The PANY Bulletin

Psychoanalytic Association of New York
Volume 39, Number 1 Spring 2001

Scientific Meeting
A Species of Melancholy: Knowing/Not Knowing of the Analyst's Pregnancy
by Lynne Zeavin, Psy. D.
January 10, 2000
Discussant: Marianne Goldberger, M.D.
Reporter: Herbert Stein, M.D.

Dr. Zeavin's paper focused on the effects of the analyst's three pregnancies upon the treatment of a woman patient. She was particularly interested in the issue of the analyst's self disclosure as it applies to the situation of pregnancy. "Pregnancy is a disclosure. But as with any perceptual stimulus, its content is inevitably mediated by how it is received. ... The problem of what to say and how and when to say it persists. The impact of the analyst's pregnancy-perhaps like any disclosure-carries unforeseen force, generating hidden meanings for the patient that are not available in the form of a conscious response to the analyst. One cannot rely on the patient's perception, nor her/his immediate access to that perception to reliably carry information."
To emphasize that point, Dr. Zeavin described an initial interview with a young woman conducted when Dr. Zeavin was eight months pregnant. Dr. Zeavin said to the patient, "'As you can see, I'm pregnant.'" The patient said that she had not seen it. As it turned out, this patient's mother had lost a six month pregnancy when the patient was four years old. "The patient's central unconscious fantasies had to do with dangerous impregnation, contagion and death-all of which were stimulated by thoughts of and experiences of pregnant bodies. Not knowing, or in this case not seeing, was part of a longstanding narrative, not accessible to consciousness."

Dr. Zeavin took issue with those who recommend analytic self disclosure as a general approach and who seem to assume that we can understand the patient's response to disclosure from the immediate response to it. On the contrary, patients' responses to the analyst's pregnancy suggest that "even when anonymity is compromised-as with pregnancy-and even when there is a direct disclosure, a patient will generate responses and fantasies which are not knowable at the moment."

Dr. Zeavin's paper focused on the analysis of a woman which encompassed the analyst's three pregnancies over seven years. "In each pregnancy, via either her own perception or my direct disclosure, she was aware early on that I was pregnant. She then found ways defensively to contend with this awareness, this knowing." For this patient, the analyst's pregnancies proved to be traumatic, overwhelming, because they "uncannily coordinated so closely with the most overwhelming dimensions of her past that they, like that past, proved to be 'too much'."

B described the early years of her childhood as happy until her mother was diagnosed with breast cancer when B was five years old. When B was seven, her mother underwent a double radical mastectomy. Dr. Zeavin commented on the oral cast of a memory from around that time of B eating with her mother in her mother's bedroom. "In later fantasies ... B believed that she destroyed her mother's body through her own hunger and greed. She wondered about being breast-fed, did she require too much. She recalled that around this time she became terrified to separate, and refused to go to school, clinging desperately to the bannister. After that, the next thing she knew, she had become a meticulous student and hardly ever burdened her parents with her need for them."

B recalled a period of normality after her mother's diagnosis which ended when B was eleven and her mother experienced a recurrence of the cancer which was treated with chemotherapy and radiation. This led to a remission that ended when B was 18, one year before she met with Dr. Zeavin. The timing of her mother's illness had important meaning for B. She experienced it as her mother losing her sexuality-breasts, menstruation-and her place in life while B was developing. Dr. Zeavin pointed out that B's mother first became ill when B was in the midst of her Oedipal conflict, then had relapses just as B was entering puberty and as she was ready to leave home for college and independence. She saw her mother's waning as accompanying her own ascendancy. B felt "sick by association." She felt deprived of a mother and fearful of making new attachments lest she cause them harm.

B entered treatment at 19 in order to cope with her mother's illness. Dr. Zeavin saw in her a need to control emotions, maintain a false sense that everything was fine as her mother had during her remissions, and a need to maintain an illusion of control by not allowing her to be surprised by each recurrence of the illness. Her mother died about one year into B's treatment.

Each of Dr. Zeavin's three pregnancies had a different effect upon B's treatment. Dr.Zeavin stressed the importance of her first pregnancy occurring in the context of a face to face psychotherapy. B's ability to observe the development of Dr. Zeavin's pregnancy allowed her to share in it. She was more shocked by the realization that Dr. Zeavin had a husband than by the pregnancy itself. It brought up her rivalry with her father for her mother's love. During this pregnancy, she enjoyed the fantasy of sharing the experience with Dr. Zeavin.
Once B began analysis, the inability to see Dr. Zeavin became problematic for her. "Although B. did not often speak of difficulties not seeing me-not being able to see me clearly represented a feeling of a loss of control, particularly in the realm of my body and its potential surprises. This caused B. to be ever more vigilantly aware of me: my slightest movement or sound, change in tone of voice, or any gesture that she could perceive peripherally was carefully noted. For my patient, whose own mother's body was intangible and strange, present and away, intact and coming apart, revealed and then hidden, the fact of bodily change would prove to be disquieting. The subtly changing contours of my pregnant body resonated with the traumatic memory of her mother's changing body arousing fantasies of damage, invasion, and greed. What emerged in the analysis of her response to my pregnancies was a reliving of specific omnipotent mechanisms."
Dr. Zeavin's second pregnancy occurred three years after the first. B was by that time in five times per week psychoanalysis. Dr. Zeavin described her as having become "deadened" in response to her mother's death. Dr. Zeavin did not tell B about her pregnancy, and as a result she was able to observe the derivatives of B's growing awareness of it. In the early months of pregnancy, B began to associate coming to the consulting room with entering her parent's bedroom and being shut out of it when her parents had "'private time.'" She began to become interested in Dr. Zeavin's sexuality. Nevertheless, she maintained a marked ambivalence about recognizing the pregnancy.

In wondering about Dr. Zeavin's sexuality, wondering if a male colleague was Dr. Zeavin's husband, B spoke of her ambivalence about perceiving Dr. Zeavin's body. She spoke of partly averting her gaze coming into the office, but watching with her peripheral vision. "'I have a level of awareness-even though I pretend I don't.'" As B began to speculate about Dr. Zeavin's pregnancy, she would undo her awareness, calling it fantasy and even negating Dr. Zeavin's statement that she was pregnant-"'You are having difficulty seeing my pregnancy'"-by falling back to the conditional, "'If you are pregnant'". Dr. Zeavin stressed that this was the effect of trauma, of B's having to be both vigilant and unknowing of the condition of her mother's body.
Dr. Zeavin described the numerous dynamics that made it difficult for B to recognize her pregnancy and accept the recognition. There were issues of jealousy of Dr. Zeavin's relationship with her baby and her family, of jealousy of Dr. Zeavin's female sexuality-B feared femininity as a vulnerability that made her susceptible to cancer, of her own destructive fantasies in connection with the pregnancy. The conflict over perception connected to the perceiving and not perceiving during her mother's illness, such as seeing her mother's loss of hair, but then doubting it when her mother used a wig. At one point, a window was added to Dr. Zeavin's office over a weekend, but B could not be certain that it was new.

When Dr. Zeavin became pregnant again a year after the second child was born, she decided to inform B of this pregnancy "out of respect for its proximity to the previous pregnancy and maternity leave." In retrospect, Dr. Zeavin believed she had taken control of knowing and not knowing from her patient. "While there was conscious relief in being told and not having to know or come to know herself, in the end this left B. without the means to gradually contend with the traumatic information and paved the way, I think, for her experience of the pregnancies as cumulatively traumatic."

Dr. Zeavin pointed out the traumatic importance of the coincidence of three pregnancies and three occurrences of her mother's illness. She was deeply affected by the third pregnancy, experiencing it as final evidence of the hopelessness of her wish to hold on to her analyst's affection. B spoke of her hurt and rage at realizing that her analyst was more important to her than the other way around. She compared her not being involved in the decisions regarding Dr. Zeavin's pregnancy with being left out of decisions concerning her mother's treatment. B left her analysis one year after the birth of Dr. Zeavin's third child. During that year they worked on B's conflict over her aggressive wishes and fantasies, aggression that had been repressed in the face of her mother's illness. She connected dreams of being a murderer and thief with fantasies of having killed her mother through her oral greed. When she left the analysis, it was with a mixture of partly unresolved envy and rage and attempts at reparation and resolution. Dr. Zeavin finished her description of the analysis with a hope that B's parting gift to her, a creative work, was "a harbinger perhaps that traumatic memory can transform into usable human experience."

Dr. Marianne Goldberger Dr. Goldberger began her discussion addressing the ambiguity of the first appearance of pregnancy that allows for a wide difference in patients' perceptions. She said, "It immediately makes me wonder about defenses altering an individual's threshold in the ability to perceive." This led her to "transference of defense", "a concept that continues to puzzle some clinicians, despite the fact that Anna Freud brought it to the world's attention in 1936." Dr. Zeavin's patient who did not recognize Dr. Zeavin's eight month pregnancy was an example of transference of defense, in which it is the defense against the instinctual impulse rather than the impulse itself which is prominent in the transference.

Dr. Goldberger said, "Many patients, because of their own conflicts, ignore or seem to be unaware of the pregnancy for many months. Even if they do know, they may be unable to talk about it. Or their awareness, subjected to strong denial, may not become conscious. In such instances, associations may contain oblique references, through dreams or displacements, to various derivatives of the subject of generativity-- such as fertility, barrenness, gardening, Demeter, Persephony and the like."

She gave an example: "A candidate was in her second trimester and sufficiently large to be wearing loose clothing. The supervisor thought the patient's indirect allusions to the pregnancy did not yet indicate conscious knowledge because of his pervasive obsessional defenses. The week after the candidate discussed this issue in supervision, the patient dreamt he was holding a baby in his arms and then he threw it out the window. The candidate now assumed "he knows" and told him of her pregnancy. But in fact, he was taken aback and completely surprised, since his awareness was not yet conscious." Dr. Goldberger said that she agreed with Dr. Zeavin "that it may be impossible to know whether the patient's awareness is conscious. ... My intention is just to support what this excellent paper has already told us-namely, we need to be aware that even when we know a particular patient very well, there is much we'll be uncertain about."

Dr. Goldberger addressed Dr. Zeavin's allusion "to an analyst's temptations to be self-revealing, perhaps in order to relieve her own tension about not telling. In most analytic situations we can delay telling until the patient brings up an issue; urgency about self-revelation is unusual in analysis (except, of course, obvious matters of scheduling). However, if the patient does not recognize and acknowledge the analyst's pregnancy directly, we don't have the leisure to wait indefinitely to take it up, any more than we could wait if we were going to relocate to another state. Whenever the analyst brings up a reality, analytic neutrality is altered and the analyst has to be alert to the possible effects this intrusion on the patient's autonomy may have, such as bypassing defenses. Telling too early-that is, before the patient mentions it spontaneously- precludes a more informed, uncontaminated analytic opportunity to learn the unconscious meaning the pregnancy has for the patient and to understand what it means in the patient's transference to know, or to not know."

Dr. Goldberger felt that the interruption of the analysis caused by pregnancy and the birth of a child is ideally dealt with "separately from the patients' feelings and fantasies about the pregnancy. But very often this isn't possible because of many patients' pressing concerns about the analyst's 'disappearance.' For some of these patients, strong concern of this type may also be screening out other issues, such as envy, murderous wishes, competition, sibling rivalry, or other unique individual constellations."

Finally, Dr. Goldberger turned to the issue of Dr. Zeavin letting her patient know that she was pregnant earlier for the third pregnancy. She speculated that it was done because of the patient's experience with the first two pregnancies as well as her familiarity with this patient. She gave some guidelines on revealing the analyst's pregnancy early developed by a COPE study group in which she'd participated: "They include patients who themselves have had infertility problems, frequent miscarriage, as well as patients who are likely to be especially vulnerable to painful affects referable to unstable self-esteem. The reason these patients should be informed early is that they will have sufficient time available to analyze their reactions. Another group of vulnerable patients are those who have been in analysis for only a short time-they don't yet have the tools to work analytically on such difficult transference issues since they're not yet aware of them. The intrusion of an analyst's pregnancy often mobilizes intense transference reactions and brings into the foreground transference fantasies prematurely, well before they otherwise would have emerged. Many patients are reluctant to talk about such intrusions and for this reason the likelihood of enactments increases."