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Clinical Implications for the Pregnant CAT Therapist

Knight, A., 2008. Clinical Implications for the Pregnant CAT Therapist. Reformulation, Summer, pp.38-41.

Introduction

Whilst carrying out the CAT practitioner training I became pregnant. The limited literature about this led me to develop my own reflections on the impact of pregnancy on clinical practice. Below I have reviewed the general psychotherapy literature in this area and provided some thoughts with regard to CAT that are based on my personal experiences. I hope these reflections may prove helpful in some way to pregnant CAT therapists in the future, ad I would like to hear more from other people on the issue.

Literature Review

Psychotherapy literature relating to therapist pregnancy is sparse, and most of it appears to have been written in the arena of psychoanalysis. I could not find any literature written from a CAT perspective. There was only one book dedicated to this issue, written by three analysts following a survey of 22 pregnant therapists (Fenster et al., 1986). As noted by many authors, it is important to question why there is such a lack of literature on this topic. Lax (1969) suggested that it is an illustration of repression amongst therapists due to the female therapist’s need to maintain a “narcissistic masculine identification” and avoid “re-arousal of conflicts around femininity”. Wedderkopp (1990) also suggested that it reflects denial in the profession, illustrating the general social taboo about acknowledging sexual matters and also the difficulty of capturing and conceptualising the inner reality of clients’ experience.

Clementel-Jones (1985) makes reference to superstitions that surround pregnancy and how this could contribute to the professional silence. Barbanel (1980) noted that the denial supports social norms of not “telling” and of it being impolite to ask, which also result in the use of euphemisms such as “expecting’. I wonder if the lack of comment amongst therapists also reflects the fact that it is a very personal experience, which opens the therapist up to vulnerabilities both emotional
and physical.

The fact that the literature on this area lies within the analytic field inevitably influences its focus. However, a few key themes seem to emerge that are important to consider irrespective of the model one wishes to practice within and these are highlighted below.

A number of authors have made comment on how therapist pregnancy impacts on the therapeutic relationship. Lax (1969) noted that the therapist is no longer a “blank projective screen” but a “reality stimulus”. Although in CAT the therapist is not ‘faceless’, it is fair to say that up to this point the assumption is that the client will know little about the therapist’s life circumstances. Suddenly the pregnancy provides some information, and the potential for many assumptions or questions is raised for the client about the therapist as a person. This introduction of a third person or object can set up a triangular relationship within the therapy that needs acknowledging.

Wedderkopp (1990) explained that the therapist’s pregnancy could result in the client getting in touch with some core feelings by evoking a preverbal state. However, it is not only the client for whom this kind of experience may occur. Barbanel (1980) suggests that pregnancy can result in the psychic withdrawal of the pregnant therapist into her inner world, which results in the lessening of her logical ability and theoretical interests but which is balanced by an increase in her intuitive and empathic capacity. Similarly, Clementel-Jones (1985) suggested that a pregnant therapist could become more in touch with the “irrational and unconscious”. Bibring (1959) stated that the therapist experiences “benign depersonalisation”, a process of disintegration and reorganisation which means that the therapist may be facing similar issues as the client. This process may therefore provide an opportunity for the client and therapist to access more primitive feelings. Gottlieb (1989) noted the importance for therapist to be able to cope during this emotionally and physically vulnerable time without developing neurotic countertransference reactions based on her own pathologies.

Overall, these authors appear to be acknowledging that there is a lot of scope for new events to occur within the transference and countertransference processes and that the therapist needs to be aware of what could be activated for both her clients and herself during this time. There is also an acknowledgement within the literature that this can be very enriching for the therapy but that caution must be used because the therapist’s own feelings about her pregnancy, circumstances, and health also come into play. For example, a number of authors have noted that it may be common for the pregnant therapist to feel guilty or fearful about the client’s response. Lax (1969) noted that the therapist’s anticipation of the client’s hostility or envy could be evoked by the client’s sense of deprivation and also by unresolved conflicts within the therapist’s own life.

Alongside the potential for envy or hostility, there is the potential for the pregnancy to bring up a range of other issues for the client, such as rage, separation, Oedipal conflicts, and sibling rivalry (Gottlieb, 1989). Paluszny and Poznanski (1971) highlighted themes of rejection and identification with the therapist and Nadelson et al. (1974) commented on the client possibly experiencing feelings of sexual conflict. Berman (1975) carried out some research amongst nine pregnant psychiatrists and found that therapists reported increased violent behaviour, therapy termination, inappropriate sexual behaviour, and unplanned pregnancy amongst their clients.

Naparstek’s (1976) interviews with therapists suggested that they were surprised by the primitive, affect-laden responses of their clients. Some examples of how such issues could be acted out include: the client may feel things about the therapist’s ability to nurture and care for them dependent on the therapist’s ability to do so for herself and the baby; the client may envy the baby for potential displacement of them in the therapist’s care; the client may identify with the baby or with the therapist; the client may begin to mother the therapist-mother.

It seems that whatever the response of the client, it is important to ensure that the potential for the loss of the therapist’s analytic function is monitored. It is also important to acknowledge the potential for a co-existence of both positive and negative feelings towards the therapist and that “a situation of this sort offers plenty of scope for resistance and collusion, but can also be profoundly enriching” (Gottlieb, 1989). Katzman (1994) suggests that experiencing powerful competing emotions about the therapist could be useful in helping the client to develop the ability to contain and handle opposing feelings.

There are clearly a range of possible responses from clients to the therapist‘s pregnancy and it has been noted that there can be both similarities and differences for male and female clients. One difference refers to the Kleinian idea that men can fear women’s creative capacity in the ability to become pregnant, reproduce, bear, and nurture children and may respond by a desire to dominate. Females could have a wish to compensate for destructive urges, loss, or feelings of separation and compensate by becoming pregnant. Lax (1969) suggested that women may act out according to the blueprint of childhood wishes and defensive patterns, whereas men may experience dangerous impulses related to oedipal temptations, which are ordinarily repressed. Men may also experience the infantile wish to be able to have a child to which they may respond with denial and isolation.

Different issues may become pertinent not only with different clients but also at different stages and experiences of pregnancy. Certain stages may result in the therapist being influenced by physical or emotional exhaustion during sessions or becoming distracted by the movements of the baby. Towards the end of pregnancy the limitations for the therapist as a result of bodily changes become increasingly apparent to the client and therefore need to be acknowledged.

At the beginning of pregnancy, one of the first issues relating to therapy is when and how to discuss this with clients. Wedderkopp (1990) noted that it is important for the client to recognise the pregnancy in their own time and in their own way. How this happens reveals important information about the client. However, once the pregnancy is very obvious she recommends that the therapist mention it in order not to collude with denial. “It is not the unexpected events or modifications in technique that interfere with successful analysis, but the analyst’s silence in the face of such unanticipated occurrences” (Wedderkopp, 1990). Similarly, Katzman (1993) and Naparstek (1976) found it important to introduce the issue early, to allow exploration of feelings and decrease the ‘acting-out’ behaviour.

The literature also looks at the impact of having to terminate therapy early or have a long gap during the therapist’s maternity leave. This applies more to long-term therapies. The time-limited nature of CAT allows the therapist the chance to plan clinical work in advance to avoid such problems. Despite this, it is still important to think about the role the pregnancy can play in relation to ending as it may contribute to any enactments that occur. For example, the client may feel that the therapist is abandoning them for the child, particularly if the ending occurs in the later stages of the pregnancy. Also, any potential for further treatment at the follow-up session is unlikely to be possible between the client and the pregnant therapist. In such circumstances a CAT therapist is able to make use of CAT tools to explore such issues within the framework of a collaborative and authentic therapeutic relationship.

CAT Theory and the Use of CAT Tools by the Pregnant Therapist

CAT theory can help the therapist consider some of the issues highlighted above. For example, thinking about the client’s ‘zone of proximal development’ (ZPD) (Ryle and Kerr, 2002) encourages the practitioner to take an idiosyncratic approach to deciding when and how to discuss the pregnancy with each client. The sequential diagrammatic formulation (SDR) and the goodbye letter can be used in therapy and supervision to explore issues related to the pregnancy. The SDR enables discussions to be held regarding any possible RR re-enactments triggered by the pregnancy. The goodbye letter provides an opportunity to reflect on any pregnancy related re-enactments that occurred during therapy or could occur in relation to the ending of therapy.

Using CAT Tools as a Pregnant Therapist:

Case Examples

Below are two case examples that illustrate how my own pregnancy was explored with clients using CAT tools.

Case Example 1

I saw X for a 24 session CAT and the pregnancy became visible about halfway through this contract. One of the core difficulties X was experiencing was a fear of being criticised for her ability to parent her only daughter who was two years old. She had high expectations of herself and others in relation to caring, and had a desire to receive the perfect care she wished she had experienced as a child. Initially it seemed that X was keen to deny the presence of my pregnancy, and I waited for her to acknowledge it in her own time. However, after some time it seemed important not to collude with any possible denial of the pregnancy and I therefore introduced the topic myself. This occurred in session 17 when we also began to talk about the ending of therapy. This triggered a shift in the therapeutic relationship and for the first time X began to cry. She stated that she felt sad that she would not get to see me each week as I had always been here and not let her down. This enabled us to discuss the possibility of an enactment of her target problem procedure (TPP) of seeking perfect care from me, which seemed threatened by the pregnancy, resulting in X feeling abandoned. Because this was already on the SDR, we were able to discuss it and X recognised the pattern.

In later sessions X began to talk about issues related to her parenting in a way that appeared mindful of my views. For example, she began to talk about how she only buys the best brands for her daughter and she began to give me advice about pregnancy and parenthood. It seemed that my new role as a mother as well as a therapist resulted in an enactment of her TPP related to her concerns about being criticised as a parent. Once again we were able to use the SDR as a tool to explore this. In the goodbye letter I was able to revisit her TPPs and use them to illustrate her behaviour. This seemed to have a powerful impact on how X understood herself.

Case Example 2

I saw Y for a 16 session CAT and the pregnancy became visible about half way through this contract. Y had initially attended therapy due to his anger and aggressive behaviour. A core reciprocal role (RR) for him was one of ‘powerful and aggressive to powerless and vulnerable’. In order to deal with fears of feeling vulnerable, he would either become attacking or avoidant. From the outset of the therapy he had seemed to struggle with how to assess and deal with the power dynamic in our therapy relationship. At times in early sessions, I had felt threatened by him and my sense of vulnerability was enhanced by my pregnancy. In supervision, I wondered whether he was trying to assert power in order to avoid becoming vulnerable with me. As with X, Y did not mention my pregnancy but appeared to have noticed it. During one session he lifted up his t-shirt to show me his scar from having his appendix removed the previous week. In supervision it was suggested that he was sharing with me his vulnerable hidden object in the hope that I might share mine. It was agreed at this point that I should introduce discussion about the pregnancy in the next session. However, I had to cancel the next session due to sickness. When we met the subsequent week he appeared concerned and asked about my well-being. We talked about what his concerns were and he was able to share that he was worried that I had problems with the pregnancy. This had resulted in him thinking about me as a person and not simply his therapist. He said that it had helped him to realise that it was important to think about things from other people’s perspective and not simply assume they were letting him down. He also stated that he was pleased I was looking after myself and the baby. This led to a shift in the therapy where struggle for power stopped and he became able to share his vulnerabilities with me. He began to cry in subsequent sessions and to discuss his feelings about having abandoned his only child, as well as feelings of sadness about his own childhood experiences of neglect and abuse. This process led to the development of a possible exit from his core TPPs, which was then clearly outlined in the goodbye letter.

The Use of the ‘Self’ as a Pregnant Therapist in CAT

Being pregnant can enhance the therapist’s ability to authentically use the ‘self’ within the therapeutic relationship. Fenster (1983) found that the therapist’s pregnancy allowed both therapist and client to “meet each other more simply and directly with the possibility of caring and concern”. Katzman (1994) stated that “whatever the orientation of the therapist, her expanding womb may force her presence not only into the room but also into connection with her client”. The ‘self’ becomes increasingly present and to deny this could result in therapist enactments that could have a detrimental impact on the therapy. However, by acknowledging the impact of the pregnancy in a way that was within the client’s ZPD, the therapist could bring any enactments triggered by it into the discussion. The practical techniques employed in CAT can then help facilitate collaborative exploration of RRs and TPPs brought up by the preganancy.
Katzman (1994) suggested that this increase in the use of the self results in movement towards a ”self-in-relation perspective” and subsequently in becoming a better therapist. This seems to fit very appropriately with the theory of CAT.

Reciprocal Role Enactments in Relation to the Pregnant CAT Therapist

Although a therapist’s pregnancy may trigger a range of different enactments within the therapeutic relationship, it seems that there are a number of key RRs that are worth bearing in mind. The key themes from the analytic literature can also be described in terms of RRs. Below are some examples that seem relevant based on the case examples just given.

The theme of increased vulnerability can become important in both the transference and counter-transference. A therapist’s sense of vulnerability and her desire to protect the pregnancy could potentially increase enactment of ‘angry and abusing to weak and vulnerable’, as demonstrated with client Y. It could also be possible for the client to feel more vulnerable, for example if the pregnancy activated ‘preoccupied and distant to vulnerable and alone’ with the client feeling left out in the triangular relationship between them, the therapist, and the unborn baby. This may be particularly important when the therapist is feeling distracted by the pregnancy for different reasons at different stages.

In terms of timing, a common theme that can emerge, particularly at the start of a pregnancy, is that of ‘hostile and envious to fearful and guilty’, with the therapist adopting the fearful and guilty position. Again this seems to be something that can be induced by the therapist’s own countertransference in anticipation of the client’s reaction. As for the end of therapy, it is often important to consider re-enactment of RRs in the therapeutic relationship, such as ‘abandoned to abandoning’ and ‘rejecting to rejected’, but when the therapist is pregnant these may need to be considered even earlier. For example, this became important to explore with client X as soon as we began to discuss my pregnancy although we still had another seven sessions remaining.

Conclusions

Some important issues regarding the clinical implications of therapist pregnancy have been highlighted here for further consideration. The literature base on this topic is limited and so there are a number of areas that have not yet been touched upon, such as the differences that may be experienced depending on the specialty in which the therapist works. Different issues also arise when working with groups rather than individuals. I‘m sure that important issues also arise when returning from maternity leave and when there have been problems related to pregnancy, for either the therapist or the client, such as miscarriages or infertility. I have not commented on the experience of being a pregnant therapist within the context of a therapeutic service, but I believe this would be of interest. As a therapist working within a CAT framework, I would like to develop a clearer understanding of RR enactments that a pregnant therapist should be mindful of. I would welcome others filling this gap in the CAT literature in order to assist pregnant CAT therapists in the future.

References

Barbanel, L. (1980). The Therapist’s Pregnancy. Blum. B. (Ed.) Psychological Aspects of Pregnancy, Birthing and Beyond. New York: Human Sciences Press, Ch.14.
Berman, E. (1975). Acting out as a response to the psychiatrist’s pregnancy. Journal of American Medical Women’s Association, 30, 456-458.
Bibring, G.L. (1959). Some considerations of the psychological processes in pregnancy. Psychoanalytic Study of the Child, 14, 113-122.
Clementel-Jones, C. (1985). The pregnant psychotherapist’s experience: colleagues’ and patients’ reactions to the author’s first pregnancy. British Journal of Psychotherapy, 2 (2), 79-94.
Fenster, S., Phillips, S. & Rapoport, E. (1986). The Therapist Pregnancy: Intrusion in the Analytic Space. Hillsdale, NJ: Analytic Press.
Gottlieb, S. (1989). The pregnant psychotherapist: A potent transference stimulus. British Journal of Psychotherapy, 5 (3), 287-299.
Katzman, M. (1994). When reproductive and productive worlds meet: Collision or growth. In Fallon, P., Katzman, M. & Wooley, S.C. (Eds). Feminist Perspectives of Eating Disorders. New York: Guilford Press.
Lax, R.F. (1969). Some considerations about transference and counter transference manifestations evoked by the analyst’s pregnancy. International Journal of Psycho-Analysis, 50, 363-372.
Lemoine-Lucciono, E. (1987). The Dividing of Women or Woman’s Lot. London: Free Association Books.
Nadelson, C., Notman, M., Arons, E. & Feldman, J. (1974). The pregnant therapist. American Journal of Psychiatry, 131, 1107-1111.
Naparstek, B. (1976). Treatment guidelines for the pregnant therapist. Psychiatric Opinion, 13, 20-25.
Palunszny, M. & Poznanski, E. (1971). Reactions of patients during the pregnancy of the psychotherapist. Child Psychiatry and Human Development, 4, 266-274.
Pines, D. (1982). The relevance of early psychic development to pregnancy and abortion. International Journal of Psychoanalysis, 63, 311-319.
Wedderkopp, A. (1990). The therapist’s pregnancy: Evocative intrusion. Psychoanalytic Psychotherapy, 5 (1), 37-58.

Full Reference

Knight, A., 2008. Clinical Implications for the Pregnant CAT Therapist. Reformulation, Summer, pp.38-41.

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