The Pregnant Therapist

by Marika Mikulak

Pregnancy can be a beautiful experience and it can also be a distressing one. It can be a long-awaited occurrence or an accident that disrupts life and comes unwelcome. A long time ago pregnancy left the privacy of people’s homes and entered the political sphere, with never-ending discussions about the woman’s right, or lack of it, to end it. Like many other human issues, it is a complex one. Here my focus is on the pregnancy, particularly the first pregnancy, and psychotherapy, and more precisely on the pregnant therapist and the challenges and implications for both therapists and clients.

The review of available literature on the subject highlights that most research is from the perspective of therapists and their self-reporting of the experience. This article will follow this trend to some extent. As I began to reflect on my own pregnancy and my work as a therapist, the more I realised that it had various facets. I wondered how it affects pregnant therapists working with clients who can bring distressing things to share. How we as therapists mind ourselves in this work when pregnant and how our pregnancy might affect the work, clients’ reactions, potential parallel processes, and the impact maternity leave may have. Finally, I also became curious about institutional aspects and whether accreditation bodies have policies related to it.

It is important to note that while I will speak about my experience as a female pregnant therapist, other therapists who are soon to become parents also need to be mindful of their needs and emotional reactions to impending parenthood which may affect their work. This is a journey that is different to mine so I will not be commenting on it.

Pregnant Therapist’s Self-Care

Becoming pregnant earlier in my career would certainly have been a greater challenge than it is now after 10 years of practice. As always, personal work and awareness of myself helps to navigate the work and recognise what is mine and what is not, to remain connected and separate, to use family constellation’s language (Hellinger et al., 1998), and to use all the self-care practices that have become a second skin, thus, protecting me and the baby from becoming a prisoner of someone else’s nervous system (Siegel, 2017).

After sessions, prompted by my supervisor, I regularly checked in with myself and my growing baby inside, to see how we were doing and if there was anything we needed at those moments. Gerber (2005) highlights that part of the self-care is the creation of a comfortable and supportive working environment during pregnancy. This includes extra breaks, attention to scheduling appointments, allowing pauses for additional nutritional requirements, stretching, and emotional regulation through stress-based interventions like mindfulness. She also encourages equipping your office with extra pillows and whatever else might make sitting more comfortable, particularly at the later stages of pregnancy.

Early in my pregnancy, I had several female clients in their 30s who were either trying for their first/ second baby or were pregnant themselves. I was acutely aware of my state, while they did not yet know. Some of them were describing difficult or even traumatic experiences during the first labour, and how they were disrespected or dismissed by maternity ward staff which led to fears and worries concerning the second pregnancy. In this case, my self-care revolved around holding my clients and allowing them space for whatever they needed to explore, while addressing my own anxieties about what was to come and grounding myself in the knowledge that my experience did not have to follow theirs. Supervision, peer groups and personal therapy are places where any difficult material or reactions can be processed safely. They also offer additional holding which is so important during the time when we not only hold clients but also our babies.

Interestingly, the findings of the National Maternity Experience Survey (2020) in Ireland show that 85% of women had a good or very good overall experience while 15% did not report positive experiences. Only 50% of women using the services partook in the survey so we do not know the other half’s perspective. Interestingly, antenatal care got 7.4 out of 10 with the highest-scoring question concerned with being treated with respect and dignity and the lowest-scoring question related to the provision of information about changes in mental health during pregnancy. Mental health focus was again scored lowest for antenatal care at home. This related to the GP practice nurse/midwife and discussions on the topic at the 6-week check-up. It seems that mental health, so crucial during and post-pregnancy, requires more attention from the health care providers.

Impact of the Pregnancy

Once pregnant, many questions that were never relevant previously began to emerge: when to tell my clients, what words to use, how much to reveal and when during the session to bring up this topic. Of course, supervision and the experience of other peer therapists have supported me in navigating this. The realisation that there is no ‘one size fits all’ model helped and it resulted in my thinking about each person I worked with and considering their individual clinical needs.

It has also been crucial to consider my needs and my readiness to share this information. When it came to telling clients I felt an unexpected resistance to the disclosure and letting clients into my private life: a life that was about to change so dramatically and it was impossible to even imagine how exactly. I also experienced some anxiety around the impact of maternity on my private practice, on my beloved career, and on my availability to it. It was not just about informing clients of an impending break in our sessions; it was about my identity changing to include being a mother. Zucker (2015) puts it well: “pregnancy asserts the therapist’s presence and shatters her privacy in a way that nothing else does.” When one is an employee of an organisation, there is a clearer path to follow: maternity leave and then you come back, if you wish, to the same post that you left. However, when you are self-employed, there is more flexibility around when to take a break and for how long. This is often linked to your financial situation as well. There is also uncertainty about what you will be coming back to. Some clients might take this opportunity to end therapy, some might be back after the break, and finally, some might seek support elsewhere. Driemeier Schmidt et al. (2015, p. 51) state that pregnancy: “is a moment of transition in the vital cycle of a woman, in which she renegotiates her personal and professional identity, adjusts relationships and develops a new relation with her baby during the preparation for the experience of maternity/motherhood.”

Other practical questions followed: what will be the dates and length of the maternity leave? Who will manage the clients while I am on leave? One of the things I learnt is putting limits on accepting long-term clients at some stage of my pregnancy knowing full well that my availability to them has an expiry date. This does not mean saying no but rather informing potential clients from the onset of the impending maternity leave and leaving them with a decision to come or look for support elsewhere.

Whether to tell clients or wait and let them bring up the topic themselves was another question on my mind. I believe there is no right or wrong answer and again there is no one size fits all. Zucker (2015) recounts “so when my body changed shape and my protruding belly filled the consulting room, the traditional therapeutic construct got turned on its head.” The physicality of the changes in the body, whether spoken about or not, became visible at some stage in the 2nd trimester (after 4 months). Then, the whole question of self-disclosure becomes redundant as the eyes see what they see when you work face to face. Nowadays living in the post-pandemic world, which has immensely popularised online therapy, clients might never see the physical changes of the pregnant body and it is completely up to the therapist to reveal, or not, what is occurring.

The study by Wolfe (2013) specifically looked at whether this highly visible and major event in a therapist’s life and the client’s full awareness of it leads to interactions in the therapy room that are less professional and more personal. The literature review done by Wolfe (2013) seems to stress that the therapist’s pregnancy is a strong stimulus for clients and that their reactions to it vary. The majority of clients, between 73-84%, reported feeling happy for the therapist but simultaneously some also felt jealous, competitive, and resentful (Katzman, 1993; Matozzo, 2000). Fallon and Brabender (2003) identified three main themes associated with the therapist’s pregnancy: symbiosis and separation, envy and competition, sexuality and jealousy. The experience of separation and loss is due to therapists being less available to their clients and more focused on the baby. The actual absence during maternity leave can evoke feelings of abandonment, rage, anxiety and sadness.

The second theme pertains to the envy towards the baby who gets the therapist’s attention and care or the envy towards the therapist which is particularly experienced by clients with fertility issues. The latter, however, is not always the case. One of the first clients I told about my pregnancy was a woman in her late 20s who was interested in long-term work. A significant factor in me telling her early was her inability to have children due to a medical condition and her history, and the fact that she was interested in long-term work which I knew at that stage would be interrupted by my maternity leave. I did feel anxious informing her, yet also obliged to bring it into our second session while we were still in the process of deciding whether we would continue to work together. According to Grossman (1990), the pregnancy can lead to a role reversal where clients become tender, caring and helpful towards their therapist. Her reaction was somewhat in line with this whereby she said: ‘I want to make you feel at ease; I am in acceptance of the fact that I cannot have children and I have no issue with other people having them.’ I responded that she did not need to make me feel at ease and that this was a space for her to express whatever she experienced in relation to my pregnancy.

Coming back to Fallon and Brander’s themes, sexuality and jealousy reflect the meaning behind the pregnancy which tells clients something about the outside relationships of the therapist and their sexual life. This theme also encompasses jealousy towards the therapist’s partner which has been linked to oedipal issues and increased erotic transference, particularly from male clients.

An interesting consequence of the therapist’s pregnancy is acting out in the form of early termination of therapy, missing sessions, delayed payment, more promiscuous sexual behaviour, and other behavioural changes (Wolfe, 2013).

How My Clients Reacted to the Pregnancy

I started telling my clients in my 5th month as that was when I felt ready. Most of them reacted positively to the news, they were visibly happy and explicitly congratulated me. After telling several of them, I wondered about this ‘good news’ and whether there is a general societal expectation of reacting positively given that having a baby is often a better event than a loss, death or relocation. One of my clients spoke about this being a valid reason to take a break as opposed to closing down or downsizing the practice which can more easily bring up feelings of abandonment. What I found interesting was that often after the first response, there was a line or two that was more about them, such as “I will be fine”, “You taking a break won’t affect me”, or “Thank you for telling me so early, I feel emotional and respected”. I kept my ears open more to those passing comments, those gems that I felt could be explored to increase the awareness of their reaction to change, temporary loss, or other outcomes. I always came back to them allowing space to delve more into the meaning of their words. Some clients reacted with jealousy, openly expressing it but not in an aggressive way, rather showing their desire to also be pregnant and their readiness for it in their lives.

In my 11th week, one of my female clients shared her news of early pregnancy. At that stage, she did not yet know I was pregnant as well. I was doubly careful at picking the moment to inform her of my state, not wanting to dim or encroach on her experiences of unfolding pregnancy. My supervisor suggested that she might wonder anyway about me having or not having children and that was confirmed following my disclosure. The parallel process was trickier at times than I had expected, and I had to be extra careful not to mix my experiences with hers, the bracketing was at work. Certainly, my own experience helped me to understand and empathise with her emotions and needs, so there were positives to it as well.

Institutional Approach

Institutional attitudes surprised me. The Irish Association of Humanistic and Integrative Psychotherapy has some policies around it, namely Bye-Law 4A, Section 3.1 which sets out that members who wish to take parental leave from their practice for less than a year, because of pregnancy or the birth or adoption of a baby or for other reasons relating to their children, do not have to become non- practising associates. When asked if some deductions of a yearly fee are offered, unfortunately, the answer was no. This can be hard when in private practice and money is not coming in while you are caring for your baby or when you need to take an earlier leave due to a risky pregnancy. It is only when you are non-practicing for more than a calendar year, you could avail of the non-practicing fee rate of €65, but maternity leave, at least in Ireland, does not usually last that long. Is this a subtle form of discrimination or just not warranting too much attention to mothers-to-be? I also contacted the Irish Association of Counselling and Psychotherapy which seems to offer an option for fully accredited members to suspend their practice for a minimum of three months and a maximum of twenty-four months and in this case, you can apply for inactive membership which costs €105.00 per annum. This option seems more attractive and adapted to the needs of pregnant therapists and other therapists who may wish to take some leave to care for their offspring.

Conclusion

Pregnancy in the therapy room, as I have tried to demonstrate in this article, has various facets and some consideration is necessary around the impact of such an occurrence on the therapeutic process. Pregnant therapists need to take care of themselves, this includes their logistical and emotional needs, and of their clients as they prepare for their therapist’s maternity leave. The usual supports of supervision, peer groups and therapy are crucial in this process as they provide a holding space so important during this experience. Finally, institutionally it does not appear that support is always sufficient and it begs a question whether again women, and in this instance, mothers, experience some level of discrimination or at least their needs are not fully accommodated at this significant time in their life.

Marika Mikulak trained as a psychotherapist at the Flatstone Institute in Cork and completed her postgraduate studies at the Metanoia Institute in London. She is an accredited member of IAHIP. She is a lecturer in the PCI and has a private practice. She can be contacted at marika.mikulak@gmail.com

References

Fallon, A. E. & Brabender, V. M. (2003). Awaiting the therapist’s baby: A guide for expectant parent- practitioners. Lawrence Erlbaum Associates.

Gerber, J. (2005). The pregnant therapist: Caring for yourself while working with clients. American Psychological Association. https://www.apaservices.org/practice/ce/self-care/pregnancy

Grossman, H. Y. (1990). The pregnant therapist: Professional and personal worlds intertwine. In H.Y. Grossman & N. L Chester (Eds.), The experience and meaning of work in women’s lives (pp. 57-81). Lawrence Erlbaum Associates.

Hellinger, B. With Weber, G. And Beaumont, H. (1998). Love’s hidden symmetry. Zeig, Tucker & Co.

Katzman, M. A. (1993). The pregnant therapist and the eating-disordered woman: The challenge of fertility. Eating Disorders, 1(1), 17–30.

Matozzo, L. (2000). Impact of the therapist’s pregnancy on relationships with clients: A comparative study. (Doctoral dissertation) Retrieved from ProQuest Dissertations and Theses.

National Maternity Experience Survey (2020) Findings of the National Maternity Experience Survey 2020 https://yourexperience.ie/wp-content/uploads/2020/09/National-Maternity-Experience-Survey- results.pdf

Driemeier Schmidt, F. M., Fiorini, G. P. and Rohnhelt Ramires, V. R. (2015). Psychoanalytic therapy and the pregnant therapist: A literature review. Research in Psychotherapy: Psychopathology, Process and Outcome. Vol. 18. No. 2. 50-61.

Siegel, D. (2017). Developmental trauma - An interpersonal neurobiological approach to transforming developmental trauma into integration and resiliency. Workshop in Cork in May 2017.

Wolfe, E. (2013). The therapist’s pregnancy and the client-therapist relationship: an exploratory study.

Masters thesis, Smith College. https://scholarworks.smith.edu/theses/944 on 11th May 2023.

Zucker, J. (2015, April 28). The pregnant therapist. New York Times. https://archive.nytimes.com/ opinionator.blogs.nytimes.com/2015/04/28/the-pregnant-therapist/?_r=0 on

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