A case study of a mother's intertwining experiences with incest and postpartum depression

EMPIRICAL STUDIES

A case study of a mother's intertwining experiences with incest and postpartum depression

IDUN RØSETH, Cand. Psych1, ROB BONGAARDT, PhD2, PER-EINAR BINDER, Professor3

1Department of Psychiatry, Telemark Hospital, Skien, Norway; 2Department of Health Studies, Telemark University College, Porsgrunn, Norway; 3Department of Clinical Psychology, University of Bergen, Bergen, Norway

Abstract

The association between childhood sexual abuse (CSA) and major depression disorder (MDD) gives reason to suspect that many mothers with postpartum depression (PPD) have a history of CSA. However, few studies have investigated how CSA and PPD are related. In this case study we explore how the experience of incest intertwines with the experience of postpartum depression. We focus on participant subject “Nina,” who has experienced both. We interviewed her three times and we analysed the interviews with Giorgi's phenomenological descriptive method to arrive at a contextualised meaning structure. Nina's intruding fantasies of men who abuse her children merge with her recollections of her own incest experiences. She may succeed in forcing these fantasies out of her consciousness, but they still alter her perceptions, thoughts, and emotions. She feels overwhelmed and succumbs to sadness, while she also is drawn towards information about CSA, which in turn feeds her fantasies. The psychodynamic concepts of repetition compulsion, transference, and projection may provide some explanation of Nina's actions, thoughts, and emotions through her past experiences. With our phenomenological stance, we aim to acknowledge Nina's descriptions of her everyday life here and now. With reference to Husserl, Heidegger, Merleau-Ponty, and Minkowski, we show that Nina's past is not a dated memory; rather it determines the structure of her consciousness that constitutes her past as her true present and future. Incest dominates Nina's world, and her possibilities for action are restricted by this perceived world. Any suspension of action implies anguish, and she resolves this by incest-structured action that in turn feeds and colours her expectations. Thus anxiety and depression are intertwined in the structure of this experience.

Keywords: Child sexual abuse; incest; postpartum depression; descriptive phenomenology; case study

Correspondence: I. Røseth, Department of Psychiatry, Telemark Hospital, Skien, Norway. Email: roseth@sthf.no. Telephone: +47 41200462. Fax: +4735003773

(Accepted: 18 June 2011; Published: 12 July 2011)

Citation: Int J Qualitative Stud Health Well-Being 2011; 6: 7244 - DOI: 10.3402/qhw.v6i3.7244

© 2011 I. Røseth et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http://creativecommons.org/licenses/by-nc/3.0/, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Psychological trauma from childhood may haunt a person in her everyday experience of both herself and others and restrict her possible thoughts, actions, and feelings. Pregnancy and birth may elicit memories of abuse and contribute to the development of postpartum depression (Buist & Janson, 2001; Mason, Rice, & Records, 2005). The prevalence of childhood sexual abuse (CSA) in women has been estimated at between 8.2 and 30.4%, largely dependent on the definition of CSA, the measurement, and population studied (Anderson, Martin, Mullen, & Romans, 1993; Finkelhor & Dziuba-Leatherman, 1994; Heimstad, Dahloe, Laache, Skogvoll, & Schei, 2006; Sariola & Uutela, 1994). Narrowly defined sexual abuse (contact abuse) has a prevalence of about 5.6% and a yearly incidence of 3.2% (Finkelhor & Dziuba-Leatherman, 1994). Childhood abuse and neglect have been associated with increased risk for major depression disorder (MDD) (Widom, DuMont, & Czaja, 2007). An estimated 5% of all new mothers experience MDD and many of these remain undetected and untreated (Gavin et al., 2005; Glavin, Smith, & Sorum, 2009). Also, studies have shown an increased incidence of depression during the first 5 months postpartum (Eberhard-Gran, Tambs, Opjordsmoen, Skrondal, & Eskild 2003; Gavin et al., 2005; Munk-Olsen et al., 2009). Subsequently, it is not unreasonable to assume that there are many postpartum depressed mothers with a history of CSA.

A few studies have investigated how CSA might affect the experience of birth and motherhood (Cohen, 1995; Eberhard-Gran, Slinning, & Eskild, 2008; Heimstad et al., 2006; Mason et al., 2005; Parratt, 1994). Childhood sexual abuse is associated with fear of childbirth and increased risk of complications during delivery (Eberhard-Gran et al., 2008; Heimstad et al., 2006; Leeners, Richter-Appelt, Imthurn, & Rath, 2006). Parratt (1994) found that experiences concerning privacy, touch, and control during childbirth were potent links to memories of sexual abuse, but found few commonalities between different cases in how these memories affect childbirth experiences. Mason et al. (2005) found that childbirth contributed to the recall of abuse where the women engaged in a cognitive frame of reference similar to abuse; they felt easily victimised and out of control. However, they concluded that the mothers’ experience of PPD was similar to that of women not exposed to CSA.

Childhood sexual abuse victims are likely to experience parenting difficulties. Cohen (1995) compared 26 incestually abused mothers with a control group. The results indicated that the sexually abused mothers were less skilful in maternal functioning than the control group. Survivors of incest had an increased tendency to have rigid role expectations, to be non-cooperative, and to be less able to share responsibilities with their partner. There was a clear tendency for these mothers to have a negative view of their own competence and to feel they were a failure, overwhelmed, exhausted, inadequate, and guilty. In addition, they found that survivors of incest had a reduced ability to communicate freely and openly with others. Douglass (2000) found that women with a CSA history more often report distress in intimate child care because they associate it with their abuse. Other researchers found that abused parents have reported being more overprotective, have a more intrusive and impulsive parenting style, to have low self-esteem and ambivalence about parenting, difficulty setting limits, and feeling resentments towards their children (DiLillo & Damashek, 2003; Möhler, Biringen, & Poustka, 2007; Möhler et al., 2009). In addition psychological disturbances, especially MDD, posttraumatic stress disorder, and generalised anxiety disorder are found to mediate the relationship between CSA and parenting difficulties (Schuetze & Eiden, 2004).

These studies give important clues about how motherhood may affect survivors of incest. However, there is little research describing how a history of incest intertwines with the experience of PPD. This article is a preliminary attempt to fill that void by using a descriptive phenomenological approach (Giorgi, 2009).

Method

We report on a single case to make possible an in-depth analysis of the complex meaning patterns of incest and PPD intertwined. The participant was involved in a larger phenomenological study on the general meaning structure of PPD (Røseth, Binder & Malt, accepted for publication). Only she related PPD to incest, and her rich descriptions called for, and made possible, a separate case study analysis enabling a comprehensive understanding of the phenomenon.

The study is anchored in a phenomenological philosophy that originated with Husserl (1962). This philosophy was developed further by, amongst others, Merleau-Ponty (1962 ) and made accessible to psychology as a scientific research method by Giorgi (2009). Husserl articulated the insight that consciousness is intentional; it is always directed towards an immanent object (e.g., memories, fantasies, or hallucinations) or a transcendent object (an object in the physical world). He pointed out that all phenomena are a product of both the intentional act and the intended object, thus phenomena are in essence relational and context dependent.

The phenomenological method requires that the researcher suspends, or “brackets,” theoretical, and practical preconceptions and assumptions about the phenomenon that is the object of study (Husserl, 1962; Merleau-Ponty, 1962). Another important methodological process is to withhold an existential claim, meaning that the researcher suspends belief in the existence or “reality” of the phenomenon under investigation (Giorgi, 2009; Husserl, 1962). To bracket and withhold the existential claim helps the researcher to keep an open mind and to see the phenomenon in a fresh light and thus let it “speak for itself.” However, this does not mean that it is possible to become totally free from preconceptions and prejudices due to prior knowledge. A basic pre-understanding of the phenomena under investigation is also a premise for understanding it (Heidegger, 1962). In this context, bracketing simply means an attitude towards the experience of the participant in which the researcher disciplines herself not to actively add her own preconceptions and theories.

A phenomenological research interview does not correspond to any usual type of conversation, it is a special inter-subjective situation aimed at exploring the participant's life world. Both the researcher and the participant are motivated to fulfil this aim. A good interview depends on the interviewer's ability to make the participant feel safe and comfortable, thus enabling her to reveal sensitive and sometimes painful information about herself (Kvale & Brinkmann, 2009).

For this case study we have used Giorgi's descriptive phenomenological method. This method usually involves at least three subjects; several persons share their view on and experiences with one and the same phenomenon. However, in this study we describe and discuss the phenomenon through one women's experience of living and reliving her incest as part of her PPD. We refer to her as Nina. Nina was interviewed three times, with each interview lasting from 45 min to 1.5 h. She initially felt insecure in the interview setting and needed assurance of our independence from the public health care system. It was important that the interview was conducted in a relaxed atmosphere in her home and that we spent some time to “attune” to each other before the digital recorder was turned on. The resulting descriptions were rich in meaning and well suited for a case study.

We analysed the interviews with Nina in four logical steps (Giorgi, 2009). The first step was to read the entire transcript of each interview several times to get a sense of the whole. Secondly, for each interview we divided the transcript into meaning units by being sensitive to and marking shifts in the psychological meaning of what was said. In the third step, we transformed the meaning units into a psychological language, where we identified the more general character by imaginative variation. During imaginative variation, the researcher probes her descriptions by trying out different formulations and thereby teasing out invariant meanings. Here the researcher also reads between the lines, teasing out the coherence between explicit meanings and meanings lying implicit in the descriptions. For the fourth and final step, we synthesised the transformed meaning units of all three interviews into a contextualised meaning structure. We did not, however, proceed through these steps in a strictly linear fashion; the analysis was a dynamic process where we moved back and forth between steps, especially steps three and four, until the final contextual meaning structure was described.

The participant received information about the study both verbally and in writing. She was assured confidentiality and any information in her description that might reveal her identity has been changed or removed. The participant gave her informed consent both verbally and in writing to take part in the research project. She was informed of her right to withdraw from the study at any chosen time without stating a reason. The Norwegian Regional Committee for Medical Research Ethics had approved the study beforehand (nr: S-08247a).

Findings

Nina is a second time mother, married and in her mid-20s. She was subjected to childhood sexual and physical abuse by her father. When she disclosed the abuse to her mother, her mother chose to support her father and stay with him. As a consequence Nina felt it impossible to live with her family and moved to a foster home. Since she left her family she has had no contact with her father, and for many years she did not talk to her mother. She has difficulties trusting and opening up to others with details about her past—this includes close friends and lovers. Over the years she has managed to keep her memories and the accompanying feelings at a distance by having many superficial relationships and by working a great deal, leaving little time to think about and reflect on her childhood trauma. But when she entered the study she was diagnosed with MDD and posttraumatic stress disorder. Nina found that her incest experiences suddenly resurfaced after the birth of her second child, a daughter. Her trauma invaded dramatically how she existed in her life world and how she anticipated her future.

Contextualised meaning structure

For Nina, PPD means to be thrown into a world full of men who abuse children. Before giving birth she could keep traumatic memories of incest at the fringe of her daily life consciousness. After giving birth she is overwhelmed by an anxious vigilance and intruding fantasies of men who abuse children. Her fantasies merge with recollections of her incest experiences. This intertwined Gestalt of memories, fantasies, and experiences is so painful that she hardly ever succeeds keeping it out of her consciousness, and as a consequence it has an enormous impact on her daily life. That is, it alters her perceptions, thoughts, and emotions, i.e., her mode of existence. Overwhelmed, Nina succumbs into fatigue and sadness. Nevertheless the CSA experiences of unknown people interests and attracts her. She actively seeks out information about CSA, which in turn feeds her anxious vigilance and fantasies.

This contextualised meaning structure reveals three highly interrelated constituents that can be separated for the sake of analysis: from maintaining distance to overwhelming closeness, the attraction of the world of abuse, and difficulty separating self from baby.

From maintaining distance to overwhelming closeness

Already during her second pregnancy, Nina worries about what would happen to the unborn girl and preferred to have a boy. She explained this worry as based on the belief that girls are more exposed to sexual abuse than boys. She does not experience birth itself as traumatic, but her troubling perception of the baby girl as vulnerable and easy prey to abuse increase steadily after birth. The anxiety thus dominates her perceptions of the world, her thoughts, and emotions.

So it's also a big … after the birth, that I've had a girl … I'm so afraid that … although it can happen to boys too … of course. But I'm really afraid that one day someone will abuse her or do something to her … These are things I just can't get out of my head … Sometimes it's fantasies too, but I try to push them far away, I don't want to go into detail, it's kind of all in my head. I just don't want to think about them at all.

The vulnerability and dependence of the baby girl activated general anxious vigilance and fantasies concerning the girl's possible future abuse. Most of her fantasies are vague and general, more correctly described as an anxious situation, any situation where her children are alone with any man. Her fantasies are so painful that she tries to force them out of her conscious focus. She described her increased vigilance and fantasies as closely related to her own memories of incest, which came to the forefront again after giving birth.

It's come more often … I haven't always managed to force it to go away, so to speak. In the past, it would sometimes come like a flash into my life again, and then I've just thought that it was something that happened then … it'll never happen again. It's not a part of my life any more. And then I've managed to get rid of it again. But now I've seen how vulnerable children are … and they don't have a chance against grown-ups … When you see how vulnerable they are, you feel helpless on their behalf. Because ultimately there's nothing I can do … I'm afraid that something will happen to them. [Researcher asks: the same that happened to you?] Yes, or worse things. So I notice that I'm really hung up on it [sexual abuse] … it really gets to me … I get so upset about what happened [to me] before, so I feel afraid that it's going to happen to my children. I'm very … I'm absolutely terrified that something will happen to them, that they'll meet the wrong kind of people who'll mess them about or …

Our analysis shows that memories from the past experience with incest merge with anxiety provoking fantasies about possible future abuse. This merger is more difficult to push out of conscious focus than it was before the childbirth. This future moves in on Nina mercilessly and she grieves as if the anticipated abuse has already happened. She is overwhelmed by the insight that she cannot protect her children forever. Her daily functioning such as preparing meals, playing with the children, or socialising with friends diminishes. She becomes depressed, feeling powerless, and immobilised; her body is fatigued and filled with emotions that she cannot control. In short, when actual and possible abuse merge, anxiety and depression intertwine.

The attraction of the world of abuse

Nina watches the news or reads about abuse of children on the Internet and experiences their pain as if was her own.

I identify with the feelings they [abused others] have, I know how many of them can feel, and then I experience the grief that I had … Yes, I know the fear, and feel sorry on their behalf.

The information about the abuse experience of other people's children, feeds fantasies about her own children being abused. To this, she reacts emotionally with strong and sustained feelings of anxiety, grief, and anger. Moreover, the information on the Internet fuels her perception of men in general as sexual abusers, which increases her anxiety. Yet these strong negative emotional reactions do not prevent her from seeking this kind of information. On the contrary, she actively searches for information on CSA; she conveys that she feels drawn towards it.

[A]nd then I'm really upset about—I don't know, after I've got really very upset—I let things get at me so much, what goes on in the world, and so on. And then I'm stupid enough to sit and read a lot of stuff on the Internet, about children and so on. Abuse and violence and things like that. It really gets into me.

Anxiety provoking and destructive as it may be, information about CSA attracts her. Moreover, much of her daily life, especially her relations to men next to kin, is coloured by fantasies about abuse of her children. Nina says:

They are very sick thoughts to think, but they are about the sexual abuse that I have experienced. That I don't trust him [my husband] … When he takes the children in the shower, or reads for them in bed, then I get very … I prefer that my husband is not in the room when my children are in bed … And this is not just about him, it counts for all men.

Difficulty separating self from baby

Nina's vigilance and anxiety concerning the possible future abuse of her children is closely connected to her own past experience with CSA. Nina says that she knows that the incest experience influences her present depression.

Well, it just makes me go around being afraid of it, all the time. And it was actually a thought that stuck in my mind before the birth, when I was pregnant, that I didn't want a girl, I feel afraid that more things can happen to a girl than a boy. And that's obviously because it happened to me before; I had a father who was, you know, not quite all right.

However, in her descriptions during the interview, she was not fully able to separate her own suffering from the potential suffering of her child. The insight that she professed, did not seem to change her obsessive worry about her child's safety. Most of the time Nina did not concern herself with her own traumatic past, rather she seemed fully immersed in the anticipated traumatic future of her children.

Our analysis shows that she did not generally experience her strong sustained feelings of anxiety, grief, and anger as related to her own abuse, despite her rational understanding of this relation. She experienced her feelings as connected to her children's future abuse. Accompanied by her fantasies she thus grieved this anticipated abuse. She had clear aggressive and vengeful fantasies of how she would hurt the abusive men if she could catch them. The drama of incest presents itself to her as an ongoing threat, not as a traumatic part of her past. Thus, her past trauma approaches her from the future, haunting her through her own children.

A phenomenological description of Nina's “here and now”

The birth of her baby girl alters Nina's everyday life. Increasingly she finds herself in a world full of dangerous men who will abuse her children if given the chance. While struggling to hold her traumatic memories and images at a distance, she is tormented by a general anxious anticipation and fantasies concerning possible sexually abusive situations that her children may encounter. Nina's past casts long shadows forward, especially onto her children's future, shadows that have an enormous impact on her life here and now. How can we understand this?

In phenomenology, the experience of a coherent self and a continuous world is described as inherently temporal and historical. Husserl's description of time perception provides us with an understanding of how Nina's experience is structured with regard to time (Van Gelder, 1999). According to Husserl, a person's consciousness has a triple structure: retention, primal impression, and protension. Retentions are intendings of past events. A primal impression is what happens now. Protensions are intendings of future states. Retentions are not memories; they are direct experiences and not representations. Likewise protensions are not images, they do not reveal something absent as something present but rather anticipations, “directedness” towards future events. This threefold structure of time perception is the basis for our sense of continuity, both the continuity of our self and the world around us.

Heidegger's (1962) work Being in time provides a further understanding of the complexity of lived time. When we anticipate a future event, the future in some way happens now. It is part of the current phase of consciousness, even though it is directed towards an event that may happen in the future. Moreover, we approach the future on the basis of our past. Also, the past and the future form the present; what is now is the way it is because of the past and the future. Thus, we are in some way already committed to the future by the present we perceive. This phenomenological description clarifies how Nina's past informs her anxiety about the future and how, depressed, she lives and grieves this future in the present. “The experience is held together and derives its coherence and meaning from the future event to which it refers and for which it is preparatory” (von Eckartsberg, 1972, p. 167).

Merleau-Ponty (1962), with his description of the object-horizon structure of our consciousness, clarifies further how events from the past can lie in the horizon of our consciousness and colour our whole existence. Merleau-Ponty was inspired by Gestalt psychology when he wrote about the dynamic figure-ground structure where perceptions, thoughts, and feelings may change from being in focus to lying at the fringe of the experiential horizon and vice versa. An important aspect of the Gestalt principle is that for the creation of meaning, the fringe of the horizon is as important as the focal object. Moreover, any change in the horizon may alter the whole meaning of what is in focus for consciousness. There is no doubt that the birth of a baby girl implied a major alteration of Nina's life. However, it was not the baby girl herself, but the meaning she had for Nina that changed her mode of existence. Nina's world is once again dominated by abusers and victims, only now it is her child and not herself that is perceived as a victim and all men are abusers, not only her father. Merleau-Ponty (1962) explains that new perceptions and new emotions may replace the old ones, but that it is only the content that changes and not the structure of experience. The traumatic “memory” that dominates Nina's life is not representational. It survives as “as a manner of being and with a certain degree of generality” (Merleau-Ponty, 1962, p. 83). This past is not like a dated memory, a representation of the past that can be made present in Nina's consciousness; rather it determines the structure of her consciousness that constitutes her past as her true present and future.

Traumatic memories seem to be lingering in the horizon of her consciousness and may at any time become the focus of her attention. Even though Nina directs her attention elsewhere, the traumatic memories form the background of her experience, giving the focal intentional object its form and colour. She is not unconscious of her trauma, but chooses not to address it directly. Merleau-Ponty (1962) supports this description: “Forgetfulness is … an act; I keep the memory at an arm's length, as I look past a person whom I do not wish to see” (p. 162). Contextual changes, such as the birth of a baby girl, may change and reorganise the whole experiential Gestalt, where the memories of CSA prevail in Nina's effort to create meaning in her lived world.

Experience has an ever-present atmosphere of elusiveness, of something incomplete and out of reach (Shapiro, 1976). Experience is therefore filled with tension; it is both a threat and an attraction. We may never fulfil the elusive event; it might continue to hover over us. The elusiveness of experience is evident in Merleau-Ponty's object-horizon structure as it implies that we can only focus on one facet of an object at the same time, while all the other facets are present as possibilities for approach. Thus, the horizon presents possibilities that might be experienced in the future. These possibilities afford approaching, they afford straining at or leaning towards. Incest dominates Nina's world and her possibilities for action are restricted by this perceived world. Minkowski (1970) states that the opposite of action is expectation. In action we move towards the future. But in expectation the future closes in on us, moving towards us. And expectation always implies intense anguish as it is a suspension of activity—activity which is “life itself,” as Minkowski (1970, p. 88) writes. To stay in anguish over time is unbearable; action must overcome expectation. Nina acts in an attempt to reduce overwhelming anguish when she seeks information about CSA on the Internet. But unfortunately for Nina, the action of seeking information does not overcome the uncertainty; instead it feeds and colours the expectation, creating intense anguish. Her anguish-creating action stalls time, which is an important aspect of depression (Minkowski, 1970). Anxiety and depression are thus intertwined in the structure of Nina's experience. They are two sides of the same coin.

Discussion

Nina's re-entry into a world of abuse may be interpreted as the need to work through and master her experience of CSA. However, the way she acts in this world does not lead to any mastery or learning; on the contrary, it increases anxiety and depression. What is more, Nina describes how she seeks destructive information against her better judgement. Her search for information about CSA on the Internet seems partly involuntary. A possible explanation for the driven, persistent quality of such behaviour may lie in Freud's concept of repetition compulsion (Freud, 1958). The individual feels compelled to repeat the repressed material as contemporary experience. Fairbairn (1986) explains repetition compulsion as the effort to master traumatic experience through a fixation on a painful situation. In this view, repetition compulsion may be an unconscious repetition of a traumatic relationship with a traumatising bad object, where the subject has a concealed hope that the bad object eventually will turn into a good object. From this perspective, Nina hopes that she (or her mother) will be able to protect her children (or herself) from abuse. If not, she hopes that she (or her mother) at least will be able to detect it and punish the abusive man (or her father), i.e., that the mother in the end will prove to be good. We could also assume that she hopes that the men (or her father) in her surroundings do not end up abusing her children and, thus, also in the end turn out to be good. Thus, repetition compulsion can be seen as an attempt to master a situation by wanting unconsciously to go through the same situation, and hoping that it does not end badly as it did in the past. The person who repeats compulsively is then described as loyal to her primary objects, despite the traumatic and difficult relationship to them. The loss of a “bad” primary object is, according to Fairbairn, equal to an objectless world, which is experienced as far more distressing because it also implies the loss of parts of the original ego.

Nina holds very painful memories and anxiety that thrust her away from her focal consciousness. In recent psychoanalytic literature, Bromberg (2003) theorises that traumatic events that we find difficult to incorporate are dissociated away from the self as a “not-me,” in order to protect the perceived vulnerable self. Thus, a part of oneself becomes detached and hidden in the unconscious. Somehow, however, the detached part continues to hover over the person, as the dissociation is not complete. The conscious self still has some access to the “not-me.” The previously dissociated “not-me” experiences are enacted by transference and projection into the surrounding world.

In this psychodynamic line of thinking, Nina's emotional and pre-symbolic memories are lived as a real threat in the present and near future, the threat of sexual abuse of her children. Nina does indeed seem to exist in a world full of perpetrators and victims. Her feelings towards her abusive father can be said to be transferred or redirected towards all other men. She somehow transfers her past into the present and the future, and projects her own feelings onto her children, who thus take on the role of victims. Thus a possible psychodynamic interpretation is that Nina's compulsion to seek destructive information on the Internet is motivated by complex and contradictory emotions connected to her trauma.

The concepts of transference, projection, dissociation, and repetition compulsion rest theoretically on the construct of the unconscious. Nina's repetition compulsion is then explained by unresolved conflicts that are repressed into her unconscious and that motivate her recurring projection and transference. What really only exists in Nina's mind is unconsciously transferred and projected onto the world and the people around her.

In his seminal book from 1972 A different existence Van den Berg directs our attention to this way of reasoning. The concept of projection, Van den Berg points out, implies that something within the person departs from her, moves towards and attaches itself to objects and other persons in the world. In the case of transference, a feeling that she has for one person can detach itself from that person and latch onto other people in the world. Thus transference and projection indicate that emotions can be objectless and attached to other objects at will. Van den Berg infers from this that these psychodynamic concepts imply that the person in essence is detached from the world and others. This in turn means that transference and projection imply a negation of the person's reality. “Transference” denies what the person sees in others and “projection” denies what the person sees in the here and now; the person sees only herself (Giorgi, 1985; Van den Berg, 1972). In a more recent critique of such Cartesian trends in psychodynamic thinking, Stolorow, Orange, and Atwood (2001) point out that this “doctrine bifurcates the subjective world into outer and inner regions [and] reifies the resulting separation between the two” (p. 469). The mind appears as an isolated container of internalised relationships that can be studied largely detached from the surrounding context.

Taking seriously Nina's account of her situation, and in consistence with our research method, we prefer the phenomenological understanding of how incest and depression intertwine in Nina's life world. In doing so we open up for mental health work grounded in and directed at her illness experience. This experience gives her little room to act: Nina's anxiety and depression are two sides of the same coin; that is, aspects of a world with a “frozen” structure in which all new experiences are given old meaning. For the mental health worker or psychotherapist this would imply that instead of seeking incidents in the past that serve as causal explanations for current problems, it may be more fruitful to concentrate on the patient's current difficulties and elaborate on her situation in the here and now—helping to “melt down” the frozen structure. In her world the problems lie in her non-knowledge, in what she is not directly conscious of, but which severely restricts her potentialities (Mook, 1985). In therapy the aim is to tactfully and gradually reduce her restricting non-knowledge and to uncover what her limited mode of existence means to her. Thereby the therapist gradually introduces the unfolding possibilities of existence for her. Thus, instead of speaking of transference and projection, the therapist accepts the client's descriptions of her world. Nina's problems lay in her relationship to significant others in her world and it is in this world that she has to regain her health (Mook, 1985). The therapist could start working with the fact that Nina has difficulty trusting men in her surroundings and what this difficulty actually means for her. As both past and future meet in the present, their appearance is dependent on how we view them from the present. It follows that it is Nina's present mode of existence in her world and the consequences it has for her that we must take seriously and not a superimposed theory.

Conclusion

Through a case study we analysed how a mother's experiences with incest and PPD intertwine. Using Giorgi's phenomenological method of analysis we derived a contextualised meaning structure of the experience. In this structure, traumatic past experiences merge with destructive present behaviour and anxiety-filled expectations about the future. Past, present, and future pivot around sexual abuse by untrustworthy men. The psychodynamic understanding of this meaning structure of experience emphasises projection and transference as concepts bridging past, present, and future. Together with the concept of repetition compulsion, projection and transference may explain the participant's mode of being in generic terms. But we preferred to stay close to Nina's specific descriptions of the world she lives in and moved on to a phenomenological understanding. This allowed us to describe Nina's perceived past and future as intricately related to her here and now intertwining experiences of anxiety and depression.

Acknowledgements

We thank the participant who so generously shared her experience with us. We thank Ulrich F. Malt and Olav Tangvald-Pedersen for their comments on a draft of this article, and the NORMOOD project for intellectual and organizational support.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

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About The Authors

Idun Røseth
Telemark Hospital
Norway

Department of Psychiatry

Rob Bongaardt
Telemark University College
Norway

Department of Health Studies

Per-Einar Binder
University of Bergen
Norway

Department of Clinical Psychology

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