Some basic assumptions, albeit held to varying extent by different schools of thought, underpin therapeutic treatments:

• Motivated to seek meaning, healing, and reciprocity, most human beings share a propensity to love, desire, and suffer.

• As adults we constantly renegotiate boundaries in social contacts, using self-other regulatory mechanisms to demarcate degrees of intensity and safe distance with our lovers, family, friends, carers, community, society, and internalized memorabilia.

• Proficiency in adult relationships rests on a sense of inner security, which in turn is rooted in the quality of early care and later formative experiences and the way these continue to be processed in adulthood.

• Conversely, unprocessed issues from the past are repeatedly and blindly played out as we engage others to enact scenes from our internal worlds, seeking to provoke similar affective responses.

• Imagined and actual traumatic impingements intensify mental distress. Emotional disorders severely affect more than a quarter of all adults at some point during their lifetime. Periods of heightened vulnerability—transitions (for instance, our children's adolescence, our own midlife), or life events (such as marriage, retirement, births, and deaths) inevitably involve disruption, necessitating reappraisal for the individual and often, renegotiations for the whole family.

• A person's self-esteem, internal resources, fantasies, and type of defensive strategies, as well as the quality of his/her emotional relationships at any one time will determine the significance of both phase-specific predicaments (such as promotion at work, or grandparenthood) and responses to unforeseen painful crises (of health, loss, economic, or psychosocial traumata).

• While elaborating new levels of comprehension we revisit old conflicts and anxieties, and in addition to experience-evoked strategies, persistent unconscious issues resurface at each new phase, as a trait or defensive tendency.

• In general, the meaning ascribed to each life event determines its impact. Responses may range from confusion, inertia, regression or defensive retrenchment and compulsive repetition, to posttraumatic growth and healthy recovery after the initial shock.

• The degree of disturbance and capacity for reorganization fluctuate across the life cycle in accordance with concurrent circumstances and age-related comorbidity risks; the nature of personal aspirations and flexibility of one's own approach to attaining these.

Psychotherapy, which provides emotional support and fosters understanding, can boost resilience in people susceptible to retraumatization.

While many people achieve a flexible spectrum of relating, for most patients intimacy is a prime area of concern. Working therapeutically with these individuals or couples, we realize that love is fundamental, and like all primary affects including anger, fear, and surprise, it has both universal physiological components and diverse individual and cultural manifestations. Many people come into therapy having discovered the pernicious nature of the compulsion to repeat the past, which threatens to destroy new relationships.

In the West, personal expectations of intimacy are also influenced by bombardments of flamboyant erotic imagery, larger-than-life passions, and a cacophony of lyrical narratives that provide the cultural backdrop of symbolic representations of ‘love’. Indeed, there is some concern about the ‘tyranny’ of a milieu that so invades and controls the most private recesses of the human mind through its proliferate media, commercial and service instruments, displacing the authority of religion and elders with transmission of ‘manufactured fantasies of total gratification’ (Lasch, 1978). Some contemporary discontent and difficulty in finding satisfaction in love, work, and play stems from persuasive media communications—articulating primitive illusions of unconditional love and everlasting sexual excitement, which resonate with our own cherished infantile fantasies.

Today's message of ‘Love as a crucible for identity’ is ambiguous—juxtaposing 1960s images of hedonistic free choice and sexual exploration with nineteenth century romantic ideas of mature conformity, duty, and loyalty. The composite mythology poses a dilemma, endorsing adulthood as both ‘a prolonged adolescent-like period of continuing crisis, challenge and change’ (Swidler, 1980, p. 130), and a search for sexual perfection. This blend of individualistic exploratory ‘self-actualization’ and self-centered indulgent materialism contrasts with social obligation, ethical responsibility, and a sense of global accountability. Precariously poised in the twenty-first century, we occupy a world of contradictions, uncertainty, and cynical leadership, with disturbing antidotes of fundamentalist terrorism or arrogant military triumphalism. Poignantly, faced with mortal danger, victims distil their emotions sending messages saying simply: ‘I love you’.

On an individual level falling in love in adulthood is a form of re-cognition, investing a ‘familiar’ stranger with heightened emotions transferred from internal figures and unconscious projections that attempt to probe and occupy the other, hoping to activate the desired archaic response. Sexual partners are often unconsciously selected not only for their resemblance to early ‘objects’ of desire but for their ‘transformational’ capacity to re-evoke early solicitations. The search is a ‘memorial’ one of surrendering to the other as a ‘medium’ to alter the self (Bollas, 1979). (This is also the evocative basis of transference in psychotherapy.) Each partner brings to intimate sexual encounters their cumulative past including emotional relationships, unresolved conflicts, and unfulfilled cravings that they wish to satisfy alongside hopes of adult development. Healthy unions that respect difference and allow each partner to flourish, facilitate further growth despite the pull to repeat and gratify unprocessed archaic desires.

Every couple acquires an identity of its own in addition to the distinctiveness of each of the mates. The twosome becomes the repository of both partners’ conscious and unconscious sexual fantasies and desires, wishes, and wants. This potential joint system undergoes vicissitudes ‘of gratitude and guilt, of stereotyping and conventionality, of deceptiveness and long-range destructive and self-destructive scenarios’ (Kernberg, 1993, p. 653). One source of tension in adult relationships that persist over time, is a potential mismatch between needs of the couple and each partner's personal transformational hopes—both to play out childhood myths and to relinquish these and expand their own self-definition. The latter may clash with the dyad's requirement to preserve equilibrium in the face of growing family and occupational responsibilities (see Gould, 1993).

In addition to explicit social expectations and each partner's implicit personal aspirations—love relationships in early adulthood include persistent collusive unconscious ‘contracts’. When contested by one partner, these are transferred to new relationships by the other. The significant other may personify ‘lost’, repudiated, or dangerous parts of the self. Their ‘pact’ may provide breakaway from negative aspects of their respective archaic parents, may mutually confirm each other's shaky sense of identity by boosting defiance, or promote reciprocal idealization, fostering an illusion of dyadic fusion or a means of denying separateness (see Dicks, 1963; Clulow et al., 1986; Raphael-Leff, 2005)—a spectrum reflecting the severity of joint pathology. Erotic desire and sexual activity further shifts the boundaries, temporarily blurring psychosomatic, gendered, and transpersonal distinctions.

Unconscious contracts are very difficult to disentangle especially when the partners’ respective underpinning configurations dovetail. If these persist into parenthood, to avoid recognizing the pathological nature of their interaction the couple may enlist the new baby in fantasy enactments. Assessment for couple therapy must therefore evaluate the nature of their ‘shared internal world’ and their capacity to confront pain rather than evade it (Lanman, 2003).

In recent years there has been a dramatic shift to cohabitation as the first mode of union in Britain, and although three in five permanent relationships do result in marriage, 35% of couples living together dissolve within 10 years, followed by an average of 3 years alone before starting a new relationship (ISER Report, 2000/1). Ironically, the high level of failed marriages is ascribed to more negative behavior following premarital cohabitation with its greater autonomy (Coghan and Kleinbaum, 2002). Failure is also attributed to factors such as premarital sex, racial, and religious heterogamy. However, the picture is complex. The US National Survey of Family Growth indicates that marriages contracted after 1980 are becoming more stable, possibly due to rising age at marriage and increased cohabitation (Heaton, 2002). But, according to the US Census, almost half of all couples in first marriages divorce and a further fifth separate. American second marriages have a 10% higher rate of divorce (and one in three children come from ‘broken’ homes). The British Office for National Statistics indicates that about 70% of subsequent UK marriages end in divorce, and 50% of these occur between ages 35 and 55.

Numerous studies find women more disappointed in marriage, which does not match the nurturing and relational intimacy of their unconscious expectations. Seemingly, men are less aware of the build up of problems and less accepting of the end of a relationship, continuing to sustain unrealistic expectations of reconciliation and suffering increased health and psychological problems following the break up (Gorell Barnes, 1998). Nonetheless, with therapy and/or delineation of their emotional priorities, many (childless) individuals eventually go on to happier relationships. When offspring are involved, a common pattern in separation among both married and unwed couples is that children mostly reside with their mothers, with decreasing contact with noncustodial fathers (despite governmental decrees on shared parental responsibility even in failed adult partnerships). In almost half the cases, separation may lead to paternal withdrawal or lack of access (Cockett and Tripp, 1994), estrangement and loss of contact within two years (Simpson et al., 1995), and even denial of paternity. In fact USA and UK surveys find that one-third to one-half of men's children from previous relationships go unmentioned by nonresident fathers compared with custodial mothers’ reports.

Parting may come as a welcome end to quarrelling, but often involves reduced economic security, geographical relocation and for a child, a disrupted family, change of school, friends, neighborhood, loss of relatives, and restructured network. Faced with a preoccupied, sad or angry resident parent with no other emotional support, a child may resort to role reversal to comforting the jilted adult (see Gorell Barnes et al., 1998). Separation anxiety, depression, and psychosomatic symptoms are not uncommon following a divorce, as are less visible symptoms of low self-esteem and often irrational self-blame for the break up. Pre- or postseparation family therapy or conciliation counseling may be indicated. However, during the conflictual process of separation, therapists may be drawn into unconscious identifications (Wallerstein, 1990) and countertransferential roles (judge, magician, or servant), which render them ineffectual (Vincent, 1995).

Recent widespread disclosure of domestic violence and sexual abuse demonstrate the potential dangers of asymmetrical intimate relationships with devastating consequences for defenseless victims—long-lasting impairments in their emotional, physical, psychosexual, and interpersonal functioning. Violence and victimization are implicated as both cause and consequence of family breakdown, community disintegration, isolation, and alcoholism or substance abuse. Child-bearing raises the risk, with increased vulnerability, dependence, and raised tensions. Given ubiquitous antenatal health provision pregnancy is also a prime time for detection and intervention (Reading, 2003). Abused mothers of young babies require therapeutic intervention. Special group sessions in aggression-control benefit motivated perpetrators. Victims in refuge accommodation are usually offered brief and time-limited counseling or outpatient group psychotherapy. Those who have been exposed to extreme and repeated exploitation by intimates require longer-term clinical care to overcome distrust and achieve internal reparative work. In cases of chronic violation and extreme emotional harm, extended psychodynamic treatment is justified by elevated risk of repeated victimization and transgenerational transmission (Dutton and Holzworth-Munroe, 1997). Inconsistent government and nongovernmental organization responses to domestic violence and child protection concerns indicate a need for more comprehensive interagency guidelines (Waugh and Bonner, 2002) to both alleviate long-lasting psychological distress and prevent recurrent crises and medical interventions.

As in perversions and prejudicial attacks, a central essential aspect of most deviant practices is dehumanization. In a world where women feel powerless as agents in an adult world, they may employ their power as mothers to inflict emotional and bodily harm on their children. Perverse mothering often follows on intergenerational propagation of sadomasochistic pathology where the mother who treats her child as part of herself also maltreats her child as an expression of her own self-hatred (Welldon, 2002). Sexual abuse, prostitution, eating disorders, self-mutilation, and compulsive exercising similarly reflect attempts to both control and to attack the body-self. Munchausen by proxy, another a perverse use of a child as an extension, is fatal in about 10% of cases. Psychotherapeutic treatment is fraught with issues of control, deception, and corruption which pressurises the therapist to act abusively rather than think (Lloyd-Owen, 2003). Male offenders usually lack the maternal masochistic identification with the victim. The victims of pedophiles’ sexual and violent abuse are usually genetically unrelated; in extreme cases a sadistic component leads to homicide. Invariably, adult abusers were maltreated children, and retrospective studies reveal that childhood sexual exploitation rarely occurs as an isolated feature but is associated with physical and emotional abuse, neglect, and household dysfunction (Dong et al., 2003).

Preventative measures are as necessary as corrective ones to break the transgenerational cycle.

Psychodynamic theories of adult maturation stress both cognitive development towards wisdom and affective growth towards mature love (Erikson, 1980; Emde, 1985; Stevens-Long, 1990; Kernberg, 1993). Some themes are applicable across the reproductive years, although a medley of challenges now replace previous phase-specific ‘psychological tasks’ (e.g., Erikson, 1950; Jaques, 1965) and some growth issues are suspended or defy the expected sequence:

• Adolescence: a prolonged search for identity is stirred up by puberty, role confusion, and multiple choices, exemplified by idealization of mentors and use of peer group both to escape a sense of inadequacy, and as an experimental arena to explore self-definition and sexual identity.

• Early adulthood: given today's (ostensible) equal opportunity, many women as well as men prioritize education and career ambitions over intimacy. A healthy search for love is instigated by greater stability and tolerance of loss (versus feared isolation).

• Maturing adulthood: desire to reproduce reflects readiness to nurture (versus stagnation anxieties or desires for generational lineage). Postponed reproduction or waived parenthood suggests expanding ‘generative identity’ and/or increasingly antithetic conditions of domesticity and work attainments.

• With rising longevity and postmenopausal reproduction, midlife crisis may equally accompany retirement, belated parenthood, discovery of irreversible infertility, or empty nest syndrome.

• A late adult crisis usually follows challenges to bodily integrity, with death's ultimate inescapability forcing reappraisal of one's accrued sense of order, ethics, and personalized meaning to counter despair.

Emotional upheavals stimulate psychic reorganization and formative reconfigurations of identity. Maturation builds on reworked concerns, self-reflection, and integration of change. Lifelong confrontation with ‘developmental challenges’ (Settlage et al., 1988) and resolution of conflicts bring a series of commensurate changes in self-representation. Although shifting, fragmented, and elusive, identity nevertheless has a subjective continuity. We bring old emotions into new situations, investing them with unresolved issues transferred from the past and recreate archaic scenarios in the present. Insight is enhanced by withdrawing projections and confronting human frailty and complexity. The hallmark of maturity is one of diminishing omnipotence and increasing agency. Accepting one's own contradictions, failures, and destructiveness increases the desire to contribute and conversely, acknowledging one's own input to difficulties fosters meaningful new choices.

Social forces structure our lives, with influences beyond our ken forming us and shaping our decisions. This ‘social unconscious’ (Hopper, 2003) remains unexplored due to personal resistances, ‘normative reticence’, and ideological constraints. Over the last few decades, breakdown of traditional structures in postindustrialized societies has resulted in disordered life-course sequences. Britain is a prime example: improved nutrition has lowered the age of menarche, and despite Western demarcation of adolescence as a prolonged transitional period of maturation, earlier sexual activity, relaxed social mores, and diminished restrictions means Britain now has the highest rate in Europe of very young teenage mothers [triple that of France and Sweden, quadruple that of Italy, six times that of the Netherlands, and 10 times that of Switzerland! (Kiernan, 1997)] with associated emotional and socioeconomic hardships. Conversely, with access to further education and career promises, many women postpone child-bearing until their mid-thirties or beyond and a whole industry of fertility treatments has arisen to assist waning fecundity. These technological innovations in turn pose false hopes adding tension to the anguish of infertility. Successful interventions create further unprecedented doubts and emotional distress, as new kinship categories and ethical dilemmas arise.

Modern-day maternal career expectations often vie with the infant's needs, which have changed little over the millennia. Serial cohabitation replaces marriage, with a rise in unwed and same-sexed parents. Social stratification leaves new parents unprepared for the impact of a baby on their lives. More importantly, smaller families deny people opportunities to rework and resolve their own infantile issues in the presence of babies before having their own.

Worldwide, changing demographic and socioeconomic parameters of the reproductive years include urbanization, which alters family patterns, dispersing extended families and forming viable, yet often isolated, small and emotionally intense nuclear units. Even in developing countries birth rates have declined substantially, largely due to changing attitudes, abortion, and efficient contraception. Safer childbirth and decreased infant mortality diminish the need to have many children to ensure some will survive. Earlier puberty and longer life expectancy shift commencement of adulthood and extend its upper range and versatility well beyond menopause. However, adulthood is no longer synonymous with childbearing and the rate of childlessness-by-choice is estimated at 12–20% across Europe.

Psychologically, ‘life-style’ decisions are never straightforward, and inflated expectations influenced by media depictions and sociopolitical changes often contribute to frustration, disillusionment, and depression. Rising unemployment, housing shortages, deteriorating transport, poor education, and health service facilities have become a feature of what I call ‘de-developing’ as well as developing countries. And data from cross-national surveys in ‘restructuring societies’ such as Brazil, Chile, India, and Zimbabwe show that common mental disorders are about twice as frequent among the poor (Patel et al., 1999). Women in all societies are 1.5–3 times more likely than men to develop depressive and anxiety disorders (Ustun, 2000) peaking during the reproductive years, with postpartum and other psychiatric disturbances across the lifespan (Swartz, 2003)—explained not by biological factors but childhood adversity and/or psychosocial entrapment in marriage and motherhood (Brown et al., 1995; Craig and Pathare, 2000). Sex discrimination is rife—there are still disproportionately few female tertiary students even in the West, and worldwide the market reveals earning differentials, segregated work conditions, and postmaternal downward occupational mobility, for professional women too. Even in privileged Europe, gender equity for parents remains a myth, with women struggling to fulfill often conflicting domestic and work roles, both in traditional (largely Catholic) southeastern European countries (where the fertility rate has now dropped below 1.7 births per woman), and in the more generously state-endowed northwestern European countries (see Hobcraft and Kiernan, 1995). On the other hand, the Western trend towards postponed, concentrated parenthood, thrusts young children into their parents’ mid-life crises and juxtaposes adolescent offspring's turmoil with parental elderliness. Coupled with social mobility and geographical migration resulting in dispersal and loss of extended families and support systems it fosters an intensely interdependent and overburdened couple relationship and/or parent–child bond.

Conversely, in many third world and particularly sub-Saharan African countries, the life span of adults is now declining to four decades (!) due to famine, violence, and disease, especially AIDS, in addition to dietary deficiencies and maternal mortality. Healthy life expectancy at birth varies both within social groups and between societies [29.5 years in Sierra Leone, 33.8 years in Afghanistan to 69.9 in the UK and 73.8 in Japan (WHO, 2003)]. With 29.4 million HIV/AIDS sufferers worldwide (10 million of whom are between ages 10 and 24!), increasingly, grandparents care for orphaned toddlers and, as the mid-generation die off, numerous child-headed households are left to cope with emotionally devastating aftermaths of adult wars and sexually transmitted diseases.

Finally, disturbances of the reproductive years relate to changing attitudes about the quality and duration of intimate relationships and a contemporary, often colliding quest for self-actualization, contributing to the complexity of (post)modern life. Given all these factors it is no longer meaningful to think in terms of normative ‘life cycle’ frameworks. Therapists working with adult patients across the reproductive years, from adolescent sexuality to postmenopausal childbearing, must identify ongoing developmental challenges. Emotional disturbances occur within this matrix of rapidly changing psychosocial demands, cultural and ethnic resource variations, and gender/cross-generational differences in overstrained nuclear families.

The higher incidence of antenatal depressive symptoms in inner cities are also associated with socioeconomic disadvantage—no educational qualifications, unemployment and poor support or no partner in second or subsequent pregnancy (Bolton et al., 1998). For the woman who actually has another inside her, distinctions between self and other, outer, and inner may blur. While most expectant mothers experience a variety of mixed feelings fluctuating over the course of a day if not an hour, some pregnant women take a fixed stance. This may center around depressive issues of feeling insufficiently nurturing; or persecutory anxieties about being depleted and exploited by the baby (if intolerable these lead to fetal abuse or an abortion to expel the tyrant). Obsessional defenses geared to regulating closeness become jeopardized by the ultra-intimacy of having two people in one body. Compulsive actions fail to ward off danger, and the struggle to keep good and bad apart is imperiled by the uncontrollable ‘invader’ who threatens to reveal her hidden badness. Intrusive thoughts break through, with a risk of enacting these antenatally in physical attacks on the fetus, or in postnatal violence or sexual abuse (Raphael-Leff, 1997). Expectant fathers, too, are prone to emotional disturbances (Lovestone and Kumar, 1993), in addition to experiencing envy of the woman or fetus. ‘Talking cures’ are a treatment option for psychiatric disorders in pregnancy as both medication and maternal illness may have an adverse effects on the fetus (Cott and Wisner, 2003).

There is a substantial overlap between depression and anxiety in the pre- and postpartum periods (Da Costa et al., 2000) but antenatal depression possibly has a higher prevalence than postnatal depression, which it frequently precedes (Evans et al., 2001). Although no causal connection can be sustained by available evidence (Oates, 2002) in addition to direct effects on the fetus of alcohol and substance abuse in pregnancy (Siney, 1999) there is a growing body of work linking maternal antenatal emotional disturbance and later behavioral problems in the offspring. Prenatal depression has even been claimed to produce differing effects on fetus and newborn according to ethnicity and socioeconomic status. In a longitudinal study of over 10 000 women that examined antenatal disturbance separately from postnatal depression, anxiety in late pregnancy was found to pose an independent risk associated with behavioral/emotional problems in the child at 4 years of age (O'Connor et al., 2002). Preventive interventions in pregnancy and perinatal therapy consisting of individual or joint sessions that continue after the birth, benefit expectant mothers or parents experiencing emotional overload, irresolvable antagonism or revival of previous troubling experiences.

High-risk categories are conflicted pregnancies, including unplanned, untimely, or highly ambivalent. Emotional sensitization, including conception by donor gametes or following on prolonged infertility; family history of obstetric complications, or psychiatric treatment. Complicated pregnancies, including eating disorders or substance abuse, multiple fetuses, concurrent life events such as bereavement or eviction, socioeconomic problems, and lack of emotional support (Raphael-Leff, 1993/2001, p. 193). Similarly, people encountering perinatal losses, whether abortion, miscarriage, stillbirth, neonatal death, and abnormalities often feel the need for grief counseling. A therapeutic atmosphere in which to examine and express their feelings of shock, sorrow, guilt, shame, and/or desperation is essential as these are often negated in a conspiracy of silence or placation (‘you can always have another baby’) by well-meaning friends and professionals alike (Raphael-Leff, 1993).

In the West of every 1000 women having a baby it is estimated that two develop puerperal psychosis, 17 will already be psychiatric patients, 100–150 experience postnatal depression or persecution, 300–400 suffer mood disturbance and temporary emotional distress. While some female postnatal disturbance is attributed to hormonal fluctuations, birth of a baby is in itself a highly arousing experience for carers of either sex. Exposure to the infant's urgent crying and nonverbally expressed needs often touches a raw nerve in the adult, conflating demands and their evocation. Direct contact with the smells and feel of primary substances may reactivate in the adult implicit ‘procedural’ memories in feeling. Paradoxically, to function sensitively, the parent must remain receptive to these and draw on them to empathically understand the baby's needs. However, if the adult is overwhelmed by his/her own infantile feelings or too susceptible to the baby's, parenting becomes problematical (Raphael-Leff, 2000a).

With a first baby, a couple's sudden shift from intimate dyad to triad retriggers old mother/father/child issues of inclusion/exclusion, and now that the new parents are in the powerful position on the triangle, they may inflict ancient jealousies and unresolved sibling rivalries on their dependent baby and each other. The ever-present third, both stranger and part of themselves, enriches yet disrupts the intimate sexual partnership. For women, a new baby ‘ruins’ postindustrial life-styles and careers. The cost is high: by keeping the child, a mother loses half her expected lifetime's income and not surprisingly, compensates by unrealistically high expectations of motherhood (Leach, 1996). A women who has cared for her own narcissistic mother since childhood, may feel unwilling to mother the baby and/or envious of the care she herself provides. Feeling endangered by the infant's fragility or neediness a father or mother may withdraw emotionally or physically. These problems are well served by parent–infant therapy, couple or individual psychodynamic therapy. Conversely, when issues of dominance/submission are enacted in violent or sexual maltreatment of the baby, crisis intervention is crucial, at times necessitating removal of the offender or the baby from the family.

As in all disturbances, when resources are scarce, mental health priorities must focus on prevention, identification of high-risk cases, and early referral for treatment. In many societies, well-baby clinics exist and primary health carers are in a prime position to identify infant disorders such as disturbances of sleep, feeding disorders, traumatic stress, failure to thrive, persistent crying, and behavioral complaints, which both contribute to, but are also symptomatic of family dysfunction. In these cases developmental guidance may be the first call of action, especially with very anxious inexperienced parents. This involves supportive counseling by community nurse, health visitor, or therapist whose observation of the parent–child involves spontaneous ‘advocacy’ (speaking on behalf of the nonverbal baby), and commentary about ongoing interaction fostering freedom to experiment with new ways of relating, affirmed by the infant's responses. More contemplative carers can use brief parent–infant therapy. The nonjudgmental ‘holding’ of a therapeutic relationship can help them reflect on painful issues in their own infancy and ways these may be impinging emotionally on their current interaction with the baby. Such external support and insight can eliminate ‘ghosts’ that have come to occupy the nursery (Fraiberg et al., 1975). All communication involves mismatches and the mother–infant capacity for co-creative processes and ‘interactive repair’ (Tronick, 2003) is enhanced when negative internal representations alter in the adult. (Interestingly, ‘distorted’ representations have a better outcome than ‘detached’ ones.)

In cases where the family disturbance stems from a carer's deep-seated unconscious representations of the baby as a defective baby-self, long-term psychodynamic individual therapy offers a safe haven to work through infantile experiences associated with these attributions and to regain ownership of them. In families where the disturbance is clearly related to the partners’ interactive dovetailing, conjoint couple or family therapy will enable them to identify their patterns.

About 2% of childbearing couples suffer loss of a baby through miscarriage, stillbirth, or SIDS (sudden infant death syndrome). The process of mourning perinatal losses is hampered by the unknowable and the inexplicable. Death in the midst of procreation seems an obscene ‘nonevent’ and unmanageable feelings include love–hate conflicts, grievances, and excessive or inhibited grief (Bourne and Lewis, 2003). Crisis support, grief counseling, and information about diverse reactions and gender differences in mourning help parents feel less guilty, ashamed and stupefied, and less likely to rush into a replacement pregnancy. The need for individualized, compassionate midwifery care in the pregnancy following neonatal loss is also stressed by a joint Australian-Canadian study of a Special Delivery Service program and supportive healthcare services (Caelli et al., 2002).

Birth of a special needs baby constitutes a potential trauma for the parents whose guilt, grief, and anger reactions will be influenced by a complex interplay of intrapsychic and external factors (such as severity and correctability of the defect, how they discovered it, and the nature of the medical procedures required). As with all trauma, parents tend to experience an initial sense of shock, disappointment, anger, and injury to self-esteem followed by a period of painful intrapsychic dis-equilibrium. After mourning both the wished-for-child and their own losses there is a gradual restoration of intrapsychic equilibrium and capacity to value the child as separate rather than a negative extension of the parent (Mintzer et al., 1984). According to need, antenatal preparatory counseling, early postnatal support, grief work, or longer-term therapeutic contact may be indicated and/or access to a support-network of like-minded parents may be helpful, at different points over the years.

Increasingly AIDS is becoming an issue when linked to maternity in one of three ways:

• An HIV positive woman chooses to conceive—to ‘fulfill’ her ‘feminine destiny’, compensate her for the illness, create an illusion of immortality or leave a living legacy behind her when she dies.

• A woman discovers through antenatal screening that she is HIV positive following rape or voluntary sexual contact (one in three in Southern Africa).

• A woman whose partner is HIV positive chooses to conceive or finds herself pregnant with anxieties that she and/or the baby may develop the virus.

From supervision of midwives, therapists, and counselors on different continents, in all three situations the juxtaposition of a life threatening illness with life-giving pregnancy is an impossible aporia. Disclosure of HIV in the context of pregnancy is accompanied by stages akin to mourning—shock, confusion, denial, abandonment, anger, and mixed feelings about her own survival. Annihilation anxiety mingles with guilt about bringing an orphan into the world, remorse at possibly infecting her baby, shame about having to break the news to her family (with the social stigma of AIDS still rife), and anxieties about the uncertain course ahead, including treatment (or its unavailability). Fear that pregnancy will exacerbate the illness, ambivalence about the need for a C-section, fantasies cum reality of her body and milk being poisonous and experience of unknown side effects, often lead to inconsistent treatment of the baby who is both overinvested and envied yet repudiated. Clearly the need for supportive counseling is great but not often acknowledged as an ongoing perinatal need by overstretched service providers. (Work in Soweto demonstrates the effectiveness of trained lay befrienders and leaderless support groups.) The bereavement process in children of parents with AIDS is complicated by secrecy, shame, ostracism, and neglect. Behavioral symptoms such as stealing, self-harm, truancy, and drug taking may be relieved by grief work that offers the child stability and possibilities for open communication (Aronson, 1996).

There is a threefold increased rate of depression within 5 weeks of delivery (Cox et al., 1993) with prevalence rates of 10–22% for severe depression. Symptomatology (unrelated to age, marital status or education, although increased by lack of confidante) includes diminished pleasure, depressed mood, energy loss, guilt, and sense of worthlessness. Depression also has a high comorbidity with anxiety disorders, substance abuse, and eating disorders. However, wide community studies of new mothers indicate that about half of those who meet operational clinical criteria for psychiatric ‘caseness’ remain undetected by family doctors and other professionals.

Apart from the sufferer's distress, psychological effects on the partner and parenting is of ongoing concern. High rates of couple disharmony, conflict, and separation are associated with assortative mating, and contemporaneous psychiatric morbidity in partners (Burke, 2003). Serious mental illness in primary caregivers has long-term repercussions. Assessment of parenting capacity must focus on the level of disturbance, instability, paranoia and impulse control, responsibility and the degree to which a child is involved in the parental psychopathological system (Gopfert et al., 1996), or deprived by the quality of their emotional functioning. Results show disturbed parents are less responsive, less attuned, at times rejecting or hostile, inconsistent, or ineffectual (Mowbry and Lennon, 1998). Specific studies of adverse effects of postnatal depression find that the child's cognitive development and sociability are impaired long after resolution of the maternal illness (Murray and Cooper, 1997). When associated with vulnerability factors such as psychosocial adversity and marital discord, the risk increases (Brown et al., 1995) and untreated parental illnesses persist with 30% still suffering at 1-year postpartum (Pitt, 1968) with chronic depression or recurrent relapses.

Health visitors and other primary carers find that not surprisingly, mothers who are worn down by persistent socioeconomic deprivation and chronic depression are often apathetic, demoralized and powerless, displaying emotional numbness, low self-confidence, depression and insensitivity to, and/or overreliance on, their children for support. Conversely, perfectionistic mothers with good social skills often go undetected by professionals as they hide their severe depression under a façade of bright coping mechanisms. When these fail, reluctance to admit defeat or ask for help carries a high risk of suicide. Finally, in cases of persecutory driven illness, where the baby becomes incorporated in the paranoid or depressive system, infanticide is a danger.

Given that early infancy is deemed a critical period for emotional development, and that neuropsychological evidence reveals that the developing brain itself is affected by maltreatment, over- or understimulation (Schore, 1999) early detection and speedy treatment are imperative. In most Western countries, the regular high scrutiny of antenatal care offers an opportunity to identify women at risk for both puerperal psychosis (with 50% chance of recurrence) and other forms of postnatal disturbance, if midwives and traditional birth attendants are trained. Couple therapy during pregnancy as well as postnatal parent–infant or family therapy help prevent family dysfunction hardening into an established and intractable interactional pattern. Family intervention programs aim to improve parental functioning ante- or postnatally. Some attempt to ‘optimalize’ the relationship and to address the child's emotional, cognitive, linguistic, and social needs, through home visits, mother–infant group intervention and a variety of toddler's stimulation groups and community-liaison supervised work rehabilitation (Heinicke et al., 2001). Disturbed parents may benefit from specialized group therapy (Puckering et al., 1994).

Research has confirmed the raised risk of emotional and behavioral disturbance in children of a mentally ill parent (Marks et al., 2002). The association is strongest in cases of personality disorder and chronic or recurring depression in the parent. Although some depressed mothers manage to sustain warm, even excessively affectionate relationships with their ‘savior’ child (Radke-Yarrow et al., 1988) affective disorders restrict the capacity to engage sensitively. Children suffer from the depressed parent's persistent unhappiness, emotional preoccupation and self-blame, or the overactivity, grandiosity, denial, and contempt of mania (Pound, 1996). The inconsistencies of bipolar illness are thus particularly confusing. Owing to domestic disruptions the admission rate of children to care is high, with a 44% chance of psychiatric disorder in adulthood versus 2% noncare controls (Rutter and Quinton, 1984). A high genetic loading is responsible for some morbidity in adulthood but the deficits in care, the tense, unhappy, or unpredictable domestic atmosphere, and the anxieties about the parent's welfare result in defensive organization in the offspring.

Two main patterns of dysfunction in children of chronically depressed parents are overidentification and depression (1.6 times that of matched controls) with poor self-esteem or an ‘oppositional syndrome’ (Pound, 1996) of detachment, substance abuse, and/or antisocial behaviors (more common in boys). Protective factors enable some children to develop well despite the presence of psychotic manifestations within their families. Of central importance are dispositional attributes, family cohesion, and the relationship to the non ill parent and other warm supportive figures and an intimate confiding friendship with a peer. The child's personal resources of resilience, compassion, high self-esteem and self-reflectiveness are both protective assets and outgrowths of coping with psychopathology.

In the UK, 28% of (urban) family-practice attenders and 50% of psychiatric outpatient populations have a personality disorder, presenting with a variety of symptoms such as violence, anxiety and depression, self-mutilation, sexual disinhibition, substance abuse, and eating disorders. This narrow repertoire of habitual coping strategies adversely affects flexibility of response in relating. Conduct disorders and a high risk of chronic delinquency are more common in children of personality disordered parents, who often themselves suffered from ineffective parenting, harsh discipline, and childhood sexual abuse and/or violence. Across studies, a triad of demoralizing factors recurs in association with psychiatric disorders: environmental hardships, poor or deteriorating relationships of cohabitation and early trauma or cumulative adversity (see Cox et al., 1987; Brown et al., 1995).

When one member of a family has schizophrenia the effect of an atmosphere of negative ‘expressed emotions’ on maintaining illness and exacerbating psychotic relapses has been demonstrated, as has family intervention to improve communication patterns and to foster recognition of each family member's differing needs (Kuipers et al., 2002). When hostility and criticism are predominant features of interaction family therapy is indicated.

Parent to child transmission clearly operates over several generations. Less clear is the effect of the child on the parent, and the two-way impact of their exchange. At the best of times the arduous nature of parenting can feel persecuting when resources are depleted. When an unsupported parent is also highly sensitive and confused or delusional, the child's ordinary neediness may seem like a criticism of his/her poor parenting, which is then projected back into the child as hostile condemnation. Internalized, this in turn reinforces the child's sense of unentitlement and low self-esteem.

On the positive side, although it poses emotional challenges and unmanageable risks for both vulnerable parents and susceptible infants, caregiving, especially of very young children, also offers new opportunities for reworking rather than enacting old grievances. Through parenting collusive partners may differentiate from each other and acknowledge their own parents as both a reproductive couple and idiosyncratic individuals in their own right.

Parents’ unresolved developmental issues are often reactivated as the child reaches an equivalent phase (Benedek, 1959). These weak links constitute the parental flash point, sometimes necessitating therapy. But, often, within the safety of a secure couple relationship, mothers and fathers can utilize the upsurge of revitalized emotions to liberate themselves from past restrictions, deprivations, and irrational prohibitions. In the absence of a loving extended family, parents benefit from creating one, by establishing a community of like-minded friends, joining an existing self-support group or participating in groups exploring parenthood, which offer encouragement pre- and postnatally, and at different stages of the child's development. Once again, presence of a confidante for a single mother, or resilience of the relationship for a couple, and their capacity to share both perils and pleasures of parenting will determine their mental health and emotional climate in the home.

Dads are often relegated to a secondary position, treated as supporter or breadwinner, or in psychoanalytic parlance seen as the ‘third’ element, necessary to break the ‘symbiosis’ of the pre-oedipal mother–child dyad. Nonetheless, from the mid-seventies the literature reveals burgeoning awareness the father's affiliation in his own right, effects of his absence, and ‘hunger’ for the reality of this relationship (Gurwitt, 1976; Layland, 1981; Herzog, 1982; Lewis, 1986; Glasser, 1985; Cath et al., 1989). The relatively few longitudinal infant observations within families that do include the father, note both paternal input and parental rivalry over the baby (Yogman, 1982; Boston and Carter, 2002; Cardenal et al., 2002).

Researchers’ sexual bias is reflected in studies. By contrast to 72 types of child psychopathology attributed directly to maternal care (Caplan and McCorquodale, 1985) only 1% of empirical clinical investigation is dedicated to fathers (Phares and Compas, 1992). These few studies indicate that paternal alcoholism, detachment, absence, panic disorders, and/or depression (Field et al., 1999) have deleterious effects, particularly on ‘externalizing’ behavioral problems in older children (Connell and Goodman, 2002). On the other hand, children of highly motivated involved fathers show increased cognitive competence, empathy, less sex stereotyped beliefs, and more internal control (see Pruett, 1992; Lamb, 1997). Effects of involuntary male primary care due to high unemployment is yet to be studied.

Unlike tightly orchestrated traditional patterns, contemporary parenting allows for choice among a variety of ideologies and differing conceptions of caregiving. First time parents are often unprepared for the demands of parenthood—lacking babycare skills possessed by a 4 year old in developing societies. Furthermore, with smaller nuclear families and social mobility, many Westerners lack not only the supportive network, but the emotional experience of exposure to babies while growing up. As a result, most arrive at the point of parenthood with few realistic guidelines and many archaic grievances and irrational expectations intact, having failed to process their own infantile feelings in the evocative presence of an infant before the birth of their own.

In nondirective societies, such as our own at the moment, the choice of goals and priorities informing a new parent's mode of parenting will be determined by their own unconscious internal model and current beliefs (in addition to socioeconomic constraints). Like developmental theories, these internal paradigms vary from belief in the newborn as benign and vulnerable, to assumptions about innate aggression and need for socialization. Maternal orientations (predictable from pregnancy) include facilitation, regulation, and reciprocation (Raphael-Leff, 1986, 2005). A woman of the Facilitator orientation treats motherhood as a vocation and herself as uniquely able to fathom her infant's needs because of their close communion during pregnancy and breastfeeding. Therefore, keeping her baby in close proximity at all times, she devotes herself to adapting, spontaneously gratifying needs as they arise. Conversely, a Regulator mother tends to regard mothering as one role among many she performs. As she believes the newborn is undiscriminating and treats mothering as a learned skill, shared care is possible. Unlike the Facilitator who locates security in providing exclusive care, a Regulator establishes security in predictability. She introduces a routine that allows for consistent transferability between co-carers to regulate the adaptable baby and train him/her to fit in with social demands. Paternal orientations, too, include Participators who relish providing primary baby care and Renouncers who see it as ‘women's work’ until the child is older, when his paternal influence will be required. Reciprocators of either sex do not adapt (like the Facilitator) nor expect the baby to adapt (like the Regulator), but treat each incident as requiring thoughtful negotiation and responsive compromise.

Sympathetic partners (whatever their personal orientation) serve a protective function for each other. Conversely, when partners’ ideas about caregiving clash, postnatal distress is often related to disjunctive dynamics between them or to obstacles preventing expression of their own optimal parenting style. Thus enforced separation from her baby (due to economic necessity or a medical problem) may precipitate depression in a Facilitator, while enforced togetherness (such as unemployment) triggers it in a Regulator (Raphael-Leff, 2005). A Participator partner relished by the Regulator, may feel persecutory to the Facilitator if he undermines the exclusivity of her care. Conversely, a traditional husband who forbids her to work, or the absence of help with child care and consequent lost sense of ‘personhood’, evokes postnatal distress in a would-be Regulator. A Renouncer may jealously guard his rights, feeling that his wife's excessive devotion to their baby detracts from his portion. An envious Participator father may unconsciously sabotage his wife's capacity to breastfeed. Fathers are not exempt from postnatal disturbance, which is often externalized in acting out and high alcohol consumption, and as noted by GP's and researchers alike, an increased incidence of psychosomatic symptoms and psychiatric morbidity (Lovestone and Kumar, 1993). Therapists and health professionals too, tend to be adherents of one particular orientation and puzzled by, or disapproving of parents who hold a different stance.

Almost a quarter of American and British families are mother-headed. This may be due to death, desertion, separation, or choice. Interviews with over 5000 British women found a threefold risk of depression among single mothers (Targosz et al., 2003). Four nationally representative studies of lone motherhood cite reduced income as the single most important disadvantage and cause of negative outcome.

Widowhood means children are affected by maternal bereavement as well as paternal loss and may feel excluded, especially where the topic of death is deliberately avoided. Secrecy, evasion, and lack of communication compound bewilderment leading to guilt, inability to mourn, and a pervasive sense of incompleteness. Family grief counseling may be indicated. Shared grief reduces adverse effects but offspring and surviving parent are often at different stages in their mourning (Robinson, 1996) and introduction of a step-parent may result in polarization, and unconscious splitting of the dead ideal and live substitute (Gorell Barnes et al., 1998).

Desertion has long-term traumatic effects on the remaining partner's self-esteem especially when the disappearance is unanticipated and involves mystery. In addition to a sense of puzzlement, like the jilted parent, the abandoned children may feel guilt, rage, disillusionment, loss of an ideal, hopes, and expectations. In addition, she may experience intense feelings of jealousy and loneliness, with possible depression. Individual or family therapy may be necessary to prevent creeping role-reversal of the child caring for the distressed parent.

The quality of lone parenting as a result of parental separation is determined by both partners’ capacity to resolve their own conflicts and the degree of preparation, explanation, and subsequent discussion with the child(ren). The latter's ability to sustain a mental relationship is crucial, at times in the face of the remaining parent's erasure of traces of the absent one and/or severing of contact. For both resident parent and child, psychological processes may involve a range of feelings from relief through shame, envy, rage, and grief affected very much by their resilience, the circumstances of separation, and degree of emotional support available. Open communication rather than denial of loss helps adjustment. Similarly, much is determined by the lone parent's inner state—psychosexual contentment with the separation, capacity to reflect, and curiosity, liveliness, and enjoyment of the parenting relationship.

When family disintegration coincides with crucial developmental transitions such as pregnancy in the woman or a child's entry to puberty, adaptive challenges and stresses are compounded, and in the latter case, associated with problems such as truancy, uncontrolled aggression, school drop out, teenage pregnancy, and minor delinquency. The lone parent may feel overburdened by these. However, although severe psychological and behavioral problems are two to three times more prevalent in children from divorcing families, 70–80% do not manifest severe or enduring problems (Hetherington and Stanley-Hagan, 1999). Nonetheless, multiply disadvantaged children are at high risk of developing conduct disorders, especially in adolescence. Most studies attribute better adjustment to parents capable of providing a relatively conflict-free emotional climate of separation with cooperative shared supportive and consistent care. Given strong evidence that during the painful conflictual process of separation itself many children experience difficulties with peers and schoolwork, mediation or ‘conciliation’ counseling to help incompatible partners cum parents to separate appropriately seems to be as important as couple therapy to help others to stay together.

Men are likely to ‘re-partner’ more quickly. However, as 90% (!) of children live with their mothers they are most affected by her choices such as introduction of a stepfather and/or ‘reconstituted’ step family. Women are deemed ‘less inept’ at introducing a new partner and outcome studies indicate relative ease of accepting step-fathers compared with step-mothers, especially before age 7 and if the household routine is maintained in the previous style. Stepmothers generally fare worse, are often demonized with mythical ‘wicked’ malevolence, and doomed to fail, due to higher expectations that women act as emotional carers for traumatized kids (Robinson, 1996). Jealousy over lost intimacy with the lone biological parent and rivalry with new children raises emotional issues that may require therapeutic help (see Gorell Barnes et al., 1998).

In all these situations there is no single pathway of adaptation, no set sequences of stresses, or timescale for resolution. Much is dependent on connection to an extended family and particularly the role of grandparents in mitigating the disintegration of an old way of life, maintaining links, and establishing order and closeness in the new one. In families with very young children, secrecy may prevail with fictions regarding true paternity engineering a break with the past. Conversely, when the separation coincides with a child's entry to adolescence, the double emotional adaptation may result in withdrawal and avoidance or increased turbulence, including arguments, hostility about displacement and possible violence. When family therapy is not an option, young people's walk-in counseling clinics may provide a neutral place for airing grievances and discussion.

In addition to these disrupted families, another group of fatherless children are those raised from the outset by a single mother. Longitudinal studies comparing one and two parent families find that single mothers by choice express greater warmth towards their child(ren) who, unsurprisingly are also found to be more secure and unlikely to develop emotional or behavioral problems (although they perceived themselves to be less cognitively and physically competent than peers living with two parents). Similarly, lone lesbian mothers, who in addition, engage in more interaction with the child compared with heterosexual single mothers (Golombok et al., 1997). Findings suggest that children of lone mothers are not disadvantaged in relation to their mothers, but express lower self-esteem related to absence of a second adult.

The contemporary increase in fertility problems is almost equally distributed between men and women. Subfertility is partly a natural function of aging due to postponement of childbearing, and partly attributable to environmental toxins, increased intake of medications, and after-effects of a rising incidence of sexually transmitted diseases. Only a very small proportion of cases of ‘unexplained’ infertility may be attributable to psychological causes, and this is decreasing with refined diagnostic techniques. However, when people are referred for psychotherapy for psychogenic inhibition of fertility, psychodynamic treatment can be effective in addressing the underlying unconscious prohibitions and associations (Christie and Morgan, 2003).

The majority of people suffer from the psychological impact of any/all of four aspects of infertility itself:

• the prolonged period of trying to conceive

• the blow of infertility assessment and diagnosis

• the unremitting demands and increasingly bizarre nature of treatment procedures

• and the outcome—whether accommodating to enforced childlessness, or to birth of a child after so much hope and anxiety (Raphael-Leff, 1992, 2001).

Contraception has fostered an illusion of control over fertility. Discovering that conception does not necessarily follow emotional readiness for a baby can feel devastating. Dawning realization that something is wrong often leads to mortification, and disagreement within the couple as to whether to seek help or give up on the idea of having children. One partner may feel satisfied with the richness of their life or resigned to fate. Or anxious about shameful exposure and/or fearful of bodily incursion during investigations. The other may ache for a child or feel desperately hurt and cheated. Counseling or couple therapy can explore these differences enabling some resolution—whether rewarding ‘child-free’ lives, or a decision to pursue treatment.

Investigations can be prolonged and involve physically invasive, painful, and humiliating procedures, including postcoital tests and reports to a third party about their private lovemaking. Scrutiny activates sexual problems and impotence. Psychosexual counseling addresses tensions exacerbated by routine hospital procedures (Pengelly et al., 1995). Old feelings of disgrace and incapability come flooding back, as attitudes towards the omnipotent parents of childhood are transferred on to the fertile experts. Diagnosis produces a further self-deprecating sense of feminine insufficiency or, conflating virility and potency, masculine embarrassment about quality of sperm. Partners experience shame at needing help ‘to do what any animal can’. Feeling singled out a couple may isolate themselves in secrecy, deeming themselves outcasts from the human race, overwhelmed by powerful emotions of envy, rage, sadness, and despair. Seeking meaning, the past is scanned for punishment-deserving misdemeanors, and animosity festers in self-recriminations or accusations. An existential crisis occurs at being last of a genealogical line. When only one partner is infertile and resents the asymmetry of their positions, this leads to further acrimony, self-sacrificial separation demands/declarations and even threatened suicide. Individual or couple therapy becomes imperative to restore equilibrium and reappraise their resources in the light of the new situation. Evaluation after 6 months of cognitive-behavior therapy found an improvement in sperm concentration, a reduction in thoughts of helplessness and a decrease in marital distress (Tuschen-Caffier, 1999). At this junction too, some will opt for medical treatment, others will accept childlessness together, or negotiate the fostering/adoption route or indeed, decide to separate.

Treatment brings yet another host of emotional roller-coasters, with recurrent cycles of hope and despair, elation and deflation. Beguiled by promise of increasingly fantastic solutions, the momentum often prevents the couple's pause to reconsider personal needs. Nonetheless, they periodically reassess their desire for parenthood, weighing up the emotional, physical, and financial toll of their predicament against the intensity of their wish for a child. Lucky ones conceive; others continue to pursue conception, often well into menopause. Some desist from IVF treatment, allowing fate to take its course. Resigning themselves to childlessness, some grieve their losses, take up contraception again, finding emotionally rewarding avenues apart from parenting. Yet others now invest their energies in pursuing increasingly unattainable adoption of a baby. A proportion go on to seek solutions that may involve receiving donated gametes/fertilized embryo, or surrogate gestation. In these cases reproduction becomes a medically orchestrated production, with long-term emotional repercussions for offspring and parents.

Because assisted reproductive ‘success’ is often measured by conception, parenthood following prolonged infertility may come as a surprise, fraught with the sudden switch of self-image and extensive demands, often involving treatment-induced twins or triplets and complications due to prematurity. Nevertheless, a study of IVF mothers rate them as highly attentive and the infants more playful (Papaligoura and Trevarthen, 2001), perhaps because of the emotional investment of producing them. In all cases, provision of a therapeutic space for individuals/couples/families to think about the ramifications of their ordeals benefits all involved.

Finally, to the question of why some people are so devastated by the inability to conceive while others adjust, albeit with sadness. This seems related to ‘generative identity’. I propose that childhood recognition of the limitations of sex (being male or female), genesis (not self-made), generation (only adults procreate), and generativity (it takes two) can take three courses, either: (1) acquiescence and promise of future reproduction; (2) denial, leading to gender dysfunctions; or (3) a poetic leap into creativity as a means of imaginatively overcoming restrictions and deferment. In adulthood, infertility hits hardest those who have unconsciously invested all their potential creativity in deferred procreativity (Raphael-Leff, 1997, 2001).

The mid-life paradox is that of ‘entering the prime of life, the stage of fulfillment, but at the same time the prime and fulfillment are dated. Death lies beyond’ (Jaques, 1965, p. 504). Somewhere between 35 and 45 most of us begin to realize that half of life is over. Points of reference change with the individual's realization that s/he ‘has stopped growing up, and has begun to grow old’ (Jaques, 1965, p. 505). Taking stock we register unachieved youthful dreams and the unlikelihood of our anticipated outstanding contribution.

Mid-life reevaluation is precipitated by changing relationships to elderly or dead parents, to childlessness or self-reliant children. Shocked by illness or unexpected deaths we register signs of the biological clock's slowing down in our own bodies. Crisis may take the form of self-doubts, uncontrolled weeping, panic attacks, fear of loss or accidents, nonspecific anxieties, and resistance to change. Pertinent catalysts are failure of personal ideals and collapse of defensive illusions of reversibility, correctability and invincibility. Memory loss, discovery of one's ineffectuality at work or elsewhere, lack of influence over colleagues, politicians, or family members accompany growing awareness of one's own mortality. The quandary begins with a sense of irritation, confusion, and futility, which is then suppressed, or denied by manic counteractivity, but nevertheless returns with increasing insistence and urgency. Although dissatisfaction or meaninglessness is often pinned on environmental factors, ultimately we come to identify interior origins of our own state of mind. In health the process forms a cyclical sense of defendedness against ‘alienation’. As conflicts we try to resolve prematurely gradually build up, this leads either to inauthentic solutions and ‘stagnation’, or to a courageous self-examination promoting ‘regeneration’ and a gradual shift from reliance on external to internal referents (Polden, 2002).

Freud's is one of the earliest depictions of a mid-life crisis. His self-analysis began aged 40 after the emotional upheaval instigated by his father's death. Delineating shared origins of dreams and symptoms, he combined his ambition to be a scientist and theoretician with his youthful dream of becoming a great healer (Lohser and Newton, 1996). Some years later, the 37-year-old Jung described both the pain of his split from Freud, and the fruitfulness of his psychological turmoil eventually leading to individuation (Jung, 1930). Like Freud's generalization from recognizing oedipal residues and intimations of mortality in himself, Jung also emphasized applicability of his theories to others. Erikson (1980) indicates that vicissitudes of growth following crises are determined by the subject's capacity to be identified with others. The ability to feel that one belongs to a whole—a family, a society, the human race—makes the idea of one's individual finitude tolerable.

The psychological scene of the reality and inevitability of one's own eventual personal demise is defined by Jaques (the psychoanalyst who invented the phrase ‘mid-life crisis’), as its central and crucial feature. Death—at the conscious level—instead of being a general conception, or an event experienced in terms of the loss of someone else, becomes ‘a personal matter, one's own death, one's own real and actual mortality’ (Jaques, 1965).

Self-transformation induced by the changing sense of time includes reappraising the past and questioning future actions. By liberating ourselves in middle adulthood from the codes and regulations of those who formed us, we gain freedom but have to relinquish illusions of absolute safety and familiar assumptions that guided us (Gould, 1993). Reexamina-tion of values and expectations occurs with a gradual acceptance of becoming an ‘elder’ (Settlage et al., 1988). Preoccupation with time restrictions and aging instigate a powerful intrapsychic shift from being left to leaving, culminating in late adulthood coming to grips with illness/death of contemporaries and oneself (Colarusso, 2000). Grandparenthood may form a narcissistic buffer against old age, providing emotional refueling and a sense of genetic continuity as well as a screen against separation anxiety regarding the shrinking self and world. It offers a benign means of denying imperfections in oneself by selective identification with desirable qualities of the grandchild (Cath et al., 1989). Likewise, the mature individual may achieve a form of wisdom that enables him or her to become a ‘keeper of meaning’, guiding others in the preservation of past cultural achievements (Vaillant and Koury, 1993).

Part of mid-life development takes place within intimate relationships wherein unconscious heritage and irrational forces from the past are recognized as obsolete ‘scripts’. Healthy relationships are predicated on respect for separateness and ability to tolerate difference and integrate contradictions. In couples, this depends on synchronous rather than asymmetrical personal growth of both partners, who also simultaneously work at deepening the relationship itself. However, separations after collapse of long-term commitment or a partner's death may prompt growth. In the absence of the Other (unconsciously relied on to process or ‘hold’ one's feelings) inhibited people may experience an upsurge of autonomy or recognize their emotional vulnerabilities (see Polden, 2002).

Similarly, a time comes in middle age when we begin to question the unrewarding achievement-oriented busyness of our pressured lives. Typically, resistance to insight in middle age externalizes internal conflicts on to relationships or work situations. Initially, the solution seems to lie in life-style modifications—drastic changes of environment, job, and/or partner. Excitement of an illicit sexual passion, romantic escape to sea or countryside, compulsive activity or conversely, withdrawal from work in absenteeism or stress-related illness. However, when the erotic affair becomes domesticated or the new place overfamiliar, mid-life discontent returns with a vengeance as the external solution fails and internal patterns reassert their defensive hold. The definition of mid-life depression as ‘inhibition of feared aggression in the face of loss of status’ (Polden, 2002, p. 226) links the destructive grip of depressive guilt, self-doubt, and helplessness to breakdown of defensive coping mechanisms. Psychotherapy explores how avoidant or ambivalent defenses were originally developed to combat early insecurity.

Although men continue to be fertile until their 80s, a common feature of later years noted by a variety of practitioners and researchers is a decrease in gender dimorphism. The phantasmic integration (possibly eased in both sexes by biochemical changes and hormonal reductions) of feminine and masculine aspects of the self, which might have been suppressed earlier in adulthood. Jung (1930) described ‘psychic androgeny’ after a 6-year period of numerous dreams and intrapsychic struggles, during which he coined the term ‘anima’ to describe his own feminine muse.

This shift towards ‘psychic bisexuality’ (as Freud called it) is not without its stresses, particularly in macho men, who passionately pursue overt masculinity. An Older Adult Program at Northwestern Medical School found that first hospital admissions for acute psychiatric illness in men aged 55–65 revealed similar early histories underpinning a variety of presenting symptoms, ranging from severe alcoholism, diffuse anxiety states, to significant and often suicidal depression or paranoid psychosis in a wide socioeconomic and ethnic spectrum of patients. Hemmingway is cited as an example of this syndrome. The common denominator of breakdown is a sense of ‘manhood at risk’. Case histories reveal repudiated early identification with a ‘destructively dominating’ gender-defying mother while at the same time unconsciously retaining her ‘driving ego ideal’ for him to resemble the maternal grandfather. Simultaneously, denied affection for, yet identification with, the defeated fathers (Gutmann, 1990). Male late onset disturbance begins with threatened reemergence of early feminine traits, usually connected to increasing mid-life independence of a previously submissive, needy wife for whom he served as Protector. As cultural acceptance of female assertiveness increases, the equivalent crisis in women is recognizable as a feature of hysteria, obsessionality, or manic disinhibition.

The major form of psychic disability in older people worldwide is depression, peaking around mid-life and again in old age. Many times more prevalent in women, depression is consistently linked to stressful life events entailing losses: breakdown of marriage or bereavement; menopause, loss of sexual attractiveness and fertility; failed hope of having a child or loss of identity related to ‘empty nest’ sense of worthlessness, and/or declining professional recognition with belated motherhood or retirement. In women late onset psychoses too, tends to be depressive.

A ‘third individuation’ (Oldham, 1988) occurs when, caring for aging parents, middle-aged ‘children’ are suffused with revived recollections of the invincible parents of childhood. Watching them falter brings home human frailty and the inevitability of pain and eventual death. Illness, separation, and loss inevitably arouse intimations of mortality and lack of a parental buffer between self and grave shifts one a generation. Loss of living repositories of early experience leads to poignant awareness of one's own faulty archival memory and potentialities that are no longer possible. Regression and turmoil, resurfaced unresolved parent–child conflicts sometimes results in prolonged ‘melancholia’ rather than mourning. Bereavement, with adult reworking of the integrative ‘depressive position’ (Klein, 1940), leads to relinquishing omnipotent forms of mental functioning, allowing appreciation of long denied losses. This new crisis often brings mature people to analysis or therapy with great benefit. Accepting loss brings liberation and the further stage of autonomy achieved by confronting one's own mortality and limitations.

Interestingly, studies of spousal loss in mid- and later-life find that bereaved partners who showed little grief after their spouses died were the best adapted over a 7-year follow-up, apparently related to realistic adult expectations. Although grief reactions are varied and not highly predictable from the dynamics of mourning, they are intrinsically self-limiting. The less stunting the marital relationship prior to the death, the more limited the grieving, and the greater the probability of personal growth (Lieberman, 1993). Prolonged grief responses involve the highest dependency, guilt, and anger toward the deceased and benefit from bereavement counseling/therapy.

Sex differences are striking with 25–30% of successful suicides following spousal death occurring in men over 65; far fewer occur in older women seemingly due to their anticipation of widowhood and preparation for loss. Women tend to place more emphasis on relatedness than men, engaging others in emotionally satisfying ways that bring about a ‘postspousal individuation’ (Colorusso, 2000)—flowering follows mourning, learning to be alone as opposed to lonely. Others dedicate themselves to grandmotherhood, travel, or study, or find new creative resources within themselves and a sense of liberation.

Time is relative. If in healthy adulthood the 20s are a transition period in which attitudes toward time are still strongly influenced by childhood experience and physical growth, the 30s constitute an adult watershed. Now too old to die young (Dorfman, M., 1994, personal communication), time sense is dominated by mid-life themes, as signs of physical aging shatter childhood and adolescent notions of time in unlimited supply, which is gradually replaced by ‘the shift from time left to live to time lived’ (Neugarten, 1979, p. 890). As puberty forces psychic reorganization, so dwindling fertility changes the sense of self. Approaching 40 the shift from ‘physical progression in childhood to physical retrogression in adulthood’ is integrated. A poignant emotional sophistication experienced by a healthy individual as ‘an exquisite mental state which, perhaps more than any other, defines what it means to be human’ (Boschan, 1990).

Time operates on memories, bringing trauma within the purview of the self. Freud's theory of ‘nachträglichkeit’ locates psychic-metabolization of experience in ‘retrascription’—stratified reframing or recontextualization of memory at each new developmental phase (‘successive registrations represent the psychic achievement of successive epochs of life’ (Freud, Dec. 6, 1896). A central feature of the emotional upheaval of later life is reformulation of past experience within a different sense of human temporality; and acceptance of irreversibility and finitude.

The intensity of a mid-life crisis clearly relates to disturbances in defenses that have served to deny death. Patients with predominantly narcissistic pathology often stop and ‘freeze’ time both to negate their own finitude and to protect themselves from contact with emotions, their own and others’. As omnipotent control of time fails, they are confronted with ticking of the biological clock and inevitability of death. In therapy they reveal the threat of destruction posed by others and a narcissistic difficulty in subject/object discrimination (Boschan, 1990). Similarly, confrontation with the fact that time is running out for the achievement of grandiose dreams, may result in despair. Finally, Time stretches ahead to be filled. In women, relative longevity raises the odds they may live as long after menopause as before it (Greer, 1991), and those who have lived in the shadow of others may feel invisible or suicidal in their absence.

Psychoanalytic or psychodynamic therapy fosters the central task of accepting reality limitations and overcoming the fear of death (presented symbolically as fear of psychic death), which may release creativity, depending on the quality of internal relationships. Integration of essentially realistic positive internalizations in the course of therapy creates a benign psychological context that enables the individual to cope more effectively with subsequent vicissitudes of the life cycle that begin with a mid-life crisis and continue throughout aging and senescence (Blatt and Blass, 1990).

Both the old idea of phase-specific maturational tasks and contemporary emphasis on a potential for continuous (albeit nonlinear) growth have fostered growing acceptance of older adult therapy (contrary to Freud's pessimism about nonamenable rigidity). Indeed, therapy is sought for specifically age-related issues—such as diminution of potency, changing marital relations and/or empty nest syndrome; retirement or loss of effectiveness at work; aging, the race against time and the inevitability of death. ‘Developmental tasks’ achieved by mid-life relate to ‘love, work, and play’: ability to enjoy one's sexuality; capacity to relate to people in depth; awareness of one's ambivalence and concern about aggression towards one's loved ones; satisfaction in hard work, leisure and meaningfulness of life. Failure in any of these indicate pathological defenses (Jaques, 1965; King, 1980; Hildebrand, 1982; Kernberg, 1993; Limentani, 1995).

In conclusion, exceedingly rapid contemporary sociocultural changes, complex postmodern admixtures, and fragmentation create disordered life cycle sequences and disrupted intrapsychic and psychosocial adaptive systems. Seen in this context, disturbances often form a defensive reorganization, breakdown, or arrest with a potential for reformulation and change. Therapy in later life offers space for contemplation for those who cannot find it in solitude. When the capacity to enjoy being alone has not been acquired in the childhood presence of a loving nonimpinging carer, it may have to be learned (and fear of solitude unlearned) in the presence of a therapist (Winnicott, 1958). The invariable ingredients in all types of therapy are provision of a safe confidential space and reliable, neutral but caring therapist. Growth of the therapist by confronting suppressed aspects of his/her self stirred up while sitting with the patient, will reflect both intrapsychic and interpersonal pressures.

While cognitively oriented therapies rely on guided reformulations of maladaptive patterns to install more rational ones, psychodynamic treatments encourage emotional reexperiencing of past configurations within the therapeutic sanctuary, and freedom to explore anything that arises in the mind, however irrational. Words (and silence) within the ‘playground’ of therapy often disclose unprocessed archaic forces coexisting alongside increasing sophistication. Older adults who can relinquish certitude and overcome resistance to ambiguity, gradually form newly discovered unconscious linkages thereby enriching a well worn narrative of love, work, and play.