The Therapist's Pregnancy

Intrusion in the Analytic Space

Sheri Fenster, Suzanne B. Phillips, Estelle R.G. Rapoport

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317758297
• Edition: 1
• Topic: Psychology
• Subtopic: Interpersonal Relations in Psychology
• Index: Psychology

In the first book-length examination of the impact of pregnancy on the therapeutic process, Fenster, Phillips, and Rapoport explore the variety of clinical, technical, and practical issues that arise out of the therapist's impending motherhood.

Chapter 1
Overview of the Literature

Psychological Aspects of Pregnancy

Pregnancy is generally portrayed in the research literature as a time of emotional and psychological upheaval. Such factors as increased depression (Tobin, 1957), psychological tension (Grimm, 1961; Light and Fenster, 1974), anxiety in the first and third trimesters (Lubin, Gardener, and Roth, 1975), mood lability (Jarrahi-Zadeh, Kane, Van DeCastle, Lachenbruch, and Ewing, 1969), diminished cognitive acuity in the first trimester (Murai and Murai, 1975) and in the third trimester (Jarrahi-Zadeh et al., 1969) and altered perceptual processes (Davids, DeVault and Talmadge, 1966; Colman, 1969) have been noted.

Indeed, in much of this literature pregnancy is seen as a hurdle to be overcome, with a hoped for return to the prepregnant state of psychological equilibrium (Breen, 1975). Other studies, however, have emphasized that pregnancy is a normal developmental phase. In this view, having a child is a critical transition period for most women and couples, involving alterations in roles, values, relationships, and physiology (Benedek, 1956; Bibring, Dwyer, Huntington and Valenstein, 1961; Pines, 1972, 1982; Breen, 1975; Ballou, 1978; Entwisle and Doering, 1981). These changes are seen as ultimately calling into question old solutions and leading to new levels of intrapsychic equilibrium and organization (Breen, 1975).

For example, the research or Bibring et al. (1961) sees pregnancy as entailing a general loosening of defenses, with "the appearance of more primitive content material, and major shifts in significant relations to people and activities" (p, 26). Bibring's sample was composed solely of primiparous women (first-time mothers), and her results suggest that a first pregnancy precipitates a normal developmental crisis during which partially resolved conflicts are revived, requiring a new intrapsychic organization of personality. The element of crisis is seen as a necessary and crucial facet of the movement from childlessness to parenthood. Crisis is seen within this framework not as pathological, but as a turning point in development. Moreover, much of the woman's psychological evolution is seen as occurring after the birth of the baby, along with the ongoing experience of motherhood.

Focusing on specific areas of flux, psychoanalytic writings on pregnancy stress the psychological pressure at this time to come to terms with one's feelings about one's mother (Deutsch, 1945; Benedek, 1956; Pines, 1972, 1982; Ballou, 1978). Benedek (1956) notes the pregnant woman's heightened dependency needs, which evoke feelings and memories of her early sense of her own mother. Pines (1982) describes a first pregnancy as an "important developmental phase in a woman's lifelong task of separation-individuation from her own mother" (p. 318). She also sees it as a "crisis point in the search for a feminine identity ... a point of no return" (1972, p. 333). Another task involves the acceptance of the internal representation of one's sexual partner, both physically and mentally. And, finally, Pines (1972) describes the pregnancy as a "visible manifestation to the outside world that (the pregnant woman) has had a sexual relationship" (p. 334). In general, these writers stress that the turmoil of pregnancy may, indeed, facilitate the transition to motherhood, rather than merely being a peripheral symptom of the pregnant state. Ballou's research (1978) suggests a relationship between the pregnant woman's ability to reconcile her sense of her mother with her own ability to establish a sense of her child as a person. Ballou discusses changes in feminity, identity, and marital relationship. In addition, Ballou also points out that the agitation of pregnancy may facilitate the transition to parenthood.

Research regarding parity is also of interest. Many research findings indicate that although multiparous women experience a shorter and less difficult labor, first-time mothers experience most other aspects of pregnancy more positively (Winokur and Werboff, 1956; Cohen, 1966; Grimm and Venet, 1966; Doty, 1967; Westbrook, 1978). Such factors as apprehension, rejection of the child, and dissatisfaction with the wider family all increased with increasing parity. Only the fear of pregnancy and of labor was higher among primiparas. Evidence from these studies thus suggests that the adaptational tasks facing multiparas, rather than being more easily accomplished, appear to be far more psychologically profound than those of first-time mothers.

Finally, a minority of studies has found pregnancy to be a time of general emotional stability for more women when compared with matched female medical patients (Osborne, 1977), with the MMPI standardization sample (Hooke and Marks, 1962), and with a control group of nurses and student midwives (Murai and Murai, 1975). Overall, however, the majority of research confirms the presence of at least some psychological tension and depression in the pregnancies of normal women. Mood fluctuations are seen to herald adaptive developmental processes.

The Pregnant Therapist: Alterations in Self

It seems safe to assume that the pregnant therapist can be expected to experience many of the intrapsychic, interpersonal, emotional, and developmental changes attributed to the majority of normal pregnant women. Nevertheless, only ten articles in the literature directly address the subject of the therapist's internal state during her pregnancy (Lax, 1969; Paluszny and Poznaski, 1971; Benedek, 1973; Nadelson, Notman, Arons, and Feldman, 1974; Balsam, 1975; Baum and Herring, 1975; Schwartz, 1975; Butts and Cavenar, 1979; Barbanel, 1980; Rubin, 1980). In addition, two unpublished pieces, one by Phillips (1982) and another by Titus-Maxfield and Maxfield (1979), take an extended look at countertransference phenomena. In general, the writers cited do confirm the presence of sometimes disruptive feeling states in the therapist at this time and discuss their ramifications within the therapeutic relationship.

A process or introversion, self-absorption, and withdrawal from patients has been noted during the therapist's pregnancy (Balsam, 1975; Barbanel, 1980; Baum and Herring, 1975; Paluszny and Poznaski, 1971; Phillips, 1982; Rubin, 1980; Schwartz, 1975). A hyperawareness of physiological changes, the presence of daydreams and thoughts about the baby, and a decrease in intellectual curiosity are factors that appear to make this a more difficult time for therapists to attend fully to their patients. While most authors view this self-absorption as generally distracting from the treatment process, Nadelson et al. (1974) assert that therapists often also experience a simultaneous and paradoxical increase in acuity and sensitivity toward patients at this time.

Also common to therapists during pregnancy is a stance of "business as usual" (Lax, 1969; Benedek, 1973; Baum and Herring, 1975; Schwartz, 1975; Titus-Maxfield and Maxfield, 1979; Phillips, 1982), By adopting this attitude, therapists are often seen as colluding with patients and staff in denying the impact of their pregnancy on their work and professional relationships. Titus-Maxfield and Maxfield (1979) understand this mechanism of "denial" as the therapist's effort to minimize the anxiety aroused by the unknown consequences that her pregnancy brings to the therapy. For example, they would find themselves "responding to [their] own and [their] patients' anxiety by attempting to treat the baby's birth as calmly and routinely as if it had been a trip to a professional meeting or a summer vacation" (p. 5). Similarly, Lax (1969) suggests that the therapist's tendency to not "hear" patients' allusions to the pregnancy reflected a fear of the patients' hostility and—specifically with male patients—the therapist's need to maintain a "narcissistic masculine identification" as well as to avoid the "rearousal of conflicts about femininity." Lax also noted the therapist's sense of guilt because of wishes to stop work and devote her time entirely to her baby as influencing her use of "denial."

Other writers point to the therapist's heightened vulnerability, mood swings, fatigue, and emotional lability at this time (Baum & Herring, 1975; Lax, 1969; Nadelson et al., 1974; Titus-Maxfield & Maxfield, 1979]. A common arena of conflict was also seen to be the therapist's feeling of inadequacy about her abilities to be a helping person because of fears regarding physical limitations (Nadelson et al., 1974; Rubin, 1980) and the difficulty of integrating the dual roles of motherhood and career (Nadelson et al., 1974; Schwartz, 1975; Butts and Cavenar, 1979).

A final area of concern noted in the literature is the clinical and personal issue of self-disclosure and exposure within the treatment setting. The therapist's pregnancy breaches the analytic custom of anonymity regarding one's personal life outside the treatment setting. Because of this breach, brought on by the therapist herself, consideration of how much the patient has a right to know, and what is best for the patient, is usual. Barbanel (1980) feels this decision depends on the patient's developmental level, and on whether the patient has siblings or children. Browning (1974) acknowledges the difficulty in knowing how much to reveal to child patients. Titus-Maxfield and Maxfield (1979) suggest that a focus on the genetic determinants of patients' reactions at this time is, in reality, the therapist's resistance to the difficult interpersonal process at hand. Changes in the therapist create tension in an otherwise reliable and consistent structure, and the therapist may react by avoiding the uncertainty of the present situation for such "knowns" as the patient's history. In addition, the therapist has heightened feelings of relatedness toward particular patients, especially mothers (Titus-Maxfield and Maxfield, 1979; Rubin, 1980).

Patient Reactions to the Therapist's Pregnancy

Although the structure of the therapeutic situation emphasizes listening to the patient without necessarily requiring that the patient be concerned with the therapist, it is generally agreed that the patient can, and often will, speculate a good deal about the therapist as a person.

Stone (1961) suggests that although therapists can control the explicit and manifest communications of their feelings and opinions, it is questionable whether other gross data can be suppressed. Yet, even if her patients can discern a good deal about her under normal circumstances, the pregnant therapist introduces information about herself—and an alteration in the analytic frame—quite unlike the everyday "data" discussed by Stone. In this regard, then, the literature on "special events" in the life of the therapy is pertinent.

According to Weiss (1975), a special event may be "anything which alters or intrudes upon the basic analytic situation" (p. 75). Tarnower (1966), Katz (1978), and Weiss (1975) all found a strengthening of transference paradigms as a result of such special events as the chance meeting between therapist and patient, the late arrival of the therapist, the therapist's illness, and the like. Rather than distorting the analytic work, these events allow glimpses into intense feelings and fantasies about the therapist that were previously held at unconscious or preconscious levels. Especially with patients who keep the transference pale, such special events are thought to crystallize the intrapsychic clash between the therapist as a real person and as a transference figure. In addition, these authors also point out the technical errors that are potentially part of such unforeseen events and the patient's (and sometimes the therapist's) wish to return to the previous "safety and regression of the analytic situation and to the silent gratification of the transference" (Weiss, 1975, p. 75).

Given this context, then, the therapist's pregnancy may be seen as such a special event in the therapy. The writers cited below discuss some of the predominant transference paradigms attributed to this event and the resulting ramifications within the treatment and the therapeutic dyad.

Lax (1969) presents material her pregnancy elicited in six adult analytic patients. She felt that whereas her male patients used denial and isolation much of the time, the women suffered a "profound transference storm" and ultimately identified with the therapist. Positive transference reactions were not discussed. Lax also suggests that patients who are only children react quite differently from those who have siblings, although these differences were not described in detail. The most striking distinction, however, occurred between her neurotic and her borderline patients. Lax felt that her borderline patients found it much more difficult to differentiate between the transference and the reality aspects of their reactions. These patients became aware of Lax's pregnancy sooner than the neurotics and reacted "with much greater intensity," including acting-out behavior. Overall, Lax describes a process in which, with her pregnancy, the childhood situation was recreated and she was "cast in the role in which the patient originally experienced the mother" (Lax, 1969, p. 364).

In an article devoted to the patient's initial recognition of the therapist's pregnancy, Goodwin (1980) reports that women tended to "recognize" the pregnancy sooner than men, a finding that is corroborated by Bender (1975). Goodwin also found that the more intensely involved patients also "recognize" the pregnancy early. Recognition may be expressed in acting out (missed appointments, rage outbursts at siblings, pregnancy) or associative material and dreams. Questions regarding confidentiality, statements about "something queer in the room" (Benedek, 1973), and sexual concerns were also seen as signs of a patient's undisclosed recognition of the pregnancy. Also addressing the issue of recognition is Barbanel (1980), who found that in preference to accepting the possibility that she might be pregnant, patients felt more comfortable assuming the therapist was fat, was gaining weight because she was without a man, or was homosexual.

Paluszny and Poznanski (1971) described patient reactions to their pregnancies during residency training. They noted central themes of rejection, sibling rivalry, oedipal strivings, and identification with the therapist and the baby in both their adult and their child patients. While they saw temporary regressions in some patients at this time, they did not feel there were any permanent setbacks.

Nadelson et al. (1974) comment on the upsurge in patients of feelings of sexual conflict, fears of abandonment, and memories of previous loss; the revival of issues with siblings, competition; and an intensification of the ambivalent mother—child relationship in the therapeutic interaction. From their work with children, these authors cite the child's accusations that the therapist is not a good mother as putting a strain on the therapist, who is simultaneously working through her own feelings about her maternal identity. In addition, children may ask frank questions about sex or may become physically aggressive as a result of their jealousy.

The effect of the therapist's pregnancy on the treatment of children is also addressed by Browning (1974). She points to the heightened mechanisms of denial, displacement, and fears of abandonment in children. Browning advocates telling child patients as much about the baby as they want to know because, in a sense, the baby "has become part of the treatment, unlike other aspects of the therapist's personal life" (p. 481). She acknowledges, however, that it "was not always clear just where one should draw the line in terms of how much personal information to reveal" (p. 481). Certain issues, such as who will be caring for the child, seemed particularly important for her young patients to ask about and discuss in therapy and seem to reflect a displacement of personal concern. The impact of the therapist's pregnancy on a child, and especially on adolescent patients, is an area that deserves further attention.

Titus-Maxfield and Maxfield (1979) discuss patients' concerns about how the therapist's pregnancy would change their relationship with the therapist. They noted patients' wishes to be helpful and to spare the therapist further stress. Also typical was an attempt to separate the person of the therapist from the therapy, which the authors understood as patients' wishes for a return to the previous anonymity of the therapeutic situation. In addition, the authors noted that some patients wanted to leave or terminate treatment after learning of the therapist's pregnancy. This withdrawal was seen as masking powerful feelings of dependency on the therapist, which had until then gone unrecognized.

Cole (1980) discusses the reactions of three female patients to her pregnancy. In each case, the pregnancy was viewed as highlighting the patient's own dynamics and issues, as well as intensifying the experience of the transference. One patient profited from the catalytic effects of the pregnancy regarding transference material, whereas another patient terminated precipitously because of intense feelings of abandonment. A third patient used reaction formation and denial during the pregnancy but could later express feelings of loss and envy. Similarly, Bender (1975) found that patients integrate their responses according to their individual histories and conflicts. She concluded that the pregnancy did not skew the treatment but, rather, intensified certain issues, particularly fears of abandonment. Patients commonly identified with the therapist as someone about to die or be injured.

Barbanel (1980) and Schwartz (1980) also describe the varying uses that patients make of the therapist's pregnancy, both positive and negative. Schwartz focuses her discussion particularly on the therapist who terminates with patients as a result of her pregnancy.

The differences between group and individual reactions to the therapist's pregnancy are examined by Raphael-Leff (1980) and Breen (1977), who noted family themes, sexual curiosity, and themes related to parental sexuality in their groups. In individual therapy, however, feelings of exclusion, deprivation, competition with the therapist's husband, envy of the therapist's creativity, and impingement by the outside world were expressed. Breen's sense was that the individual setting represented the early mother-baby relationship; the group setting the later child—family experiences. This does not mean that individual patients necessarily showed more primitive defenses than patients in group. Rather, the group could more easily use the defenses of denial and splitting, and the loss of the good therapist was not catastrophic. However, Breen felt that in the individual setting, the patient had to deal with ambivalent feelings toward the therapist-parent more intimately and directly.

Several authors have attempted to examine the social factors that have heretofore discouraged an examination of the therapist's pregnancy. Benedek (1973) suggests this avoidance results from pregnancy's being one aspect of a taboo subject, sexuality. Barbanel (1980) discusses the historical trend for women to hide, or not talk about, their pregnancies. She suggests that the taboo may relate to the fear that talking may result in a feared outcome (i.e., miscarriage). In addition, childbirth has, since biblical times, bee...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• 1. Overview of the Literature
• 2. The Fenster Study: Longitudinal Findings on Twenty-two Pregnant Therapists
• 3. Transference Themes and Patterns of Response
• 4. Countertransference Reactions During the Therapist's Pregnancy
• 5. Alterations in the Treatment Process: Implications for Technique
• 6. Management of Practical Issues
• 7. Treatment of the Adolescent Girl During the Therapist's Pregnancy
• 8. The Pregnant Therapist as Group Leader
• 9. Supervising the Pregnant Therapist
• 10. The Homosexual Patient and the Analyst's Pregnancy
• 11. The Impact of Motherhood on the Therapist
• References
• Author Index
• Subject Index