From research to clinical work in pregnancy

1
From research to clinical work in pregnancy

• Massimo Ammaniti
• (Sapienza University of Rome)
• massimo.ammaniti_at_uniroma1.it

2
For a woman and for the couple pregnancy is an
extremely important transition phase, during
which one prepares to become a parent and to take
care of a child who will be immature and
dependant for all his first year of life.
Research and clinical contributions have lent
specific attention to the construction of the
maternal identity, defined by Stern (1995)
maternal constellation, and to the development of
maternal capabilities during pregnancy, which are
indicative and foretelling of the mother-child
relationship after birth, even in at-risk
situations.
3
The psychology and the psychopathology of
pregnancy have been studied using research tools
that have addressed different areas. In this
paper we will take into consideration a few of
the more relevant research areas for this
phase 1) The psychological dynamics connected to
the attainment of the maternal identity, analysed
through the mental representations of pregnant
women 2) The formation process of the mothers
attachment to the child during pregnancy, which
prepares the stabilization of this attachment
after birth 3) Mental states specific to
pregnancy, such as the primary maternal
preoccupation (Winnicott, 1956). The assessment
of prenatal parenting has been done through
research instruments with different purposes
semi-structured clinical interviews,
self-report-questionnaires and scales.
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1) Semi-structured clinical interviews that
investigate the pregnant womans mental
representations, focusing attention to the
womans past experiences, to how she copes with
pregnancy and maternity and to how she
progressively creates the image of the foetus and
of the future child. To study the mental
representations the woman has of herself as a
mother and of the child in a more systematic way,
attention is put on the structure of the
narration the woman does during the interview.
The interview is very susceptible an instrument
for exploring parenting mental representations
when they are still not defined and stabilized.
5
Among prenatal interviews, the IRMAG-R (Interview
for Maternal Representations during Pregnancy-
Revised Version, Ammaniti et al., 1992-2008) must
be noted this is a semi-structured interview
made of 41 questions which bring women to tell
their experience of pregnancy and of becoming
mothers their stories are not evaluated by their
content, but on the basis of their narrative
structure. The Interview is performed between the
6th and the 8th month of pregnancy and is
audiotaped and transcribed. The average length of
the Interview is approximately 45 minutes.
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The Interview explores the following areas I How
the mother organizes and communicates her
experience through a narrative structure II The
desire of maternity within the personal and
marital history III Partners and familys
reactions to the news of the pregnancy
IV Emotions and changes in personal life, in
relationship with the husband/partner and
between the two families occurred during
pregnancy V Impressions, negative and
positive emotions, maternal and paternal
representations space for internal baby
VI Temporal perspective expectations for the
future VII Historical perspective with
respect to the mothers past
7
The narrative structure of the interview is coded
considering the mother's representation of
herself as a mother and her representation of the
child on the basis of seven parameters
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Richness of perception It refers to the womans
acknowledgement of herself as a mother and of the
child this parameter evaluates the way the
episodes, the feelings and the emotions of the
woman herself, of her partner and of the future
baby are told. Openness to change This parameter
evaluates the mothers flexibility towards those
physical and psychological transformations which
are specific to the experience she is living,
referred to herself and to the future baby. It
evaluates the capability of recognising these
physical and psychological changes which involve
herself, her emotional, sexual and relational
life as being part of the process. It evaluates
the capability to modify the representation of
the baby as the pregnancy goes along.
9
Intensity of the involvement This scale is used
to measure the breadth of the womans
psychological involvement in confronting
experiences connected to the pregnancy, to the
child and to her relation with the child this
can be found in the description of the emotional
echoes caused by the event as well as in the
womans participation to the interview. Coherence
It measures the storys coherence, by which the
woman, through a well organised and logical
narrative flux gives a comprehensible picture of
herself as a mother, of the child and of her
relation with the child. Coherence is found in
the plausibility of the story told and in the
capability to provide evidence and episodes which
sustain her considerations and her evaluations.
10
Differentiation It evaluates the level of the
mothers acknowledgement of her personal
boundaries, of her stable mental and physical
characteristics, of her specific needs and
wishes, differentiated from those of her partner
and of her parent figures. It evaluates the
degree to which the mother is conscious that the
child has his own mental and physical
characteristics, with specific boundaries and
specific needs. Social dependence It evaluates
the degree of influence and dependence, to the
limit of subordination, of the womans
representation of herself as a mother and of the
child from the opinions, judgements and messages
coming from the partner, the family, friends, the
social context, mass media, social and medical
institutions.
11
It measures the degree of conformism towards
others, which can in extreme cases cause a
flatness of representation and a lack of personal
elaboration. Predominance of fantasies It is
used to measure the emerging of fantasies
regarding the pregnancy, her future motherhood
and the representation of the child, intended as
all those images, metaphors, analogies, open-eye
and night dreams, expectations, fears and wishes
which characterise the way a woman imagines the
pregnancy experience and the representation of
herself as a mother and of the child. The
fantasies can refer to the pregnancy itself, to
the womans body, to delivery, to rearing, to the
integrity and physical health of the baby, its
physical and character qualities, to the mothers
role these can all have a more or less realistic
quality. It is not only the number of fantasies
which must be considered in assigning the score
but their importance and their impact on the
representation of the mother and the child.
12
These seven parameters all refer to the womans
representation of herself as a mother and to her
representation of the child and are codified in
scales with a five-point range (from 1 to 5). The
assignment of the final score individuates three
different styles of maternal representation Int
egrated/Balanced The integrated/balanced maternal
representations are coherent narrations, in which
the description of the experience the woman is
living is rich in episodes, moods, and has an
intense emotional involvement in an atmosphere of
flexibility and openness towards the physical,
psychological and emotional transformations the
mother is confronting. The relationship with the
child is already present during the pregnancy,
and the child is considered as a person with his
own motives and moods.
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Integrated/Balanced Mothers Martinas story is
a perfect example of an Integrated Mother model .
In her answers, we feel the importance she gives
to her pregnancy on which she has concentrated
all her forces. A great capability of recognising
her mental states as well as her husbands
emerges from her words, as if she is used to
examining herself and the people who surround
her.
14
Q Would you tell me about your pregnancy? A
This was a desired pregnancy, completely, even
because Im more than 30 years old. I was once
married, then separated and now I live with this
new man who gives me great tranquillity. I have
always wanted a child, so I thought I had to have
it now or decide Id have a life without
children. So I did all the tests, a year before,
I got prepared it definitely was a planned
pregnancy. When I became pregnant, I had just
switched to a new job, since I was planning to
have a child I had switched from a full-time to a
part-time job. I have many interests, I do
artistic gymnastics and many other things I
dont believe you have to quit everything when
you have a baby. Of course you will be dedicating
most of your time to the baby, but you have to
keep doing your own things.
15
Q How did you face this pregnancy? A I had
some problems, from a physical point of view.
Psychologically I faced it very well. Of course
you are a bit shocked, I think that happens to
everyone because theres something new, something
you dont quite understand, especially when you
have your first ultrasonography, when its still
tiny, you see this little spider. And then this
child is growing inside of you. It kicks you, and
you feel something weird and think Oh God,
theres a baby growing inside of me. I know its
not really strange but it just surprises you. I
actually accepted it from the start I wanted a
child so much of course its also important that
the man I live with now gives me such
tranquillity.
16
Q Would you tell me how you felt when you first
found out you were pregnant? A When I first
found out, because of the practical problems with
my job I wasnt actually sure if I should be
happy or not. Then I thought that everything
could be arranged, because even when confronting
problems of schedules, of work, when you know
youre going to have a baby it all becomes
relative before the baby. At first youre a bit
surprised, even because they tell you youre
pregnant but you cant feel it yet. You feel as
usual, normal, at least until you start growing a
belly.
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Q Who else did you tell? A My mother, my
father, my cousin Q All the same day? A Yes,
the same day. I called my mother that evening. I
wasnt sure if I should tell her immediately, or
how to tell her, if in person. Then I just
called.
18
Q When did you notice the first changes in your
body? A Everybody asks that. In the first few
months, only around the fourth month when the
belly starts becoming noticeable. At that stage,
when its still small. You actually feel as if
you are only overweight and you feel ugly. Now
that I have a big belly, I have no problems if I
pass before a mirror I see it. Q Have there
been specific moments of great emotion during the
pregnancy, until now? A Some times I feel very
sad I dont know if this is normal, or connected
to the pregnancy. For example I am more easily
upset and seem to feel things more intensely.
19
Q Do you have specific fears? A Im afraid
the baby might have some problems, defects, but
its not a great fear Im actually convinced I
will deliver a beautiful girl. I dont know why,
but Im convinced. Q Have you had dreams
related to the pregnancy? A One dream I
remember, because it was only a couple of nights
ago, I was losing blood from my mouth, I dont
know why. In general when I dream I see myself
pregnant, yes, Im always pregnant in my dreams
now, even if I dont remember them clearly.
20
Q When you realised there was a baby girl
inside of you what did you feel? A As I said
before, a lot of amazement. And in this period, I
feel very creative. Alessandro said Of course,
this is the most creative of periods! And I
answered Actually, if you think about it, you
and I have created a girl, created her from
scratch, because before there was
nothing. (Zero) Q And the awareness of this
new being came with her first movements? A With
the first movements, yes, but even more in this
last month. I really feel her, I feel shes in
here.
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Q What do you imagine her like? A Beautiful.
I imagine her beautiful. And then obviously she
sleeps. She has to sleep for months. And then I
imagine her calm, friendly and always smiling. Q
And physically? A I imagine her tall,
skinny. And blond with blue eyes. Simply
beautiful.
22
Q Would you say that there already is a
relationship between you and the baby? A I
dont know. I sing lullabies to her, inventing
them. I talk to her, simple things like How are
you?. I talk to her in my head more than with my
voice. In the morning I tell her Now I will sing
a lullaby for you, calm down. Q Have you
chosen a name? A Yes, we will call her Chiara.
Its not a family name, we just chose it from
the start. Its nice, its a name we like.
23
Q What do you think she will need in the first
months? A Most of all love, lots of love,
attention, in the first months especially. She
needs to feel in a warm atmosphere, full of care,
where she is taken care of, welcomed. Q What
kind of mother do you think you will be in the
first months? A In the first months I would
like to be tolerant, open. I hope to be very
stimulating for the baby, and very caring. Q
What kind of mother you dont want to be? A I
dont want to be obsessive, anxious,
authoritarian in a bad sense.
24
Restricted/Disinvested The restricted/disinvest
ed representations emerge from narratives in
which a strong emotional control prevails, with
mechanisms of rationalisation towards the fact of
becoming a mother and towards the child these
women talk of their pregnancy, of motherhood and
of the child in poor terms, without many
references to emotional events and changes. The
storytelling has an impersonal quality, is
frequently abstract and does not communicate
emotions or specific images .
25
Restricted/Disinvested Mothers Flaminia is a
young woman who shows a restricted representation
of herself as a mother and of her child. Even
though she gives value to her motherhood
experience, Flaminia wants to maintain her
independence and self control and does not want
to be too conditioned by the child that is about
to be born.
26
Q Would you tell me about your pregnancy? A I
must say I was very lucky, I never had any
problems. Even in the first three months, I had
no nausea, vomiting etc. I did some things which
youre supposed to avoid, like skiing, going on a
motorcycle but I felt ok, felt I could do it.
But my first three months were characterised by a
certain nervousness, a state of tension. After
the first three months I started getting used to
the idea and calmed down. I still had no physical
problems. Then slowly, with great difficulty, I
started getting used to the idea of my body
transforming.
27
Q Why a baby in this moment of your life? A I
thought about it a lot because I didnt feel
ready, even if Im not a kid anymore. I always
had this idea I wouldnt have kids. Im not crazy
about kids, Ive never been drawn to them much.
Then, maybe because you feel the need after a
number of years in a marriage, or maybe because
my husband who wasnt convinced either, changed
his mind it was a series of things which pushed
me towards this decision. Q What did you feel
when you found out you were pregnant? A I am
quite cold, as a person. I dont get carried away
easily, so even in this case I wouldnt have
told anyone, Id have kept it for myself. I
first needed to get used to the idea.
28
Q Have there been specific moments of great
emotion during the pregnancy, until now? A
Maybe when I did the ultrasonography towards the
fourth month. Thats the first time you actually
see this little growing being and you see it
whole. But mostly my feeling was a reflection of
the great emotion I could see on my husbands
face. Seeing his reaction, I let myself be
influenced by his state of mind mood and felt it
as if it were a feeling of mine. Q During the
pregnancy, were there times when you felt worried
or mad about something? Have you ever felt any
particular needs? A I cant think of anything
now. The preoccupation everyone has, on the
babys health.
29
Q Have you had dreams during the pregnancy? A
Yes, but I never remember my dreams. I remember I
was eating yoghurt in the last one, but I have no
idea what it might mean. Q How do you imagine
the baby? A I actually dont imagine it. Q
Do you imagine its physical features, its
character? A No. Q And its sex? A Not even
its sex, I didnt want to know and I dont want
to think about it. It will be a surprise.
30
Q Do you and your husband talk to the baby or
use nick names? A Yes, but its mostly my
husband who talks to it, not me. Even if I feel
there is a bond between the baby and me, I
still cant bring myself to talk to it.
31
Not integrated/Ambivalent The not
integrated/ambivalent maternal representations
are those found in confused narrations,
characterised by digressions and by the
womans difficulty in answering questions
in a clear and articulate way. The coherence of
the story is poor, and an ambivalent
involvement of the mother towards the
experience she is living, towards her partner and
towards her family is present. These
women often express contrasting attitudes
towards their motherhood, or towards the
child. The son or daughter is frequently awaited
to satisfy the caregivers needs.

32
Not Integrated/Ambivalent Mothers Roberta is
an example of Not Integrated Mother. A young
woman of twenty-nine years old, the idea of
having a child has made its way in her amidst
many ambivalences and uncertainties, showing
all the difficulties that a not integrated
mother manifests in fully accepting a maternal
identity.
33
Q Would you tell me about your pregnancy? A
In the beginning we had many things, those
egoistic projects of settling everything first,
because we started out with nothing, and we
thought well think about a baby later on. So
lets say it wasnt a thought, like we both had
of the baby in the beginning. Then when things
started working out, everything, we looked
each other in the eye and said what do you
think about it? I am thirty already. And he
didnt want to, he had decided that he was
already old when we married he had already
settled, so he had some difficulties, he said
he didnt want to be a grandfather. () He
had these problems, fears, which I didnt have,
mine were completely different, like how will I
help my child in 20 years time, finding a job,
or school for example.
34
Now Im completely terrified on how to do things,
and the kinder garden, the people he will hang
out with cause we know what its like, and my
mentality is not live by the day, maybe I worry
too much about everything around me. Thats why
I used to say lets wait then one fine day this
decision just arrived. What do you think about
it? And maybe yes, its time, we made a joke
about it, Time to take on responsibilities...
Thats when I started thinking, I started asking
around, how many children, how long did it take
etc. Someone told me I thought about having the
first one for four years and then the second in
twenty day others go Immediately, one after
the other. These kind of things. I said O God,
I waited so long, and now Im thirty, in fact
this was my fear, I said Youll see that now
that I want one, it wont come. ()
35
I looked for a laboratory where they could do my,
my urine test and so I did it, and she goes
Congratulations and I was practically walking
trying to avoid holes, absurd, because I had
taken two buses to get there, and I was walking
as if over boxes of eggs, I was afraid of ruining
this thing. I thought Oh my God maybe I did
something in the first days. () In the
beginning, after a month and a half, I started
having nausea problems, upset stomach, lots of
saliva, so that after two months I was thinking
Why on earth did I do it?. Because I was really
sick. () I was thinking What a terrible
pregnancy Im going to have because some would
say Its all going to end soon and others I
threw up all the way to the ninth month. ()
36
And my doctor said its mostly psychological.
On one hand we wanted it, but on the other
maybe there was a part of truth, because I was
very embarrassed to tell my boss, I didnt know
how to tell him. Q How did you feel when you
found out you were pregnant? A I found
out after only a week, and there I was, telling
the nurse Are you really sure?,
because maybe it could be like with those
pharmacy tests, which are uncertain. They told
me in the pharmacy that if its sure, when it
appears clearly its positive, that is, its
negative no, no its positive, when it appears
clearly when its uncertain it could be positive
or negative. I was so excited because its not
I was saying No, its not possible, in that
moment it wasnt ready. ()
37
In the laboratory, he said Look, the stick
doesnt become pink if its not positive so
nothing, this thing was pink, if you say so it
must be, you guarantee, when I walk out of
here I can tell my husband. Q How did you
feel and how did your life change during
pregnancy? A How did I feel? Happy, really
happy personally, and all the people around me
where happy, so it was really nice except for my
boss, maybe, because probably for him it wasnt.
But aside from that, even with the people we
know, I found people very happy to give me some
advice, things like dont do this, or that. Dont
gain too much wait or eat all you can cause its
for the baby, everyone. Younger people will say
Dont eat too much, youll get fat and older
people will say Eat a lot so you have a big
healthy baby, clearly not.
38
Q Have there been specific moments of great
emotion during the pregnancy? A Yes, when I did
my ultrasonography in the fourth month, when they
said this is the heart beating and on the
screen monitor there was this confused image, but
when we saw the head, I absolutely didnt imagine
that I could see a profile. It really gave me a
strange impression, seeing it. () Then theres
this thing which doesnt excite me but amuses me.
I have found out that, in the morning, drinking
very hot milk, the baby does some strange
movements. And I feel them even when I drink cold
water, directly out of the fridge so sometimes I
switch from a hot thing to a cold thing to see
what reactions it has.
39
Q Are there dreams you remember of this
pregnancy period? A Yes, I realise I have been
dreaming more, but mostly its bad dreams.
Sometimes sad dreams, sometimes bad ones, really
bad. Q What did you feel when you first
realised there was a baby inside you, ? A
Happy, because I thought its there, so I have
to be careful of what I do, to do things to not
The first period for example I was very anxious
and I had terrible pains in the stomach and I was
afraid the baby felt pain too.
40
Q How do you imagine this baby? A Wishing is
different from imagining. How I imagine it, I
dont know, I imagine the baby ugly and dark,
with dark hair how I wish it to be instead is
different, obviously beautiful and with clear
eyes, beautiful well, Id like one thing, one
wish, that it doesnt look like me. Q Do you
imagine the baby as a boy or a girl? A I
imagine it as a boy but I hope its a girl.
41
Two independent, trained, certified, and reliable
judges code IRMAG interviews according to the
above described seven rating scales. Inter-rater
reliability for IRMAG scales ranged from .89
(coherence) to .96 (predominance of fantasies ),
with a mean reliability of .92. Inter-rater
reliability with respect to the main category was
94 (k.83, plt.001). Disagreement was solved by a
third rater. Statistical validity is supported
by an exploratory factor analysis using oblimin
rotation, performed both for maternal
representation of herself as a mother and of
her child.
42
Considering the statistical characteristics of
the Interview the screen plot suggested that two
factors should be extracted, in both cases. The
two dimensions formulated to define the construct
of mother's mental representations of herself as
a mother were confirmed by factor analysis and
accounted for 70.50 of the post-rotational
variance. Measures of internal consistency
(Cronbachs alpha) were conducted to examine the
reliability of the two dimensions (F1, M2.99, SD
.40, a .85 F2, M2.61, SD .58, a .52 ).
43
In the same manner, the two dimensions formulated
to define the construct of the mother's mental
representations of her unborn infant were
confirmed by factor analysis and accounted for
78.95 of the post-rotational variance. Measures
of internal consistency (Cronbachs alpha) were
conducted to examine the reliability of the two
dimensions ((F1, M2.89, SD .40, a .93 F2,
M2.63, SD .73, a .45 ).
44
At the end of the interview the are 5 scales
modelled on semantic differentials, each
containing 17 pairs of opposite adjectives. The
first three scales designate the individual
characteristics of the unborn infant, of the
womans self and of the infants father.
Comparing the three lists, it is possible to
evaluate if the representation of the baby is
more influenced by the womans
self-representation or that of her partner. The
other two scales, deal with the maternal
characteristics of the pregnant woman and those
of her mother. In this case adjectives will refer
to affective orientations, personal lay-out,
maternal role, maternal sensitivity and
competence.
45
The interview is used to assess how information
and emotions concerning the woman herself and her
child are organized, whereas the five scales give
us a picture of the contents of the
representations. The two instruments can be used
together (Ammaniti et al. 1992 Ilicali, Fisek,
2004) and independently (Ammaniti, Tambelli,
Perucchini, 1998 Pajulo et al. 2001 2006). To
explore the configuration of paternal
representations and their differences from the
mothers the I.R.PA.G. (Interview for Paternal
Representations during Pregnancy-Ammaniti,
Tambelli, Odorisio 2006) is used. As indicated
in table 1, fathers representations have a
different distribution confronted with mothers
ones.
46
Tab. 1 Distribution of Maternal and Paternal
Representations during Pregnancy (IRMAG/IRPAG)
Group Integrated Ambivalent Restricted
Mothers (N162) 89 (54,9) 35 (21,6) 38 (23,5)
Fathers (N162) 93 (57,4) 15 (9,2) 54 (33,4)

• ?hi2(2, N324) 10,87 g.di l.2 p 0.004.

47
The results reported in tab 1 show that in our
sample the integrated/balanced parental
representation is equally distributed among women
and men, as opposed to the restricted/disinvested
one more common among men and the non
integrated/ambivalent one more common among
women. These data confirm the differences of
psychological orientation of mothers and fathers
during pregnancy, even though the mothers and
fathers attitudes draw closer after birth. The
use of IRMAG-R in at-risk pregnancies allows to
study the contents and structure of maternal
representations which give significant indication
to evaluate parenting capabilities during
pregnancy and the postnatal period.
48
Tab. 2 Distribution of Maternal Representations
during pregnancy in risk and non-risk mothers
Group Integrated Ambivalent Restricted
Normal mothers (N239) 60,7 (145) 20,1 (48) 19,2 (46)
Risk mothers (N132) 43,2 (57) 34,1 (45) 22,7 (30)

• ?hi2(2, N371) 11,93 g.di l.2 plt 0.003.

49
In at-risk situations, persistent preoccupations
and phobic fears have been found a specific
scale is being created for these. This scale
allows us to detect the levels of pervasiveness
and intrusiveness of fears in relation to the
pregnancy, to delivery and to the rearing of the
child. The scale for the evaluation of the risk
factors is, like the others, an ordinal scale
with a five point range. The IRMAG-R can be used
for research in the clinical field to study the
psychological state of women during pregnancy or
for at-risk situations, in medically assisted
pregnancies or in projects to support motherhood.
50
2) Self-Report Questionnaires and Scales have
been used to assess attachment processes during
pregnancy, when emotional ties start rising
between mother and child. The construct of
prenatal attachment (Cranley, 1981 Condon, 1993
Muller, 1993) takes account of the mothers
affective investment for the foetus, which is
the most precocious and basic form of human
intimacy (Condon Corkindale, 1997, 1998).
Condon (1993) has suggested a hierarchical model
of attachment based on five subjective
experiences which derive from maternal love
experience and mediate this core experience and
overt behaviours. These subjective experiences
are expressed in maternal disposition "to know"
the loved foetus, "to be with" him or her, "to
avoid separation or loss" of the loved object,
disposition "to protect" the foetus and finally
"to gratify" the foetus's needs.
51
The quality and evolution of the prenatal
attachment is influenced by many factors, first
of all by the advancing of the pregnancy which
entails growing ties between the mother and
child, hastened by the appearance of foetal
movements. Aside these factors, the personal
history of the woman and of the couple have a
significant influence on prenatal
attachment. Obviously this attachment is not only
present in mothers but in fathers as well,
although in 15-20 of the fathers this affective
attachment to the foetus seems not to rise
(Condon,1993). The instruments more frequently
used to study prenatal attachment are Self-Report
Questionaires.
52
Maternal Fetal Attachment Scale (MFAS) (Cranley,
1981), based on 24 items upon which an agreement
score from a range of 5 points is expressed.
Higher the score in the items and more definite
and consistent is the mothers attachment to the
foetus. The items refer to 5 basic components
differentiation of self from foetus, interaction
with foetus, attributing characteristics to the
foetus, giving of self, role taking. Measurements
of internal consistency (Cronbachs alpha .85)
are good on the total of the items, while the
subscales have lower scores (between 52 and 73).
Typical of the MFAS is that the items evaluate
the mothers behaviour more than her feelings or
thoughts. In the validation sample used by
Cranley, this instrument was used between the
35th and 40th week. The scale of maternal
attachment was later adapted to a specular
version which measures the fathers attachment to
the foetus.
53
Maternal Antenatal Attachment Scale (MAAS)
(Condon, 1993), based on 19 items, the response
is rated on a 5 response options, enquiring as to
the frequency and /or intensity of these
experiences over the preceding 2 weeks. The
scale was used during the third trimester of
pregnancy and has good levels of internal
consistency (Cronbachs alpha gt.80). It measures,
beside a global attachment value, two underlying
dimensions quality of involvement and intensity
of preoccupation. From the characteristics of
these two factors, four styles of attachment can
be identified positive-preoccupied,
positive-disinterested, negative-preoccupied,
negative-disinterested. The fathers version is
based on 16 items, 14 of which are in common with
the mothers, as Condon sustains that prenatal
attachment, even though it has a common basis for
mothers and fathers, has specific aspects as
well.
54
Prenatal Attachment Inventory (PAI) (Muller,
1993). The inventory is based on 21 items. The
response to each item is rated on a 4-point
Likert scale. The higher score indicates greater
attachment. In structure it is similar to
Cranleys scale but the aspects explored are
different. It refers to attachment theory,
describing womens thoughts, feelings and
relationship towards the foetus. Two constructs,
in particular, are extremely relevant in the
theoretic model at the basis of the PAI
attachment relation to the partner and adaptation
to pregnancy, because according to Muller (1993)
these are both positively related to prenatal
attachment. The statistical analyses have shown
good validity and internal consistency
(Cronbachs alpha varies from 81 to 91 in all
researches that used it). Mullers instrument
does not allow an evaluation of fathers prenatal
attachment.
55
The measurements from the self-evaluation scales
described above concern the quality and quantity
of the emotional investment of the parents
towards the foetus without, however, going into
more complex elements (mental representations of
the parents, parents attachment models).
Therefore these scales can be used together with
other research instruments.
56
3) Inventories have been used to study the
psychic state during pregnancy, such as the
primary maternal preoccupation, a mental state
Winnicott (1956) described as almost an illness
that a mother must experience and recover in
order to create and sustain an environment that
can meet the physical and psychobiological needs
of her infant. He hypothesised that this special
state begins towards the end of the pregnancy and
continues through the first months of the
infants life. If Winnicotts concept had a
clinical sense, it was later explored by means of
a semi-structured interview, Yale Inventory of
Parental Thoughts and Action,YIPTA (Leckman et
al., 1999) within which an Inventory
systematically explores the mothers and fathers
preoccupations and thoughts.
57
The specific content of the YIPTA covered the
thoughts and actions associated with three
domains of caregiving (Care), relationship
building (Relationship) and anxious intrusive
thoughts and harm avoidant behaviours
experienced/performed by parents (AITHAB). The
YIPTA is designed for the use of experienced
clinicians and has been used at the eighth months
of gestation, at two weeks after delivery and
three months after birth. The measurements of the
Early Parental Preoccupations and Behaviours,
besides outlining the psychic states typical of
mothers, highlight depression and anxiety
symptoms that can appear during pregnancy, while
the AITHAB measurements highlight intrusive
thoughts and harm avoidant behaviours which are
conceptually related to obsessive-compulsive
disorders (OCD). It can be hypothesised that some
forms of OCD that appear in this period are the
dysregulative result of this specific psychic
state that appears during pregnancy.
58
Both parents present the highest levels of
preoccupation towards their child around birth
time (between the eighth month of pregnancy and
the second week after delivery). Thoughts about
the baby during the period of Winnicotts primary
maternal preoccupation occupy the minds of the
mothers and fathers for respectively 14 and 7
hours a day. At the eighth month of pregnancy
(Leckman et al., 1999) the following has been
found preoccupations on the babys health in 95
of the mothers and 80 of the fathers (health,
growth, aspect), thoughts of damaging the baby in
37 of the parents (making it cry, shaking or
hitting it, dropping it). These thoughts are a
reason of personal distress in 20 of the cases.
59
The progress of thoughts and preoccupations shows
that these tend to appear around the eighth month
of pregnancy and reach their climax around the
second month after birth to then slowly
disappear. (fig.1). The YIPTA permits an
evaluation of the level of parental preoccupation
which is an important psychic state during
pregnancy and the postnatal period because it
focuses the parents attention on the babys
health and stimulates better caregiving
capabilities. In the mothers depression and in
obsessive-compulsive states the level of
preoccupations can occupy the mothers mind
completely and interfere with her maternal
capabilities.
60
(No Transcript)
61

• Clinical implications
• Desire of motherhood and of pregnancy (Pines,
  1972). This element has important implications
  for adolescent pregnancies, in which a
  narcissistic attitude is in the foreground.
• To this purpose it is important to notice how the
  news of the pregnancy was received and how it was
  (or wasnt) communicated to the family.
• The pregnancy takes on a different meaning
  depending on the personal history of the woman,
  on her experience of attachment as a child, on
  her adolescence dynamics, on her relationship
  within the couple and especially of her
  relationship with her mother.

62
Our research (Ammaniti et al., 1995) has outlined
three different maternal styles
(integrated/balanced, restricted/disinvested,
preoccupied/ambivalent) that correspond to
observations in the clinical field (Raphael-Leff,
1993) which have drawn attention to different
configurations facilitator, regulator and
reciprocator mothers. Our researches point out
that these psychic maternal configurations do not
overlap with attachment models which on the
contrary are relatively stable. These maternal
configurations are influenced by pregnancy
psychological dynamics, that is by the maternal
constellation (Stern, 1995) within which a
motivational system based on caregiving and on
the childs protection is activated. As stated by
Stern, the pregnant woman tends to rely on other
women who have had children and have gone through
the motherhood experience.
63

• From this point of view, the relationship with
  ones own mother represents the most significant
  relational area because a woman facing pregnancy
  is undergoing a great transformation from woman
  she is becoming a mother, and this is possible
  only if she is authorised and sustained by her
  mother, who is her identification model.
• In clinical situations, this relationship can
  become particularly conflicting, as a competitive
  dynamics of depreciation is established and
  feelings of jealousy, envy and refusal are cast
  upon the mother figure.
• Often in pregnancy, the woman has a tendency to
  idealise her maternal capabilities and to
  defensively depreciate her own mother regarding
  this, the birth of a child can help the
  elaboration of the ambivalence and stimulate a
  more adequate identification with ones own
  mother.

64

• An important area is the womans representation
  of the child she bears. In most cases, the child
  is given personal features, a nickname, he is
  attributed intentions, motives and can even be
  considered a partner for conversations.
• In other situations, in the detached mothers for
  example, the child is considered a foetus, not a
  person yet and is not represented with personal
  features and characteristics.
• In at-risk situations, the child can be perceived
  as a danger, a threat for the mothers autonomy,
  a dependent presence, even a parasite (Ferenczi,
  1941).

65

• Regarding the area of preoccupations and fears,
  these can appear during the last phases of
  pregnancy which are directed to a psychological
  focusing on the child (primary maternal
  preoccupation, Winnicott, 1956).
• However, it is in this phase that
  psychopathological shifting towards
  obsessive-compulsive disorders can reactivate or
  appears for the first time.
• In the primary maternal preoccupation, the
  persistent ideas are similar to obsessive ideas,
  so is the avoidance of certain ideas such as
  hurting the baby and the need to verify
  everything is ok. The substantial difference is
  that these preoccupations are egosyntonic while
  obsessive ideas are egodystonic.

66

• Considering the psychopathological risk in
  pregnancy, depression represents a frequent
  condition (10 OHara,1997) which can have
  important consequences on the course of the
  pregnancy, of the delivery and on the
  mother-child interactions after birth.

67

• Therapeutic implications
• Pregnancy is a particularly fertile phase for
  psychological work the woman has a more
  accentuated introspective orientation and there
  is more permeability between the unconscious and
  conscious spheres, which is demonstrated by
  richness of dreams.
• Even open-eye and subconscious fantasies occupy
  great space and are centred on the child and on
  her own maternal function.

68

• Therefore it is a privileged time for working
  with women on the maternal constellation centred
  on her role as a mother, on her child and on her
  relationship with her own mother. This work can
  have a preventive function in view of the
  postnatal period and at the same time a
  therapeutic function, especially in at-risk
  situations.

69

• A few words on the women who were in
  psychotherapy before their pregnancy in this
  case the other motivational systems which where
  in the foreground earlier now tend to become
  marginal in the womans life and in the
  therapeutic space the maternal constellation
  area becomes more and more central, and within it
  conflicts of the past with the parent figures can
  reactivate.
• In this phase, the future mothers psychic world
  is embodied with the physical experience of
  transformation caused by the pregnancy and the
  growing presence of the child.