Birth Psychodrama
 
Senior Psychologist Neşe Karabekir, Psychodrama Therapist and Educator, Pregnancy and Childbirth Therapist
When founder of Psychodrama J.L.Moreno defined the theory and hypothesis of Psychodrama in 1920s, he in fact unknowingly laid the foundations of prenatal and perinatal psychology and psychodrama.
Moreno sets out from the spontaneity phenomenon in developmental psychology. From the onset which is embryonal stage, individual who spontaneously interacts* (has an actual relationship) with one's own world, brings the concept of role to all dimensions of one's own development by taking at least one role in each moment of one's existence.
Moreno says that 'childbirth is the first spontaneous act of mother and baby'. But baby starts acting in mother's belly as early as embryonal stage; it is a parasitary act and a parasitary role. Together mother and baby prepare for childbirth throughout the whole pregnancy as a functional organic unit. This is why in birth process spontaneity of baby is important alongside development. Moreno terms this as 'S. Factor'. ( 1974, Ozbek, Leutz)
Prenatal embryonal stage and the moment of birth are crucial. Newborn infant makes transition from the life inside the uterus to outside world thanks to the ability of spontaneity; this way, a transition from parasitary role to newborn's somatic role occurs. Moreno identified all of baby's roles with the birth; these are somatic, psychic, social and transcendental roles.
Latest studies refer to 12 separate senses which fetus develops in mother's womb. (2003, Chamberlain) The existence of various senses such as sense of touch, hot and cold, pain, sound, balance and finding direction in space, smell, taste, sucking/ licking, discovering with mouth, vision, telepathic connection with parent, and feeling of transcendency, are proven. These senses should be analyzed in the light of Moreno's role hypothesis as well, and also contain somatic, psychic, social and transcendental roles as can be seen. And this tells us that baby starts to take all these roles in mother's womb, before birth. Therefore prenatal psychology is vital.
Although it does not fall under this definition, prenatal psychodrama is held by psychodrama therapists in both individual and group therapies. Expectant mother faces with herself, her baby, her partner, her mother, her fear of childbirth, and moment of birth, and acts in some scenes, and this way she both finds closure from the past, and rehearses the future in a safe environment. Individual and group therapies held with expectant mothers regarding prenatal stage will be referred to in subsequent articles.
This article is predominantly about 'Birth Psychodrama', an unprecedented therapy/ applied for the first time in the world.
Examples also contain some case studies (with changed names) from various births in which the writer has personally participated in the last three years as a Pregnancy and Childbirth Therapist. (54 Childbirths between 2010-2014):

WHAT IS  BIRTH PSYCHODRAMA?
Moment of Birth psychodrama involves using individual psychodrama during whole birthing process, especially for expectant mother, in situations that requires it. Every single definition/ term in this sentence should be clarified: What is birthing process, how long does it take? What are the situations that might require psychodrama? Should the applications exclusive to the mother involve others like expectant father etc.? What is individual psychodrama, is there any difference between individual and group applications?
Let's begin with the last question. Because individual psychodrama techniques will be discussed in this article minimally, You can find the details of these techniques as a separate section in the Psychodrama Group Therapy Handbook in which the writer was a guest author.  (2000, Altınay,D.) 
The most important detail regarding individual psychodrama in moment of birth psychodrama is therapist being a guide and as active as possible, and feeling spontaneous enough to play various roles during sessions. All individual psychodrama techniques can be used in accordance with the needs, depending on the stage of birth. Sometimes in situations when moving is difficult, only mental psychodrama (mental role changing technique) can be utilized. In particular, changing roles with the baby, and taking baby's role are widely used. It is possible to work with everything such as people, events and fears, feelings, old memories that come to expectant mother's mind during birth process. When therapist changes roles, it is as effective as when the expectant mother changes roles with these. So the therapist should eminently undertake all of the functions of members in group therapy.
In Moment of Birth Psychodrama, it is important that the therapist is informed about pregnancy and childbirth psychology, all drug-free techniques, birth physiology and medical interventions aside from therapist's own area of expertise, and utilize these when required (endorphin massage, breathing, mental space, suggestion, affirmation, music, sound, light). Because the therapist will accompany the mother during birth process, he/ she should also be trained as a doula (birth supporter). Therapist must be informed about all pros and cons of all possible medical interventions. Therapist must speak the same language with the birth team in decision-making process, and know what each intervention means to the expectant mother.
There are stages in birth process: early labor, dilation, labor, delivery of placenta and post-natal stage ( Coker, H. Childbirth with no Regret Education lecture notes). Every birth has its own timing and this is why it is conditional for the therapist to be informed of these stages and general medical rules. Therapist should be able to anticipate which subject to work on for which stage of childbirth, and what the expectant mother needs in each stage. In early labor, therapist can also hold an individual psychodrama session to work on tensions, which might cause obstructed labor. Dilation mainly occurs during in hospital (giving birth at home is rare and in current health system, this happens rarely in big cities, if any). In this stage, individual psychodrama can be used in situations when dilation halts, labor does not progress, prolongs for no apparent physical reason and  mother starts to feel birth waves as pain due to stress.
In moment of birth, not only the mother but also the expectant father, family members, and doctor/ midwife may benefit from individual psychodrama. This stage is discussed in detail in Childbirth with no Regret (R) philosophy (www.dogumakademisi.com). This article merely addresses moment of birth practices for mothers. But regardless of the delivery method, for the birth team working with the philosophy that aims a childbirth with no regret for everyone who witnesses childbirth; the personal traumas, prejudices, psychological blockages of father, family members (especially mother's mother) and health personnel can affect childbirth and the mother who is open to all stimuli in moment of birth. This is why individual psychodrama sessions can be held for everyone who unintentionally disrupts moment of birth, if needed.
Moment of birth incorporates all the lifetime fetus spent in mother's belly, the  memories of mother and father, especially mother, all blockages, traumas, positive and negative moments. Here we see that Moreno's philosophy of MOMENT is before us in all its clarity. MOMENTS contain both the past and the future. MOMENT OF BIRTH contains all the past and the future as well. This is why Moment of Birth Psychodrama both incorporates all the elements of psychodrama, particularly individual psychodrama, and at the same time presents a completely authentic technique and hypothesis along with it. 
Features of Moment of Birth Psychodrama:
 All basic techniques of psychodrama and all subsidiary techniques of individual psychodrama are used. ( 2009, Altınay, D.) Therapist is the guide and supposed to enter into and change many roles and be active.
 During birth process, depths of life can be experienced in a very short time.
 Goal is to overcome obstructed labor, non-progression and stress.
 It is a practice which can be used before any medical intervention, has no side effects, and quite often prevents unnecessary intervention.
 It is never an alternative to medical intervention; but it is supplementary. Sometimes it is sufficient in facilitating childbirth, and sometimes helps mother to accept a medical intervention.
 Efficiency is increased when the doctor, midwife and hospital personnel are open and respectful towards this practice. It is significant when doctor makes room for it before or during medical intervention, and midwife acts in accordance with the results of this practice; this is how teamwork occurs.
 Individual and group sessions held with the expectant mother during pregnancy, facilitates and speeds up moment of birth psychodrama. Even if no sessions were held during pregnancy, best results are achieved. Because during pregnancy, especially in moment of birth, woman has a distinct brain frequency. This frequency called alpha frequency which occurs in brain during total relaxation, hypnosis, suggestion or meditation, makes expectant mother open to all stimuli. This is why it is possible to use this state of openness positively.
 As mentioned before, therapist should be informed about childbirth preparation methods, and trained as a doula, and utilize instincts and creativity.
According to Moreno, after childbirth, even during pregnancy, mother is the double of the baby. Following the parasitary role in mother's womb and transition to social placenta stage, other roles begin. Social placenta procures interactions and human relations necessary for social development, just as organic placenta provides the fetus with nutrients for organic development.
The most crucial addition in moment of birth psychodrama, is the placenta functioning as some kind of double during pregnancy. It is significant that the colloquial term for placenta is  “baby's double” , and it may be supporting this hypothesis in connection with collective subconscious. Placenta feeds the baby throughout the whole pregnancy via umbilical cord. Blood and all liquids are transferred from mother to baby, and baby to mother without mixing.
The foundation of Moment of Birth Psychodrama was shaped around the following facts:
1) Placenta is the common double of both the mother and the baby. Both during pregnancy and childbirth, particularly subconscious knowledge flows from mother to baby via placenta.
2) The alpha frequency in moment of birth facilitates surfacing of subconscious. With the help of this frequency, the individual who would normally need lots of warming up and scenes, can access very deep records in a short time during moment of birth. ( 2006, Brizendine)
3) Oxytocine and endorphin leading, birth hormones provoke the ecstasy (transcendency) stage in moment of birth and causes mother to be open to all stimuli.
Case studies below are in words of Childbirth Therapist:

CASE 1) ELİF (28 years old. first pregnancy)

We held several sessions during pregnancy, and she had a comfortable pregnancy. But in the last month of her pregnancy, her father passed. Elif's husband told this to her over the phone, she went there and had the chance to say her goodbyes. She felt at ease but of course she would like her father to see her daughter. She was comfortable when labor began, she was focused on birth. It was obvious that no one or nothing  could impair her concentration. She was at home when birth waves started, our midwife went over to check her and there was dilation, everybody was happy. When dilation reached 6 cm, they arrived at the hospital with our midwife and her husband. This is the time when the doctor and I (pregnancy and childbirth therapist) go to the hospital. Doctor makes necessary checks, and I evaluate everyone's psychological state. Although everything was looking normal, in several hours it turned out that there was no progress. Halt in progress is common, but the waves had stopped which means that birth was obstructed. It was so that they had started chatting with the midwife. They spent a night like this, the labor had completely stopped at 6 cm. It was time for moment of birth psychodrama. Otherwise the next step would be giving her artificial oxytocin, colloquially artificial pain/ induced labor (it is instilled intravenously, a chemical which artificially induces contractions) and she did not desire that. But it was also important how long the doctor would wait with the size of dilation. Elif and I had some private time and the frequency of waves allowed us to work. I asked her to take the role of baby. We had tried this before, during her pregnancy. Then, she had changed roles to ask the baby what kind of birth baby would desire, and if there was anything baby wanted to tell us. It was easy for her, and baby started talking through mother. And at that moment we realized why the labor was obstructed. As the baby was speaking through her mother, he said he was with his grandfather, they were spending time together, this was why he delayed his delivery just before he was coming out, and that was really important at that time. He was very clear and determined, and speaking very confidently. I expressed that I understood the situation well, and that this encounter was a great opportunity. I asked what they were doing. He said they were sitting and chatting. I asked if the grandfather had anything to tell us or his daughter. When he said “my grandfather is a bit offended by his daughter,” I told Elif to stop and take her father's role. This time she sat on the armchair in the hospital room, as her father. After I asked his name, how he was and so on, (I decided not to prolong the session because birth waves were back) I started playing Elif. Father said he was a bit offended because she ignored his passing; he could understand that she was in the last month of her pregnancy and trying not to get upset, but he demanded more attention anyway. He wanted to give his grandson some life lessons. Then we changed roles; I became the father, and Elif herself. This catharsis was very useful for me. Because I wanted to complete the session before waves became more frequent. She apologized to her father in tears. She confessed that although she was very sad, she was acting and trying not to face it, for baby's sake. Her father had already forgiven her, he gave her some tips for the baby. Elif and her father said their goodbyes. As I was still playing the father, I hugged Elif and wanted her to bid a real farewell.  Because the waves were more frequent, instead of asking her to take the baby's role again, I wanted her to watch her baby and her father saying goodbye to each other in her mind. I told the baby that it was time for him to come to us. I was already working on her breathing and giving her massages for birth waves, until her midwife arrived. From then on, Elif knew what to do. It was enough for me to speak as a therapist to  leave all the roles (in moment of birth psychodrama a deroling ritual isn't always necessary.)  I called her midwife, and after giving her the necessary information and telling her which words to use to facilitate the labor, I left the room. I separately informed the father waiting outside and the doctor. The labor continued after wards without a halt and Elif happily met her baby.    

CASE 2: SEVDA (38 years old, second birth) Sevda could not experience her first childbirth as she had desired, and was almost traumatized. Later she came to the conclusion that she was not well-prepared, and came to childbirth education with her husband; she exercised, worked on the traumas of her first birth. In her first labor, she had allowed her mother to be with her so she would not be offended, or upset. But her mother was a dominant woman and told what to do and what not to do throughout the whole childbirth. She became her nightmare although she had meant well. After the labor, she did not want to see her mother for a long time. When she came to us for the first time, recalling her labor was still bringing tears to her eyes. We held sessions both with her and her mother during her pregnancy. This time she wanted to have water-birth, and she was convinced that the second labor would be easier anyway. She was also happy that the issues with her mother in first labor had been resolved. She was ready for her birth. Her mother had also realized what she had done wrong in her first childbirth, and decided not to be in the hospital this time. I was the one to inform her about the birth process, via phone. In the meantime, I also held a session with Sevda's husband. (While working with expectant mothers, I make sure I hold meetings with their husbands and mothers. If it is necessary and I think that they are affected, I also meet with other prominent female family members such as sisters, aunts, sister-in-laws.) During our session, Sevda's husband Ahmet mentioned that Sevda was very influential in the family, and was the one calling the shots. (I kept this in my pocket. I keep the information I might need for the mother during childbirth, from all sessions.) Labor began but it was slow, midwife spent 24 hours with them in the house, and went to the hospital when labor speeded up.  A birthing pool was ready and filled for her in the hospital. After some time, as the labor was going really well,  it was time for her to enter the pool and she did. Water always relaxes and sometimes even makes us think that waves stop. After Sevda entered the water and spent several hours there, labor which was going really great was obstructed. Her doctor and midwife urged her to get out of the pool, but she was resisting to that, thinking that if she was to get out, they would never let her back in, and water-birth was what she wanted. When she started to have a conflict with her doctor and midwife, I told everybody to leave the room. I had asked her doctor to allow us to hold a session before. I calmed her down and said “Let's talk to your baby,”. She was still inside the pool, and I was outside. I asked her to take the baby's role with help of relaxation and some special techniques. The baby's name was Deniz. I asked Deniz how she was, what was going on. Deniz said she was jammed, and definitely wanted to go out. I said “We too are waiting here for you, but there may be some trouble,”. Sevda playing the baby, started to cry and in a baby's voice “I cannot come out like this, water scares me, I cannot go,”. She was both crying and splashing the water inside the pool. She kept crying, saying “I don't want my name, nothing works out the way I want it to, always whatever my mother says,”. I calmed Deniz down, told that I was going to speak with her mother, that Sevda would never want her baby to feel that way, and she had assumed that water-birth would be more comfortable for the baby. I told Sevda to get out of the role. She was astonished. She realized that she treats her baby the same way her mother treats her. I joined this with the information her husband gave me. She said she would treat her children and husband differently from then on. She asked me to call the doctor, she was going to leave the pool. When she left the pool, her labor regained its previous speed in a few hours. She totally let herself go and met her baby the way her body (in fact her baby) wanted. Baby's name was not Deniz anymore.
Moment of Birth Psychodrama is about working with what is healthy, spontaneous, and creative while staying on Moreno's course. Childbirth itself is health, spontaneity, creativity. This way, generations that come into this world with respect, love, with people  valuing their birthrights and  their needs during childbirth, will be healthy too.
September 2013
Senior Psychologist Neşe Karabekir, Psychodrama Therapist and Educator, Pregnancy and Childbirth Therapist/ Co-Founder of Istanbul Psychodrama Institute and Istanbul Birth Academy
nesekarabekir@istpsikodrama.com.tr
nesekarabekir@dogumakademisi.com
 
Special thanks to Gulru and Baby Pamir for sharing their moment of birth with us.

Sources
Altınay, D. (2000). Psychodrama Group Therapy Handbook- A lot about Life. Sistem Publishing
Altınay, D. (2009). Psychodrama 400 Warm-Up Games and Subsidiary Method. Sistem Publishing
Brizendine, L. (2006) . Female Brain. Say Publishing
Chamberlain,D. (2003). Communicating with the Mind of Prenate in JOPPPAH
Çoker, H. (2006-2013) Education for a Childbirth with no Regret Lecture Notes www.dogumakademisi.com
Özbek A. & Leutz, G.(1987). Interaction on Stage in Psychodrama Group Psychotherapy, Group Psychotherapies Association