And Baby Makes Three

By Stacy Notaras Murphy

I remember the first client I told about my pregnancy. I was starting to show and realized I couldn’t put the news off any longer. Dawn (client names have been changed throughout to protect confidentiality) was the one person on my caseload I was nervous about telling because she was going through fertility treatments to become pregnant herself. In my anxious state, I made the impatient decision to start my notifications with her rather than learning from and building on my experiences in telling other clients.

“You might have some feelings about this, but I’m pregnant,” I blurted out at the end of a session. Dawn paused, smiled and said, “Well, thank you,” and then she left. Though we kept working together, we never really discussed her feelings about how I delivered the news of my pregnancy to her. I look back on that with such regret. I wish I had had more of a strategy in that moment.

I was meeting weekly at the time (and still to this day) with a peer supervision group made up of therapists who are mothers. Our experiences of telling clients about our pregnancies are all somewhat similar, and they include both hits and misses. We all recall times when we used the information to good therapeutic effect. We also recall instances in which the news derailed what might have happened under other circumstances.

According to the U.S. Department of Labor, women make up approximately 70 percent of all counselors. In addition, nearly three-quarters of ACA’s membership is female. These numbers suggest that it will not be particularly uncommon for clients to work with a counselor who is pregnant during treatment. Although studies and papers on the topic are not plentiful, the subject comes up in wider discussions of transference, countertransference and ethics. Among the questions to consider are when to reveal the pregnancy to clients, how much detail to offer and how to ensure proper client care both leading up to and during maternity leave.

While many clients have little conscious reaction to their counselor’s pregnancy, others have strong feelings that can be named with the counselor or that show up in other ways. One colleague described a client who threw himself into a crisis just before her maternity leave began. In their work, it became clear that he had done this to give her the opportunity to prove her commitment to him — by attending to his needs despite having an infant at home — or to unmask her as the abandoning mother he recalled from his own childhood.

Not all therapeutic alliances are deeply challenged by the counselor’s pregnancy, but most will experience some impact, if for no other reason than it necessitates a break in the counseling process. Preparation, awareness and collegial support are indispensible tools during this time.

Moment of truth

Patti Anderson is an ACA member and licensed professional counselor (LPC) in private practice in Washington, D.C. She is also the mother of one school-age son and younger twin daughters. During her first pregnancy, Anderson was a full-time counselor at a university. She left that position after her maternity leave ended and launched her own private practice. Her second pregnancy happened five years into building that business. “I noticed I felt more pressure and anxiety with the second pregnancy in regard to finances, clients and the business’s ability to withstand my maternity leave,” she reflects.

Anderson says a vital support was having supervisors who were available for help and quick consultation. “For me, that availability was key to being able to quickly check in to manage countertransference and unique client issues,” she says, adding that her second pregnancy had more emotional components. “It was a real balancing act between what’s best for my family, what’s best for my clients and what’s best for the business. As you can imagine, sometimes those things clash, and sometimes the problems, solutions or truth of the situation were unconscious to me, but my supervisor really helped me tease them out.”

Once, during a session with a long-term client, Anderson was overcome with morning sickness. Because she was only about four weeks along at the time, she had not planned to tell anyone about the pregnancy for several more weeks. “[The client] noticed that I didn’t look well,” Anderson says. “She has good boundaries and didn’t ask what it was, but I could tell she was worried. I was scared to tell anyone yet, so I let her leave the office with the ambiguity of what was wrong hanging out there. Later, I decided to call her and explain the situation. She was really relieved, as she thought I had cancer, and appreciated me following up with her.”

That experience reminded Anderson that clients can be forgiving of our mistakes, and that those times often serve to deepen the work that counselors do. “The best lesson I learned was to treat each client individually, mindfully tell them and talk with them about it when it [was] appropriate for them within reason,” she says. For some clients, simply knowing her due date was enough detail, and Anderson notes that limiting the information about her pregnancy helped demonstrate good boundaries for certain clients. Still, other clients had specific questions about how her work schedule might change after delivery.

Laura Jessup is a counseling resident and ACA member working as a therapeutic day treatment specialist at a middle school in Manassas Park, Va. At the time of our interview, she was pregnant with her first child and had just revealed this news to her caseload of five adolescent clients.

Having recently told teachers and staff at the school, Jessup wanted to tell her clients in person before they heard it elsewhere.

“I thought about the word choice I would use with each of them and particularly about how I would avoid putting too much of the focus on me during this part of the session,” she says. “Even though it was my news and experience, I wanted to keep the focus of the session about them.” She notes that she wanted to be able to talk to each of the adolescents about how her pregnancy would affect them, help process their individual reactions and answer any questions they might have.

Jessup says she didn’t receive any advice from her supervisor about how to announce her pregnancy in the counseling room. “Truthfully,” she says, “I did not think to consult any reading materials or articles. I briefly consulted with a colleague regarding if I should sit down each of my clients and share with them the news or just wait for them to find out eventually from others. She helped confirm my initial instinct that I should tell them directly.”

Traversing transference

The reactions Jessup received were mixed, but one stood out. Jessup had worked for more than a year with Cara, a 14-year-old female. After being told the news, the adolescent’s first statement was, “Well, what’s going to happen to me? Who’s going to be my counselor?”

Jessup knew heading in that she was unlikely to receive the socially appropriate “congratulations” response from such a young person. In fact, Cara’s egocentric, developmentally appropriate reaction confirmed Jessup’s choice to reveal the pregnancy to her clients directly. By being patient and interested in Cara’s own experience of the news, Jessup learned even more about the adolescent’s history and interior world.

Cara “went on to elaborate about how one of her favorite teachers had just recently left for maternity leave, and she was experiencing some conflicts with the substitute teacher who had replaced her,” Jessup says. She tried to alleviate some of Cara’s concerns by explaining that she would be on maternity leave only during the summer break. “She expressed some relief but then reminded me that pregnancies don’t always go as planned and that I might have to be on bed rest or have to leave work earlier than expected,’” Jessup says. The two have continued to process the experience, which has ended up revealing new details about how several of Cara’s family members have experienced miscarriages and complicated pregnancies.

Sometimes transference issues are more hidden, as in Cara’s case, while others are right at the surface. Anderson worked with a woman, Tanya, who had lost a baby at 20 weeks. “As I got more and more pregnant, she starting reexperiencing the trauma, and we used those sessions to really provide her with a safe space to talk about the difficult emotions coming up for her around my pregnancy,” says Anderson, who also worked closely with Tanya’s psychiatrist to ensure she had another outlet for processing her feelings.

Timing is everything (to new clients)

Once the word is out about a counselor’s pregnancy, she also must consider what impact that might have on any new clients she takes on before her due date. W.E. Wang, an LPC and ACA member in Fairfax, Va., is now a stay-at-home mother. Before having her child, Wang worked in a partial hospitalization program where she led groups and counseled individuals for an average of three months at a time.

Wang says conscious consultation with co-workers and supervisors was key to getting her ready to talk about her pregnancy with clients. She prepared for those discussions with clients by thinking through the details she wanted to share — such as the starting date of her maternity leave — and those that she wanted to keep private. “The most important advice that I received from my colleagues was that I needed to be aware of my needs,” Wang says. She notes that her colleagues and supervisors encouraged her to pay attention to her own self-care and to set boundaries about whether she wanted to publicly share the child’s gender.

“My clients were surprisingly accepting of the news,” Wang recalls. “Most reactions were related to anxiety on how the pregnancy might affect their treatment. I did start treating a few clients midpregnancy, where it was obvious to them. One client in particular was very guarded, even skeptical, about my ability to work with her since the presenting problem was related to anger outbursts and difficulty coping with mood swings.”

Wang explained that the client, Mary, a married woman without children, first arrived at a group session and was the only new member present. When Mary recognized that Wang was pregnant, her facial expressions revealed surprise and agitation. “She proceeded to share that she [could not] allow herself to be angry with a pregnant person. Therefore,” Wang says, “she worried that she [could not] be completely open and honest during treatment.” Wang explained that she worked as part of a treatment team made up of several professionals who were available to help Mary.

Together, Wang and Mary worked to create a plan in case Mary felt her anger escalating, such as removing herself from the situation or asking for support from another team member. Wang also took the opportunity to explain that she worked to keep her treatment process transparent and that there would be plenty of room to discuss the pregnancy if Mary ever had anything to process. “Throughout treatment, we worked on grounding skills and increasing awareness of her emotions,” Wang says. “She did not appear to have any other concerns relating to my pregnancy for the rest of the time I worked with her.”

In contrast to those working in agency settings, many counselors in private practice often set a date when they will stop taking on new clients. I recall thinking it would be fine to do an intake in my sixth month of my first pregnancy, but when time came for my maternity leave, I regretted having to cease working with that client after what felt like a short time together. Rather than set her up with a support network to get through my time away, we decided together to transfer her case to a colleague. During my second pregnancy, I was much more conservative about accepting new clients after the third month and made sure to disclose this information with every new referral that came in.

Anderson also chose the “open book” route and allowed new referrals to assess their own personal comfort levels working with someone about to take a leave of absence. “I had a couple of people who did not return after I had the babies. I attempted to follow up with them to make sure they found someone else. I felt like I did everything I could to provide them a safe space to handle this transition, but at the time,” she acknowledges, “it felt more personal, like I did something wrong.”

“My supervisor helped me really take a look at those pieces and work through them,” she says. “I also had a few who canceled our first appointment upon my return. I felt like I knew what that was about for many. It was good material and helped clients uncover abandonment and anger issues. It also gave me a look at how they operate with others in their lives.”

Anderson advises counselors to consider their own personal style of connecting with their clients and to use that style to help clients process the new information about the pregnancy. “It helped so much when I moved from seeing the process as more of a policy or procedural issue to authentically, openly incorporating it into my therapy,” she says.

Transition planning

ACA member and recent counseling graduate Renee Rivera is working toward licensure in New Jersey. She was engaging in individual therapy when her own counselor got pregnant. One day, Rivera’s counselor sent her a text message canceling an appointment because she was not feeling well.

“I responded that I didn’t know she had been sick and hoped she felt better, at which point she [texted back] that she wasn’t sick, she was pregnant,” Rivera says, adding that they had been working together weekly for about eight months. “I received a phone call the following week from a new therapist informing me that [Rivera’s counselor] was on maternity leave and that she would be taking over my sessions. When I showed up for the session a few weeks later, I was informed that the new therapist was no longer with the group, and I would be seeing someone else [new] again.”

Reflecting on the experience as a client, Rivera found the entire situation odd and somewhat overwhelming. Considering the experience as a trained counselor, she says the circumstances were poorly managed. “I respect not immediately disclosing the pregnancy, especially if you aren’t planning on going on maternity leave immediately and feel you have time to broach the topic later,” she says, “but to be told via text message while canceling an appointment feels like a boundary issue. It was almost like having a conversation with a friend, which is not what I expect when talking to my therapist.”

“Additionally,” she continues, “I felt like the team did not have a proper plan to deal with my therapist’s maternity leave. When the interim solution they adopted did not work out, I was never informed and, as a result, ended up not having an appointment for about a month, at which point the mix-up and other issues related to me having to switch therapists were never addressed. Although I ultimately handled the transition well, I can imagine that other clients may have had a more difficult time with the situation and ultimate adjustment period.”

Having lived through this series of therapeutic missteps, Rivera recommends that counselors have a transition plan and seek to include colleagues and other staff members in that strategy, if appropriate. “Depending on how long you may be on maternity leave, a client could be significantly impacted as a result of the pregnancy,” she says. “Being sure that they are prepared to make the adjustment to either not seeing you for an extended period of time or meeting with a new therapist will make the transition that much easier, especially for clients who may struggle with change and transition.”

Jessup agrees that counselors ought to take the time to create a transition plan for each client and discuss that plan at the time they reveal news of the pregnancy to the client. “Having a plan in place and being able to verbalize it to the client early on also demonstrates to the client that the counselor is considerate of his [or] her needs and is working to ensure that they continue to receive quality treatment,” she says.

Use it or lose the chance

Although it’s a disruption to business as usual, a counselor’s pregnancy can become a conduit for new insights and a deepening of the therapeutic alliance. One of my clients once reflected that seeing me, then at age 33, change physically into a mother actually challenged her long-held, biased expectations about her own mother’s ability to parent her because she had her as a teenager.

Similarly, Heather Tustison, an ACA member in Boise, Idaho, is approaching her first pregnancy as an opportunity to normalize pregnancy as part of the general human experience. Tustison serves as a clinical supervisor at her own private practice and training facility, where she sees an average of 20 clients per week and supervises four interns. At the time of our interview, she noted she had been unable to find many materials about how to deal with client issues and pregnancy. As such, she consulted with colleagues and decided to start disclosing her condition to clients at the four-month mark.

Her clients’ reactions ran the gamut from positive (“Your child is going to be so well-adjusted!”) to fearful (“What will I do without you?”). Tustison says the most transference has come from those clients with abandonment issues. “Their intensity has increased and their symptoms have increased the closer we [get to] my due date,” she notes. She adds that she chose to bring her observations of the clients’ reactions into the counseling process to help them explore the roots of their concerns.

Tustison has worked with her clients to normalize the human experience of attaching to someone who then may not be as available due to pregnancy or some other physical issue. She also urges counselors to consider and possibly disclose any physical reactions to pregnancy that may be preventing them from performing their job in the same way they did before. “I have had to make restroom breaks a part of the ‘hour session,’” she says. “My baby is positioned very high, and I often sigh or yawn just to breathe. Both may be seen as inconsiderate or disrespectful but have been unavoidable.”

****

Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org

This article first ran in the April 2014 issue of Counseling Today magazine.