Awaiting the therapist s Baby A Guide for Expectant Parent practitioners

by April E. Fallon and Virginia Brabender

Awaiting the therapist s Baby A Guide for Expectant Parent practitioners Author April E Fallon and Virginia Brabender Isbn 9780805824933 File size 21MB Year 2003 Pages 384 Language English File format PDF Category Family and Friendship The passage into and through pregnancy and new parenthood is one that affects all aspects of a therapist s life including work with patients It presents special therapeutic challenges as well as special therapeutic opportunities Drawing on the scattered literature interviews with people who have been in the roles of therapists

Publisher :

Author : April E. Fallon and Virginia Brabender

ISBN : 9780805824933

Year : 2003

Language: English

File Size : 21MB

Category : Family and Friendship

A Guide for Expectant Parent-Practitioners

Irving B. Weiner
Advisory Editor

A Guide for Expectant Parent-Practitioners

April E. Fallen
7776 Fielding Graduate Institute
The Medical College of Pennsylvania

Virginia M. Brabender
Widener University


Mahwah, New Jersey

Copyright © 2003 by Lawrence Erlbaum Associates, Inc.
All rights reserved. No part of this book may be reproduced in
any form, by photostat, microform, retrieval system, or any other
means, without the prior written permission of the publisher.
Lawrence Erlbaum Associates, Inc., Publishers
10 Industrial Avenue
Mahwah, NJ 07430

Cover design by Kathryn Houghtaling Lacey

Library of Congress Cataloging-in-Publication Data
Awaiting the therapist's baby : a guide for expectant parent-practitioners / April E.
Fallen, Virginia M. Brabender.
p. cm. — (The LEA series in personality and clinical psychology)
Includes bibliographical references and index.
ISBN 0-8058-2493-6
1. Women psychotherapists. 2. Pregnant women. I. Brabender, Virginia. II. Title.
III. Series.
RC440.82 .F355 2003


Books published by Lawrence Erlbaum Associates are printed on acid-free paper,
and their bindings are chosen for strength and durability.
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1

We dedicate this book to the mothers in our lives
who have mentored us in our transition to motherhood.
April pays tribute to Elizabeth Fallon,
Elizabeth Englemann Goers, and Marie Englemann.
Virginia honors Elizabeth Brabender, Virginia Ruhling,
Mary Scalise, Lillian Weisfeld, and Frances Whitmore.

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Judith Schoenholtz-Read






Patient Reactions to Therapists' Pregnancy: Dimensions
of Transference


Therapists' Reactions Within the Therapeutic Setting:
Dimensions of Countertransference


The Developmental Journey From Pregnancy to
Motherhood: Psychological and Physiological Changes
and the Management of Their Impact on Treatment






The Developmental Status of the Patient



The Diagnostic Status of the Patient



The Therapeutic Modalities





Relationships With Peers and Supervisors



The Adoptive Parent


When the Therapist's Wife Is Pregnant:
Entrance Into Fatherhood


Conclusions and Future Directions






Author Index


Subject Index



Getting pregnant, being pregnant and giving birth is a major life passage
for any mother so it is surprising that many aspects of the experience have
been silenced in our literature. Where do we go to find the stories of pregnancy? What literature has captured the passionate, sometimes frightening fantasies as well as the profound physiological changes that occur
in pregnant women? Where are the stories of spouses, lovers, children,
parents, and colleagues all affected by the many and diverse changes taking place in the expectant mother? Carolyn Heilbrun (1988) in Writing a
Woman's Life lamented the literary void. She explained that women's biographies have been incomplete and that vital female experiences have
been omitted. The price our culture pays for the silencing of women's intimate bodily experiences is costly in psychological terms.
What matters is that lives do not serve as models; only stories do that. And it is a
hard thing to make up stories to live by. We can only retell and live by the stories we have read or heard. We live our lives through texts. They may be read,
or chanted, or experienced electronically, or come to us, like the murmurings of
our mothers, telling us what conventions demand. Whatever, their form or medium, these stories have formed us all; they are what we must use to make new
fictions, new narratives. (Heilbrun, 1988, p. 37)

The meanings and interpretations of female bodily experiences during
pregnancy are uniquely individual yet women tend to seek to understand
them through the external messages powerfully embedded in our culture.


Images of pregnancy as a period of confinement, a time of vulnerability
are still with us. Within my lifetime, pregnant teachers were not allowed
into their classrooms, flight attendants could not work, nurses had to
take leave from their profession, to name a few examples. Pregnancy was
something women had to endure behind closed doors. Many popular
movies promoted and still promote the pain and danger associated with
childbirth and disconnect women from the complex physiological
changes they experience. Little attention is paid to the importance of sexuality as it relates to pregnancy. In a fashion-centered world, women's relationships are often threatened by bodies that swell and sometimes never
return to their pubescent form. Different families, ethnic and religious
groups celebrate and ritualize the period of pregnancy and childbirth with
ceremonies that focus on the gender of the child where the woman's body
is a vessel for the lineage and provides continuity for traditional values.
As Daniluk (1998) stated, sexuality is shaped by "unique biological, psychological and social realities" (p. 19), and so is pregnancy.
By weaving the narratives of pregnant women therapists gathered
through their research and the research of others, April Fallen and Virginia Brabender have eloquently crafted a complex and scholarly map to
help guide both pregnant therapists, their supervisors, colleagues, and
students. The clinical vignettes highlight the rich variety of unique personal experiences and frame these in the broader therapeutic context as
they play out in the expectant mother's progression from conception
through childbirth as seen in therapy sessions, supervisory interactions
and family relationships. Within an analytic framework, the deeply personal stories are related to therapeutic issues and techniques; they provide
very practical guidance about how to handle difficult issues that inevitably arise. The authors' talent in integrating research and personal experience in the analytic framework should inspire the pregnant therapist to
deal with the many issues that have been left unspoken.
This book is skillfully organized to reveal how pregnancy creates complex sets of relationships and contexts. It breaks new ground in exploring
the unique set of concerns faced by the therapist who is adopting and the
therapist whose partner is pregnant. The relationships are given voice,
understood and communicated to enable the therapeutic process to flourish. The multiple levels of interactions in the role of the pregnant therapist
with the patient and the supervisee within the broad professional and
family context are systematically examined. The structure acknowledges
the influences of the clinical setting, whether private practice or community/hospital clinic. The authors' consideration of how the pregnancy or
the adoption affects clients with different diagnoses ranging from the seri-



ously mentally ill to patients with personality disorders to those with less
profound distress, is a significant contribution to a rather scant literature;
the powerful and often frightening fantasies that are sometimes awakened both in the patient and the therapist are recognized. The reactions of
child and adolescent patients to pregnant therapists are carefully examined; the authors offer useful advice about the appropriate therapeutic
techniques. Difficult themes of envy, jealousy, and hate and related problems associated with patients' acting out are identified as they occur in
therapeutic relationships.
Focusing on the mutual dance of interactions, the authors clearly and
sensitively present dilemmas related to the central issue of therapist transparency and decisions about self-disclosure. They also offer information
on practicalities including how to schedule appointments during the pregnancy, what to say when taking leave, returning or terminating practice,
and how to handle being sick. For adoptive parents, there is advice on
how to make clinical decisions amidst the uncertainty that often accompanies the adoptive process. Throughout the book, research is cited and
described in support of points.
Fallen's and Brabender's perspective is optimistic and brave as they
navigate intimate waters through each trimester in the pregnancy. They
have offered therapists invaluable tools and guidance not to be found
elsewhere in dealing with the many unusual issues facing the expectant
parent. The human aspect of therapeutic work so easily neglected comes
alive through a therapeutic metaphor: the fetus within the therapist's
womb can represent new life for all in the relationship—mother and
child/therapist and patient.
Judith Schoenholtz-Read, Ed.D.
Fielding Graduate Institute
Santa Barbara, California

Daniluk, J. C. (1998). Women's sexuality across the lifespan: Challenging myths, creating
meanings. New York, NY: Guilford.
Heilbrun, C. G. (1988). Writing a woman's life. New York, NY: Ballentine.

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We are grateful for the many individuals who have helped us with this endeavor. This book could not have been created and written without their
collaborative effort. Along the way we met a number of people who spontaneously and enthusiastically shared their personal experiences with us.
We also would like to thank all the therapists, men and women too many
to mention by name, who completed our questionnaires and interviews at
a point in their lives when time was very precious and juggling professional and personal lives was often a struggle.
Our initial efforts at developing questions, interviewing, and collecting
vignettes were aided by Dr. Nadine Anderson, a postdoctoral student,
and two spirited graduate students, now full-fledged psychologists—Lori
Maiers and Keeley Rollins. They were also central in networking to find
therapists with the appropriate life experiences who would be willing to
share their experiences. Some of this research was also financially supported by a Provost Grant from Widener University.
Many colleagues and friends supplied us with leads on willing participants, brought our attention to relevant literature, provided us with particularly poignant and personal clinical material, and/or contributed editorial comments. In particular we wish to thank Beth Albrecht, Susan
Anderer, Joan Cooper, Gloria Crespo, Francine Deutche, Ted Fallen,
Tammy Feldman, Rachel Ginzberg, Stuart Lipner, Corinne Masur, Sam
Osherson, and David Ramirez for their special efforts.
We want to thank the editorial staff at Lawrence Erlbaum Associates
who carefully and critically read every word that we wrote. In particular



we wish to acknowledge the special efforts of Susan Milmoe, whose patience and enthusiasm for our project was especially appreciated, and
Eileen Engel, who brought this manuscript to final fruition. A special
thanks goes to Judith Schoenholtz-Read who agreed to write a foreword
and who carefully read the entire volume and produced a thoughtful review in record time. We also want to thank the special secretarial efforts
of Kim D'Eletto, Carol Bricklin, and Helen Pokropski.
Lastly, we wish to acknowledge the importance of our families in this
work. Our children, Emile, Jacob, and Gabi, provided us, first hand, with
the life experience which became the subject matter of this book. Our husbands, Rao and Arthur, both willing participants in this life transition,
gave us their enthusiastic emotional support to complete the project and
with little complaining aided us in the additional childcare hours required
to complete such a project.


The metamorphosis into motherhood is a transformational experience
both personally and professionally. Pregnancy is a wonderful time in the
life of a woman. Yet at the same time, it is one of enormous anxiety and
stress, for multiple reasons. In order for a woman to traverse this developmental milestone, she needs to engineer and revise personal and professional identities, quell and reorganize her internal conflicts, develop a relationship with her neonate and adjust her other relationships, and
handle the concomitant changes in self-esteem as a result of all of the
above. These demands are stressful. Depression and anxiety are the two
most common manifestations of her stress. The depression rates for
mothers with young children are considerably higher than those with
older children (Rubenstein, 1998). These symptoms and the general experience of stress can in turn negatively affect fetal and infant development
(Dunkel-Schetter, 1998; Rini, Dunkel-Schetter, Wadhwa, & Sandman,
1999). Stress, in particular, is associated with a decrease in birth weight
and early delivery. Ensuing early maternal expectations of vulnerability
can then hinder the development of the child.
Pregnancy and motherhood, of course, are not new phenomena. They
are ensconced in culture and tradition for millennia. What has changed
from previous generations is the unique way in which the current generation of women is attempting to define, improvise, and negotiate multiple
professional and personal identities in a climate in which cultural definitions of those identities are murky and fluctuating. More women are
working outside the home and for longer hours than in the past. For ex1


ample, in 1950, 12.6% of married mothers with children under 17 worked
outside the home for pay. In 1994, this figure increased to 69%, and 58%
of wives with children 1 year or younger were in the workforce (Hochschild, 1997). In addition to greater numbers, since the 1980s the average
worker has increased his or her work by 164 hours per year, the equivalent of 1 month's worth of work (Schor, 1992). Thus, as Hochschild
wrote, "More women were on board the work train and the train was
moving faster" (1998, pp. 6-7). The struggle to accomplish this work and
balance home responsibility is more difficult and draining than in the
past. As Lerner so aptly put it in The Mother Dance, "Most mothers
struggle with how they will nurture both their babies and their work, a
struggle for which terms like balancing and juggling seem far too glib"
(1998, p. 43). Yet, women who desire to work outside the home and do so
reportedly have better mental and physical health (Hochschild, 1997).
Working for pay offers challenge, social ties, control, positive feedback,
and structure.
As training directors and psychotherapy supervisors, we both have had
repeated experiences of having anxious students and trainees in psychology, psychiatry, and social work, as well as young professionals enter our
offices eager to discuss their pregnancies and its implications; they expressed concern about how this life event would affect the continuation of
their training both in the classroom and in the field. How would they be
able to manage the demands of pregnancy and, ultimately, of a young
child simultaneously with their enormous work responsibilities? Would it
even be possible for them to do so? How would their patients respond?
Would their supervisors be understanding of their needs for special accommodations? If they received such accommodations, would their compeers resent it?
Listening to the fears and concerns of our students invariably whisks
us back to an earlier point in our own careers when each of us dealt with
the circumstance of pregnancy. At that point, we were both fairly established. Nonetheless, each of us faced a myriad of special issues. For example, each of us was running a long-term psychotherapy group and needed
to decide whether to have an interval in which the group did not meet or
to hire a substitute therapist. We silently wondered whether our professional images would be altered in the male-dominated psychiatric institutions in which we practiced and what the consequences of the shift might
be. Would motherhood imbue us with projected attributes that would encourage our colleagues to view us as more maternal or as less available to
patients? Would these projections in turn foster or discourage their referrals to us? Like our students, we too, wondered if we could integrate our


disparate responsibilities in an effort to do it or "have it all"? Or would
the combination of motherhood and professional activity essentially ensure the compromising of our careers and the emotional shortchanging of
our children and family life? If we feared that others would see us as less
competent, it was perhaps because we feared we might become so. At the
same time, we suspected that this new experience of attachment that accompanies a pregnant woman and then a mother could only deepen our
understanding and empathy of all whom we encountered professionally.
Certainly pregnancy—especially a first-time pregnancy—presents the
therapist with much that is new. There are two levels that must be successfully negotiated by the mental health professional so that pregnancy
can be a catalyst to her work: the feelings engendered in her and those
around her and the practical decisions imposed on her by her newfound
state. These two levels are deeply intertwined, for each pregnant woman
must traverse her own and others' projections, and these in turn affect
the practical decisions she makes. With regard to the first, the therapist
must brook the spectrum of feelings, fantasies, conflicts, and impulses
that are activated within her and in those around her by the pregnancy.
Moreover, this negotiation is necessary regardless of theoretical orientation. For example, if a therapist using a behavioral regimen is attempting to have a patient proceed through a desensitization hierarchy for a
phobia, but the patient is consumed with feelings of envy toward the
therapist because of her pregnancy, the therapist will be forced to
reckon with the envy in order for the patient to fully participate in the
desensitized procedure.
The second level the therapist must address is the series of professional
practicalities and decisions that pregnancy presents. The moment it is
confirmed, she can choose to either reveal it to others whom she encounters professionally or to withhold the information until a later time. She
must decide whether to accept new patients and responsibilities or to
abridge her current activities. Many other necessary decisions present
themselves as the pregnancy progresses. The therapist's ability to navigate her own vast sea of feelings and those of others surrounding her
pregnancy will inform her decisions. And the quality of her professional
decisions will undoubtedly affect her sense of well-being during and following the pregnancy and also affect the well-being of those with whom
she interacts. There also may be long-term professional consequences of
her choices made during pregnancy. For example, failure to provide a severely disturbed patient with the necessary supports during the maternity
leave could lead to suicidal gestures or lesser forms of self-destructiveness.
On the other hand, the therapist's careful forecasting of, and planning


for, the maternity leave may strengthen the severely disturbed patient's
capacity for trust.
The complexity of the experience of pregnancy for the therapist and for
those in her professional environment in conjunction with the demand on
her to make good clinical judgments requires that she has access to abundant resources to help her through this period. Of particular benefit are
any tools that will help her anticipate her own likely reactions to the pregnancy as it progresses as well as the reactions of others. For example, a
therapist who knows that sexual acting-out is a common response in certain types of patients to therapists' pregnancies will respond to nascent
manifestations of such acting-out with alacrity and equanimity. If these
are handled with forethought, the therapist will be less likely to react with
the confusion or guilt that can deter a prompt but well-formulated intervention. Resources will also enable the therapist to appreciate the diversity of possible solutions to the problems that present during pregnancy.
For example, many therapists have thought about the issue of how to
communicate with patients about the birth of the baby and about the advantages and disadvantages of providing various types of information
such as the gender and health status of the child.
In the past, women mental health professionals struggled over how to
define professional identity and integrate their professional selves with
their personal lives, as well as how to manage their patients in an altered
framework. It was a lonely struggle, as there were fewer women in the field,
and they generally did not want to call attention to any differences from
male counterparts. Many were worried that if they revealed their difficulties, they would not be taken seriously as professionals; pregnancy was
viewed as a liability. We were struck by the stories of pregnancy told by
some of our more senior colleagues and by the few brave souls who published accounts. Female therapists described their feelings that many patients were not aware of their pregnancies, their sense of inadequacy to deal
with the associations around the pregnancy, their concern that to call attention to their pregnancy when patients did not make direct statements focused on their narcissistic desires, their frustration that their supervisors
had so little to say about their pregnancies or their work with the "elephant
in the room." One therapist told us that her supervisor, a kind elderly male,
in his attempt to be helpful insisted that she have a reprieve from supervision until after she returned from her maternity leave, although she intended to continue to see patients for another 3 weeks. Most authors who
mentioned pregnancy and its impact on the therapeutic interaction for
both the therapist and patient alluded to it primarily in negative terms.


As Lazar put it, "I think every pregnant therapist is faced with a sense
that she is introducing a gradually increasing intrusion into the patient's
analytic space" (1990, p. 213). Pregnancy, an exciting life event, was a deviation in the therapeutic frame, provoking issues and conflicts around
loss, early mother-child relationships, sibling rivalry, and sexuality. With
a sigh of relief, some before us found that most patients could deal with
these issues as they were manifested in the therapeutic context during
pregnancy. Yet, for many therapists, there was little discussion, which
greatly increased the potential for acting out to occur. Likewise, for the
therapist, pregnancy stirred up dormant intrapsychic conflicts potentially
making her more sensitive to her patients, and at the same time more vulnerable to her countertransference. For the therapist in isolation, her own
issues may have contributed to her inability to recognize the impact that
the pregnancy had on her patients, thus rendering her ineffectual in dealing with the therapeutic material. There were practical issues to manage
as well, which without consultation would require each pregnant therapist to reinvent the solutions. Indeed, in prior decades, pregnant therapists had few resources available.
Now various kinds of resources may be available to the therapist in
formulating an approach to the consequences of her pregnancy for her
work as a therapist. Certainly, a rich source of information and support
are colleagues who faced the circumstance at some earlier point.1 Supervisory colleagues may be particularly helpful. They may be aided by their
own past experiences in recognizing responses to the pregnancy that are
both common and unusual on the part of the patient and practitioner.
The supervisor's empathy for some of the difficulties the pregnant therapist experiences is also likely to be a much valued resource.
Another potentially valuable resource is the growing literature on the
pregnant therapist. Certainly if one is in a professional environment
where role models are lacking, the literature on this topic becomes an important substitute. Beyond this, however, the pregnant therapist can consult the literature to help her delve more deeply into some aspect of her
experience, sometimes in concert with others in her professional environment who are interested in this topic. We have identified myriad articles,
several dissertations, and one prior book written on the topic of the pregnant therapist. Whereas early attempts to cover this topic dealt primarily
with the pregnancy's ramifications for the long-term individual therapy
'As we discuss in chapter 8, it is not unusual to have multiple pregnant staff particularly
in internships and psychiatric residencies.

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