The Therapists Pregnancy
Barbanel, L. The Therapist&Mac226;s Pregnancy, B. Blum (ed.), Psychological Aspects of Pregnancy, Birthing and Bonding, New York: Human Science Press, Ch. 14, 1980.
A therapists pregnancy must be dealt with in therapy. Avoiding the discussion of the therapists pregnancy whether or not the patient spontaneously brings it upinvolves the denial of patients perceptions. These perceptions properly belong in the treatment situation. Four clinical examples will be presented, two for whom the Therapists pregnancy led to greater integration and growth, and two for whom it resulted in greater disruption.
A subsidiary thesis relates to the topic of miscarriage, a topic even more absent in the psychological literature. Here too, to deny and to avoid the discussion of the topic where the therapist clearly has experienced a miscarriage is to deny the patients experience and to avoid an opportunity for associations that can offer rich material for therapeutic exploration.
Having experienced four pregnancies in 5 years, two resulting in live births and two in miscarriages (one late enough in the pregnancy to necessitate sharing with patients the sad news), it became clear that the patients reactions to the pregnancies was an important ingredient in their treatment. Some patients openly asked if I were pregnant; others symbolically (by dreams) announced recognition of my condition while others had to be told of my pregnancy. Among the issues that required consideration were transference and countertransference aroused; relationship of the patients dynamics to recognition of the therapists pregnancy; and the issue of the therapists pregnancy as related to the broader issue of the woman therapist.
Although there is some literature on the topic, it is scattered and incomplete. It is my contention that this is not accidental, but reflects certain notions about therapists, pregnancy, and the combination of the two. Lax (1969), cited only two previous papers on therapists pregnancies (Hannett, 1949); Le Bow, 1963). In a more recent review of the literature, five more articles on the topic (Benedek, 1973; Browning, 1974; Nadelson et al., 1974; Paluzny & Poznanski, 1971; Schwartz, 1975), and one chapter in a book (Balsam, 1974) were found. Although these six articles do not constitute a complete treatment of the topic, the contrast between the period before 1969 and after is striking. The simplest explanation for this change might be an increase in female therapists of childbearing age who are seeing patients and having children. On the other hand, it my be related to social and psychological changes resulting in female therapists becoming more likely to write about their experiences with patients during their pregnancies. Statistics are not available to test either hypothesis, but I suspect the latter to be true. I believe that in the past there was denial of the therapists pregnancy in the literature, by the therapist and by the patient. The recent openness of discussion is worthy of greater exploration.
Many factors support denial, by both the patient and the therapist. The topic of pregnancy is generally not discussed in our society. Many women avoid telling that they are pregnant until the pregnancy is quite advanced. It is not considered polite to ask a woman if she is pregnant. Historically, women went to great pains to hide their pregnancies. Among Orthodox Jewish women, for example, the fact that a woman is pregnancy is not mentioned throughout her entire pregnancy. Euphemisms are used to describe pregnancy, e.g., expecting, in a family way, with child. In the literature on pregnancy and its effects on the pregnant woman, there is a smattering of discussion of the taboo against discussing ones own pregnancy. Klein (with Potter and Dyk, 1950; Klein, 1957) suggests that some of this taboo relates to the fears about pregnancy and the notion that talking about it might make the feared outcome come true. Childbirth is associated with pain, danger, and death. The pain of childbirth, the danger to the mother and child, has an enormous written and oral history. From biblical times onward, the fears and suffering of women have been associated with childbearing. From generation to generation, the stories, myths, and tragedies get passed on. The incidence of death in childbirth has been reduced enormously in our society, yet birth and death are clearly associated in the unconscious and sometimes conscious awareness of most people. Both birth and death are mysterious and unpredictable. Both resist human control and have elaborate mythologies, religious rituals, superstitions, and fears surrounding them.
In therapy, presumably, these taboos on discussion should not operate. In the therapeutic setting, the unthinkable and unmentionable can be thought and mentioned. Sexual associations, angry thoughts, even homicidal impulses, not mentioned in polite company are all permitted in the therapeutic session. However, all of this is with the basic ground rule -accepted by most therapists- that the therapist must remain anonymous. The therapists pregnancy is a most personal matter, involving a very blatant admission of sexual activity. It is a statement about a relationship to a man and to a family. Not only is the therapists pregnancy clearly a violation of the rule of the therapists keeping her personal life out of the consulting room, but it is a violation that is unique to women therapists. Pregnancy is certainly not part of the therapist-expert-doctor (i.e., male) role. It is, therefore, out of the purview of that role. If to be female is somewhat suspect to the therapists role, then to be pregnant is to be guilty. Guilty because ones female functions intrude and, paradoxically, because one cannot fulfill the female functioning of mothering ones patients. It follows from this that if the pregnancy has to occur, it is certainly better that it be kept out of the consulting room as much as possible.
If the therapists pregnancy is not discussed, the patient and therapist can recreate the parent-child situation, where certain secrets, namely of the bedroom, are not discussed. As we know in relation to secrets that parents attempt to keep from their children, the children always know on some level. Child therapists help children to verbalize this knowledge. To not do so with adult patients, because of some notion about anonymity, would be carrying the notion of anonymity to an extreme that Stone (1961) describes as involving pathologic or pathogenic avoidances (p. 37).
Patients knowing of the therapists pregnancy can be expressed many ways. Often, this knowing is expressed quite early in the pregnancy. For example, a 26-year-old female patient noted the abstract design on my print dress, interrupted herself in the middle of the completely different topic, and exclaimed, the design on your dress looks like fallopian tubes. This dress has been worn before with no comment from her. This comment was made on the exact day that my pregnancy had been verified. Around the same time in another pregnancy, an unmarried female patient reported neglecting birth control for the first time. Another patient became pregnant and had an abortion. A fourth patient began to report dreams about babies. It is certainly possible that these were coincidences, and were related to the transference relationship, independent of my pregnancy. However, it is not likely. It is more likely that these are instances of different levels of knowing. Pregnancy is an area where the irrational abounds. Bibring (1959) writes that with the increasing emphasis on the scientific in our society, less attention is paid to the irrational, emotional aspects of human experience. Such instances, as described above, strike one as that irrational side of human understanding.
Assuming that each of the above examples indicates the patients subliminal awareness of the therapists pregnancy, this awareness might be regarded as a kind of primitive identification with the therapist and therefore with her pregnancy. This plausible explanation is difficult to prove. Of the four patients cited, not one of them was the kind of patient who somehow guessed or intuitively knew other things about the therapists life. Rather, the receptiveness seemed related specifically to pregnancy and to childbirth and the meaning that it held for the patients. For each of the patients, the therapists pregnancy caused a great deal of upheaval. It is possible that the most unrelated patients make the most primitive identifications, and notice the pregnancy the earliest. Lax (1969) found that her borderline patients became aware of her pregnancy much earlier, and reacted with greater intensity. Also, she noted that patients diagnosed as borderline found it much more difficult to differentiate between transference and reality aspects of the situation.
The amount of denial some patients use in relation to the pregnancy is enormous. Lax (1969) reported that male patients use denial to a much greater degree than do female patients. A 20-year-old male patient, whom I started to see during the 5th month of my first pregnancy, was told that I would be away for 8 weeks in the summer. I did not mention that I was pregnant. He persisted in not noticing. When I did tell him, at a point where not noticing was quite unlikely, his reaction was You mean you wont be traveling this summer? Although it may be true, as Lax found, that for male patients the therapists pregnancy causes less upheaval than for female patients, this was not the case for this young man. The extent of his upheaval will be described in case C.
Other denying patients notice some change but do not attribute it to pregnancy. Several patients commented on my gaining weight, and associated it to my overeating because of neurotic problems. In fantasizing about the kinds of problems I might have, the problem of not having a man and of being homosexual were mentioned frequently. When these patients were asked what else getting heavier might be associated with, two patients replied: Youre not pregnant! In both cases, it was preferable for the therapist to be neurotic, without a man, and/or homosexual to her being pregnant. During one of my pregnancies, a patient noted that I had had my hair cut, but did not note the pregnancy. Along with her comment about my hair being cut (a rather minor change compared to the physical changes related to a 6-month pregnancy) she stated, I never notice anything usually. Another patient said that my style of dress had changed in the last 6 months; she wondered why.
Denial or avoidance on the patients part is easy for the pregnant therapist to reinforce due in part to countertransference issues. Some (e.g., balsam, 1974; Paluzny & Poznanski, 1971) have noted the tendency of pregnant women to withdraw psychic energy from the outside world and to retreat to her inner world. Others (Bibring, 1959) note that the transient nature of pregnancy leads to avoidance by the therapist. Still others (Paluzny & Poznanski, 1971) note the tendency of the therapist to be less interested in the theoretical side of treatment.
No mention is made in the literature of the positive countertransference manifestations that may be evoked by the therapists pregnancy. This might reflect a standard of the therapist as male. With that standard, the therapists or other womens issuespresent only negative effects and problems. However, it would seem, and experience confirms, that the pregnant therapist might experience some positive effects in the treatment that is related to the pregnancy. The therapists pregnancy can present an opportunity for the patient to mobilize ideation that leads to problem solving and resolution as well as to disruption and regression. Nadelson et al. (1974) points out that working through the conflicts around the therapists pregnancy can be therapeutic for the patient. Similarly, although the therapist may find herself withdrawing energy from the therapeutic situation to her own body, she also may find that her empathic and intuitive resonance with patients is heightened as she becomes more sensitized to her own body. Although the scientific recedes, the irrational and emotional side of the process can become more available.
When the therapist consciously decides that the pregnancy must be dealt with in the treatment, several issues arise. These include when it should be brought up (if the patient persists in not noticing); how much should be discussed with the patient; and in what cases should the pregnancy be used as a corrective educational experience for the patient (i.e., discussing the mystique and mis-education about pregnancy). The answers to these questions depend upon the patients developmental level. There are patients who will never bring up the therapists pregnancy, as there are patients who do not bring up other topics without encouragement. There are patients for whom a passing comment might be sufficient and excessive dwelling might reflect the therapists self-involvement rather than the interests and needs of the patient. Particularly important in the patients history is the mothers pregnancy history with the patient and/or siblings. Also developmentally important is whether or not the patient has children. Most important is the degree of the patients pathology. Where the patient has difficulty distinguishing on any level between reality factors and transference factors, the most intense reaction to the pregnancy, and inversely the most intense denial, is likely to occur.
Whether the pregnancy remains a superficial topic in the treatment or a rallying point for many current and past fantasies, it is likely to evoke certain specific issues. Themes evoked include sibling rivalry, Oedipal problems, separation anxiety, envy, sexuality, hostility and competition, and fear of abandonment.
An adaptation of categories developed by Paluzny & Poznanski (1971) is used to discuss the following cases. Patients reactions to a therapists pregnancy are divided into two groups: those for whom the pregnancy offers the opportunity for greater integration and those for whom the pregnancy results in greater disruption and regression. A distinction between the use of the material evoked by the therapists pregnancy to deal with current life situation or to deal with problems rooted in early life circumstances also is made.
Case A. Integration and the Use of Material Evoked to Deal with Current Issues
A, 28-year old aspiring singer, came to treatment because of an incapacitating depression that was at times, accompanied by suicidal thoughts. She had been unable to look for work for some time. At the start of treatment, she was a housewife for her husband and their cat. Her relationship with her husband was stormy, with loud angry fights, both verbal and physical. The fights seemed to have at their core competition and power issues. He was a successful businessman. When she became at all successful in singing (e.g., a performance with favorable reviews), he increased his demands for wifely services. When he was invited to a prestigious social event, she became too depressed to go.
A was the only child of immigrant parents. Her father had wished to be a singer but had become a successful lawyer instead. Her mother, a rather passive narcissistic woman, had made it her ambition to make A into a star. Dancing and singing lesions along with a great deal of grooming effort had made up her childhood. A was extremely pretty but felt that her prettiness was of no use. She stated: People think that things come easily to you because youre pretty, but you never get anything really important from being pretty. It was not clear that A wanted to be a singer. She could not achieve much; she believed that only people like her husband or me, her therapist, could achieve. When she did achieve something, she immediately denigrated it. As the treatment progressed, she found herself more able to do things other than singing and the depression lifted somewhat. She and her husband both wanted a child and she attempted to conceive. After some time with no success, they found through medical tests that he had a problem that could be corrected by surgery.
During her fertility testing, she had a dream in which I appeared as her mother. With much prodding, she associated the dream to my pregnancy. She reacted with delight; she had noticed that I was getting heavier but had not wanted to mention it. During the course of my pregnancy, she spoke only of delight in it, how the pregnancy meant that she could have a baby also, etc. At the same time, the mother in her dreams turned into a dark, foreboding, witchlike character. Her associations revealed that she felt I was too powerful at times, both active and fecund, and therefore potentially destructive. That I did not become destructive and yet remained active was somewhat curative for her.
As surface delight was congruent with her need to identify with me as the good, active mother. It was through this identification that she was able to give up her depression. (My pregnancy did not symbolize for her the birth of a sibling; sibling rivalry was not a significant issue in her life.) Shortly before treatment was terminated (prematurely because of her husbands job taking them to another city), she had a reinstatement of the depression and suicidal impulses that put her into a panic state. She telephoned me several times in great fear. Although I said very little to her on these calls, except to indicate that I was available to her, at the next session she reported that she felt she had really beat the depression. She had let me in; she would never be along with the depression again. It was like living in a house alone; once you let somebody else in, youre never alone in it again. For this woman I was the benign identification model. When my pregnancy ended in a very late miscarriage, A reacted to the news with tears. By this time in the pregnancy, the malevolent witch was not appearing any longer for her. Although we explored her hostile wishes in relation to me and my pregnancy, what was most striking was the way in which she was able to use this experience to find her own strength. I had survived; she could survive and she could offer genuine sympathy.
Case B. Integration Through the Evoking of Primitive Associations.
B, a 26-year-old woman, has been treated for several years at a clinic. This previous treatment had been quite successful in helping her go from an erratic work history to an advanced degree and a position of great responsibility in a large university. She had moved from her parents home to an apartment of her own. Her relationships with people had changed. When she first began treatment she had hardly any significant relationships. Slowly she had developed a few rather distant but enduring ones. She had one woman friend and had begun a pursuit of men. Two dates with the same man were about al she could tolerate at the time she began her second treatment. Her aloneness and feeling of being shut out and peculiar were most apparent in her presentation of herself. This feeling had its roots in her parents barely attending to her in favor of several other siblings, particular a psychotic brother, several years her junior. Symbolic of this was her sleeping in her parents living room because the psychotic brother refused to share a bedroom in the apartment with another brother. All of her siblings had a place in a bedroom; she alone slept in the living room.
B was one of the first patients to notice my pregnancy, which she came to through a dream about an older woman having a baby. Her immediate reaction was that I was foolish. Why would a woman want to have a baby? She would get fat, become burdened, not be able to work or have fun, etc. This was presented in her character bland, unrelated manner from which she went on to discuss the latest boyfriend and her problems having an orgasm.
Some time in the middle of the pregnancy, she noted that childbearing might not be too terrible if I were doing it. (I must have my reasons.) She informed me rather sadly that she did not think she could have children because of her problems. Towards the end of my pregnancy, when the presence of the sibling was very apparent and the ensuing separation had to be dealt with, B had a dream in which I was helping her decorate her apartment. With pain-racked sobs, she told me that if I had been her mother I would have made a place for her (a room for her?), as I must be doing for my baby. I would not have allowed her to sleep in the living room. Her feelings about her apartment (rather sparsely furnished), her men, and her own body followed this discussion.
Most apparent in her relatedness to my pregnancy was her primitive identification with me as her mother, herself as baby, and the somewhat helpful use that she could make of it. Her relatedness to the pregnancy had much more transference than reality to it. It somehow provoked the deepest of pain for her and ultimately some resolution of it.
An interesting postscript was Bs reaction to meeting me and my, then, 9-month-old daughter on the street (she lived in the same neighborhood). B stopped and made some nice comments on the child. During the next session, she spoke of how she felt it was important to me that she say nice things about the baby. She experienced her opinion to be valuable to me. Clearly, she was able to see herself related to me as another adult and not only her mother.
Case C. Denial, Regression, and Flight.
C, a 35-year-old man, was the oldest male child of four. He was much favored by his mother and ambivalently attached to her. His persistence in not noticing my pregnancy with yet another sibling reflected his difficulty with this ambivalence. When this pregnancy resulted in a late miscarriage, he almost immediately asked to use the couch. He insisted that it would be easier to talk while not facing me. He was able, therefore, to deny and isolate the fact of the pregnancy and the death of his hated sibling. Other important issues in his life identification with his mother and pregnancy envycould also thereby be avoided. These interpretations were not made to C. I, erroneously, believed that it was too soon in treatment for such interpretations. C left treatment soon after to take a business trip for several months. He came back in a panic from the interrupted trip because he had, in a rate that frightened him, almost killed a man that had cheated him in a business deal. Treatment resumed at that point with the connections made to the therapist and her baby as the hated objects that he wished to kill.
Case D. Disruption of Treatment to Handle the Intolerable
D, a 28-year-old graduate student in English literature, was in treatment with me during all of my four pregnancies. For her, birth was associated with death. She could not tolerate either pregnancies or miscarriages. The eldest of three sisters, she was supposed to replace an elder male sibling who she had watched die as a young child. This replacement plus the death of a friend of hers during the first of my pregnancies, made my miscarriage intolerable for her. Her anger and hostility toward me, as well as her guilt for the death of the fetus, was too much for her to face. She left treatment for 6 months, by which time she assumed it would all be over. The second pregnancy, (resulting in an early miscarriage), went unnoticed by her. During the next pregnancy, she took a trip out of town, to return when it was over and baby and mother were home safely. During the fourth of my pregnancies, she stayed until I took leave, but called me several days after my leave began in great depression. Her mother had become ill, which was too much for her to deal with at that time. This telephone contact with her during my leave seemed to reassure her that I was still alive and available. She resumed treatment after the birth of my second child, somewhat better able to look at her depressions and regression, but never quite able to get to her deeper feelings about pregnancy, childbirth, and death.
For both patients, C and D, my pregnancies were intolerable, and resulted in enormous disruption and regression. Certainly there might have been better ways to deal with these patients so that flight did not occur. The important point is, however, that the pregnancy of the therapist was the occurrence that led to the greater disruption and potential disorganization of the patient.
The cases presented are meant to be illustrative, not prototypic. From them, we can see that as each patient presents a unique history and constellation of reactions, so it is the case with their relationship to the therapists pregnancy. Reactions vary as much as reactions to the therapist herself vary. Similarly, countertransference issues will differ for each therapist. The real personality of the therapist as always, will have its effect. For one therapist it is the stormy angry feelings of the patient that are the most difficult to relate to, for another, the tender protective feelings evoked in the patient may be intolerable.
In general, the pregnancy of the therapist evokes complicated reactions in treatment and strains the therapist understanding and skill. Several things are important. The pregnancy must be noted, explored at different stages of the pregnancy and allowed to flourish as an issue for discussion and an outgrowth of the patients history. Some decision about how long she will work has to be made by the therapist and communicated to the patients, whether or not they ask. Some decision about how much reality will be shared with patients must be made by the therapist, e.g., the date of birth, sex of child, nature of labor, etc. How much the therapist uses her pregnancy as an educational experience for patients, where applicable, has to be decided. These questions need to be answered individually by each therapist faced with them. The answers may vary according to the history of the patient and should have as their goal the facilitation of treatment.
Concerning miscarriage, Cain et al. (1974) show the neglect of the topic in standard textbooks of obstetrics and psychiatry. Considering the high incidence of miscarriage, this is striking. There is only one article (Hannett, 1949) that deals with an analysts miscarriage. The analyst did not tell her patients that the reason for her absence was her miscarriage. She left it for them to surmise or not. Cain et al. discussed childrens reactions to a therapists miscarriages, which are similar to patients reaction to a therapists miscarriage. An initial puzzlement, followed by guilt over the hostile thought towards the fetus that magically came true, guilt over envy of the therapist, and blame of the therapist for having actively killed her baby. Surely if the therapist could not carry a fetus to birth, she could not be an adequate mother to the patient. Along with these reactions are also the fears of childbearing that women patients have that get exaggerated. For male patients, all of the discomfort, fear, awe, and disgust that they feel toward womens insides get stirred up. For some, there is little deep meaning, for others very deep transferential issues come up leading to a period of chaos and hopefully resolution. The reactions vary, as do the reactions to the pregnancy itself, from minimal treatment ones to enduring profound effects.
The long-term effect of the therapists pregnancy on the treatment of a particular individual would be difficult to measure. My observations indicate that it can and should be used as a productive event in the treatment. Although it should be clear that great turmoil and disruption can occur, skill and creative handling of the situation can lead to movement in the treatment that might have otherwise not occurred.
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