studies on fetal motility and behaviour (seeChapter 1) have been conducted with lengthy (up to twenty-four hours)and frequent (weekly or even daily) ultrasonographic recordings. Whenit came to deciding how frequently and for how long to observe thefetuses to be selected, however, I opted for a particularly conservativeand safe approach. Weekly observations as with Infant Observation inthe post-natal stages, though they would have certainly added preciousinformation as well as scientific respectability to my study, seemed tome to be untenable. First and foremost I did not want to expose anybodyto even faintly remote or hypothetical risks, and secondly I did not want


to overburden mothers with too frequent visits to the clinic and withsome discomfort particularly during the later stages of pregnancy.Therefore I decided to limit the sessions to five to six observationsduring the mothers monthly visits to the clinic when ultrasounds wereroutinely performed anyway to check the growth and development ofthe fetus. As with Infant Observation, a duration of about sixty minutesfor each session seemed to me to meet the requirements of absolutesafety while not causing too much discomfort for the mother and forwhoever was going to hold the probe. (It is frequently not realized thatcurrent probes looking vaguely like portable phones which are gentlyapplied to the abdominal wall of the mother are in fact very heavy forthose holding them. Several devices have now been designed to holdthe probe in place, particularly during studies of fetal behaviour, butnone of these were available in the two hospitals where I conducted mystudy.)

Another potential unfavourable effect now frequently attributed toultrasounds, particularly within psychoanalytical and psychologicalcircles, is that of interfering with or interrupting the mothersphantasies about her child-to-be by introducing reality too harshly andtoo prematurely into the delicate balance of her mental processes. Thisharsh and non-biological confrontation between reality and phantasycould in turn affect her moods and therefore indirectly her fetus andsubsequently her relationship to the child once it was born. Otherauthors, however, point out how the visualization of the unborn fetusseems in general to be greatly reassuring for most mothers and tofacilitate bonding. This could be particularly important for thosemothers having to undergo a Caesarean section who often complain ofa feeling of unreality when confronted with their child, as the fact ofnot having gone through the natural stages of the birth process oftenmakes them feel that the child has come out of nowhere and thereforedoes not properly belong to them.

Though we do not have any instruments to measure such subtlechanges and correlations and we can only rely for the moment onmacroscopic information, I was well aware of this problem which willcertainly need much further investigation in the future. On balance,having observed the visible effects that ultrasounds seemed to have onmothers during my preliminary year of acquaintanceship with them,it seemed to me that none of the mothers I had observed appeared tobe obviously negatively affected or influenced by the sight of their childon the screen. The reactions varied from interest and excitement toreassurance, and in a few cases to indifference and blankness accordingto the basic personality of the mother. These observations, albeitsuperficial, preliminary, and certainly not conclusive, encouraged meto continue with my project.

INTRODUCTION 11

Most of the mothers I subsequently chose to follow in the pre-nataland the post-natal stages, simply forgot about the ultrasoundobservations, seldom mentioned them again in the following years, andseemed to continue to relate to their children in their own natural andparticular way. The scientific role of the observer as well as her projectof research also seemed to be soon accepted and almost forgotten bymost mothers, busy as they were looking after their newborn children.Of course this apparent forgetting does not mean that the motherswere not profoundly influenced by the experience of the research andthat it may well have affected the way they responded to their children.I doubt very much, however, whether this factor alone can account forthe consistency of pre- and post-natal behaviour though it may wellhave been a factor.

As I describe below, I and the obstetricians asked the mothers toparticipate in the research, explaining what it involved, and all thosewe asked agreed to take part. Since my aim, as in Infant Observation,was to observe the behaviour of an undisturbed fetus in its naturalenvironment, no stimulation other than the ultrasound procedure itselfwas applied during the observations. In the case of some fetuses who,for example, were unusually motionless, the obstetricians agitated themothers abdomen after the observation was over in order to check thatthe fetus was able to respond and move normally. Needless to say, ifany emergency had been revealed, the scan would have been stoppedimmediately in order for the obstetricians to take appropriate action.

The scans were recorded on videotapes, thus permitting a futuremore detailed analysis of the behaviour being observed.

With the parents and obstetricians permission, I also tape-recordedtheir spontaneous comments during the observations, except for twooccasions when a mother withheld permission temporarily. This audio-recording gave an extra element of precious information in judgingretrospectively if what had been noted and commented upon at the timewould find any confirmation in the subsequent development of thechildren. Whilst videotaping and audio-recording were not thought tobe appropriate in the post-natal stages, during the already highlytechnical ultrasonographic observations video- and audio-recordsseemed to be much less obtrusive than they would have been in a homesetting and were soon forgotten in the heat of the observation.

Each fetal observation had a strong emotional undertone. Suchintangible emotional undertones are generally lost in the review of thefaithfully accurate videotapes. In anthropological research inparticular the observer becomes an important tool of research byadding to the records of the observations those subtle emotionalparameters that no videotape can record. Whilst registering thebehaviour, the observer can also describe his reactions, his


impressions, emotions, and so on, as well as the type of behaviour thatmay be elicited by his presence in the field. Therefore, in addition tovideo- and audio-recordings, I decided to take some notes after eachfetal observation, registering the impressions and emotions elicited inme by the events and the interchanges taking place during theobservations, thinking that these too could be potentially useful in thecase of a retrospective review of this study.

Another important issue I had in mind was whether to have differentobservers studying the pre-natal and post-natal stages, to reduce apotential bias due to pre-conceived expectations. Though this aspect isusually considered irrelevant in ethological research, it needed someconsideration here as my studies were to be applied to the much moreemotional situation of human beings. Already during my preliminaryexploratory observations, however, as well as in my long experiencewith Infant Observation, I had noted how important it was for mothersnot to feel that they were just subjects of scientific inquiries orexamination; they needed to be allowed to establish a humanrelationship with whoever was observing them too, and continuity wasvery important to them. In the transcription of most of the tapes (seeChapters 2 and 3) it will be noted that I was mostly silent during theultrasonographic observations, but much non-verbal contact wasestablished with mothers during the scans whilst verbal contact in theform of general interest was usually sought by me and by some of themothers before and after the scans. As taught by Bick, I avoided directquestioning as such and no questionnaire was used. I left it to themothers to volunteer whatever information they wanted to tell me. Bythe time their children were born, most of these women were alreadystrongly attached to me and looking forward to my visits in the privacyof their homes. If one accepts the view that a well-trained observer mayhimself become an important tool of research, continuity of observerseems to be essential for the spontaneity and the continuity of theobservations, particularly in this exploratory research. Therefore Idecided to do both the pre-natal and post-natal observations myself.

However, I do not want to minimize the criticism that such continuityof observer may have influenced my results, and the possibility ofhaving separate observers for the ultrasound scans and post-natalobservations will be one of the factors I shall consider in future research.

Throughout this study, as I have already remarked, my counter-transference feelings were carefully monitored and accuratelyrecorded in separate notes, trying to keep the actual recording of theevents taking place during the observations as free of them as possible.This will be reflected in the actual layout of this book, where thoseobservations that I report in detail are in fact kept as separate as ispossible from my interpretations and summaries of them. This

INTRODUCTION 13

inevitably leads to repetition, but has the merit of allowing the readerto compare raw data with my inferences about it. The detailed reportsof observations are taken directly from my notes and/or transcribedtapes and are enclosed in quotation marks.

As I have described above, my method of observing the babies andmothers post-natally followed the method of Infant Observationdescribed and taught by Esther Bick (1964), which is close to themethod of participant observation used by anthropologists andethologists. I realized of course that I was interested in and thereforelooking for any consistencies or contradictions that I would find withthe pre-natal observations, but I tried to put these expectations to oneside of my mind while making and later recording the homeobservations so that I could allow the behaviours of the baby, themother, and the other members of the family to emerge as freely aspossible. The frame of mind of the psychoanalytic observer of infantsis close to the free-floating attention recommended by Freud (1912).

As with psychoanalytical sessions, I made notes only after the homeobservations in order to avoid interfering both with the spontaneity ofthe interchanges taking place and with the possibility of registeringand responding freely to the emotions arising during the observationitself. After each observation I tried to recollect and record as manyrandom facts as possible, keeping them as far as I could separate frommy inferences about them. As is common practice in naturalisticobservations, the language of each recording was kept whereverpossible descriptive, non-selective, and non-specialist.

As with ethological research, the review of this study was mostlyretrospective, and when re-reading my notes and transcribing tapes Ifound it almost unbelievable how much I had recorded without myremembering it. As I have already indicated, I had tried to concentrateon observing and recording the ongoing situation and feel I was largelysuccessful in doing so. It was only later when reviewing and comparingmy notes to prepare this book that my appreciation of the continuitiesof pre- and post-natal behaviours began to crystallize for me out of themass of observational detail. The concordances were often so dramaticthat I was amazed that I had not been more aware of them at the time.

I am aware that the reader is likely to think me disingenuous whenI say that I was not very much aware of such continuity when I wasmaking the observations. It would not be unreasonable to think that Iwanted to believe that there were continuities and therefore foundthem. Further, in some cases the reader may find it possible that themother, having seen the scans, told her young child about them, whichmay have influenced the childs behaviour. I cannot disprove eitherallegation though neither fits my experience. I hope that thepresentation of the material, even though it has to be selective, will at


least make clear some of the bases for my assertion of continuity, whichis indeed the central finding that I report in this book.

Field techniquesOnce these preliminary considerations were clear in my mind, my planwas submitted to the ethical committee of the hospital for approval.

Mothers were then contacted through the hospital when they camefor a routine check-up. No criteria of selection were used in choosingthem. The first mothers who happened to be there on that day wereapproached by my colleagues, I was introduced to them and asked ifthey would like to participate in the research. All the mothers who wereapproached accepted enthusiastically the idea of the scans and follow-up visits at home. Several other mothers who were there on that daywere equally enthusiastic, and many more mothers than we couldactually observe wanted to participate in the study. Most of them saidthat it would have been interesting as well as reassuring to bemonitored so closely during pregnancy. The observations seemed infact to be perceived as extra care and extra attention to be given to justa few privileged mothers.

Where the husband was not present at this initial contact with themother I said that I would like to talk to him if possible and tried toarrange to meet. After carefully explaining that I wanted to observetheir yet unborn children in the pre- and post-natal stages to seewhether or not one could detect some kind of continuity in theirbehaviour, I told all the mothers that they were under no obligation tocontinue this study unless they wished to do so and were therefore freeto withdraw from it at any stage. Informal consent was also obtainedfrom the parents regarding any possible future publication of thematerial collected during the observations. I then explained that, oncethe baby was born, I would visit them at home once a week, each visitlasting about one hour, until the baby was one year old and that,subsequently, the visits were to become monthly during the secondyear and then two or three times during the following years. Duringmy visits mothers were encouraged to continue as much as possibletheir daily activities undisturbed by my presence. It is perhaps notoften realized how easy it is to fit in with the routine of family lifeparticularly when an infant seems to dominate it for a while and whenthe focus of the observation is that infant. Mothers are usually verybusy and most of their activities centre on the child, while the observerand their scientific aims are easily left rather in the background.

Most mothers very much welcomed the presence of a sympatheticobserver ready to listen to them, giving them an opportunity to talkabout themselves, their child, and their problems. It is also seldom

INTRODUCTION 15

realized how very lonely many mothers feel nowadays in the isolationof the all-absorbing task of looking after a young child. Nuclear familiesand modern high-rise apartment blocks do not offer them muchpossibilty of contact or of sharing their experiences or of receiving helpfrom their neighbours and friends. Though most of the mothersvolunteered a lot of information about themselves, their families, andtheir work during the course of our prolonged acquaintanceships, onprinciple I never asked them any direct questions and left it very muchup to them whether they wanted to tell me anything or not. Sharing ornot sharing important information was considered to be in itself asignificant feature of the observation.

My first ultrasonographic observations were started in 1983.Mothers were invited to come to the clinic in the early afternoon, aftermeals, and the observations took place in a dark, quiet room. They wereallowed to bring whoever was with them into the room and most of thetime they did in fact come accompanied by someone. Besides myself,one or two obstetricians were also usually present. As my ability tointerpret ultrasounds increased, I gradually took over the actualprocess of performing the observations, thus alleviating the usuallyvery busy obstetricians. By the time I came to observe twins the probewas mostly in my hands.

My original plan had also been to be present at each deliverythedelivery being often regarded as a highly important and oftentraumatic event for the child as well as a turning-point, setting mentaland emotional life in motionbut unfortunately this was only possibleonce (see GiuliaChapter 2), because the obstetricians, certainly toobusy dealing with more vital matters, almost always forgot to phoneme. In all cases, however, I was able to obtain detailed reports aboutthe delivery and about the attitude of the mother and of the baby duringthe following hours. The observations then, as I said, continued at thehospital and at home.

Singleton pregnanciesSince the type of observation I used is enormously time-consuming,particularly if note-taking has to be accurately performed after eachobservation, and since I already had in mind for reasons I will explainlater to observe several twin pregnancies, the number of singletonpregnancies I followed in the pre- and post-natal stages was in the endrestricted to three. However, my experience of fetal behaviour wasalready based on the many pregnancies which I had been able to followin the course of the preliminary year of acquainting myself withscanning techniques. Chapter 2 of this book presents a detaileddescription of the three singleton pregnancies and children I observed


in the pre-natal and post-natal stages. Some preliminary results of thisstudy have already been published (Piontelli 1987).

Twin pregnancies

Why twins?My reasons for studying twins were slightly different from the usualcontroversy of nature versus nurture that has attracted so manyscientists to study twins since the publication in 1876 of Galtons paperThe history of twins as a criterion of the relative powers of nature andnurture.

Some kind of study of twins had been in my mind long before startingmy preliminary ultrasonographic observations of single pregnancies.A generic interest had been further stimulated several years before thisresearch during a brief psychotherapeutic consultation lasting just afew sessions over the span of three weeks. A very young (eighteenmonths) and very intelligent child was brought to me by his sensitiveparents whom he seemed to be driving mad with his incessantrestlessness and lack of sleep. When I first saw Jacob, while his parentswere explaining all his troubles to me, I noted that he seemed to moveabout restlessly almost if obsessed by a search for something in everypossible corner of the limited space of my consulting room, looking forsomething which he never seemed able to find. His parents commentedon this, saying that he acted like that all the time, day and night.Occasionally Jacob also tried to shake several of the objects inside myroom, as if trying to bring them back to life. His parents then told methat any milestone in his development (such as sitting up, crawling,walking, or uttering his first words) all seemed to be accompanied byintense anxiety and pain as if he were afraid, as they put it, to leavesomething behind him. When I said very simply to him that he seemedto be looking for something that he had lost and could not findanywhere, Jacob stopped and looked at me very intently. I thencommented on his trying to shake all the objects to life as if he wereafraid that their stillness meant death. His parents almost burst intotears and told me that Jacob was, in fact, a twin, but that his co-twin,Tino, as they had already decided to call him, had died two weeks beforebirth. Jacob, therefore, had spent almost two weeks in utero with hisdead and consequently unresponsive co-twin. The simple realization ofthis, as well as the verbalization of his fears that each step forward indevelopment, starting from the first warning signs of his imminentbirth, might have been accompanied by the death of a loved one forwhom he felt himself to be responsible, brought about an almost

INTRODUCTION 17

incredible change in his behaviour. All this in turn facilitated anintense process of mourning in his parents who had until then beenunable to express the intense pain, anxiety, and guilt that the eventhad caused them. This episode had always remained in my mind,together with a desire to know more about the mysterious link whichoften unites twins. Such a link, as well as the awareness of a terribleloss, in Jacobs case seemed to date back to his experience before birth.

One of the most intense debates within the psychoanalyticalmovement centres on the psychological birth of the human infant; itscapacity to live mentally and emotionally in the outside world once outof the narrow boundaries of the womb. On the one hand are the analystswho consider that the infant is not psychologically born for at least thefirst few months of its post-natal life and regard it as an ego-lesscreature still living inside a kind of post-natal womb. On the other handare those analysts who consider mental life to be operative from birth,and for most of them the actual event of birth is regarded as the turning-point that sets mental functioning in motion. Only with meeting otherhuman beings after birth do they consider that the infant begins to feeland think. Very little mention can be found in psychoanalyticalliterature of the possibility of mental life, ego functioning, andawareness in the fetus and of the possible bearings of this previousstage, fetal life, not only on the future development of the individual,but also on the mental functioning of the baby.

Recently, however, much interest has been centred on the effect ofmaternal influences on the fetus during pregnancy. Manypsychoanalysts believe that maternal emotions and even phantasiescan have a strong impact on the fetus and therefore may determine theoutcome of its future personality as well as its future sanity orpathology, but here again the fetus is considered almost as a non-entityand in its extreme form this view tends to consider the fetus as a totallymalleable tabula rasa on which the mother leaves her imprint, andpregnancy is regarded as important only in so far as her state of mindis concerned.

All debates on the origins of mental life are rendered even moreheated by the objective difficulties encountered in studying it. When Ifirst decided to observe fetal life with ultrasounds it seemed to me thatthe observation of twins, starting from the pre-natal stages, could beof great importance in developing at least tentative answers to thequestions raised by these differing views of infant development. Inparticular I wanted to observe what happened when two fetuses werecontained in one womb. Several questions and hypotheses were in mymind. If one postulated that mental life proper and relationships onlybegan after birth with the meeting of other human beings, whatconsequences could be derived from the presence of another similar


creature inside the womb? Is the fetus anyhow too immature andtherefore the presence of the other twin totally irrelevant for thedevelopment of its future mental and emotional life? Or, if not, couldthis perhaps entail a more precocious awareness of another livingentity similar to, yet different from, oneself? Could this, in other words,bring about a precocious psychological birth? And, further, could arelationship between two twins be observed already in utero? Couldthis precocity of relationship influence and in some extreme cases evenobliterate any future relationship? Are there similarities and/ordifferences in the pre-natal behaviour of twins? Is individuality alreadyevident at such precocious stages as for single fetuses, or does the factof living in the same environment somehow blur any individual spur?And, in the case of monozygotic twins, does the fact of having the samegenoma mean automatically the same reactions and the samebehaviour? And if one hypothesis is that maternal phantasies,emotions, and states of mind have a deep impact on the fetus, whatabout twins: are they both affected in the same way by them? If onefollows the extreme view of the all-importance of the maternal state ofmind during pregnancy, both twins should receive the same kind ofimprint.

I therefore decided to observe twins before and after birth, and, asin the case of singleton pregnancies, I first read the current literatureon twins, especially the obstetrical literature, and then observedseveral twin pregnancies by ultrasounds before selecting four pairs oftwins to follow in both the pre- and the post-natal stages.

During my study of twins I decided to delay the beginning of theobservations by about two weeks (eighteenth to twentieth week)compared with singleton pregnancies. As with singleton pregnanciesthe observations then continued at monthly intervals till the end ofpregnancy. Each mother was therefore subjected to an average of fiveultrasonographic observations lasting about one hour each. Nostimulation was applied during the observations.

Chapter 3 of this book deals with a detailed description of the fourtwin pregnancies and, therefore, eight twins I observed in the pre- andpost-natal stages. Some preliminary results of this study have alreadybeen published (Piontelli 1989).

Child analysisThe second and complementary (if one may so call it) line of researchI decided to pursue was to extend my studies by using thepsychoanalytical method with patients who were still close, in achronological sense, to the event of their birth.

INTRODUCTION 19

Though I already had a lot of experience of treating children parallelto my observational studies, I decided to concentrate for a while almostexclusively on the treatment of several very young children. So far Ihave treated twelve young children all under four years of age.

While longitudinal observational studies can help us to understandhow certain behaviours, emotions, and defences may have originatedin the subjects under observation, child analysis can help to understandwhat the remote emotional experiences of our young patients, includingperhaps emotions starting from their pre-natal past, might have beenand might have felt like.

It is not my aim here or later in this book to explain the principles ofchild analysis, nor its techniques, as these are generally well known.In the treatment of my young patients I adhered mostly to thetechnique of child analysis as described by Melanie Klein (Klein 1926,1929, 1930, 1932, 1961).

Many important papers and treatises have been written on thistechnique as well as on other approaches and on child analysis ingeneral. Full discussion of this topic would certainly take me too farfrom my central theme. My accent here is on the importance that childanalysis can have for the study of fetal life. Very few psychoanalyticaltheories, however, and very few authors who have written on fetal lifewill be mentioned here. This is not because I regard the work of mypredecessors or contemporaries as having no influence on my work,but, rather, because the work of so many of them starting from Freudhas been so essential to it that I feel I cannot do them justice in a fewsimple quotations. A review of psychoanalytical literature on fetal lifeis also beyond the scope and length of this book. This too does not meanthat I consider psychoanalysis as a less important tool of research thanobservational study. Psychoanalysis has become so much a part of ourdaily life that I feel it would be inappropriate to enter into detail aboutits principles and theoretical approaches. I only wish, therefore, tostress a few points here.

Since its origins psychoanalysis has never been just a cure, but moreproperly its therapeutic aspects have always been linked with its useas a tool for research, albeit of a particular kind. Freud himselfconsidered his interest in the depth of our mind to be closer to that ofa scientist than that of a healer, and child analysis in general hascontributed greatly to a better understanding of mental functioning inadults.

Though child analysis largely suffers from the same limitations asadult analysis when trying to reconstruct the past of our patientsthrough their present manifestations in the transference, certainly inchild analysis one deals with subjects who are still very close in timeto the actual event of their birth and for whom their pre-natal past is


not yet a very remote past. Presumably in young children one can findeither actual memories of their peri-natal state or at least traces of itstill relatively undistorted or coloured by the accretions of later life. Iftheir pre-natal life and/or birth has been disturbed or traumatic, it maystill be possible to observe its reverberations on the actual state of mindof the child.

In working with very young children (I am referring here to patientsbetween the ages of two and three as were most of my young patients)one often has the added advantage of knowing a good deal about theiractual pre-natal and peri-natal history which, unless activelydiscouraged, parents are usually keen to describe. In addition, in childanalysis we also have the chance to make first-hand acquaintance withthe childs parents and therefore we can form a fairly direct impressionof them and of what the childs early object relations might have beenlike.

When analysing very young children, as in Infant Observation, onedeals mostly with non-verbal communication. With children who arenot too severely regressed or disturbed, one often has the opportunityof testing intuitions through the actual responses and reactions (verbalor otherwise) of the child to our interpretations.

In one case (see GiuliaChapters 2 and 4) I had in fact the unusualopportunity of following the same child with serial pre- and post-natalobservations and then of treating her later (though only twice a weekfor just over one year) with psychoanalytic psychotherapy. In thischilds case one could see how the psychoanalytic method can clearlyenrich, as well as confirm, many of the intuitions reached throughsimple observation. Giulias case also shows us how, though temporallyand spatially living in the post-natal world, many of the elementsobserved during her pre-natal past are still re-lived in her present. HadI not known how far back many of these elements dated, I mightcertainly have attributed at least some of them to much more recentconflicts arising from and within her post-natal environment. Whenseeing a child like Giulia for a consultation like that described inChapter 2 without knowing so much about her previous past, one couldeasily wonder if her present dramatic state of closure towards theoutside world and her obsessive search for food could be linked perhapsto some traumatic event and deprivation she had suffered in herinfancy or more recent past.

Whilst certainly Giulias pre-natal and early post-natal observationscannot give a complete picture of the infinite variables and complexitiesshaping each unique human being, the direct observation of somefeatures of her distant pre-natal past as well as of her very early post-natal life has undoubtedly added for me a different dimension to thestudy of the phenomena to be observed in the consulting room.

INTRODUCTION 21

The five other children whose case-histories are briefly reported inChapter 4 illustrate how aspects of their current psychopathology wereseen and interpreted by me as being connected with their pre-natalexperience. All these children, albeit in their own peculiar, mostly non-verbal way, seem to have been able to communicate to me what someof their pre-natal experiences might have felt like.

I am well aware of course that one could argue that I was seeing inmy child patients only what I wished to see and that the samephenomena could have been given other meanings. Yet the responsesand the evolution in analysis of some of these children (particularly ofthe three less severely disturbed onessee Cases Nos 4, 5, and 6 inChapter 4) has added conviction to my intuitions and consequently tomy formulations.

Had I not observed several infants pre- and post-natally, I wouldhave certainly looked at the phenomena I was at the same time seeingin the consulting room in a different light, and, similarly, if I had not,right from the start, worked clinically with young children whilecarrying out the pre- and post-natal observations, these would havehad much less depth and conviction.

Though the chapter on child analysis may seem less central to thethemes treated in this book, the analysis of many of my young patientswas certainly central to me during this study.

Concluding remarksSome hypotheses and considerations of a more speculative naturederiving from my observations and psychoanalytic work will bedescribed in Chapter 5. These should be taken as simple workinghypotheses to be tested by further observation and psychoanalyticalexamination.

My central finding, as described above, is that there is a remarkableconsistency in behaviour before and after birth and that many smallchildren show signs after birth of being influenced by experiences theyhad before birth.

This book will certainly be disappointing for anyone looking forcertainties and definitive answers. I hope nevertheless that it willmake interesting reading and will open new perspectives into this age-old, yet still almost totally new and complex field, as well as makingthe fetus seem a less foreign and alien creature than we usuallyconsider it to be. The continuum uniting all of us with our pre-natalpast will I hope become evident to any reader.

Unfortunately, with the limited means at my disposal it wasimpossible to gather a large number of observations comparable tothose of the customary medical, biological, or even psychological


research. This fact, however, is usually a general and almost intrinsiccondition of psychoanalytical and observational research, which ismore conducive to depth and longitudinal study. One normally tendsto favour in it depth of understanding, each single individual understudy and the length of longitudinal observation, rather thanstatistically meaningful numbers. Such depth and length areenormously time- and energy-consuming, yet in psychoanalysis and inInfant Observation alike one can learn more, within their particularframe of reference and angle, from the detailed description andanalysis even of one single case history than from a collection of moreanonymous data. A cooperation of all such branches of scientific studyof human behaviour and development will enhance the possibility offurther scientific progress and understanding in these fields.

Much more simple and direct observation of fetal behaviour ingeneral will still be needed before one can have a picture of it sufficienteven to try to formulate more sophisticated ways of interpreting andquantifying it. When Jane Goodall first ventured into the forests ofGombe near the shores of Lake Tanganyika to study the largelyunexplored behaviour of our close phylogenetic relatives, thechimpanzees, she first carried out a very thorough and detailed, as wellas humane, observation and recording of chimpanzee behaviour,before adding, almost twenty years later, tables and charts andlaboratory testing to her original work (Goodall 1986, 1990).Explorations into fetal life are still largely like explorations into adistant and faraway world, and, as I said, when approaching the pre-verbal world of the human fetus one has certainly a lot to learn fromthe methodology and conclusions (albeit adapted carefully to man) ofsuch disciplines as ethology which deal with non-verbal behaviour. AsHinde (1982) says, ethologists regard a descriptive base as essentialfor tackling all the problems with which they are concerned andN.Tinbergen in the introduction of the 1969 reprint of his famous TheStudy of Instinct warns us that no natural science can afford to rushthrough the preparative descriptive phase and through exploratorywatching of natural events before developing an experimental attackand plunging into quantification and experimentation (Tinbergen1969).

Perhaps quantification and experimentation may never be fullyapplicable to this type of study which centres on the individual and hisinner as well as his environmental world.

Studies on human beings are also rendered much more difficult anddebates about them more heated by the fact that we are studyingsubjects from our own species, and this inevitably entails emotionaland often irrational responses in us all. When it comes to studying therealm of the innocence of childhood and even more so the sacred realm

INTRODUCTION 23

of maternity, one can inevitably expect much emotional disruption anddispute. My case histories also lack the asepticity that could renderthem scientifically more acceptable and less emotionally stirring,following as they do the tradition of case-history illustrations once sofrequently used in medicine and so brilliantly carried on by Freud, Thistradition unfortunately runs the strong risk of being lost.

Summary of aims of research

1 To discover, by ultrasonographic and post-natal observations,whether or not there are continuities of behaviour before and afterbirth.

2 To investigate with pre-natal and post-natal observations of twinsissues relating to individuality, psychological birth, and theinfluence of maternal emotions during pregnancy.

3 To complement the observational part of the research by thepsychoanalysis of very small children in order to study the waysuch children live out and express certain pre-natal experiences inthe treatment situation.


1Fetal behaviour and fetal environment

My aim in this chapter is to provide some basic information for thosepsychoanalysts and lay readers who are interested in these areas ofresearch but have little time for deepening them.

When approaching the field of fetal mental life, one has to relyprincipally on data made available by medicine and biology in ordernot to fall into the realms of pure imagination and wild speculation.Though there is more to the mind than simple movement, it is mainlythrough the somatic manifestations of the fetus that one could hopereasonably to infer something about its possible mental functioning.

Within the vast realm of medical and biological research, I will referin particular to investigations in the field of fetal behaviour as it canbe observed with ultrasounds. In pursuing my interest in thebeginnings of mental life, I decided to concentrate mainly on the studyand observation of fetal motor-behaviour, both because this was moreeasily accessible to my direct experience and did not require extremelyspecialized skills and because it was also closer to my previous practiceof observing infants and young children. In Infant Observation too onehas to rely mostly on overt behaviour to infer the mental and emotionalexperiences of the baby, as movement is seen to represent a means ofcommunication with its physical and human surroundings.

Moreover, through motility fetal perceptions can also be investigatedindirectly, as perceptual mechanisms are often associated withparticular motor mechanisms and their output can only be observedafter it has activated some kind of motor response. Central mechanismstoo can be seen in action in the coordination and activation of variousmotor mechanisms. Therefore, through motion one can deductimportant information about sensory and higher functions of the brain.Selected findings on these will be also reviewed in this chapter.

These areas of research have now become extremely specialized andincredibly extensive. I will therefore only be able to give a rathersuperficial outline of them. One could too easily get lost in the meandersof histology, neurophysiology, or neurochemical transmission and all

too far removed from the macroscopic interest of the psychoanalyst inthe anfractuosities of the mind.

Contrary to many popular beliefs, no fetus develops in pure isolationand its behaviour is also a reflection of the interaction with its pre-natalenvironment. Hence at least a rough knowledge of some of thecharacteristics of the fetuss habitat is also essential for thecomprehension of fetal actions and reactions. Therefore, afterdiscussing in some detail fetal movement and the sensations andstimuli reaching the fetus, I will try to describe briefly certain aspectsof intra-uterine environment.

These areas of research are rapidly and continuously expanding andtherefore by the time this book is published it may well be that otherfindings will have become available and some of those mentioned heremay have already become obsolete. I hope, however, that myindications will be useful to readers and will stimulate their desire todeepen their knowledge in this fascinating field.

Fetal motility

Early investigationsFetal motility began to be investigated scientifically only towards theend of the last century, and, before ultrasounds were introduced,several techniques were used to study it.

On the one hand one had the possibility of relying on the directpalpation of movements through the maternal abdominal wall oftenaccompanied by auscultation with a stethoscope. Particularlyimportant and incredibly modern were the observations and intuitionsof Preyer. As early as 1885, he wrote in his classic book SpeziellePhysiologie des Embryos that fetal movements started probably longbefore the twelfth week of pregnancy and he considered fetal motilityto be spontaneously generated and not a mere response to outsidestimuli. He believed that the movements to be seen in the newbornwere similar to those of the fetus and he recognized the abnormalityand excess of movements of deformed fetuses. He also described fetaldrinking of the amniotic fluid. All this was to be confirmed by theadvent of ultrasounds, as, for instance, the onset of spontaneousmotility was seen to start at 7.5 weeks post-menstrual age(Ianniruberto and Tajani 1981; de Vries et al. 1982), and sucking andswallowing movements have now been clearly visualized.

Generally speaking, though, apart from several brilliant butunverifiable intuitions, such studies permitted only a rough estimate

26 FETAL BEHAVIOUR AND FETAL ENVIRONMENT

of the quantity of clearly perceptible movements during the later stagesof pregnancy.

More detailed observations were obtained through the study of non-viable aborted fetuses, particularly through the observation of theirresponses to various kinds of stimulation. Several observations werederived from such studies. In 1928 Minkowski described thespontaneous and induced motility of pre-agonic aborted fetuses fromthe second month of pregnancy. More recently Hooker (1952) andHumphrey (1978) continued along the same line of research andexamined elicited movements in detail. The critical condition of theobserved fetuses, though, rendered these observations less reliablewhen it came to formulating principles about the physiologicalcondition of the fetus.

The same applied to many pioneering studies on lower animals(Carmichael 1933; Coghill 1929; Kuo 1932; Windle 1940), with theobvious added difficulty of drawing information from different species.Moreover, an interest in the origins of reflexes and neuromusculardevelopment prompted these researches. Though these studies werecertainly very thorough, these authors held the view that reflexesrepresented the fetuss earliest neural functions and that fetalmovements were only induced by external stimulation. Manyspontaneous movements were in fact only visualized later with theadvent of ultrasounds and their contemporaneity with movementpatterns elicited by stimulation was then observed. We can now statealmost with total certainty that fetal motility is endogenouslygenerated and not a mere response to external stimulation (Prechtl1984, 1989).

Fetal motility was also investigated in premature infantsparticularly by Gesell (1945) and by Saint-Anne Dargassies (1966).Gesell noted that the fetal-infant remained true to its fetality eventhough born before its time and Saint-Anne Dargassies noted thatneurologic maturity was primarily related to gestational age and notweight.

Another means of obtaining information on fetal movements was torely upon accounts from mothers of their sensations. Severalresearchers, such as Walters (1964), Edwards and Edwards (1970), andSadowsky et al. (1979), recorded and classified movements perceivedby mothers. The first fetal movements (quickening) are usuallyperceived around the sixteenth week. Their presence was foundgenerally to be a sign of well-being of the fetus, while theirdisappearance or diminishing below a certain frequency, aphenomenon described as movement alarm sign, was found to beconnected with fetal distress (Sadowsky and Yaffe 1973).

FROM FETUS TO CHILD 27

All these methods, though clinically useful, had the disadvantage ofbeing highly subjective and could not, for obvious reasons, be appliedto the early stages of pregnancy.

Ultrasonographic investigationsA real breakthrough in the study of fetal motility and of fetal life ingeneral was represented by the advent of ultrasounds, as theypermitted the observation of the undisturbed fetus within its naturalenvironment.

Ultrasonographic observations were described for the first time in1971 by Reinold, who observed fetal movements between eight andsixteen weeks post-menstrual age. (It should be remembered that whileembryologists when speaking of embryonic or fetal age refer toconceptional age, it is now common practice in obstetrics to refer togestational or post-menstrual age, as for the patient it is usually mucheasier to remember the first day of her last period rather than thesupposed date of conception.) Reinold classified fetal movements intotwo groups: (1) strong movements involving the whole body, and (2)slow movements limited to fetal parts. A similar classification wasmade by Juppila in 1976. In the meantime technological advancesbrought ever clearer and more detailed images. In 1980 Van Dongenand Goudie described a more detailed study on the progression ofmovements between seven and twelve weeks. A classification ofindividual movement patterns was first developed by Birnholz et al.(1978) and subsequently by lanniruberto and Tajani (1981) and by deVries et al. (1982).

Other authors (Manning et al. 1979; Roberts et al. 1979; Patrick etal. 1980, 1982; Rayburn 1980; Visser et al. 1982) concentrated on thestudy of movement during the later stages of pregnancy.

Spontaneous fetal motility emerges and becomes differentiated at avery early age. The first type of pattern, still unclear and hazy, seemsto be represented by the transient class of the so-called just discernible(de Vries et al. 1982) or vermicular movements (Ianniruberto andTajani 1981); small shiftings of the fetal contour lasting from half asecond to two seconds which appear between seven and 8.5 weeks ofgestation and disappear from the fetuss repertoire two weeks later.According to Prechtl (1989) the first visible movements appear at about7.5 weeks and consist of slow flexion and extension of the vertebralcolumn with passive displacement of arms and legs. The repertoireexpands rapidly from ten weeks onwards (at ten weeks, for example,hand an

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