Psychodynamic Practice

Vol. 14, No. 1, February 2008, 27–42

The pregnant therapist

Emma Dysona and Gail Kingb*
a
72, Sheppard Avenue, Bowring Park, Knowsley, Merseyside, L16 2LD; bInstitute of
Lifelong Learning, University of Leicester, Leicester, UK
(Received May 2007; final version received October 2007)

This paper draws on the theoretical understanding and personal

experiences of two psychodynamic therapists regarding therapist
pregnancy and the implications for and impact on clinical practice.
For one an unexpected pregnancy provoked reflection on the process of
being a therapist. For her the pregnancy was complicated by her
experiencing hyperemesis (severe and excessive vomiting for the
duration of the pregnancy), which meant that she was unable to
practice. For the other the interest arose out of her experiences as a
supervisor to three pregnant trainees and of her own therapist becoming
pregnant. The pregnant therapist can anticipate some physical and
emotional changes but other changes may be less predictable such as
increased vulnerability and anxiety, maternal preoccupation, altered
relationships with colleagues, and an increased need for support and
good supervision. This paper discusses clinical issues relating to frame
violations, when and how to disclose, clients’ responses, acting out,
transference and countertransference issues, the change from a dyadic to
a triadic relationship, breaks and endings. The authors suggest that
pregnancy provides an opportunity for clients to work though some
issues, in particular separation and individuation, loss, envy and sibling
rivalry. Little to date has been written on the subject of the therapist’s
pregnancy from the therapist’s perspective. This paper seeks to raise
awareness and stimulate interest in this important but neglected area.
Keywords: pregnant therapist; psychological crisis; transference;
countertransference; therapeutic relationship; supervision

Introduction
Pregnancy creates significant disturbances in all pregnant women, regardless
of their state of psychic health (Bibring, 1959) with reactivation of early
conflicts, intense introversion, time-limited regression, ambivalence, anxiety
and identification with the foetus (Deutsch, 1944), increased psychic
flexibility and vulnerability (Cullen-Drill, 1994), while negotiating enormous

*Corresponding author. Email: gmk3@le.ac.uk

ISSN 1475-3634 print/ISSN 1475-3626 online

Ó 2008 Taylor & Francis
DOI: 10.1080/14753630701768958
http://www.informaworld.com
28 E. Dyson and G. King
physical changes over a relatively short period of 9 months. A number of
authors (Bibring, 1959; Bienen, 1990; Clementel-Jones, 1985; Maushart,
2000; Stern & Bruschweiler-Stern, 1998) describe this experience as a normal
‘psychological crisis’, which particularly affects the primigravida who faces
the impact of pregnancy for the first time. All these aspects of pregnancy
inevitably and significantly impact on the functioning, being and practice of
the female therapist (Cullen-Drill, 1994) and subsequently have profound
implications for the client and the therapeutic relationship (Nadelson,
Notman, Arons, & Feldman, 1974) as well as for colleagues and for
supervision (Baum & Herring, 1975; Butts & Cavernar, 1979; Fenster,
Phillips, & Rappaport, 1986; Goldberger et al., 2003; Imber, 1995; Schrier &
Mahmood, 1988).
Pregnancy becomes obvious and inevitably leads to an interruption or
ending of therapy which needs to be addressed with the client. The pregnant
therapist faces questions such as ‘How does the pregnancy impact on her
emotional functioning as a therapist?’; ‘How does it affect the transference
and countertransference relationship?’; ‘What issues are raised for clients by
the therapist’s pregnancy?’; ‘Do the effects of the therapist’s pregnancy
change, facilitate, impede or have little effect on the therapeutic work?’. It is,
as Cullen-Drill (1994, p. 6) states, ‘important to understand the impact of
pregnancy so the therapeutic gains can be maximized during this period’
especially since many therapists continue to work throughout their
pregnancy (Deben-Mager, 1993; Etchegoyen, 1993; Guy, Guy, & Liaboe,
1988; Uyehara, Austrian, Upton, Warner, & Williamson, 1995).
Given that pregnancy is such a common and frequent phenomenon in
therapeutic life there is surprisingly little literature concerning the therapist’s
pregnancy, which takes the therapist’s perspective as its main focus. The
literature has mainly focused on the reactions of clients to the therapist’s
pregnancy. Even when therapists do discuss their clients’ reactions, they
omit to comment on their personal experiences of pregnancy and their
experiences with clients. When the impact is discussed it is often in negative
terms such as helplessness, anxiety, guilt, narcissistic preoccupation, and
mood swings (Baum & Herring, 1975; Guy et al., 1988). Fuller (1987, p. 10)
refers to the therapist’s pregnancy as a ‘problem’ while Schwartz and Silver
(1990b, p. 191) discusses it with ‘illness and disability’. Furthermore the
literature is imbued with assumptions, for example that a pregnant therapist
is an active heterosexual; that all pregnant therapists will feel ‘an inner calm’
in the second trimester and will experience a ‘nesting urge’ in the third
trimester (Deben-Mager, 1993, p. 131) thereby perpetuating myths and
patriarchal value systems around pregnancy and mothering.
Clementel-Jones (1985) addresses this gap in psychodynamic writing and
considers that the avoidance reflects therapists’ reluctance to acknowledge
their responsibility for the therapeutic environment. Wedderkopp (1990,
p. 40) contends that the lack of literature reflects the therapist’s collusion of
 Psychodynamic Practice 29
denial with clients which many experience in the face of the therapist’s preg-
nancy. She believes this is attributable to the pregnant therapist experiencing
considerable anxiety and guilt at the ‘breach in the analytic setting’, which in
turn leads to unconscious fears of eliciting attacks. Browning (1974) points
out that the issue of self-disclosure is central to this subject and involves
confronting phantasies of omnipotence. Wedderkopp (1990, p. 39) describes
this difficulty referring to ‘the multilayered, polymorphic nature of the
experience between the pregnant therapist, her baby and her patient which is
so difficult to conceptualise and render intelligible’.

Introducing pregnancy from a psychodynamic perspective

Pregnancy is a unique and personal experience. No two women experience
pregnancy or successive pregnancies in the same way but some experiences
are common to many women and so while some generalizations are made
the authors do not presume that all pregnant therapists experience what is
discussed here. Pregnancy is a major life event resulting in profound physical
and psychological changes. It has been described as a ‘psychological crisis’
(Bibring, 1959; Bibring, Dwyer, Huntington, & Valenstein, 1961; Clementel-
Jones, 1985; Maushart, 2000; Stern & Brushweiler-Stern, 1998) where the
psychological organization a woman has achieved in adulthood undergoes a
‘significant degree of dissolution’ (Bibring et al., 1961, p. 26) so that a new,
matured position can be achieved. As Clementel-Jones (1985, p. 93) says,
‘The central focus of pregnancy is of not one woman: it is the two in one
body; it is the process of becoming an individual and separating out from a
parasitic merger’. Bibring (1959) has described this transient mental state as
‘benign depersonalisation’ in which the pregnant woman’s psychic
boundaries become increasingly more flexible and blurred as the pregnancy
progresses. Cullen-Drill (1994, p. 8) writes,

The psychological experience of pregnancy recapitulates the woman’s earliest

relations with her mother, especially fears and conflicts related to separation.
Often a pregnant woman ‘regresses’ to earlier wishes for dependency and
fusion with the primary love object.

Thus the pregnant woman faces re-working her infantile relationships not
only regarding her mother (Fuller, 1987) but her father too (Etchegoyen,
1993) as well as experiencing a forward-looking narcissistic identification
with her baby. This psychological crisis is a turning point in a woman’s life
and provides an opportunity for growth which encompasses loss as well as
gain. For the woman experiencing her first pregnancy this process can be
profound but in subsequent pregnancies the experience is typically less
dramatic (Nadelson et al., 1974; Uyehara et al., 1995).
This maturational crisis profoundly affects her sense of self, character,
self-esteem, and identity. Combined with the symbiotic relationship this
30 E. Dyson and G. King
leads to an increased accessibility to unconscious processes. Bibring (1959)
and Bibring et al. (1961) observe a loosening of defences, a higher incidence
of primary process thinking and primitive anxieties (about the inside of the
body, fears of loss of identity and annihilation, fears of damaging or being
damaged by the foetus, by the ‘evil eye’ or by jealous and envious siblings),
emotional turmoil, and major shifts in relation to people and activities.
Bibring (1959) also observes content material remarkably similar to that
which is usually found in severely disturbed clients, magical thinking,
depressive reactions, primitive anxieties and introjective and paranoid
reactions, particularly in relation to her own mother. The woman in her first
pregnancy is faced with working through her changing identity as she moves
from daughter towards motherhood. While the pregnant woman psychically
experiences a backward-looking identification with her mother she is also
experiencing a forward-looking narcissistic identification with her baby. As
her inner world beckons, the pregnant woman psychically withdraws,
lessening her logical ability and her theoretical interests (Balsam, 1980;
Barbanel, 1980; Paluzny & Poznanski, 1971). However, she simultaneously
experiences increased intuition, empathy and a nurturing capacity which can
impact positively on therapeutic work. The therapist needs to come to terms
with her increased physical and emotional vulnerability and the consequent
impact on her work. Facing these limitations may be a new experience and
may be a challenge to her phantasies of omnipotence (Clementel-Jones,
1985). This psychological crisis confronts the pregnant woman with deep,
primitive and powerful issues and it requires her to consistently, and at times
painfully, work through issues. The pregnant therapist thus finds herself
working hard physically and intrapsychically while at the same time working
with the unavoidable disturbance in the therapeutic relationship created by
the pregnancy and its effect on the clients.

The therapist’s pregnancy and its impact on the client and the therapeutic
relationship
This paper considers each trimester in turn while remembering that issues
are not confined to clear-cut stages. Themes interweave and overlap and
may be revisited by the therapist and/or the client at different times.

First trimester
On discovering her pregnancy the therapist may experience a range of
feelings including elation, shock, relief or disappointment. As the pregnancy
progresses she needs to come to terms with having conflicting feelings
towards her baby, pregnancy and motherhood. As Maushart (2000, p. 10)
says, ‘pregnancy is never an unmixed blessing’. Pregnancy is, by its very
nature, ‘ambivalence made flesh’ (Mosse, 1997, p. 40). The pregnant
 Psychodynamic Practice 31
therapist may feel that she wants to tell everyone, including her clients or
may delight in having a secret. She may struggle with an array of physical
symptoms, including nausea, sickness, tiredness and anxiety (particularly
around the possibility of miscarriage) as well as becoming increasingly
preoccupied with her pregnancy. This may affect her ability to be
therapeutically available, resulting in her needing to make great efforts to
attend to the tasks of therapy. The fundamental skill of listening may be
challenged, as Fuller (1987, p. 12) describes, ‘My ‘‘gross tuner’’ for listening
seems to be intact but my ‘‘fine tuner’’ is not consistently reliable’.
Another common experience in the first trimester is nausea and sickness.
Deutsch (1944) attributes this to an unconscious rejection of the mothering
role and as an expression of oral and anal phantasies of incorporation and
expulsion. Deutsch (1944) referred to her own miscarriages as an
embodiment of her identification with her hated mother. Indeed, given the
intense emotional and intrapsychic changes it is understandable that the
woman may experience somatic symptoms.

Disclosure of the therapist’s pregnancy to the client

Pregnancy in the therapist is a unique and ‘evocative’ (Wedderkopp, 1990,
p. 37) invasion of the therapeutic space but the question arises as to how and
when the client becomes aware of this invasion. Disclosure can occur in a
number of ways. The therapist can announce her pregnancy; the client may
consciously notice the pregnancy and indicate as such; the client may
unconsciously notice the pregnancy and the therapist can then help the client
to come to conscious awareness; or the client may deny the pregnancy, using
repression to keep any awareness from becoming conscious. Allowing the
client to recognize the pregnancy in his or her own time and way and waiting
for the client to give a clear indication of their awareness is desirable. The
manner and timing of this recognition may reveal the client’s central
conflicts, defences, transference and anxieties (Turkel, 1993; Wedderkopp,
1990). Notwithstanding the conflicts that are mobilized for clients and the
difficulty of dealing with an uninvited intrusion, Guy et al. (1988) remind us
that clients may also respond with genuine warmth and concern. The client’s
awareness may be conscious and revealed in the form of direct questions or
comments. Clients may reveal an unconscious awareness of the pregnancy
through material such as dreams, phantasies, and thematic concerns of
abandonment, intrusion, secrets and somatic changes.
A client’s denial may mirror the therapist’s denial or be mirrored in the
countertransference. There is general agreement in the literature that if a
client has not indicated awareness of the pregnancy by around 6 months, the
therapist needs to actively address this. This allows for some working
through of issues elicited by the pregnancy before the approaching maternity
leave. If, despite the therapist’s attempts to use symbolic references to help
32 E. Dyson and G. King
the client, the client is unable to allow any acknowledgement of the
pregnancy, there is then a real risk of the therapist colluding with
pathological denial of what will by this time be a clearly visible event.
Alternatively, she may be acting out her fear that the news will overwhelm
the client or the client’s response will overwhelm her.
Some clients notice the pregnancy but give no indication of this awareness.
Uyehara et al. (1995) refer to clients who give no indication well into the
second trimester. Such apparent lack of awareness may be attributable to the
therapist’s own reluctance to face her pregnancy and its meanings with her
client or may reflect an assumption that they are not allowed to comment on
their therapist’s pregnancy as it pertains to her private life.
It is helpful if the disclosure of the pregnancy is separated from discussing
maternity leave so that the meaning of the pregnancy can be fully explored
(Bassen, 1988; Uyehara et al., 1995). Early disclosure may evoke in the client the
phantasy of inclusion in the primal scene and may also defend against
unconscious reactions to the pregnancy in particular sibling rivalry and feelings
of exclusion (Bassen, 1988). For others, early disclosure may be experienced as
inviting seduction. It is, however, vital that the therapist’s pregnancy is discussed,
for if not, the client and therapist can recreate the parent-child situation where
certain secrets are not discussed (Balsam, 1980; Barbanel, 1980).
However, the timing and manner of the therapist’s disclosure will be
influenced by a variety of issues. Pregnancy, being a psychological crisis,
means that the therapist’s unconscious conflicts and anxieties will affect her
disclosure. Countertransferential guilt and anxiety may either blind the
therapist or cause her to be hyper-vigilant to associations in her client’s
material that refer to the pregnancy. ‘Primary maternal preoccupation’
(Winnicott, 1956) may further lead to some distortion in her misreading the
presence or absence of associations.
There are also significant reality concerns impacting on the therapist’s
timing of disclosure such as the high rate of miscarriages in the first trimester
or awaiting the results of amniocentesis. Clinical considerations such as a
client with a history of infertility or painful obstetric loss will also affect
disclosure. These clients may benefit from early disclosure to allow
maximum time for working through particularly painful issues. Clients
may experience being allowed to become gradually aware as unnecessarily
withholding and insensitive. The therapist may phantasize an ideal
disclosure which will prevent painful reactions.

Second trimester
During the second phase of pregnancy the therapist may feel relief from
nausea, sickness, tiredness, and preoccupation and in turn may experience a
sense of pride and well-being in herself, and in the pregnancy. As well as the
physical changes the pregnant therapist may have realistic concerns about
 Psychodynamic Practice 33
her clinical work including anxiety that she will pay less attention during a
session or that she may have to leave the room precipitously. She may also
be coming to terms with fluctuating feelings towards the baby, from
passionately loving the baby to passionately hating it. The pregnant
therapist is faced with reassessing her feminine identity and integrating her
roles as a daughter, mother, working woman and sexual partner. These roles
have been separated causing conflicts and tensions that are not only
restrictive for women, but also for men and society. She may face many
questions that challenge her existing defences and identifications. ‘Can I be a
good enough mother and enjoy a career?’; ‘How do I manage the logistical
problems of caring for a child and working?’; ‘Can I leave my ‘‘real baby’’ to
for my ‘‘client baby’’?’. For the therapist who has turned to role models
other than her own mother during her development or does not have a
mother who worked when her child/children were young, she is faced with
resolving these identity issues without learning from her mother. Conse-
quently she may need role models which may be found in her supervisor or
in the workplace.

Issues raised for clients through the therapist’s pregnancy

The existence of the therapist’s pregnancy, as a real event as well as a
metaphor, acts as a catalyst bringing to the forefront unresolved deep
conflicts which powerfully intensify transference and countertransference
reactions rarely in a predictable way (Benedek, 1973; Cullen-Drill, 1994;
Deben-Mager, 1993; Etchegoyen, 1993; Fuller, 1987; Turkel, 1993;
Wedderkopp, 1990). Pregnancy can be seen as a potential contamination
of the transference. However, the notion of ‘uncontaminated transference’ is
a myth, as Gill (1984) asserts, because the expression of transference is
always influenced by the ‘real’ interpersonal relationship between the
therapist and client. The client’s unconscious reactions within the
therapeutic relationship may be triggered as much by the therapist’s own
intrapsychic and physical state as the client’s own. While the therapist
maintains stability and consistency as much as possible ‘real life’ inevitably
impacts on the therapeutic relationship and can be used to facilitate therapy.
The therapist’s ability to respond non-collusively to the enhanced
transference (at a time of significant internal change) is challenged and
affected by the extent of her containment. The following example describes
how the therapist’s pregnancy revives early issues for clients.

Case example 1
Holly, aged 24 years, came into therapy to work on issues underlying her
depression and especially her relationship with her mother whom she
experienced as distant, critical, rigid and unloving. She had been in therapy
34 E. Dyson and G. King
for 7 months by which time the therapist was 4 months pregnant. One day
she commented, in a rather hostile manner, ‘You’re getting fat like you are
having a baby’. When her perception of pregnancy was confirmed Holly
reacted angrily saying, ‘That’s typical, there is always someone else to love’.
She then failed to attend the next session and left no message. The
therapist’s pregnancy had mobilized Holly’s anger towards her mother for
her neglect and her lack of affection. In the ensuing months Holly was able
to express her rage and her hurt. The experience of a warm and nurturing
therapist, who was able to tolerate her angry feelings, helped her to face her
feelings of rejection.
Countertransference manifestations may include denial of the impact of
the pregnancy, discussing only the reality aspects of the pregnancy, anxiety,
anger and resentment over the intrusion of the pregnancy resulting in
withdrawal (Schwartz, 1990a). If the pregnant therapist, because of her own
intrapsychic conflicts, is unable to recognize the impact of her pregnancy on
her clients she may be unable to respond sensitively to them. She may
misinterpret their concerns as manifestations of their own difficulties, not
considering the real possibility that they may be related to herself and her
pregnancy. The therapist’s increased vulnerability can make it very difficult
for her to tolerate her client’s hostility or aggression (particularly if she has
strong fears of miscarriage or concerns about the baby’s health), which in
turn can lead to a therapeutic impasse. It is, therefore, important that the
therapist is able to recognize her own anxieties and be supported in this. In
particular, the therapist will need to be aware of her own mothering needs if
her countertransference reaction of wanting to be the ideal mother is not to
become too intense (Deben-Mager, 1993).
Paluszny & Poznanski (1971) identify three main categories of client
responses to the therapist’s pregnancy: the first attempts to resolve conflicts by
reliving them with the therapist; the second is to respond defensively to the
pregnancy; and the third is to use the pregnancy to work through conflicts. Client
reactions will vary in their type and intensity depending on their life experiences
(particularly early life), internal object relations, investment in therapy,
character, ego strength and cultural background. Despite such variations,
similar themes typically emerge in the transference over the duration of the
pregnancy. These include symbiotic desires and longings, Oedipal conflicts, fears
of rejection and abandonment, fears of castration, sibling rivalry, feelings of loss
and envy, separation anxiety, identification with the baby, infantile wishes,
maternal loss and deprivation, sexual identity issues and fears that hostile
feelings may actually damage the vulnerable therapist (Benedek, 1973;
Clementel-Jones, 1985; Fuller, 1987; Guy et al., 1988; Nadelson et al., 1994).
Pregnancy serves as a non-verbal communication which partially
destroys the anonymity the therapist has sought to create and reveals that
the therapist has a personal life and a sexual relationship. For some clients
this may be the first time they are confronted with the therapist as a real and
 Psychodynamic Practice 35
separate person. The therapist may also be struggling with feeling that she
has violated a professional boundary, reflecting the client’s anxieties at the
apparent loss of the containing function. In Wedderkopp’s (1990, p. 38)
words, the therapist’s pregnancy ‘crystallises the intrapsychic clash between
the therapist as a real person and as a pure transference figure’.
For Wedderkopp (1990) psychic containment is enhanced, even equated,
with physical sameness and stability. Consequently this disruption in the
therapeutic consistency brings with it a sense of a breach of maternal
containment and a sense of catastrophe. Pregnancy consequently marks the
breach of the idyllic mother-child relationship and offers a unique
opportunity to facilitate the client working through their relationship with
their mother. Gottlieb (1989, p. 287) comments

Pregnancy mobilises and intensifies the universal theme of symbiotic merger

with an idealised maternal figure versus the separation from such an object and
the recognition of an ambivalent relationship with the real mother.

The therapist’s pregnant presence alludes to the possibility of symbiotic

fusion and as such becomes both alluring and terrifying. The pregnant
therapist is both an all-giving mother and someone who threatens to engulf,
resulting in psychic death (Domash, 1984). The pregnant therapist is in a
unique position to mobilize the most primitive aspects of a client’s primary
infantile symbiosis with his or her mother with a corresponding counter-
transference taking the form of maternal preoccupation as an attempt to
recreate the symbiotic merger (Gottlieb, 1989). The opportunity to recreate
this relationship in the transference and countertransference may be of great
therapeutic benefit. Gottlieb (1989) suggests that this psychic tension is
experienced by clients as an undercurrent upon which more individual and
specific conflicts and anxieties become elaborated. For a client who lacks
separation between object and self any sense of separateness of the therapist
is highly threatening, bringing with it intense feelings of object loss. The
client may feel enraged by the inevitable frustration of the intense wish to
merge with the therapist and to achieve an illusory state of narcissistic bliss
in which any form of frustration or separation is denied. The therapist is
thus experienced as the primitively-split mother who is alternately the
embodiment of good and bad. The client is confronted with the reality that
the therapist is choosing to be in a symbiotic state with her unborn baby and
is denying this to her. Feelings of vulnerability, shame and rage may then
emerge which have hitherto been kept out of the therapeutic relationship.
This is illustrated in the next case example.

Case example 2
Sarah, a 32-year-old woman, had been in therapy for 5 months presenting
with ‘issues relating to her childhood’ that were impacting negatively on her
36 E. Dyson and G. King
marriage. She had been an only child, who until she was 13 years of age lived
alone with her divorced mother. Her mother then remarried. Sarah’s initial
response to her therapist’s pregnancy was to be dismissive. However, as the
therapy progressed, Sarah recounted her feelings of ‘devastation’ when her
mother remarried and had a baby. Sarah talked about her feelings of
jealousy and of feeling excluded from the new family unit. She coped with
the loss of her mother’s attention by developing anorexia. Throughout the
therapist’s pregnancy Sarah again used food to deal with painful feelings.
Over time the therapist helped Sarah to express her feelings of love and hate
towards her mother. Later, Sarah was able to talk about her envy of her
therapist’s pregnancy, a state she very much desired for herself. Besides
being able to say she was envious she was also able to express her anger and
disappointment that the therapist would have ‘someone to love passionately’
and would ‘prefer’ the baby, and so end the therapy. Sarah came to
understand her experiences and her responses and was able to accept her
therapist as a loving and separate object.
A development of the separation-individuation process is the acceptance
of a third person in a triangular relationship. This and the therapist’s
pregnancy draw attention to the real or phantasized existence of a man in
her life and mobilizes Oedipal themes (Clementel-Jones, 1985). Clients may
experience this as Oedipal rivalry with the therapist’s (perceived) partner.
The pregnancy implies that she is connected to a more powerful man (or
woman) thus replacing the client. The client may also experience difficulty in
dealing with feelings about the therapist’s sexuality and, in particular, male
clients may fear sexual incompetence (Cullen-Drill, 1994). Further
complications can arise with gay men fearing rejection by the ‘straight’
therapist (Fenster et al., 1986) or with lesbian clients experiencing a sense of
betrayal or envy of the baby’s intimacy with the therapist (Nadelson et al.,
1974, p. 1110).
Exclusion from the primal scene may intensify sexual phantasies or
reinforce defences against them. In the countertransference the therapist
may experience her pregnancy as an Oedipal victory and may feel conflict
over her ‘exhibitionism’, fearing her client’s envy or may identify with her
clients as displaced and excluded. A client’s envy of his or her therapist’s
apparent personal fulfilment and capacity to bear and sustain a baby may
remind him or her of what he or she has never had or has lost. Such losses
may be associated with a child death, abortion, being childless or children
growing up. Although acutely painful in face of the therapist’s pregnancy,
this offers a valuable opportunity for mourning losses (Guy et al., 1988).
However, it may be difficult for the therapist to respond empathically to
such losses because she is having to confront her own fears of such loss. The
therapist may, in the countertransference, consciously or unconsciously not
pursue such losses with a client. The therapist may also in the counter-
transference feel a ‘smugness’ or guilt over having a child in the face of a
 Psychodynamic Practice 37
client’s childlessness (Lazar, 1990, p. 220). She may also feel symbolic
victory over her own mother who did not have a career and children.
With the introduction of a third object, the therapeutic relationship
shifts from being dyadic to triadic in which the baby may be perceived as an
intruder or eavesdropper. This was demonstrated by a male colleague who
cheerfully hoped the baby was sleeping while he and the pregnant therapist
discussed a client’s distressing situation. Sibling rivalry may be reactivated
as a consequence of the loss of the mother’s exclusive attention. Clients may
react by becoming anxious about missed or changed sessions and be
convinced that the therapist will not return to work (a realistic fear); will not
continue seeing them upon returning to work; or will be so involved with the
baby that the therapist will pay the client little attention.
A client may deal with sibling issues by identifying with the baby
(Nadelson et al., 1974) or appear to be identifying with the therapist saying,
‘I want to have a baby’. The client’s phantasy may be that the baby will give
her all the love she never received. What this statement may really mean is ‘I
want to be a baby’. This may provide an opportunity to explore infantile
feelings but for some clients this identification may be too frightening. The
client’s hostility towards the therapist’s child and envy of the therapist as a
mother and fertile woman may evoke conflict and guilt, which in turn may
be expressed in the phantasy that words and thoughts can kill.
Hostility may be denied or projected and expressed as, ‘I feel I am a
burden to you’. Some clients may use reaction formation, becoming
overprotective towards the therapist. It may be difficult for the therapist to
contain her own and her client’s hostility and if the therapist’s pregnancy
does miscarry, she and the client may feel overwhelming guilt over
aggressive wishes (Schwartz, 1990a). The intensified transference requires
the client to tolerate the intensity of feelings evoked. For clients for whom
this is too much to bear they may act out by missing sessions, refusing to
pay, terminating therapy or by becoming pregnant. The issues reactivated
for clients as a result of the therapist’s pregnancy may run parallel to the
therapist’s own conflicts so that it may be very difficult for her to effectively
help her client to work through particular issues. One way the therapist may
respond to such difficulties is to deny the impact of the pregnancy. The
therapist may project a ‘business as usual’ (Wedderkopp, 1990, p. 41)
attitude to allay anxiety that anything significant is intruding into the
therapeutic dyad.

Third trimester
The pregnant therapist is likely to experience increasing physical discomfort
and fatigue, some realistic concerns as well as primitive fears and excitement
about the forthcoming birth and meeting the baby. She will also be
continuing to work intrapsychically and be preparing for motherhood.
38 E. Dyson and G. King
Primary maternal preoccupation and its attendant withdrawal are likely to
intensify as maternity leave and labour are anticipated. As the birth
approaches the therapist may need to see herself as nurturing and life-giving
rather than destructive and depriving, making it difficult to take up a client’s
rage and hostility. She may resent the demands and needs of her clients
which are pulling her away from her preoccupation with her baby. The
impending separation, which can be very painful for clients, may precipitate
a crisis in a client’s life which may be experienced as frustrating and anxiety-
inducing for the therapist. She may then consciously or unconsciously wish
to be rid of difficult clients.
As the ending approaches clients’ anxieties may heighten. Occasionally
the client or therapist may deny the ‘real’ baby and its implications in an
attempt to re-establish the idealized dyad of self and mother-therapist.
Clients may also feel loss as they say farewell to the baby following a feeling
of involvement. This may be experienced as though they had participated in
the primal scene and are now shut out again.
The importance of setting an ending date is crucial for both therapist and
client and provides a frame within which feelings of separation and
abandonment can be worked through. Failure to set a date could be seen as
colluding with the client’s denial of the impending arrival of the baby and
the consequent separation of client and therapist. The therapist may also
need to work through her feelings (including mourning) as a result of an
enforced absence from work.

The therapist’s needs

Given the psychological crisis and her emotional and physical vulnerability,
the pregnant therapist needs to find ways to feel supported and contained in
her work. Regular supervision is an essential space for any therapist to
address issues arising from clinical practice but supervision can be especially
helpful for the pregnant therapist. Supervision can provide containment and
a place to explore questions and issues as to how and when to disclose, the
significance of the pregnancy for the client, heightened transference and
countertransference reactions, working with ambivalence, acting-out beha-
viour, the use of an alternate therapist (Chiaramonte, 1986; McCarty,
Schneider-Braus, & Goodwin, 1986), breaks, parallel process, suitability of
clients (Baum & Herring, 1975; Butts & Cavernar, 1979; Fenster et al., 1986;
Goldberger et al., 2003; Imber, 1990; Schrier & Mahmood, 1988), and the
ending. The issues will vary for the individual or group therapist but it is
likely that issues around sibling rivalry, sexuality, and sexual identity will be
more to the fore for the group therapist (Breen, 1977; Nadelson et al., 1974).
Fuller (1987) and Uyehara et al. (1995) recommend that supervisors have
a comprehensive understanding of the emotional and technical issues of
pregnancy and its unpredictability, and its impact on the therapeutic
 Psychodynamic Practice 39
relationship, so that they can support the therapist who can then regard the
clinical impact of the pregnancy with interest rather than anxiety. Such a
supervisor (possibly a female one who may act as an object for
identification) can enable the therapist to understand her reactions and
those of her clients.
The therapist may also benefit from personal therapy, which may
provide her with the opportunity to confront and work through conflicts
and anxieties. It may also provide support, reassurance and nurturance.
Writing a personal diary, reading around the subject and talking with other
therapists who have experienced pregnancy can also be helpful.
Colleagues’ responses to the announcement of pregnancy may vary from
approval and congratulations to dismay, and will depend on variables such
as age, personal lives, clinical position and status (Benedek, 1973). However,
just like clients, colleagues may also experience a revival of personal
conflicts. They may be envious of the pregnancy and its symbols; may fear
being abandoned or feel angry; and resentful that they may have to assume
extra work. Just as the therapist takes a rival into every therapeutic
relationship, so there will be a ‘third person’ theme in every therapist-
colleague relationship. To defend against negative feelings, colleagues may
become over solicitous or inappropriately demanding. Male colleagues may
respond to sexual and maternal feelings evoked by the therapist’s pregnancy
by focusing their increased attention on her physical changes. The
therapist’s reactions may reflect her conflicts about sexuality, motherhood
and her professional identity.

Conclusions
Pregnancy is a profound experience where a mother is born psychologically
as much as a baby is born physically. The psychic experience of pregnancy
can be a shock for the woman who previously was unaware of the
psychological crisis involved in pregnancy. Rich (as cited in Maushart, 2000,
p. 11) comments,

No one mentions the psychological crisis of bearing a first child, the excitation
of long buried feelings about one’s own mother, the confused sense of power
and powerlessness, of being taken over on the one hand and of touching new
physical and psychic potentialities on the other.

It is no wonder that the pregnant therapist’s ability to be empathically

available for her clients is challenged as a result of the intrapsychic work
that she undertakes in her first pregnancy. Despite this the pregnancy can
provide a focus for what is perhaps the most primitive phantasy of all, that
of being in a state of symbiosis. In this state the mother is all-providing;
frustration, anger, guilt and need do not exist; and the perfect mother is the
baby’s exclusive property. Conflicting with this phantasy may be feelings of
40 E. Dyson and G. King
suffocation and fears of annihilation. Out of this psychic tension other
conflicts are experienced, emerging through the intensifying transference and
countertransference. Such themes include Oedipal conflicts, sibling rivalry,
feelings of loss, envy and separation anxieties. While the pregnancy of the
therapist poses momentous challenges to the therapeutic process there are
rich opportunities for significant and valuable therapeutic gains, for both
therapist and client as they work through the often rapidly-shifting
dynamics of the therapeutic process.
Clients have to deal with an evocative and uninvited intrusion into the
therapeutic space, one that acts as a catalyst bringing deep and powerful
conflicts to the fore. For the client who is not ready or able to face such issues
or cannot tolerate such intensity of emotion, premature ending of therapy is
understandable. For clients who are able to tolerate the increased transference
and conflicts evoked and work through them, there is a sense of reparation
and modification of maternal object relations, leading to personal growth. As
a consequence of the intrapsychic experience of pregnancy and caring for a
child the therapist is likely to have a greater capacity to tolerate confusion and
uncertainty and be empathically more available for her clients.
In writing this paper we have increased our understanding of pregnancy
from a psychodynamic perspective and have considered meanings and
implications for the therapist, the client and the therapeutic relationship. We
believe that no other event in the therapist’s life impacts as powerfully on the
therapeutic relationship as pregnancy. We recognize that it is not possible to
predict which issues will be most difficult or most productive for any
particular client or therapist but if the therapist remains aware of her
changing perceptions, conflicts and needs she will be better able to hear her
client’s concerns as they evolve. We share the conclusion of Nadelson et al.
(1974) that working through these conflicts can provide a particularly
effective therapeutic experience.

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