Patient Reactions to a Psychiatrist’s Pregnancy
Publication: American Journal of Psychiatry
Growing numbers of psychiatrists are women of reproductive age who become pregnant (1). Understanding common reactions that occur during a psychiatrist’s pregnancy may help these clinicians as they conduct a variety of treatments. Patients often react to a psychiatrist’s pregnancy (2). Likewise, a psychiatrist’s pregnancy may affect her feelings and behavior toward some patients (3, 4). Although pregnancy in female psychiatrists has always been possible, the literature reflects a lack of attention to this issue, especially as it relates to the nonpsychoanalytic psychiatrist.
The earliest contributions of the literature on patient care during a therapist’s pregnancy were psychoanalytic. In 1969, Lax (2) identified frequent reactions of patients, including themes of anger, rejection, sibling rivalry, oedipal strivings, and identification with the therapist or baby. She noted that men and women reacted in different ways to their therapists’ pregnancies. The men in her series tended to use the defenses of denial and isolation and were hesitant to bring up the pregnancy. The women commented on the pregnancy earlier in its course, and their reactions were much more intense.
In the 1970s, others contributed to this topic as it concerned psychotherapists (3). Nadelson et al. (4) addressed therapists’ physical and emotional vulnerabilities during their pregnancies and considered the challenges of integrating various roles. They advised pregnant therapists to be aware of their changing needs and conflicts so they could respond to their patients’ evolving concerns during the pregnancy. A study published the next year (5) reported that residents tended to deny that their pregnancies presented special problems for their patients or for themselves.
To date, the most comprehensive work is a book by Fenster et al., The Therapist’s Pregnancy: Intrusion in the Analytic Space, published in 1986 (6). The authors conducted prospective interviews of therapists who were pregnant while they were treating patients. They emphasized the positive impact the therapist’s pregnancy often had on treatment by facilitating transference. However, they also noted that it was common for patients to prematurely terminate treatment. Bassen (7) reported on the experiences of 13 analysts and concluded that pregnancy in therapists has the potential to both facilitate and disrupt treatment, depending on the capacity of the patient and therapist to analyze their responses. She noted that the potential for premature termination seemed to be greatest in patients whose treatments were already tenuous.
A psychiatrist’s pregnancy stirs a wide range of reactions in patients. Initial reactions are usually in keeping with the social conventions of congratulations and warm wishes. However, in addition to culturally appropriate responses and genuinely positive feelings, patients may experience negative attitudes that are not typically expressed in our culture (8). Anger, rejection, and abandonment are among the most significant and perhaps most difficult feelings for patients to express. Anger is understandable from a practical standpoint when treatment is disrupted and a patient is inconvenienced. Patients’ fears about whether they will continue to receive good treatment, become sick, or have to change doctors may also contribute to frustration and anxiety. As well, unconscious envy, sibling rivalry, dependency, or parental transference may fuel anger.
A patient unbound by social convention through a state of manic disinhibition expressed her anger directly by yelling at her psychiatrist, “I hope your baby comes out backwards!” The patient’s immediate feelings were clear. However, patients who feel emotions other than joy are typically constrained by social expectations. Socially unacceptable feelings such as anger are often hidden, to emerge at unexpected times through acting out. A psychiatrist may be able to help by allowing the patient to step outside cultural norms within the safety of the therapeutic relationship. This process becomes more likely when the psychiatrist understands the common themes a pregnancy evokes.
For patients with children, a history of miscarriage, abortion, infertility problems, or sexual issues, pregnancy in their psychiatrist may elicit strong responses of loss, guilt, envy, or identification (8). These reactions are not always unconscious. For instance, identification may be the reality of one woman relating to another, as one patient commented to her pregnant psychiatrist, “Welcome to the club” of motherhood. Other authors have elaborated on the real relationship and how it can be confused with transference during pregnancy (6, 7). Thus, the treatment relationship may be complicated by the real and the transference reactions of psychiatrist and patient.
Factors that influence a therapist’s decisions about the optimal exploration of feelings include the patient’s sensitivity to abandonment, the psychiatrist’s stage of pregnancy, and the patient’s investment in the treatment (9). Clues as to how the patient will cope include how the patient has dealt with rejection and abandonment in the past, his or her sexual and reproductive history, and the extent to which the patient relies on the psychiatrist. Exploratory psychotherapy can be set up to examine these feelings. Medication management, a split treatment shared with a psychotherapist, and brief supportive therapy are not typically designed to encourage thorough exploration of patients’ feelings. Even so, psychiatrists who use these modalities can be prepared to recognize common themes brought about by their pregnancies and times in the course of pregnancy that may be critical to treatment.
During the progression of a psychiatrist’s pregnancy, there are nodal points at which patient reactions may become evident. Four such times are 1) when the patient learns the psychiatrist is pregnant, usually in the first or early second trimester, 2) during final appointments, when plans for termination are underway, 3) during maternity leave, when separation is a reality, 4) upon the psychiatrist’s return, when the patient is aware that the psychiatrist has demands outside the office (9).
We describe clinical vignettes that illustrate common psychiatrist and patient responses to a psychiatrist’s pregnancy. These treatments were tumultuous at times and perhaps in jeopardy because the psychiatrist failed to fully comprehend her patients’ reactions. Such situations may occur because of a psychiatrist’s inexperience and lack of knowledge about the real and transferential issues that pregnancy may elicit.
Case 1
Ms. A, a 39-year-old divorced accountant diagnosed with borderline personality disorder, had been seen weekly for psychodynamic psychotherapy and medication management for 5 years. She had previously seen other therapists and had been hospitalized many times for suicidal threats and self-mutilation.In this treatment, Ms. A focused on the different meanings of her self-injurious behavior and expression of suicidal thoughts and intentions. She also discussed her childhood physical and sexual abuse. She often used dissociation as a defense during times of stress, and the life situations that precipitated these episodes were explored. Ms. A was fearful of hospitalization because it reminded her of the trapped feelings she experienced as a child. The frequency of her hospitalizations dramatically decreased during this therapy, although episodes of dissociation and cutting behavior continued.During one session, Ms. A reported a dream in which the psychiatrist was pregnant. When the psychiatrist confirmed that it was true, Ms. A reacted with exaggerated and uncharacteristic elation. However, at the end of the day, she called the psychiatrist to say good-bye because she intended to commit suicide. The psychiatrist stalled Ms. A by asking to call her back, and in the meantime, she contacted Ms. A’s husband. The psychiatrist called her back as promised and kept her on the phone until her husband arrived to take Ms. A to the hospital, where she spent the night.After discharge the next day, Ms. A saw the psychiatrist; however, she could not recall the details that precipitated the hospitalization. Over the following months, her predominant expression about the pregnancy continued to be congratulatory. However, as the pregnancy advanced, she increasingly focused her concerns on the psychiatrist’s health. She often reminded the psychiatrist of her own trauma in childbirth and the difficulty she had bonding to her infant. She then apologized for possibly scaring the psychiatrist.Ms. A tolerated the remainder of the pregnancy and maternity leave without further suicidal threats. However, before the leave, she appeared depressed and described feelings of uncertainty that the psychiatrist would return. On one occasion before the leave, she arrived at the psychiatrist’s office and realized she did not have an appointment. She panicked upon having the thought that her psychiatrist had never been real. A similar scenario occurred again during the maternity leave.Before the pregnancy, Ms. A had dealt with the psychiatrist’s absences through the use of transitional objects such as her appointment card. She also drove by the psychiatrist’s office to reinforce the reality of the treatment relationship. She dealt with her depression and anger about the pregnancy with an interim therapist. However, she missed her first appointment after the psychiatrist’s return from leave. Once psychotherapy with the regular psychiatrist had resumed, Ms. A acknowledged some of her anger about the disruption in her treatment and about not being somehow included in the experience.
This vignette exemplifies the complexity of feelings and reactions that can occur in both patients and psychiatrists. The patient was tuned into the psychiatrist’s pregnancy very early, which provided a clue that the pregnancy was especially meaningful to the patient. Its impact became evident as the patient responded by threatening suicide and with increased symptoms of depersonalization, derealization, and dissociation. Very early recognition of the therapist’s pregnancy has been described in patients who use primitive defenses (10).
The content of the patient’s comments to the psychiatrist suggest rage, hostility, and identity diffusion couched in good wishes but with terrifying remarks about childbirth and disconnection. Difficulty managing her connection with the therapist may have contributed to the fear that her therapist was not real, which further strained the patient’s already impaired object constancy. On the other hand, the psychiatrist believed that the patient was truly fond of her and that the good wishes were genuine. Evidence for this was the patient’s gratitude about her improvement and the patient’s discussions about borrowing the psychiatrist’s ego when she imagined alternative ways to handle difficult situations. It seems likely that this patient had intense feelings about the pregnancy and was unable to maintain an integrated sense of self and object.
The patient’s history of abuse may have aroused transferential feelings of being unprotected and neglected by her psychiatrist. In turn, the psychiatrist may have responded to the patient’s neediness by wishing to abandon her or to be protected by her. A psychiatrist’s heightened dependency needs during pregnancy may result in less energy to nurture others or to empathize with their concerns. This psychiatrist’s lack of attention to the patient’s uncharacteristic exuberance suggests the psychiatrist’s need to be joyful about the pregnancy and to deny that it could elicit feelings of sadness, anxiety, anger, or fear. She was aware of the patient’s potential for rage, making the congratulatory response fit best with the psychiatrist’s protective feelings for herself and her baby (2).
The patient’s need to share in the birth experience, as shown by this patient, has been described as a way in which the patient can defend himself or herself against the wish to steal the infant away (11). However, this desire may have other meanings as well. It may reflect the closeness the patient feels or wants to maintain toward the psychiatrist. Or it may represent a survival response in which humans are drawn to care for infants, which transcends the boundaries of the doctor-patient relationship. Nonetheless, it presents a conflict with the boundaries that some psychiatrists maintain. Turkel (12) noted that it is difficult but essential for the psychiatrist to find balance in coping with the patient’s socially appropriate responses to the pregnancy and at the same time to be therapeutic in exploring the uncomfortable issues the pregnancy raises. The psychiatrist in this vignette had difficulty finding such a balance.
It is reasonable to consider the unconscious meaning of congratulations, questions about the pregnancy, gifts for the infant, and questions about the baby once it is born. However, it is also reasonable to allow the patient to acknowledge the event (6). Some therapists send birth announcements to patients (13). In this vignette, the psychiatrist could have more explicitly acknowledged the patient’s interest in the pregnancy as well as her concerns about the patient during maternity leave. This psychiatrist’s policy of minimal self-disclosure, coupled with inexperience in revealing her human side, made addressing such issues awkward. Bassen’s (7) description of how transference issues are inextricably interwoven with and complicate real or nontransference interactions are applicable in this case.
Often patient resistance increases during a therapist’s pregnancy (7). Certainly, the patient contributes to the pace of treatment and its ultimate success or failure. Some patients fear that the psychiatrist is fragile; this patient’s difficulties with her own pregnancy may have intensified her need to protect the psychiatrist. Ultimately, a prearranged interim psychiatrist whom the patient may have felt was stronger and less vulnerable helped the patient address some of these feelings. An interim therapist also presents less threat of abandonment because the situation and investment are temporary (12, 14).
This patient demonstrated morbid behaviors at predictable times of vulnerability. She became suicidal upon confirmation of the pregnancy, symptoms of dissociation and derealization were pronounced during her final appointments and during maternity leave, and the patient missed her first appointment after the psychiatrist returned. This case illustrates four of the times during pregnancy that patients may be vulnerable and some of the common issues and defenses that a psychiatrist’s pregnancy may arouse in her patients and in herself.
Case 2
Ms. B, a 30-year-old single female secretary with dysthymia and a history of major depressive episodes, had been seen monthly during 30-minute medication management appointments for 8 months. A psychologist referred her for medication after seeing her on two occasions that focused primarily on her depressive symptoms. Her depression had not been disabling, and she had never been hospitalized.Ms. B was a quiet woman who spoke of her loneliness, her mother’s death, and her father’s expectation that she take care of him as his health failed. During the course of treatment, she received no benefit from several antidepressant trials.Neither she nor her psychiatrist brought up the psychiatrist’s pregnancy, even as it became obvious. In her last trimester, the psychiatrist initiated discussion about the pregnancy and upcoming leave. At the next-to-last scheduled appointment, Ms. B revealed a first episode of self-mutilation, having inflicted a superficial gash to her abdomen. She ran out of the office when the psychiatrist asked questions related to suicidal ideation. Later that day, the psychiatrist telephoned Ms. B, who expressed fear that she would be hospitalized. The psychiatrist determined that hospitalization was not necessary.Ms. B returned for a final session, which focused on her elopement from the psychiatrist’s office. She expressed little understanding about the self-inflicted cut to her abdomen. However, during the maternity leave, she began treatment with a therapist to deal with childhood sexual abuse that she had not previously discussed with anyone.
In this case, the psychiatrist’s pregnancy appears to have been the catalyst for more effective treatment through psychotherapeutic work on issues of sexual abuse. In that respect, the pregnancy facilitated the patient’s continued treatment. Nonetheless, the transition from one psychiatrist to another was precipitated by a crisis. There are several issues in this case that may have contributed to the unexpected acting out by the patient.
This patient never acknowledged the psychiatrist’s pregnancy. While there are differing opinions about how acknowledgment of pregnancy should be handled, it is generally seen as an important step for the patient. While it may be desirable for the patient to bring up the pregnancy, not all patients do so. Had the psychiatrist allowed time for the patient to discuss her reactions to the pregnancy and upcoming leave, a crisis may have been averted and the transition in care may have proceeded more smoothly.
The psychiatrist’s leave is a practical matter for which arrangements must be made, and this may take a minimum of 2–3 months (15). When patients have not inquired by this point before delivery, it seems advisable for the psychiatrist to open the issue so that reactions to the pregnancy can be processed and interim plans can be made. Items to cover include the psychiatrist’s last day of work, which should precede her due date, the duration of maternity leave, how to access interim care if needed, the nature of any communication during the leave or if none is anticipated, and how the patient and psychiatrist will reconnect. Arrangements should be in place ahead of the actual leave to prevent a crisis should the psychiatrist need to begin her leave early.
Psychiatrists may not be aware of unique issues in their patients, such as sexual assaults, infertility problems, conflicts related to reproduction, and pregnancy, or prominent dependency needs (8). This patient cut her abdomen—the locus of pregnancy. This act may have reflected anger, anxiety, impaired impulse control, and self-soothing at the time the psychiatrist was leaving. The impending abandonment may have been reminiscent of the loss of her mother or the cutting may have represented a wish to get rid of the psychiatrist’s fetus or identification with the unborn child.
The psychiatrist in this case underestimated the potential for strong reactions in a patient who had brought up relevant issues of being single, grieving about her mother’s death, and resenting continued interdependency with her father. The psychiatrist did not encourage the patient to make associations to the pregnancy, nor did she seem to recognize the potential challenges her pregnancy presented. The patient’s assignment to a medication clinic may have contributed to the psychiatrist’s limited view of the patient. Despite clues that the pregnancy could hold meaning for the patient, the psychiatrist did not seriously consider this.
In this treatment relationship, the two may have unconsciously colluded in not addressing the pregnancy earlier. There may have been a countertransference response to the patient’s transference. Many abuse victims do not trust their mothers with information about the abuse, and there is typically marital and family discord along with parental neglect (16). This patient may have expected little from the psychiatrist and chose not to confide the abuse. The psychiatrist may have behaved as the negligent maternal transference figure in ignoring the current suffering of the patient or as the paternal transference figure absorbed in his own sexual needs. A further complication is the death of the patient’s mother, which may have made overt anger toward her mother-psychiatrist difficult.
The psychiatrist did not fully understand the patient and focused almost entirely on depressive symptoms. One can speculate about the many feelings a pregnancy evoked in this patient, including anger mixed with envy, identification with the fetus merged with the wish to hurt herself, sibling rivalry, guilt, and loss. Childhood memories were certainly evoked. Together, these issues probably ignited in the patient a need to finally deal with the sexual abuse she had suffered.
Case 3
Mr. C, a 30-year-old married father and health care professional, was receiving twice-weekly psychodynamic psychotherapy addressing depression, a feeling of unimportance in his relationships, and the stress of recent fatherhood. He easily recalled from childhood his mother’s nagging, infantilization of him, and worry that he would become sick. He described her preoccupation with her ill sister and his ailing father, who died when he was 12. During the treatment, he revealed that his older brother had been physically abusive to him, but his mother never knew this or chose to ignore it.After 6 months of treatment, Mr. C commented on the baggy clothing women wear. His psychiatrist, who had recently begun wearing maternity clothes, asked for his thoughts about her baggy clothing. He admitted that he wondered if she was pregnant. “That’s great! You’ll have the greatest joy of your life, the greatest delirium,” he responded to her acknowledgment.In subsequent sessions, he reported feeling rejected by his wife’s attention to their baby and then guilty for his jealousy. As the psychiatrist’s maternity leave approached, he assured her that he would be okay and would not need to see the covering psychiatrist. Two weeks before the psychiatrist’s maternity leave began, she was surprised when Mr. C expressed concern that he could become suicidal and return to illicit drug use, a habit he had kicked shortly before entering treatment. He continued to insist that he did not need coverage. Upon his return after the therapist’s 6-week maternity leave, he admitted that he had become suicidal and overdosed on synthetic opiates during her absence.
Psychiatrists easily miss negative transference. Given his feelings of abandonment by his mother and wife and the early loss of his father, this patient was at risk for intense, negative feelings about the maternity leave. He felt joy at being a father and had hope of providing a better childhood for his baby; however, fatherhood led him to feel displaced by the baby in the amount of attention shown by his wife. The intimate relationship with his pregnant psychiatrist could have replayed this scenario.
The psychiatrist was eager and relieved to announce her pregnancy and pleased that the patient seemed to respond so positively to the news. His conscious wishes that she experience the happiness parenthood brought him were likely genuine, but they also defended against his feelings of unimportance and weakness in the transference. They may have also gratified his wish to gallantly protect women. In turn, the psychiatrist may have unconsciously feared the patient’s underlying aggression and also wished for nurturance.
The psychiatrist’s sexuality is exposed by pregnancy in a way that defines her as a sexual being who has a partner. The psychiatrist may have had anxiety about the libidinal wishes of her patient and felt guilty about being overtly sexual, keeping exploration of the transference off limits. The psychiatrist superficially attempted to explore the patient’s feelings of unimportance and neglect about the pregnancy and leave; however, his denial and her incomplete grasp of latent transference reactions led them to avoid addressing manifestations of the negative transference. Instead, the psychiatrist was surprised when the patient announced concerns about his safety during her upcoming leave but quickly felt reassured that he would be okay.
His resentment about the psychiatrist’s pregnancy and leave, feelings of being unimportant in all relationships, including the therapeutic relationship, and his vulnerability to relapse with drug use when feeling stressed and angry were further explored after treatment resumed. It was easier to deal with a wide variety of feelings once therapy resumed. Supervision that encouraged the psychiatrist to deal with the patient’s potential for intense feelings of dependency, abandonment, loss, poor coping, and sexuality may have been useful in preventing morbidity in this case. Although supervision may be fraught with transference issues, several authors have described its usefulness in working through the stress of pregnancy (5, 17–19).
Discussion
These vignettes illustrate potential pitfalls in patient care during a psychiatrist’s pregnancy. Common themes arose in these patients, and the psychiatrists also had some consistent reactions. The psychiatrist in each case was satisfied to allow the patient to deny the extent to which he or she was affected. It is reasonable to suggest that countertransference reactions contributed to the psychiatrists’ reluctance to delve into the broad range of patients’ feelings.
A psychiatrist should be aware of defenses she may use in response to reactions her patients have to her pregnancy and understand that her feelings may be a result of these defenses. Morbidity in the patient may be the consequence of not recognizing these reactions. Four examples of psychiatrists’ reactions to patients are the following: 1) a protective stance for herself and her baby in response to the patient’s real or imagined aggressive wishes, 2) the need to be nurtured in response to the patient’s dependency needs, 3) guilt about wishing to be rid of the patient in response to the patient’s fear of abandonment and rejection, and 4) denial about sexual issues that may be stirred up by the pregnancy in response to the patient’s libidinal wishes.
Patients may continue to react to the pregnancy and leave the practice after the psychiatrist has resumed working. Some patients initially miss appointments or make it difficult to schedule an appointment. One patient said, “I didn’t want to return when you were ready because I didn’t want you to get credit for what I accomplished while you were out.” However, some patients can best describe their feelings about the pregnancy and leave only after treatment has resumed and everyone is safe.
There is much to be learned about the ways in which a psychiatrist’s pregnancy affects the therapeutic relationship and the patient’s outcome. The information available on this topic is based largely on observations. The vignettes presented here affirm and expand upon some descriptions that have appeared in the literature. The authors encourage general psychiatrists to consider psychodynamic themes as well as biological, social, and cultural norms when treating patients while they are pregnant.
Footnote
Received Nov. 14, 2001; revision received Oct. 12, 2002; accepted Oct. 15, 2002. From the University of Connecticut Health Center, Department of Psychiatry. Address reprint requests to Dr. Tinsley, University of Connecticut Health Center, Department of Psychiatry, 236 Farmington Ave., Farmington, CT 06030-1935; [email protected] (e-mail).
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