Psychiatr Q (2014) 85:377382

DOI 10.1007/s11126-014-9298-2
ORIGINAL PAPER

The Pregnant Therapist: The Effect of a Negative

Pregnancy Outcome on a Psychotherapy Patient
Panagiota Korenis Stephen Bates Billick

Published online: 4 June 2014

Springer Science+Business Media New York 2014

Abstract In psychiatry, pregnancy introduces an element into the treatment setting that is
complex and may require exploration. Often, in the psychotherapeutic relationship, the
psychiatrist may use therapeutic techniques and provide no self disclosure to the patient by
Tinsley (Am J Psychiatry 160(1): 2731, 2003). The patient reveals all of their innermost
thoughts. This can bring about curiosity for the patient about the clinicians life and result
in asking personal questions which can at times be uncomfortable for the therapist, particularly for those still in training. This may feel like a boundary crossing which can pose a
therapeutic challenge. The clinician is challenged to further enhance the therapeutic
relationship and further help the patient on their journey to self exploration. While it is
inevitable that patients will have reactions to their therapists, this can be played out in a
number of ways, both at the conscious and unconscious level. While numerous studies
have looked at the impact of the therapists pregnancy on the patient and their treatment,
there is no information about the effect of a therapist having a negative pregnancy outcome. Negative outcomes include the therapist having a miscarriage, delivering a still-born
or both the therapist and baby dying. This case report describes a clinical scenario in which
a psychiatry resident in training delivered a stillborn baby at 37 weeks and the impact of
that on a long term psychotherapy patient.
Keywords Pregnant  Stillborn  Dissociative identity disorder  Borderline personality
disorder  Residency training

P. Korenis (&)
Bronx Lebanon Hospital Center, Affiliated with Albert Einstein College of Medicine, Bronx, NY, USA
e-mail: Korenismd@gmail.com
S. B. Billick
New York University School of Medicine, New York, NY, USA
e-mail: Stephen@billick.com

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Introduction
In psychiatry, pregnancy of the clinician and or the patient introduces an element into the
treatment setting that needs to be recognized and explored. Often, in the psychotherapeutic
relationship, the psychiatrist may use therapeutic techniques where she is a blank, neutral
slate that does not do any self disclosure to the patient [1]. The patient, on the other hand, is
encouraged to reveal all of their innermost thoughts and feelings. Often, the patient is
curious of the clinicians life and asks personal questions which can at times be unsettling
and uncomfortable for the therapist, particularly for the ones still in training or just recently
finishing. This crossing of the boundary of what is appropriate to ask and what does not
feel so appropriate for the clinician to disclose poses a therapeutic challenge. The clinician
is then faced with the task of how to use this information to further enhance the therapeutic
relationship and further help the patient on their journey to self exploration. While it is
inevitable that patients will have reactions to their therapists, this can be played out in a
number of ways, both at the conscious and unconscious level. Consciously, this is observed
in the development of the working alliance and unconsciously through the experience of
transference and countertransference [2].
While numerous studies have looked at the impact of the therapists pregnancy on the
patient and their treatment, there is no information in the scientific literature about the
effects of a therapist having a negative pregnancy outcome. Negative outcomes include the
therapist having a miscarriage, delivering a still-born or both the therapist and baby dying.
This case report describes a clinical scenario in which a psychiatry resident in training
delivered a stillborn baby at 37 weeks and the impact of that on a long term psychotherapy
patient.

Case Report Presentation

All identifying data for the patient has been changed to maintain confidentiality. AB was a
47 year old Hispanic female, unemployed, in a domestic partner relationship, domiciled in
an apartment on psychiatric disability. She was also a mother to a now adult child. She
carried a diagnosis of borderline personality disorder and post traumatic stress disorder.
AB was sexually abused as a child by her father and reportedly was molested by him and
his friends when he would have them over for poker. AB had been an outpatient at a
community hospital in an urban setting for over 4 years. Although she was compliant with
psychotropic medication and had been managed out of the hospital since she had begun
treatment, she still had marked affective dysregulation and emotional instability. She
continued to exhibit severe dissociative symptoms which affected her interpersonal relationships and impaired her level of functioning.
Throughout the course of her treatment in the clinic, she was reportedly compliant with
her medication but had had difficulty with her regular compliance for therapy appointments. After she requested a new therapist because of personal differences and conflicts
with her first psychiatrist she was transferred to a new resident psychiatrist.
AB came under the care of the resident during the residents third year of psychiatric
residency training. They continued to work together during her fourth year of residency.
Initially, AB idealized the resident and split between the resident and her past therapist.
Despite having a history of noncompliance with appointments, AB eventually became very
compliant and made more than eighty per cent of her scheduled appointments with this
resident.

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AB struggled with a trauma from her past of sexual abuse. Despite having a conscious
awareness that this trauma occurred, she manifested symptoms of dissociation which
resulted in her having states of fugue that she referred to as, dream like states. During
these periods, which happened almost weekly, AB reported, I feel like Im dreaming and I
cant wake up from the dream. These episodes could last minutes to hours and when AB
would come back into consciousness, she described herself as exhausted and needing
rest.

Clinical Situation
The psychiatry resident had made it common practice, as advised by supervisors to not
disclose her pregnancy until it was first questioned by the patient. AB initially did not take
notice of the pregnancy until the resident was 6 months pregnant. After the residents
pregnancy began to show the patient began to ask the resident questions. She was
encouraged to explore together her feelings concerning the pregnancy and her fears about
how it would affect treatment. At that time, she reported feeling very excited that the
resident was pregnant and would often ask somewhat probing questions such as, What are
you having? Have you thought of a name yet? What does your husband think of the
baby? The resident was supervised to see these questions as crossing the patienttherapist
boundary. To these questions, the resident would try to continue exploring with AB her
feelings surrounding the pregnancy. During one appointment, AB reported that Identity 4
had a doll that she named CD to represent the therapists baby. She added that it was
Identity 40 s favorite doll and she would play with it often. She stated that Identity 4 wanted
to have play dates with the new baby. During the residents supervision, it was often
discussed how to deal with these extremely difficult and awkward encounters. The resident
was having feelings of discomfort when AB would talk about the baby, particularly about
having explicit fantasies about playing with the baby.
The resident lost her baby tragically at 37 weeks pregnant. Two weeks after losing the
baby, the resident went back to work. When the resident returned to her psychiatric
program, she was assigned an administrative role in the clinic and residency until she was
ready to begin clinical work again. The residents patients were assigned to other providers
during her absence and some had heard about the residents loss while others had not.

ABs Experience
In ABs case, when she came for her regularly scheduled appointment and asked where the
resident was, the staff told her what had happened. She was given the opportunity to be
seen by someone else in the clinic until the resident returned but she refused and stated that
she would come back when she needed medication.
When the resident contacted AB to come in for an appointment AB reported that she
had not been doing well and that she continued to see the man in black telling her to just
end it and let Identity 30 take over. As in previous sessions, they explored whether
there was an actual plan for suicide and explicit suicidal ideation. AB denied all but
reported feeling hopeless and helpless. She stated that when the resident was out of the
clinic she was very worried. She added that since she had a miscarriage in the past she
knew how the resident felt. As the appointment was ending, AB added, I havent told
Identity 40 yet. She keeps playing with the doll and is asking when she will get to play

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with the baby. The resident explored with AB why Identity 4 still didnt know and AB
stated it was because she knew how connected Identity 4 was to the resident and the baby
and that she didnt have the heart to tell her.
AB began sobbing in the office and stated that she didnt know if she was ever going to
see the resident again and was sad because she felt she had never made such a personal
connection before with a doctor. As in prior sessions, she nodded off and her eyes rolled
back into her head. She was dissociating. When AB awoke she looked over at the
resident. In a child-like voice she stated, Dr. C! It was not AB anymore at all. It was
Identity 4. Identity 4 went on to say, Dr. C I missed you! I told mommy that I wanted to
see you and play with the baby! Dr. C can we go to the park and play with daddy? I want
to color. Do you have any crayons? Dr. C I want to see the baby. Wheres the baby?
You look sad Dr. C. Where is the baby? Identity 4 kept asking to see the baby, she kept
playfully asking and finally the resident told her that the baby had died. No! Identity 4
shouted. No! I want to play with the baby. I want to see the baby. She was supposed to be
my friend. I even have a doll that has her name. AB got up from the chair and ran out of
the office. She began banging on doors in the clinic, running down the hall, into the foyer
of the clinic where all the patients were waiting to be seen and administrative staff was
going about their daily duties. All the while screaming at the top of her lungs, No! I want
to see the baby! Wheres the baby? Why dont I get to play with the baby? No! No! No!
We were supposed to play and go to the park. At this point, the whole clinic seemed to be
paying attention. Administrators looked at the resident and asked, Are you ok? Is this
going to be a problem? Pointing to Identity 4 who was hysterically shouting, screaming
and crying. Fighting back every single emotion the resident could, she began to try to talk
Identity 4 down. Identity 4, I know you wanted to play with the baby. Why dont you
come back to my office so we can talk about it some more. Maybe you want to draw
instead? XY can come with us. Pointing to the boyfriend, who always lovingly escorted
her, a tactic that had worked in the past. No! I want the baby! AB continued to scream
and would not respond to anyone who attempted to redirect her except for the resident.
Eventually, she was able to be redirected and escorted back to the office where she was
encouraged to sit down and have some water. She nodded off and woke up as AB. She
reportedly did not know what had happened and reportedly could not recall what had just
transpired. All she kept repeating was that she was tired and it was time to go home.
The psychiatric resident continued to treat AB and eventually the therapy returned to
normal and AB continued again to improve.

Discussion
Pregnancy can add to the psychotherapeutic relationship which can in turn result in a more
enriching therapeutic experience if explored and handled with expertise [3]. However, it is
also possible to have negative outcomes during pregnancy including delivering a stillborn,
miscarriage and therapist and infant death which can impact the therapeutic relationship.
When exploring the above clinical scenario, it makes one wonder how the circumstances
could have been handled to not only protect the patient but also to preserve the therapists
fragile state. That being said, the role of the psychotherapy supervisor is crucial for a
resident but even more so when there is a possibility that harm may come to the patient or
the therapist.
Numerous case reports about therapists suffering from illness or dying unexpectedly
exist from both the perspective of the therapist as well as the patient. These reports all

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suggest the importance of understanding the abandonment that a patient may feel during
these unexpected circumstances [4]. During these instances a patient, especially one
engaged in long term therapy will experience feelings of abandonment and this could also
interfere with their treatment in an extremely negative way. For instance, those dealing
with histories of trauma or abandonment may re-experience their own loss or grievances
and this could result in re-traumatizing the patient [5]. Pregnant therapists should have a set
date that they will stop working before delivery and this plan must be thoughtfully
explained to the patients. This is to try to ensure that there are minimal issues of abandonment for the patient at the time of delivery. Predictability promotes stability.
There are no guidelines currently set in stone for how to address potential negative
outcomes of the therapist in the therapeutic milieu. Potential suggestions include a contingency plan or an emergency response team [6]. In the above case, the decision to be the
only treatment provider until the end of the pregnancy was one that is a normal everyday
occurrence especially in a treatment setting where the demands are high like in a public
hospital. However, it may have been clinically prudent to introduce another clinician near
the end of pregnancy as an interim until delivery. Not every patient may warrant the
introduction of transitional providers. However, patients, like AB who not only have a
primary psychiatric diagnosis but also have a personality component will benefit most from
this.
Upon resuming treatment with the patient, the patient may feel as though they are in a
difficult position and that the tables are turned. They may want to be supportive to the
therapist who is supposed to be their rock and steady support system [7]. This is an
awkward and uncomfortable position for not only the therapist but also the patient and may
test the patienttherapist boundaries. In general, the therapist and patient relationship is a
one sided relationship that exists in the confines of the appointment time and clinical space.
When a patient is faced with a therapist either dying or experiencing an unexpected
negative outcome they may feel a dilemma of how to provide support to their therapist who
has been there with them through so many difficult times and crises. The reality that they
are an outsider to the therapist and not a friend or a family member may provide for added
anger and frustration for the patient. In addition, it may be difficult for the patient to think
of the therapist outside of the therapeutic realm. Thinking of the therapist and their real
family may bring up resentment and anger for the patient. For these reasons, the therapist
must be certain that they are ready to undertake the daunting task of returning to work to
face these potential issues head on with their patient and rebuild the therapeutic alliance.

Conclusion
In conclusion, therapists, like all people are vulnerable to lifes unexpected twists and
turns. While it is almost impossible to predict when a negative outcome may be on the
horizon, a therapist must do their due diligence to ensure that they prepare for whatever
may be in their control. When engaging with patients who have histories of trauma,
abandonment and personality disorders it is encouraged that the pregnant therapist think of
a contingency plan, educate their patient and maintain the patienttherapist boundaries.
Having an overlapping transition to a temporary psychiatric provider reduces the stress on
the patient. In the event of a negative outcome such as a miscarriage, stillbirth or death of
baby the therapist must ensure their own mental stability prior to returning to clinical
duties and explore with the patient their feelings of anger and abandonment. It is only

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through this exploration that the patient can feel understood and the therapeutic alliance
can strengthen and move forward.

References
1. Tinsley J: Patient Reactions to a Psychiatrists Pregnancy. In: American Journal of Psychiatry. 2003. doi:
10.1176/appi.ajp.160.1.27. Accessed 15 Apr 2013.
2. Waldman J: New Mother/Old Therapist: Transference and Countertransference Challenges in the Return
to Work. In: American Journal of Psychotherapy 57(1): 5263, 2003. Accessed 6 Mar 2013.
3. Bernardi E: Comment: Pregnancy in the Early Career Psychiatrist. In: Australas Psychiatry. 2013. PMID:
23426103. Accessed 4 Mar 2013.
4. Zaslow J: The Empty Chair: How Patients Cope with the Death of Their Therapist. In: The Wall Street
Journal. http://online.wsj.com/news/articles/SB109165345365483094. Accessed 19 Oct 2013.
5. Anonymous: The Death of My Therapist: A Patients Story. In: Psychiatric Times. 2008. http://www.
psychiatrictimes.com/articles/death-my-therapist-patients-story. Accessed 19 Oct 2013.
6. Breen D: Some Differences Between Group and Individual Therapy in Connection with the Therapists
Pregnancy. In: International Journal of Group Psychotherapy 27(4): 499506, 1977. PMID: 591156.
Accessed 4 Mar 2013.
7. Atlas-Koch G: Three Pregnancies and Psychoanalysis: A Thin Line Between Fusion and Separateness. In:
Psychoanalytic Review 95(2) 259283. 2008. PMID: 18416690. Accessed 4 Mar 2013.

Panagiota Korenis, MD is a fulltime inpatient attending on an acute adult psychiatry unit at Bronx Lebanon
Hospital Center a clinical affiliate of Albert Einstein College of Medicine. She is an active medical educator
and Assistant Professor at Albert Einstein College of Medicine. She is currently a Councillor for the New
York Council on Child and Adolescent Psychiatry, a member of the Cross Cultural Issues Committee for the
American Academy of Psychiatry and the Law and is Chair of the Young Physicians Section of the Bronx
County Medical Society.
Stephen Bates Billick, MD is in fulltime private practice of child, adolescent, adult and forensic psychiatry.
He is an active medical educator and is a Clinical Professor of Psychiatry at New York University School of
Medicine and also a Clinical Professor of Psychiatry at New York Medical College. He is the Past Associate
Chair for Faculty Development of the Department of Psychiatry at St Vincents Catholic Medical Center/NY
Medical College. He is the current Vice President of the American Academy of Forensic Sciences and the
Past President of the American Academy of Psychiatry and the Law. He is a Past President of the American
Society for Adolescent Psychiatry and also the New York Council on Child and Adolescent Psychiatry.

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