Geri Goldmann dissertation

Institute for Clinical Social Work

The Mutual Impact of Being a Clinician/Mother

A dissertation submitted to the faculty of the Institute for Clinical Social Work in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

By Geri Goldmann

2020

Abstract

This qualitative study used grounded theory to examine the interrelationship and mutual impact between a woman’s dual identities as clinician and mother. Particular attention was paid to the historical and current biases that constitute the socio-cultural phenomenon of “mother-blame,” the negative impact of centralizing the mother’s role in the theory and practice of psychotherapy. Single interviews of eight female clinician/mothers were conducted. Rich and complex interactions between the roles of clinician and mother emerged from the data, revealing the numerous ways in which both roles benefit and undermine each other. The data suggest that when personal experience becomes interwoven with theoretical knowledge, clinical practice becomes more open, fluid, and ultimately, a more empathic way of assessing and interacting with clients.

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For my mother

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Acknowledgments

I herein acknowledge the indispensable support of faculty, and colleagues; it took more than one village. Those villages were made up of my chair, Sylvia Sussman, PhD and first committee member, Whitney Van Nouhuys, PhD. Thank you for sharing your venerable experience and for endless patience and guidance. To Greg Bellow, PhD and Penny Schreiber, PhD, for valuable mentorship and enlightening clinical consultation. To Steve Zemmelman for challenging me to think more deeply and to Judith Nelson, PhD, who, whenever asked, gave me her full support and confidence. With gratitude to the Sanville Institute for being my intellectual oasis for seven years and making it safe for me to grow. To the Chicago Institute for Clinical Social Work, for taking me in and giving me a new home and the opportunity to complete this project, especially Denise Tsioles, PhD, John Ridings, PhD and Jacqueline Vincson, PhD. I want to express appreciation to peers who believed I could write when I believed I couldn’t, especially Sharon Mintz, MD, Michelle Dougherty, LCSW, and Laura Meltsner, MFT. Heartfelt thanks to Joan Fisch, MSW, for guiding me through the obstacles, internal and external, that cleared the way.

GG

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Table of Contents

Page Abstract……………………………………………..........………………………………ii Acknowledgements…………………………………...…………………………………iv Chapter I: Introduction ………………………………………………………......……….1 Statement of the Problem and the Background The Research Question Definitions The Culture of Psychotherapy Significance II: Literature Review ……………………………......................................……17 A Brief History of Childhood Views of Motherhood Mother-Blame Foundational Theories Feminist Critiques Intersubjective Theory: Stolorow and Atwood Daniel Stern

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Table of Contents—Continued

Chapter

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The Impact of the Therapist’s Life Experience Relevant Research & Literature III: Methods and Procedures ……………………………………........................…….65 Methodological Approach and Design Validity and Reliability Participants Data Collection: The Interview Data Analysis Presentation of Findings IV: The Findings..............................................................................................................77 Description of the Participants Overview Becoming a Clinician Being a Clinician: Impact on Motherhood Occupational Hazards Being a Mother: Impact on the Clinician Growth & Development Mother-Blame Unique Issues Summary of Findings

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Table of Contents—Continued

Chapter

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V: Discussion of the Findings………………...............................…………………….120 Motivation for the Study Discussion of the Findings Clinicianhood/Motherhood Mother-Blame Findings with Respect to the Literature Unexpected Findings Conclusions Limitations Suggestions for Further Research Appendices A: The Interview Guide………………………….........................……………………172 B: Sample Recruitment: Personal Contacts………………...............................…….176 C: Recruitment Posting for Listserv/Professional Publications/Newsletters...........178 D: Informed Consent Form ………………………………………...............………...180 E: Prospective Participant Questionnaire ……………………..........................……184 F: Sample Letter/Email to Prospective Participant…………............................……187 G: Sample Letter/Email for Prospective Participants Ineligible for the Study.......189 H: Re-Consent Information Letter…………………….......................………………191

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Table of Contents—Continued

Appendices

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I: Re-Consent Information and Participation Form………..............................……193 J: Re-Consent Signature Form…………………………………………...............…..197 References ………………………………………………………………......…………199

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Chapter I

Introduction “We all had mothers, and so we’re connected with what is done to, what is said about mothers” (Caplan, 2000, p. 238).

This qualitative study explores the interrelationship between a woman’s dual identities as psychotherapist and mother, with a particular interest in the response to “mother-blame,” a cultural attitude which hyperfocuses on maternal contributions to psychopathology. I wished to delve into the ways that clinician/mothers understand and reconcile their personal and career identities in a profession with historical roots derived from a biased way of regarding female development and character.

How and why certain psychological concepts that explain the etiology of psychopathology gained currency in Western society became an interest of mine while attending graduate school in the early 1980s. My recollection is that no matter the theory or the clinical case discussed, the presence of most psychological difficulties were traced back to the mother. This tendency seemed to extend well beyond the psychoanalytic model, contributing to a general stance held by a multiplicity of theoreticians and clinical practitioners. During this period of time when I was on the precipice of developing a professional identity, I consumed theory as a neophyte clinician, not yet possessing the skills and experience to evaluate very thoroughly what I was being taught. But given the

2 influences of my formative years, primarily the Women’s Movement of the 1970s, I had become sensitized to gender bias and I certainly experienced an emotional response to what I was learning. I am not sure how much I questioned theory then, with the exception of the now commonly held critiques and revisions to Freudian theory, but I was uneasy about some of the formulations regarding etiology that singled out mothers. It was not until two decades later, when I become pregnant with my first child, that I entertained the troubling realization, that I, as an imminent mother, could soon be held to account for any adverse outcomes that involved my maternal role. I remember laughing to myself about this thought, taking it with a grain of salt, and yet also recognizing the kernel of truth it contained.

I wish to situate my personal experience as a clinician/mother in a larger context that looks at the premises contained in several influential theories that have contributed to what some writers refer to as the culture of mother-blame (Aidenbaum, 2014; Caplan & Hall-McCorquodale, 1985; Reimer & Sahagian, 2015). I will examine this term and its implications in the literature review, as I explore the connection between theory, the culture of psychotherapy, and the impact on the clinician/mother.

My position regarding theory is echoed in the thinking of historian, Nancy Schnog (1997), who claims that theory does not simply mirror reality; it contains the power to “constitute it from within ideologically interested ‘subject positions’ [added emphasis]” (p. 8). These subject positions influence and reflect cultural views regarding child development and consequently the “proper” comportment of the maternal role. My aim is to explore the impact of what Susan Suleimon (1994) calls the “presumptions that slip unexamined” into our theories and become internalized in our psyches. In turn, these

3 are codified in cultural standards and expectations (p. 9). By getting women to talk about their experiences as clinician/mothers I hope to shed some light on the complex interaction between the two roles and how they are further affected by the standards and expectations of Western culture. For this reason, I would like to share the following personal experience.

In 1995 I brought my second born child, a three-year-old son, to a new preschool for the first time. He previously attended a toddler “class” once a week on Fridays, but it was housed in a more intimate setting and included parent participation. This setting was a larger multiclass environment, conducted more closely on a public school kindergarten model in which parents were “allowed” to stay for a minute and then instructed by the director to give our children a cheery” bye” and exit confidently. I had doubts as to whether this type of transition could be managed by my child who had never been left in a strange environment on such short notice. I experienced this approach as one that implied an attitude that if we (the parents or caretaker) were deficient in demonstrating an optimistic conviction about separation, that our child’s distress would be attributed to our own. Thus, a failure to demonstrate the “right way” to separate would be responsible for bringing about this negative consequence. Intuitively I knew this approach was not going to work and I was trapped in a Catch-22, having to act as if I believed something that I did not believe, and anticipating I would be criticized for acting on my experiential knowledge of what was best for my son. I attempted to explain my concern to the kindly teacher and her aide, when I was intercepted by the head of the preschool who assured me that this system is the “best.” Her insistence left me feeling unheard and managed,

4 rather than supported. I was “invited” to wait in the school courtyard for a few minutes to see that all was well.

As the other parents chattered and dispersed, my ears were assailed by a familiar wail of distress. I was overtaken by a sense of inner turmoil, but I dutifully maintained my post. Some minutes later, the head of the preschool sought me out and asked what would I like to do? She appeared baffled as she exclaimed, “Your child is not calming down.” I was not baffled and quickly suggested that I would like to be allowed in the classroom until it felt right for me to leave. She acceded to my wish. My presence in the classroom gave it the imprimatur of my approval as a secure and interesting place to be.

The acceptance we received from the teaching staff allowed us the time needed to separate without undue pressure or negative judgments and in a matter of a few short weeks I was able to leave my child in the classroom.

I believe this example illustrates a key unacknowledged attitude that has influenced one of the more biased ways we regard mothers in relation to their children. In this case, a model of separation-individuation that privileges early independence appears to have influenced the preschool’s policy. By taking such a stance, mothers may be characterized as impeding their child’s ability to become independent. While it is possible for a mother to impede her child’s development in a myriad of ways, it is important to consider that the underlying values of a particular theory generate a lens through which behavior is not only neutrally assessed, but also critically judged. It would be interesting, though beyond the scope of this study, to survey mothers regarding the most frequent negative judgments they have received regarding their parenting. This might tell us something about our cultural values vis-a-vis childrearing and motherhood.

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Statement of the Problem and the Background “The problem of science . . . is not that it embodies masculine as opposed to feminine values, but that it is a mirror of a structure of social domination, that it produces falsely “objective” legitimization of that structure, and in so doing fails to live up to its own standard” (Lewontin, 2001, p. 225).

Not enough attention has been paid to understanding the impact of biases embedded in psychological theories and cultural standards on women who have the dual identities of psychotherapist and mother. What has been the experience of clinician/mothers who find themselves as both purveyors and objects in theories employed by the psychotherapy professions?

The field of psychotherapy has enjoyed a significant influence on society that far surpasses the environs of the consulting room. Psychological theories and their concepts have permeated art, medicine, and politics, weaving themselves into public discourse and the fabric of daily living. Our theories and the cultural expectations they form emanate from what Pfister and Schnog (1997) describe as, psychology’s myriad shapes as an academic discipline, a healing industry, a repository of variable ideas about and metaphors of the emotions, a class ideology, and a form of popular entertainment (movies, books, and dramas about the psychological character of people and relationships (p. 4).

Psychological thinking has so permeated Western ideas that it hard to imagine our lives without its influence. With this influence comes the power to define what is normal, desirable, and healthy in our society. By the same token, these theories also delineate

6 what is aberrant, objectionable, and insalubrious. These concepts have, at times, contributed to specific cultural corollaries that have liberated as well as oppressed the human mind, body, and spirit.

Mother-blame is a ghostly manifestation underlying current theoretical models and interventions. It has been both diminished and strengthened by the ascendancy of new theories, including those with a materialist emphasis that rely on neurobiological explanations, as well as those approaches based on attachment theory. For example, neurobiological research posits that repeated interactions between caretaker and child provide the kind of stimulation that can inhibit or facilitate the development of the brain and the nervous system. These neurophysiological changes create a foundation or patterns of responses that shape the infant’s patterns of perception, behavior and emotional reactivity. This raises the question of how knowledge of this information affects the mother/clinician. One possibility is that this is useful information and positively reinforces mothers for the significance of their relationship with their infant.

Another is that by raising the stakes in terms of the mother’s performance with her infant, her anxiety regarding this influence is also raised, creating its own negative effects.

Efforts to re-balance this predisposition toward a narrow focus on the mother’s contributions to psychopathology are not intended to ignore the significance that the maternal role plays in child development, but to delineate the differences between contributing factors and blame. The contribution of the mother to the etiology of psychological dysfunction is writ large in the theories of psychology, psychiatry, and clinical social work, and continues to influence public discourse. In a recent example The New York Times published an article by Kate Murphy entitled, “Yes, It’s Your

7 Parents’ Fault” (1/7/17) based on the findings of attachment theory. Notice that this title uses the word parents and thereby avoids singling out mothers. Although framed facetiously, it reflects society’s tendency to conceptualize mental health issues in a causal manner, with the mother functioning as the primary cause. Since mothers are the primary caretakers of children, it is implicit that they are the most culpable agents in creating childhood developmental arrests or disturbances. Therefore, whether or not the findings of the model reviewed, attachment theory, actually blame mothers, the interpretation and dissemination of its conclusions in popular culture is couched in a way that contributes to and reinforces an approach that first looks to defects in mothering.

Despite the progress in women’s rights and the reformulation of psychoanalytic theory, some believe we have not shifted this problematic hyperfocus on mothers. As author Susan Suleimon (1994) explains: The dominant analytic and cultural discourse about mothers and their children— what Ann Kaplan has called the “Master Mother Discourse—continues to emphasize the mother’s crucial determining role in the development and continuing welfare of the child. This discourse fosters what Chodorow and Susan Contratto have called the “myth of maternal omnipotence”—the belief that whatever happens to the child on the way to becoming an adult is ultimately attributable to its “good” or “bad” mother (p. 42).

This statement references an attitude or focus that overvalues the impact of the mother on her developing child, with negative consequences for how mothers are regarded in treatment and society-at-large. One unintended consequence of this focus might be malignant anxiety, as mothers become hypersensitized to the potential

8 deleterious effects of their childrearing. Deficient maternal care has for many years and for numerous conditions, served as a facile way to make sense of psychopathology and create treatments for it. “Cherchez la femme” identifies mother as the default source of mental health problems.

The majority of the writing concerning psychotherapists’ motherhood, focuses on the impact of her pregnancy on the client. One example is the aptly titled, The Therapist’s Pregnancy, Intrusion into the Analytic Space (Fenster, Phillips and Rappaport’s 2015).

An internet search on the psychotherapist’s pregnancy will bring up numerous articles and references, but the same search, substituting the word motherhood for pregnancy, continues to bring up pregnancy, while showing few resources for the clinician’s motherhood. The same is true for a search of the Psychoanalytic Electronic Publishing archive; three articles were identified related to the search “motherhood and the analyst,” while thirty-three articles were offered in response to the search, “pregnancy and the analyst.” This is noteworthy considering that the clinician/mother is socialized into a profession with specific critical ideas regarding the role of maternal care and its contributions to psychological dysfunction. Although pregnancy “intrudes” visibly into the consulting room, why should motherhood, be missing from it?

The Research Question Given the manifest as well as covert influence of gender bias in clinical theory, what has been the experience of female clinician/mothers who find themselves as both purveyors and objects of such theories?

9 I investigated the impact of theory and its acculturation into the role of psychotherapist on maternal identity. I interviewed women psychotherapists regarding the reciprocal impact of their dual identities as clinician and mother. I was curious to know what impact, if any, has this dual identity had on their conceptualization and conduct of treatment and on their experiences as mothers. Relevant to this study were theoretical models that focused on the mother’s contributions to psychopathology, as well as her impact on a variety of issues clients bring to psychotherapy.

Using the qualitative approach of grounded theory, as described by Glaser and Strauss (1967) and Corbin and Strauss (2008), I conducted face-to-face interviews with women who were established as clinicians prior to becoming mothers. A constant comparative mode (Strauss and Corbin, 2008) was used to identify common and unique themes in the data.

According to anthropologist and evolutionary theorist, Sarah Blaffer Hrdy (1999), much lip service has been paid to “Biology,” “Instinct,” and “Natural Laws” without a great deal of attention paid to how maternal behavior unfolds in the real, everyday environments in which mothers actually live, or in those very different ancient environments in which women evolved (p. 26). This study attempts to address this deficit.

Definitions The following terms are used interchangeably throughout this work: Psychotherapist, clinician, therapist, and professional. The terms psychotherapy,

10 psychoanalysis, psychoanalytic psychotherapy, psychodynamic therapy, therapy are also used interchangeably.

Identity is a broad topic that has many definitions and is conceptualized by a variety of academic disciplines including philosophy, sociology, and psychology. In the widest sense, identity has to do with the categorization of similarities and differences or what Phillip Hammack (2015) calls the “universal human process of categorization (p.

11). Hammack adds that, “people are in constant states of identification, or naming and categorizing, what or who one is and to which larger categories he or she may belong . . .” (p. 11). Identity, the self, persona, personality, role, these terms all seek to describe an aspect of being human that is often intuitively understood, but ever-shifting in the attempt to capture and define. Some of these terms may overlap and can be used interchangeably.

This study examines how women regard their dual identities in their roles as mothers and clinicians, and asks the question, “How have these identities influenced one another?” Identity is a vast and complex topic that cannot be fully covered by my query, but a brief synopsis of two of its foundational theorists, William James and George H. Mead, are included to further place my thesis in context. As summarized by Hammack (2015), Mead’s theoretical lineage thus placed primary emphasis on the relational basis of identity and the significance of social interaction and the exterior world of meaning and social categories. This emphasis can be linked to Mead’s relative emphasis on the significance of the exterior world in the construction of self. By contrast, the line of theory that more explicitly traces itself to James has been

11 chiefly concerned with the interior experience and interior-exterior negotiation of identity and more explicitly concerned with identity development at the level of the individual person (p. 17).

For the purposes of this study, identity is conceived of as being made up of external factors, internal factors and the relation between the two.

The Culture of Psychotherapy “The question, but what was it like for women? was always on my mind” (Rich, 1976/1981, p. xvii).

Understanding the evolution of theoretical orientations and attitudes sets the stage for comprehending the impact of the culture of psychotherapy on the interface between the clinician/mother’s dual identities.

While acknowledging differences due to class, ethnicity and socioeconomic factors, psychotherapists may share many of the same acculturation experiences as their clients. The rules, customs, and experiences that can harm the client’s self-regard, can also harm the clinician’s. Clinicians are thus faced with, “the impossible task of sorting out the personal from the professional” (Kuchuk, 2014, p. xxvi). This dilemma is captured by psychoanalyst, Steven Kuchuk, who for many years was fearful of revealing his homosexuality. In Clinical Implications of the Psychoanalyst’s Experience (2014) he writes: “Having key elements of oneself labeled pathological, especially by the field you have turned to for healing, professional identity, and development, wreaks havoc with even the most securely formed psyche” (p. xx). If this is so, how has the mother/psychotherapist reconciled her dual identity in a professional culture that has so often held her accountable for psychopathology?

12 Psychotherapy has evolved as a practice with a multiplicity of theories that explain human emotion, cognition, and behavior. Despite differences in approach, most therapeutic efforts are directed toward the relief of mental/emotional suffering and the fostering of psycho-emotional and behavioral change or growth. The universal applicability of theory, however, can be challenged because it is formulated in a context that is “historically contingent, socially specific and politically situated” (Pfister & Schnog, 1997, p. 8). Thus, any theory may incorporate the unacknowledged biases of the culture in which it is created.

Despite psychotherapy’s positive intent and beneficial contributions to society, the theories undergirding its practice have a history of bias that have codified, supported, and at times expanded the reach of societal prejudices. This applies to concepts regarding gender and their theoretical role in the etiology of psychological dysfunction. According to Susan Suleimon (1994), the importation of cultural biases regarding the feminine into psychoanalysis and later theoretical models “lent scientific prestige to a widespread cultural prejudice, reinforcing it and elevating it to the status of a natural law” (p. 20). In particular, these prejudices regarding female development and character include, but are not limited to, the moral inferiority of women due to unresolvable Oedipal strivings, the culpability of the double-binding “schizophrenogenic mother” in the etiology of schizophrenia, and the cold-hearted maternal care personified in the form of the autismcausing “refrigerator mother” (Fromm-Reichmann, 1948; Bettelheim, 1967; Freud, (1965/1933). These are examples of formerly mainstream and highly regarded theories from leaders in the field who were well-respected. But even sources that have become obscure can have a reverberating impact on the field.

13 One obscure source was published in 1949 in the journal, Psychiatry, by a psychiatrist named Trude Tietze. Tietze’s paper gave credence to Frieda FrommReichman’s concept of the schizophrenogenic mother, which was then embraced by the greater clinical community. Tietze has been largely forgotten, but due in part to her article, the schizophrenogenic mother theory held sway over psychiatry and related disciplines for many years. This suggests that something in the culture of psychotherapy, originating from the culture at large, enabled this explanation of the etiology of a mental disorder to take hold. In Chapter Two I will outline the role of foundational and contemporary theories in the evolution of the culture of psychotherapy and its implications for clinician/mothers.

Significance The central aim of this study is to ascertain what effects, if any, have these various conceptualizations of the role of the mother had on the clinician/mother, who serves as both object and purveyor of theory in her scope as clinician. This investigation provides an opportunity to hear from those whose professional identities have been formed in the crucible of cultural bias and have been exposed to the ideas that mothers are the primary source of psychopathology. Even though this study assumes the legitimacy of the category clinician/mother, it is important to keep in mind that, “The social construct of ‘woman’ is a complex and varied phenomenon, differing in its meanings and attributions across race, social class, age, sexual orientation, and interpersonal context” (Brown, 1990, p. 228). While there may be much in common in the experience of psychotherapist/mothers, the social factors described in Brown’s quote

14 indicate the complexity inherent in any sort of generalization. This comment serves as a limit on any tendency to view the clinician/mother category as one monolithic entity.

It is notable that those about whom a theory is written, and upon whom the effects of said theory fall, often have little or no voice in the creation of that theory. Even when women or minorities participate there has often been a tendency to skew theory toward the prejudices of the dominant culture. My interest is in the ways in which women perceive themselves as mothers and clinicians as determined by the language and concepts offered by our Western culture. In terms of this study, the culture being reviewed is the culture of psychotherapy in the context of North American society. My purpose in interviewing clinician/mothers was to create an interchange between theory and lived experience. The inclusion of personal accounts with theory can be a corrective to some of these biases. Like adding seasoning to a stew, the flavoring of lived experience has the potential to make theory richer and more reflective of the complexity of real life. As such, it has the power to modify the way in which clinicians think about and approach diagnosis and treatment. This is desirable because professional influence has a significant impact on which assumptions regarding mental health are disseminated to the public. This impacts private attitudes as well as public policy, bearing directly on the quality of life for the affected populations. This is especially true regarding childrearing and mental health practices.

Personal accounts have the advantage of bringing to light previously unidentified and therefore unshared experiences. According to Dyer (2001), such experiences have the power to “educate, inspire, build rapport, normalize” (para 1) and otherwise “help people explore other ways of doing, feeling, and thinking” (para 2). The inclusion of the

15 therapist’s subjectivity in the relational/intersubjective models of psychotherapy mirrors and supports the use of first-person accounts in research, because subjectivity rather than being avoided, is valued.

Psychoanalytic theory has penetrated deeply into American culture, influencing subsequent theoretical models and modes of intervention. The field has come to recognize its own role in maintaining cultural biases regarding gender and has made some advances in redressing these prejudices (Horney, 1993; Schafer, 1974; Chodorow, 1978; Benjamin, 1988; Zakin, 2011). There is a continuing difficulty in identifying the more subtle outgrowths of gender biases regarding women and girls, that obscure their harmful consequences and role in maintaining the socio-cultural status quo. I was curious to explore how the clinician/mother has adapted to a profession with phallocentric origins. Recognizing the historical role of gender-bias concerning the close pairing of mothers with psychopathology, might suggest that it has had a deleterious impact on the clinician/mother, and yet, this may not be the case for all. As Doane and Hodges (1995) suggest, it is important to recognize that, Women are inscribed in a network of stories that both secure meaning and release it. We are not all one. In the spaces between us, between the discourses that constitute us, the heterogeneous experience of women begins to emerge (p. 80).

Creating an opportunity for the “heterogeneous experience” to emerge through the gathering and appraisal of personal accounts, allows the clinician/mother to include aspects of her experience which have may have been “split off” and thus only held privately. Making these accounts available for sharing contains the possibility of identifying new areas of universal as well as unique experience. Including the

16 experiences of clinician/mothers can contribute to a more realistic picture of the relationship between what a psychotherapist experiences and expresses in their personal and professional lives.

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Chapter II

Literature Review “We must approach our tradition with deep suspicion; we must test its claims against our own hard-won insights; we must sort and sift among its materials to see what we can use and what we must discard” (Bartky, 1990, p. 6).

What does the literature offer in terms of understanding the effects of being a clinician on the maternal role and vice-versa? Surprisingly, given the centrality of the maternal role, and a move toward the inclusion of the clinician’s life experience in the literature, there is a dearth of literature on the personal experience of the clinician/mother vis-a-vis her acculturation into the psychotherapy profession. Feminist psychotherapist, Laura S. Brown, (1990) asserts that very little has been written on women as therapists and that the literature that exists is based on assumptions rather than analysis. This is understandable given that historically, theory was most often based on the dominant social group and therefore missing the voice of other segments of society, in particular, regarding “race, class, sexual orientation, age, and able-bodiedness” (Brown, 1990, p.

229). There is however, an abundance of material that offers critiques germane to the evolving formulations of female development and the significance of the mothering role as seen in normal and abnormal child development. The literature review will examine some of those relevant theoretical critiques.

As the theory and practice of psychotherapy evolved over the decades, there have been several vital shifts in the conceptualization of human development and

18 psychological functioning that have both ignored and addressed the early biases regarding women and girls. Relevant to this progression, the role of women as mothers has been highly scrutinized from an anthropological, historical, socio-cultural, and ideological as well as psychological standpoint. Paralleling this evolution of ideas regarding female development is the central position that mothering has taken up in theory, specifically in relation to the etiology of psychopathology. This centrality has resulted in both beneficial and deleterious consequences regarding the interpretation and utilization of theory in clinical practice. It has influenced the interpretation and dissemination of this knowledge to the public as well.

First, I present a summary of the historical evolution of childhood and how it came to be regarded in Western society. This history is followed by an examination of an evolving view of motherhood that has resulted in contemporary beliefs regarding the impact of mothers on child development. Provision of an historical context helps to explain how the dissemination and absorption of the psychological model of understanding human beings came into being and its consequences for theory and practice. I then review the literature on the concept of “mother-blame” and how it is present in the culture of psychotherapy and is a reflection of an attitude held by society at large. Next, I summarize some of the theories that have served as a foundation for the practice of psychotherapy and have either reflected or contributed to Western biases regarding female development and character. This is not an exhaustive review, but includes those theories particularly relevant to my main thesis. I then look at the way feminist theory building has attempted to address mother-blame/sexist bias and include as examples, Karen Horney, Jean Baker Miller. Nancy Chodorow, and the crucial

19 contributions of Jessica Benjamin. I then summarize the contributions of Robert Stolorow and George Atwood, whose intersubjective stance required the recognition of two subjectivities and thereby advanced the “two person” model of psychotherapy. Next, I examine Daniel Stern’s synthesis of experimental and clinical observation of the neonate as an example of how changes in the way infants are regarded affect how mothers are seen. I then present the writing on the impact of the therapist’s personal life experience on clinical practice. This provides an entry point for my interviews with participants about the interrelationship of their dual roles as clinician/mothers. Lastly, I review the relevant literature related to this study, including extant research.

A Brief History of Childhood Prior to the 16th century, the concept of childhood as a distinct phase of human growth in the way we conceive of it today in Western culture did not exist (Aries, 1962).

Anthropologist, David F. Lancy (2015), explains: “Evidence of childhood in the past is irrefutable but the length of childhood and the child’s role in the family and in society were very different . . . .” (p. 6). He terms the current Anglo-American social system a “neontocracy,” in which children are valued despite being economic liabilities (p. 2).

This concept did not become part of the social fabric until the evolution of the family as a nuclear unit came about in the 16th and 17th centuries. At this time children were expected to participate in the quotidian work of the family, as well as in the extra-familial workforce. Their “value” in the family often depended on the degree to which they were economic assets (Zelizer, 1985). In Of Woman Born (1981), author Adrienne Rich

20 comments, “In a tribal or even a feudal culture a child of six would have serious obligations; ours have none” (p. 19).

Nineteenth century American children were regarded as physically sturdy, but weak-minded and therefore vulnerable to original sin. This belief led to an emphasis in childrearing on religious and moral training that required frequent prompting from adult authority figures. In the early to mid-20th century, the participation of children in the workforce declined as a result of several complex factors precipitated by the shift away from an agriculturally based economy. Sociologist Viviana Zelizer (1985) points out that the withdrawal of children from the labor force coincides with the “sacralization” of children; a view of children’s worth as “an inverse relationship between their value as economic producers and their sentimental value” (p. 10). As the participation of children in the workforce declined, their “worth” was transformed into a new type of value, creating what Zelizer refers to as the “economically worthless but emotionally priceless child” (p. 5). This principle of intrinsic worth provided the underpinning for contemporary childhood and was one of several factors that laid a foundation for the field of child development.

According to the historian, Peter Stearn (2003), the concept of the psychological or vulnerable child developed in response not only to changing socio-economic conditions, but was also affected by the expansion of psychoanalytic theory into popular consciousness. Socio-economic changes disrupted the tradition of children automatically following in their parents’ labor or career footsteps. This shift resulted in a loss of parental authority, leaving a void which was to be filled by the experts in a newly emerging psychological view of children. This inchoate perspective identified previously

21 unrecognized dynamics and vulnerabilities that required a new type of parental response.

No longer was fate or moral fortitude the determinative factor in the development of a child’s character. As stewards of the “vulnerable” child, the role of parents, specifically the mother, became the most indispensable element in the outcome of childrearing.

Consequently, whether intended or not, there was an increase in the number of ways for parents, i.e. mothers, to fail their children. Not surprisingly parents developed, “the fear that, whatever one did, it would be inadequate to help the child through its sea of troubles” (Stearn, 2003, p. 55). This atmosphere of increasing parental apprehension lent itself to services and products to address parental anxieties; hence an industry of childrearing experts, mainly directed toward the middle class, and supplied with explanatory theories and advice, was fostered. A “new kind of child” required a new kind of parent, and that parent required professional assistance.

Views of Motherhood “We know more about the air we breathe, the seas we travel, than about the nature and meaning of motherhood” (Rich, 1981, p. xiii).

In parallel with changing cultural perspectives on childhood, an evolution in thinking about the nature of motherhood and childcare ensued. This new way of focusing on the mother, though groundbreaking in some respects, also carried with it the preexisting gender biases which had been subsumed into psychoanalysis.

The term mother(hood) evokes deeply rooted and powerful associations that are echoed in Western ideologies regarding the natural and desirable attributes of the woman/mother. These have been shaped by the Judeo-Christian ethic and its portrayal of the biblical Eve and the Virgin Mary (Rich, 1981, p. 27). Philosophical dogma and

22 incipient scientific thinking reinforced or elaborated this orientation as both disciplines were filtered through the culturally bound lens of patriarchal theology.

The poet and essayist, Adrienne Rich (1981) discusses the bifurcation of woman as pure or evil, the lack of agency over her sexuality, sensuality, reproductive powers, and what facilitates a woman’s subordination to the proscriptions of a noxious patriarchy.

She suggests that motherhood has more than one meaning; it is both a social institution and a private individual realm that refers to “the potential [and actual] relationship of any woman to her powers of reproduction and to children” (p. xv). This two-fold aspect is important in understanding the intersection between an individual’s or a group’s experience of motherhood. As a social institution motherhood sets up norms and expectations that provide the context in which private experience is formed. These norms do not apply monolithically to all potential mothers, as expectations vary according to ethnicity and class (Collins, 2007).

For women of color and those not belonging to the dominant culture, this is a particularly poignant concern. Not until the political feminist writings in the 1970s and the critiques of feminist psychoanalytic theorists like Jessica Benjamin (1988, 1995, 1998) and Nancy Chodorow (1978) is the mother given sufficient leeway to inhabit a less objectified and idealized role. But even their critiques are from an Anglo-American point of view, a context that is not applicable to all women. The variation among women by class, ethnicity and socio-economic context necessitates the participation and inclusion of other voices.

The Western view of (masculinity and) femininity took a predominantly essentialist stance, that is, one which assigns innate, universal characteristics to account

23 for the differences between male and female. For example, the Freudian apothegm, “anatomy is destiny,” reflects an essentialist position. One of the early proponents of essentialism, pre-dating Freud by three decades, was the prominent Victorian philosopher-theorist, Herbert Spencer. Spencer promulgated the idea that women were more weak-minded than men and that scholarly pursuits would impair their valued reproductive capacities (Hrdy, 1999, p. 15). His thinking lent a quasi-scientific endorsement of the assumption of “natural” male superiority and further legitimized the gendering of society into specific roles, concentrating access to social and economic power in men.

The degree to which certain characteristics or traits that differentiate male from female are biologically determined or culturally influenced remains a heavily debated topic.

In her treatise, Mother Nature: a History of Mothers, Infants, and Natural Selection (1999), anthropologist-primatologist, Sarah Blaffer Hrdy poses the following two questions: What does it mean to be female?, “a semicontinuously sexually receptive hairless biped”; and What does it mean to be a mother?, “filled with conflicting aspirations and struggling to maintain her balance in a rapidly changing world?” (p. xi).

The thrust of Hrdy’s work is that the presumption of a natural maternal endowment in the human female is not so much a matter for instinct, but is more complexly context dependent. She comments on the manner in which developing science was used to confirm cultural biases regarding women: (They) use nature to confirm their own and their society’s preconceptions about how humans should behave. These men, who were more evangelists than

24 scientists, imposed their moral code on nature rather than allowing creatures in the natural world to speak for themselves (p. 10-11).

Although Hrdy’s comments hail from the nineties, a decade well past the second wave of feminism, as early as 1937 the psychoanalyst, Karen Horney, identified this same bias asserting that, “Every culture clings to the belief that its own feelings and drives are the one normal expression of human nature and psychology has not made an exception to this rule” (1937/1964, p. 16).

Hrdy’s suppositions are relevant to this study because they expose some of our assumptions about maternal identity and behavior, while providing a basis for placing our contemporary clinician/mother in a context that connects with the history of civilization.

She proclaims that, “even though the world has undergone immense changes since our ancestors lived by foraging, many of the basic outlines of the dilemmas mothers confront remain remarkably constant” (1999, p. xvi). Hrdy identifies one of these dilemmas as the ever-present conflict between the mother’s needs and the child’s needs. She contends that mothers have always had to face this predicament and that various ideologies and institutions have limited or expanded the available resolutions. Her anthropological analyses seek to show that there are maternal behaviors that stand in direct opposition to the notion of an instinctually nurturing mother.

Mother-Blame “So my interest in mother blaming began because it seemed that there was nothing that a mother could do that was right, and it was particularly interesting and painful to me because I myself was a mother” (Caplan, 2013, p. 100).

25 The literature on mother-blame is significant to this study because it exposes a strain of misogyny that was absorbed by and evolved within the development of psychoanalytic-psychodynamic theory. The field’s orientation toward mothers as the source of psychopathology and other problems in living was influenced and supported by Western patriarchal culture. This, in turn, became part of the culture of psychotherapy in which female clinicians were educated.

Mother-blame as a cultural phenomenon may contribute to a form of anxiety experienced by mothers that manifests in a sense of personal deficiency in the maternal role. This psycho-emotional response may be borne by clinician/mothers and nonclinician mothers alike.

Several definitions of mother-blame can be found in the literature (Aidenbaum, 2014; Caplan & Hall-McCorquodale, 1985; Lombrozo, 2014; Reimer & Sahagian, 2015).

For the purposes of this review mother-blame refers to a narrow focus on the contributions of the mother to a variety of mental health disorders and other types of personal problems. This narrow focus limits the consideration of other contributing factors and has resulted in an environment that directs attention to the mother’s faulty interaction with her child to explain the origin of developmental or adult psychoemotional problems.

Mother-blame is a phenomenon that has permeated the culture through the use of tropes and memes that are repeated in art, science, entertainment, and other forms of mass communication. It has been extensively chronicled in books, journal articles, and newspaper commentaries that detail its origins and effects (Aidenbaum, 2014; Caplan & Hall-McCorquodale, 1985; Lombrozo, 2014; Reimer & Sahagian, 2015). Mother-blame

26 is invoked when behavioral norms are violated and society is seeking to explain such lapses. Violations of behavioral norms can include elements that are as extreme as criminal activity and as common as emotional dysregulation. It may refer to a variety of moral and/or character flaws or differences that challenge mainstream cultural values.

An additional aspect of the mother-blame phenomenon concerns confirmation bias and apophenia. The latter is a term meaning the stringing together of unrelated details to form an expected conclusion. Apophenia is similar to “cherry-picking” data to fit one’s desired outcome. Both confirmation bias and apophenia may be thought of as non-conscious orientations that can validate a clinician’s biases by serving as filters that direct attention to material that confirms their predispositions.

As stated previously, mother-blame is a cultural phenomenon, expressed both inside and outside of the consultation room. It has taken hold in parallel with the popularity of neo and post Freudian movements and the simultaneous proliferation of child guidance expertise. Since the early 1900s, and the advent of psychoanalysis, there has been an ever-increasing amount of childrearing materials and media experts to disseminate them. This represents a shift from parental reliance on religious and moral authorities, to dependence on psychiatric experts whose focus of treatment had expanded beyond psychosis and neurosis to include general problems in living (Pfister & Schnog, 1997). The identification of previously unrecognized childhood vulnerabilities in new psychological terms had the unintended consequence of pathologizing “normal problems” and fostering parental confusion and anxiety. As more problems and disorders were identified, there were more ways for a parent to serve or “fail” their child.

27 In tandem with the proliferation of advice and advisors came an implicit message attributing fault to parents, more specifically mothers, for their children’s shortcomings and disorders. The reliance on experts may have inadvertently increased rather than diminished maternal angst. This situation lent itself to the “commodification” of services and products to address those parental worries; hence an industry of child rearing experts was born. In February 1977 child psychologist, Eda LeShan, wrote in her column in the New York Times, “I have just finished reading about 30 recently-published or soon-to-bepublished books on child care and, if I were a young parent today, I would cut my throat” (2017, p. 1).

It is not simply that the consideration of the mother as the source of pathology is problematic, it is also that the indiscriminate and monolithic attribution of pathology and even non-pathological problems to the mother that has been susceptible to filtration through misogynistic strains in Western culture. At the very least, ambivalence toward the mother figure has contributed to an attitude of blame rather than understanding or support.

In Mother-Blaming and the Rise of the Expert (2014), Ashley Marie Adenbaum attributes the origins of mother-blame to World War II, an event that was considered a test of American masculinity. The failure of some American men to successfully rise to the occasion of war was attributed to their being coddled by their mothers. This attitude was popularized by Philip Wylie’s (1942/2007) Generation of Vipers, which contained a scathing account of American mothers. Wylie coined the term “momism” to describe these infantilizing mothers who posed a danger to masculinity. Adenbaum says that, “Anxiety about female dominance eventually found expression in an emergent expert

28 ideology that dominant, overbearing mothers were a societal menace” (2014, p. 3). A strain of that thinking still exists today in conservative critiques of American culture. An example of this is the derogatory use of the term “mama’s boy” to indicate unmanly sensitivity and a clinging relationship to mother. This pejorative sensitivity is typically associated with a too permissive, liberal, or “feminizing” influence.

In contrast to Wylie’s vituperative attitude toward mothers, other experts told mothers to trust themselves, albeit with mixed messages. “Trust your instincts and train your insight, follow your baby’s nature and spare no effort on her nurture—relax and enjoy those first years and don’t forget for a minute that your child’s future is at stake” (Hulbert, A. 2003, p. 314). Each of the seven verbs in the previous quotation, exhort the mother to take on a different type of stance regarding childrearing. Then there is a final anxiety-inducing warning about the weight of those actions on the future well-being of their progeny. The cacophony of competing terms represents the landscape of childrearing in a rapidly changing world. “Trust, train, follow, spare no effort, relax, enjoy . . .” This quotation, though perhaps tongue in cheek, is what mothers hear today from experts, talk shows, the internet, books, etc. There is a mountain of advice aimed at securing the best possible outcome for one’s child.

The appeal of mother-blame can be related to the fact that mothers are the dominant caretakers/socializers of children in Western society and therefore likely to have the most influence. This situation is considered “natural,” i.e. follows the dictates of biology. While it is undeniable that biology has its role in this arrangement, many have questioned the exclusivity of this relationship given the lengthy childhoods of human beings, especially when compared with childrearing practices in other cultures

29 (Chodorow, 1978; Hrdy, 1999).Vanessa Reimer and Sarah Sahagian, editors of The Mother –Blame Game (2015), write in their introduction that, “a patriarchal society assumes that women are ‘natural mothers’” (p. 3). The idea of the natural mother, however, clashes with the reality of all the instruction/attention society devotes to “correct” parenting. It also assumes the degree of fulfillment women experience from mothering. In this regard natural equals completeness.

Despite the personal authority that mothers appear to possess vis-a-vis childrearing, some question whether mothers have, in fact, the power to create the context in which they mother (Bartky, 1990; O’Reilly, 2007). The socio-economic context of the ‘traditional’ nuclear family is viewed as a means for reproducing the type of power dynamics inherent in a predominantly patriarchal system (Benjamin, 1995; Chodorow, 1978 Rich, 1976/1981). A patriarchal system, as defined by Adrienne Rich (1976/1981), consists of: The power of the fathers; a familial-social, ideological, political system in which men—by force, direct pressure, or through ritual, tradition, law and language, customs, etiquette, education, and the division of labor, determine what part women shall or shall not play, and in which the female is everywhere subsumed under the male (p. 40).

Psychologist Paula Caplan describes the power of myth to maintain the cultural status quo, a status quo that supports a patriarchal social system. She has written about mother-blame for the lay public as well as the professional community (1985, 1994, 2000, 2013). According to Caplan, myths of “badness” ascribed to a particular group, in this case mothers, is reinforced by scapegoating, which can be based on any number of

30 characteristics including religion, skin color, and country of origin, as well as gender.

Scapegoating “locks in” a particular group so that, “No matter what the members of the scapegoated group might do, I can transform it into further proof that they are wrong, bad, or pathological, and deserve to continue to have no power and be scapegoated” (Caplan, 2013, p. 101). Evidence of this type of scapegoating can be demonstrated in the history of the “refrigerator mother” theory of autism and its deleterious effects on the mothers of autistic children.

In 1943, child psychiatrist Leo Kanner published a paper on the childhood malady that he called autism. Kanner made the observation, based on 11 subject families, that, “In the whole group there are really very few warmhearted fathers and mothers” (1943, p.

250). His brief description of the highly intelligent, yet “cold” parents resonated with a psychiatric community heavily influenced by psychoanalytic theory. Although Kanner presciently speculated that autism might have a genetic cause, an interpretation of his paper by the psychiatric establishment singled out the “refrigerator mother” as the chief cause of autism; it took hold and was further promoted by the renowned psychoanalyst, Bruno Bettelheim (1967). According to British psychiatrist and researcher Lorna Wing (1997), Kanner’s ideas about the parents of autistic children were accepted uncritically by many psychiatrists. Professionals in other branches of medicine, nursing and teaching also adopted these ideas. Even parents themselves were indoctrinated by the prevailing theories. The results were devastating (p. 16).

The refrigerator mother concept provided a context or a mindset that influenced psychotherapists in their approach to diagnosis and treatment. This resulted in the

31 unfortunate outcome of harming rather than helping the mothers who sought psychotherapeutic assistance on behalf of themselves and their children (Simpson, 2003, Wing, 1997). The documentary film, Refrigerator Mothers (Simpson, 2003), shows the excruciating anguish of women who sought help from the psychiatric establishment for their children’s disturbing behavior, only to be blamed for it, and in some cases, spend years in analysis for their own assumed inadequacies. Furthermore, disagreement with the mother-blame model was taken as evidence of defensiveness or interpreted as resistance, thereby affirming Caplan’s idea of scapegoating by providing a circular argument of fault from which mothers could not escape.

Another contributing element to mother-blame is the unidirectional focus on the effect of parents on children. This issue has been addressed by sociologist, Anne-Marie Ambert, in The Effect of Children on Parents (1992). Although there is a body of research that addresses child temperament as innate (Chess & Thomas, 1986; Kagan, 1994, 1998), Ambert observes that, “How children affect their parents, what kinds of children most affect their parents, and what characteristics in parents make them especially vulnerable to child effect are questions which are not commonly raised, even among professionals” (p. 4). Ambert makes the argument that in addition to mothers, there are “socializing agents” such as the educational system, social media, television/movies, and the music industry, that influence development. She singles out “other children” as being primary influencers because of the culture’s emphasis on individualism and the pressure for children, especially adolescents, to differentiate themselves from their parents in a society in which members of all ages are consumers.

Ambert proposes that, “As consumers, children make decisions for themselves and, very

32 often, against the will or desire of their parents” (p. 14). Thus socializing agents often place mothers and children in conflict with one another, with the social agent or peer group requiring one set of behavior or values and the parent group requiring another.

These conditions may accentuate the sorts of acting out behaviors and mental health problems later exhibited by older children and teens, behaviors for which mothers’ poor early parenting can be easily blamed.

Despite the advancements in theory and attempts to correct biases, it is reasonable to question whether the residual effects of mother-blame have been part of the experience of clinician/mothers. Mother-blame is part of the social fabric of patriarchal culture and even extends into pregnancy vis a vis the concept of “maternal impressions,” “the idea that pregnant women possess powerful psychic influences that may produce an impression, physical or otherwise, on the child she is carrying” (Mazzoni, 2002, p. ix).

The current belief associated with patriarchal culture, that mothering is natural and depends upon an exclusive relationship of intensive mothering, contributes to the hyperfocus on the mother as a primary source of psychopathology. Mazzoni asserts that because of the failure to recognize “patriarchal ideologies and systemic inequalities . . . too often mothers are blamed when their children’s life outcomes are thwarted by oppressive societal structures” (p. 7). Such structures include racism, classism, sexism, war, and the inequitable distribution of resources to meet basic needs. Furthermore, in a rapidly changing economy, with an increasing diminution of social supports, Mazzoni declares “women are increasingly called upon to perform intensive care work for their children and anyone else who cannot care for themselves” (p. 7). Given that clinician/mothers are subject to these conditions and ideologies, exploring their personal

33 and professional experiences through individual interviews helps to expose implicit biases and unconscious beliefs that may have affected them, and perhaps all mothers. It provides an occasion to include their voices as subjects rather than objects and thereby expand the conversation regarding mothering and mental health.

Foundational Theories The following section summarizes some of the theories that have served as a foundation for the practice of psychotherapy and have either reflected or contributed to Western biases regarding female development and character. The concentration on the functions of the mother and the competence with which she performs those functions characterize the way in which clinical ideas about the etiology of pathology developed. In these theories, the evidence of deficient mothering is de facto manifested in the symptoms of her offspring. These theoretical orientations do not consider the mother’s internal world and the environmental factors/pressures faced in performing maternal activities nor the temperament or special needs of the child.

Each theory contributes in some way to how psychotherapists see mothers and how clinician/mothers might see themselves. The problems Freud perpetuated with his theories of female psychology are well known and have received a great deal of attention from theory revisionists and feminists. The other theories have also had intended and unintended consequences in shaping and reflecting Western ideas about the maternal role and I wish to make that case by describing what those contributions might be. This is not an exhaustive review, but includes those theories particularly relevant to my main thesis.

34

Psychoanalytic theory: Sigmund Freud The reach of psychoanalytic theory extends deeply into American culture, so permeating Western thinking, that it is hard to imagine our lives without its influence.

There are specific “universal” beliefs that originated with psychoanalysis and continue to influence how professionals and laypersons conceive of the psyche. As cited by Schnog (1997), they include “a belief in rational conscious processes, irrational unconscious processes, and a self that develops through a prescribed set of developmental stages” (p. x). Pfister & Schnog (1997) declare that psychoanalysis offered “a developmental model of the psyche which posits growth as a progressive movement through psychosocial stages” (oral, anal, phallic, latency, genital) and Freud’s tripartite model of the mind emphasized internal conflict as the source of psychopathology (p. 4). Even though these ideas have been subsumed and sometimes discarded by later theories, they continue to hold sway.

Classical Freudian psychology mirrors the limits of 19th century scientific knowledge, as well as the cultural preoccupations of the day. Freud interpreted sexual dimorphism as hierarchical, which supported notions of female inferiority. The Freudian interpretation of the child’s discovery of obvious physical differences between male and female genitals both explained and justified the adherence to distinct gender roles in western society. His interpretation sustained masculinist cultural values regarding appropriate female roles and character, thereby delimiting female ambition.

Consequently, the differences in body parts, specifically the genitals, laid the groundwork for the gender arrangements regarding status, ability, and other power hierarchies.

35 Motherhood or more specifically, the bearing of a child, became the pinnacle of feminine psychosexual achievement in psychoanalytic thinking. Some believe this deprived the female/mother of subject status in theory, as she represents a means to an end, or serves a function (providing childrearing) rather than having sui generis status.

Susan Suleimon (1994) affirms this understanding of Freudian theory, stating that, “The traditional psychoanalytic view of motherhood is indissociable from the more general theory of normal female development and female sexuality . . .,” and led to the inextricable pairing of female identity with motherhood (1994, p. 14). Feminist philosopher, Alison Stone (2014), characterized the role of the mother in foundational theories in a particular way. She stated that, Whilst many psychoanalysts after Freud, beginning with Melanie Klein and Donald Winnicott, recognized the mother’s central importance in forming her child’s psyche, in this very respect they considered the mother only from the child’s perspective, or in terms of her effects on the child, or as the original context in which the child develops (p. 167).

Thus began the mother’s career in developmental theory as a kind of cipher in which she “has no intrinsic value,” other than the relief of drive tension (Mitchell & Black, 1995, p. 39).

Object relations: Melanie Klein.

A major shift in psychoanalytic theory occurred after the reconstruction of the childhood experience of adults was augmented by the direct treatment of children.

Melanie Klein shifted the focus from the Oedipal child’s concerns with unacceptable

36 libidinal urges to the pre-Oedipal child’s struggles with aggression towards the mother.

As a result, the role of women as maternal caregivers began to increase in importance, even though Klein focused exclusively on the child’s intrapsychic life, rather than the actual relationship with the mother (Klein, 1975).

In the Kleinian lexicon, phantasy is the mental representation of instinct. Klein’s infant is endowed with libidinal and aggressive impulses and suffers from fears of punishment and even annihilation as a response. This scenario created the necessity for defenses characteristic of the paranoid and schizoid position which, if the mother is able to manage the infant’s intense reactions, the child is able to enter the depressive position wherein objects (people) are felt to be of value.

One, perhaps unintended consequence of this orientation, is the construction of an omniscient pre-Oedipal mother (Berzoff, (2004, p. 250). According to feminist author, Dorothy Dinnerstein (1999), the reification of this all-powerful mother comes with a cost.

In her view, this formidable image is partially responsible for a near universal enmity toward the feminine.

While the mother has an assumed pre-eminent position of power in the phantasy life of the infant, Klein’s focus on the child’s internal world excluded her taking an interest in the actual mother. Paradoxically, switching the emphasis from the Oedipal father to the pre-Oedipal mother begins to foreground the mother’s position in psychoanalytic theory, eventually resulting in a rigid focus on the mother as the main source of pathology and dysfunction. Klein’s work with children and her thinking about their internal life had a tremendous impact on developmental theory, influencing Bowlby,

37 Winnicott, and others, who in turn contributed to the further development of object relations.

Object relations: D. W. Winnicott.

A one-time disciple of Klein, D. W. Winnicott (1960) was a pediatrician and analyst whose theory of the false self and its resultant disorders was based on the quality of the mother-infant interaction (Mitchell & Black, 1995). Moving away from Freud’s concept of the instinct directing itself toward an aim, Winnicott took a position that, “It was not just feeding that was crucial, but love, not need gratification, but its mother’s responsiveness to the ‘personal’ features of the infant’s experience” (Mitchell & Black, 1995, p. 125). Winnicott is well known for his concept of the “good enough mother” and false self disorders.

In a series of 60 radio broadcasts spanning two decades during and after WWII, Winnicott told women they were naturally endowed to be mothers and to trust themselves. That this expertise came from an empathic practitioner who tried to avoid “giving practical advice” (Ades, 2016), did not fully negate it as an example of the male expert ministering to the female novice. As Doane and Hodges ask, “If this relationship is natural, what is there to say? Moreover, why is it so important for him to say it?” (p. 21, 1993). Winnicott’s advice, meant to bolster mothers’ self-confidence, may have had the ironic consequence of reinforcing maternal reliance on predominantly male experts.

Consequently, even the “good enough” mother is unlikely to be good enough without professional male counsel (Doane & Hodges, 1993).

38 A troubling outcome of this well-intentioned focus on motherhood has been a tendency to view mothers as the chief pathogenic agents in psychological dysfunction.

Even for Winnicott, whose sympathies certainly were with mothers, “It was the environment that the mother provided, (not the child’s conflictual instinctual pressures) that determined the outcome. False self disorders, in Winnicott’s perspective, were ‘environmental deficiency diseases’” (Mitchell & Black, 1995, p. 125) and mother was the environment.

Ego psychology: Margaret Mahler.

Margaret Mahler is part of the tradition of post-Freudian analysts who built upon his tripartite model of the psyche by enlarging the role of the ego and object relations (Mahler, Pine & Bergmann, 2000). As a Neo-Freudian psychiatrist, she introduced a developmental theory based on the concept of separation-individuation. This led to the further development of ego psychology, self psychology, and object relations, as well as greater interest in child analysis. Mahler’s model went significantly beyond the paradigm of inevitable intra-psychic conflict to describe what observable process was taking place as the child proceeded through age specific phases of development. Her concepts added an important dimension to child development by bringing in observations based on real relationships that maintained the importance of the intra-psychic as well as the interactive aspects of development. There is a privileging of separation as a means to achieve individuation, which could be interpreted as undervaluing the role of interpersonal connectedness as an equally salient factor (Benjamin, 1998). Separation resulting in individuation is the final achievement in contrast to interdependence or mutuality. Again,

39 the mother’s place in this model is limited to supplying the necessary functions on behalf of the child’s development.

Interpersonal Psychology: Harry Stack Sullivan.

Harry Stack Sullivan, (1953/1997), the originator of interpersonal psychology, is included in this review because of his emphasis on the role that anxiety plays in “problems in living” and psychopathology. Particularly salient to my critique regarding the contributions of theory to a disproportionate focus on the mother, he considered maternal anxiety an “emotional poison” from which the infant could not escape. His “tension of anxiety,” (p. 41) is a dysphoric state that originates in the transmission of the caregiver’s feelings of anxiety to the infant through a process he called “empathic linkage” (Mitchell and Black, 1995, p. 67). According to Sullivan, the only solution for this toxic state was for the mother to cease feeling anxious. Although a reduction in anxiety is obviously desirable, can a mother actually escape feeling anxious as she experiences the vicissitudes of childcare? Again, in this aspect of Sullivan’s theory, as in those previously reviewed, the mother remains an object and there is no accounting for her Umwelt, her real-life experience of being a mother.

Self Psychology: Heinz Kohut.

Heinz Kohut (1971) did not oppose Freudian drive theory, but added an independent line of narcissistic development, separate from Freud’s phase-specific libidinal model, and added the concept of the Self, which superseded Freud’s metapsychological structures. Unlike Freud and his predecessors, “Kohut emphasized the

40 chronic traumatizing milieu of the patient’s early human environment, not the primitive urges arising from within” as the source of pathology (Mitchell & Black, 1995, p. 163).

Rather than being at the mercy of its inborn instinctual energies with the emphasis on the primacy of intrapsychic conflict, the Kohutian baby is at the mercy of its environment’s capacity to empathically respond. The chronic failure of the primary caregiver to consistently respond in an empathic manner and to allow idealization results in pathology of the self. The type of pathology that results depends upon which line of narcissism was affected by empathic failure and at what point in development this took place. According to Mitchell (1988), It is only in the absence of necessary parental provisions that tensions and difficulties arise. Growth is aborted, and the child is driven to aggressive responses and the compulsive seeking of inferior substitutes, as he tries to wrest from the interpersonal environment what he desperately needs to survive and continue to grow (p. 130).

In Kohutian terms, this places the onus on the performance of the caregiver (read mother) to offer the child empathic responses within the limits of “optimal frustration.”

The Kohutian model begs the question, “Where does this empathic mother come from?”

It assumes that she has received the empathic nurturing that enables her to provide it in turn to her own child. Has the modern mother received the support needed to successfully offer empathic responses? In the lucky case where there is such a provider, are there not multiple constitutional and social factors that may render the environment/caretaking response ineffective? As Mitchell states, “It may be that later difficulties in living are often not direct causal products of earlier deprivation and problems, but a complex

41 combination of the impact of early experience and reactions to later stresses and conflicts” (1988, p. 145).

Attachment theory: John Bowlby.

That attachment is viewed as significant in a child’s development owes a debt to the work of the eminent British psychoanalyst, John Bowlby (1973/1982). His theory was to have a monumental impact on our understanding of the child’s psychological world as well as exerting a tremendous influence on social policies concerning children.

Bowlby surmised that infant behaviors had been fashioned by evolution to obtain proximity to the mother. In turn, the mother’s responsiveness to such behaviors was viewed as a built-in predisposition serving to enhance the survival of the infant and thus the species. Bowlby redirected the focus of infant development toward the centrality of the mother-infant relationship by concluding that the impetus toward connectedness was built into our evolutionary heritage. If connection was now a key part of child development, then the nature of the connection, as well as any disruptions to it, were highly significant. This line of thinking led to Bowlby’s identification of a specific set of stress responses that infants/children manifest when this bond is disrupted. Bowlby demonstrated that children were dependent on the nature and stability of their attachment to caretaking figures in order to thrive. According to Sir Michael Rutter (1991), a contemporary, it was Bowlby’s contention that, It was essential for mental health that the infant and young child should experience a warm, intimate and continuous relationship with his mother. He laid

42 particular stress on the need for continuity and was explicit that this could not be provided by a roster (p. 17).

This arrangement worked well when the needs of the infant and the capacities of the mother were well matched, but even when well matched, mothers’ needs and babies’ needs are not necessarily in sync and are often in opposition. This conflict elicits the child’s protest and with it the mother’s physiological and psychological response. Her manner of interpreting and handling protest is, of course, a major challenge of parenting.

It places particular stress on mothers, who also have to manage the vicissitudes of their own psyches as well as meet cultural expectations regarding maternal selflessness and devotion. In addition, the outside world often casts a critical eye when confronted with a crying baby or unhappy toddler. “What’s wrong with that kid?” or “Can’t you make him stop?” are not uncommon responses in public.

Bowlby’s contributions provided an important modification to psychoanalytic theory that opened the door for further changes. It provided a way of understanding the needs of the infant/child that supported giving equal weight to separation and to connection, thus rebalancing our cultural predilection to focus on autonomy. Bowlby and attachment theory opened up the culture to placing greater emphasis on the importance of connectedness as an ongoing requisite of adult life. But it is infantocentric, and therefore amplifies the cultural framework in which a mother is continually having to choose between her needs and those of her child. According to Sarah Blaffer Hrdy, “Bowlby’s theory of attachment stings most smartly where it pricks the conscience of every mother who is aware of her infant’s needs but who also aspires to a life beyond bondage to them” (2003, p. 407). However unintentional, it has often been misinterpreted to suggest that a

43 baby requires near perfect attunement. Harvard Professor Robert A. LeVine’s two-fold critique of (2015) of attachment theory contends that it superimposes middle class Anglo-American values “into a psychiatric model of early development . . . [and that] Bowlby’s thinking was bound to a dichotomous medical model in which deviations from an idealized pattern of good mothering . . . lead inevitably to psychopathology” (pp. 5152).

Feminist Critiques Until the introduction of feminist and relational/intersubjective views, most neoFreudian developmental approaches explained the child’s emerging subjectivity (and other aspects of the child’s mind) as a result of interactions with a mother who performed essential activities, yet, served as a subjectless functionary (Benjamin, 2000). As theory shifted from the centrality of the Oedipal complex toward pre-verbal stages of development, a new focus on mothering contributed to an environment in which mothers were often seen as culpable for neurosis, psychosis, and autistic disorders. It wasn’t until the emergence of feminist thinking in the 1970s that a new lens was created through which engendered theoretical concepts could be deconstructed.

Even though several prominent female analysts, such as Melanie Klein and Margaret Mahler, made significant contributions to the development of psychoanalysis, their theories did not specifically add a feminist critique to the profession. With the exception of Karen Horney, the early contributions of eminent women psychoanalysts often reinforced or failed to fully redress negative cultural stereotyping of females.

44 Despite varying in their critiques and revisions of theory, feminist psychoanalysts share a common purpose: to retain their allegiance to psychoanalytic theory while pointing out the consequences of sexism. They have employed a variety of approaches to accomplish their task. Although agreement among feminist analysts is not universal, philosopher Emily Zakin (2011) finds that “what is shared in common are a descent from, respect for, and some minimal borrowing of Freudian accounts of the unconscious, even while criticizing and/or revising his theoretical apparatus” (p. 1).

According to Jessica Benjamin (1995), feminist approaches “question the objectivity of knowledge by challenging it ‘as absolute and privileged’, in favor of recognizing the ‘subject position’ from which that theory is developed” (p. 10). “Subject position” refers to the ability to entertain more than one perspective and tolerate paradox.

Benjamin adds, “To accept paradox is to contain rather than resolve contradictions, to sustain tension between elements heretofore defined as antithetical” (1995, p. 10). The subject position liberates theory from a Procrustean bed of internal symmetry that allows feminist psychoanalysts, in particular, room to accept and yet revise Freudian ideology.

Some feminist critiques employ oppositional arguments to address gender bias, a position that takes an accepted or traditional view and simply reverses it. For example, if men are viewed as the physically “superior sex,” then an oppositional approach would portray men as inferior and women superior. In this case characteristics that portray males as weak, such as having a shorter lifespan or being more prone to congenital syndromes would be emphasized. The main limitation with oppositional arguments is their acceptance of the traditional categories and premises used to describe, define, and rank phenomena. (Benjamin, 1995; Stearn, 2003). Jessica Benjamin notes the irony that,

45 “one is in theory more likely to be determined by a prior body of thought precisely when one thinks it can be overcome simply by rejecting its postulates” (1995, pp. 4-5). Simply reversing the cultural tendency to devalue women’s “weak” feminine traits by elevating them can result in a form of splitting in that women now possess the good traits and men possess the bad. The idea that women are “natural” peacemakers, while men are “natural” warmongers, is an example of this type of oppositional argument. In terms of psychodynamics, some of these counter arguments are appealing. Karen Horney used this approach when she introduced the concept of womb envy to counter the concept of penis envy (1967/1993).

The current theoretical trend that emphasizes pre-Oedipal development has not extirpated the Oedipal complex from theory, but resulted in an updated interpretation for those interested in retaining it as a viable concept. Jacqueline Stevens (2006) has noted that the use of the term pre-Oedipal, even by feminists, continues the tradition of reference to a gender-biased concept. Both male and female theorists have accepted its main premise. As Chodorow and Contratto (1982) point out, Feminists’ tendency to blame the mother . . . fits into cultural patterning.

Feminists simply add on to this picture the notion that conditions other than the mother’s incompetence or intentional malevolence create this maternal behavior . . . . Feminists take issue with the notion that a mother can be perfect in the here and now, given male dominance, lack of equality in marriage, and inadequate resources and support but the fantasy of the perfect mother remains: If current limitations on mothers were eliminated, mothers would know naturally how to be good (pp. 64-65).

46 This position reflects the idea that if the culture functioned as a better “parent” to mothers by providing needed social supports and rectifying gender inequities, mothers’ essential good maternal traits would be released. It locates “bad” mothering in social oppression, which indeed may be a factor, but this view still adheres to the same paradigm regarding development, that the mother is the specific etiological basis for pathology.

Feminist-oriented critiques also address gender biases by identifying the sociocultural context in which the theory is embedded and examining how we become gendered. Freud’s treatment of sexual dimorphism presented modern feminist thinkers with a challenge. Social constructivists took up this challenge, represented by the work of psychoanalyst, Karen Horney (1967/1993). Social constructivists retain their allegiance to psychoanalytic theory while reinterpreting some of its conclusions in light of feminist values. As one of the first analysts to take exception to Freud’s concept of penis envy, Karen Horney reinterpreted this idea as a primarily culturally influenced construct representing envy of male power, rather than a biologically determined given. In her essay, “On the Genesis of Castration Complex in Women,” Horney states, “an assertion that one half of the human race is discontented with the sex assigned to it and can overcome this discontent only in favorable circumstances—is decidedly unsatisfying, not only to feminine narcissism but also to biological science” (Horney, 1967/1993, p.38).

Feminist psychoanalysts reject psychoanalysis’s essentialist conceptualization of the female mind and the assertion of the girl’s inadequate resolution of the Oedipal complex. Essentialism is defined as the innate presence of a trait or characteristic in a human being that is not a result of socialization. “By assigning to women an essence or

47 determinate identity, the psychoanalytic reliance on sexual categories once again renders woman as the other to a subject rather than a subject herself” (Zakin, 2011, p.6). The consequence of the essentialist position in psychoanalytic thinking is that woman is the object for man who is the subject. Likewise, mother is the object for the baby who is the subject. Feminist critics assert that it is the interpretation of those observable dissimilarities and our responses to them that account for those variances.

Karen Horney.

It is worthwhile to reflect on the pioneering bravery of Karen Horney, who in 1922 gave a paper at the 7th International Psychoanalytic Congress in Berlin (Balsam, 2016, p. 89). Rosemary Balsam, a Yale University psychiatrist and author of “The War on Women in Psychoanalytic Theory Building” says of Horney, She had courage in first offering her opposing ideas (the paper published in 1924) directly from the podium to Freud at the 7th International Congress that was held in 1922 in Berlin, before over 250 members. That was a well-argued, levelheaded, clever, and respectful paper delivered in front of Freud, a thesis that challenged the status of penis envy as so centrally perceived by him in the formation of womanhood (p. 89).

Karen Horney was later excommunicated in 1941 from the Psychoanalytic Institute of New York for her views, which included a social-psychological perspective, and directly challenged another Freudian key concept, the primacy of the Oedipal complex (Balsam, 2016, p. 90). Her use of a social constructivist critique predated by some 50 years feminist critiques by Nancy Chodorow (1980), and Jessica Benjamin

48

(1980, 1988, 1995), who significantly reshaped ideas regarding gendered concepts of development, thereby altering theory as well as treatment.

Jean Baker Miller and The Stone Center Group.

“There are many things that women know but have not yet put into words. The powerful reasons why women have not done so are still with us.” (Miller, 1976, 1986, p. 142).

In 1976, Toward a New Psychology of Women was published as part of the second wave of American feminism. Its author, Jean Baker Miller, a psychiatrist and psychoanalyst, headed the Wellesley College Stone Center, which became a bastion of the newly emerging feminist scholarship being launched in the heretofore paternalistic culture of academia. Following in the footsteps of Karen Horney and preceding by a decade the writings of Jessica Benjamin, Miller sought to define feminine psychology outside of the values and labels imposed by patriarchal culture. To that end, in deft, jargon-free language, Miller offered the psychotherapy community a new vision.

The major theme underlying Miller’s point of view is that women’s qualities were undervalued and mischaracterized (1976/1986, p. x). She believed that the way to correct this misdirection was to study the real-life situations of women in order to derive constructs that favored women’s strengths rather than their deficits. Miller did not want to succumb to the “dominance/submission” type of dynamic that was the result of a patriarchal culture in which women were not considered equal to men. She also carefully steered away from “reversal” arguments that elevated female characteristics above male traits.

49 An example of how Miller characterizes “women’s work” differently than in the mainstream culture, where it goes unrecognized and unappreciated, follows. She suggests that activity done on the behalf of others, that is not “in direct open pursuit” of one’s own goals, “is not activity in the male definition of it” (p. 54). She goes on to describe the extent to which activity is going on during so-called passive acts such as listening to others. “Listening to another, taking in, receiving, or accepting from another are often seen as passive. However, they all generate a response, for one never merely passively receives; one also reacts” (pp. 54-5).

Miller believes that “women, by their very existence, confront and challenge men because they have been made the embodiment of the culture’s unsolved problems” (p.

58). Her view aligns with this study’s interest in understanding the ways in which women define their experiences as clinician/mothers in the context of society’s inherent sexism.

As she says in the epilogue of her seminal book (1976/1986), “It is important that women start from their own experience . . .” (p. 142).

Nancy Chodorow.

Nancy Chodorow, a sociologist, and psychoanalytic feminist (1978), challenges the premise of female inferiority inherent in Freud’s Oedipal complex. She substitutes woman’s role as primary childcare provider rather than genital deficiency as the condition that maintains traditional gender differences in patriarchal society. It is not the female body, but the female role that maintains a gender biased trajectory of development. (1978) Chodorow’s solution for this inequity is for males to become equal partners in childcare, a move that reorganizes object relations in such a way that the

50 social stereotypies of gender are diminished as the roles and characteristics for males and females are expanded.

Jessica Benjamin.

Jessica Benjamin, a feminist psychoanalyst associated with the relational/intersubjective movement, advanced the idea that the mother’s lack of a subjective self in developmental theory was a key missing ingredient. This has proven to be the most salient factor in my thinking about theoretical and cultural biases regarding the maternal role. Benjamin’s foregrounding of the mother’s subjectivity replaced the “unthought known” (Bollas, 1987) of my own experience that I had not been able to articulate. The mother as an object, according to Benjamin, “impedes our ability to see the world as inhabited by equal subjects” and leads to conceptual splitting (1995, p. 31).

This further results in particular traits becoming positively or negatively associated with masculinity or femininity, thereby reinforcing gender stereotypes (p. 18). Traits that are organized on the basis of opposition such as passive/aggressive or receptive/active reduce complexity and lead to the devaluation of one side over the other (p. 50). Benjamin’s postmodern approach is willing to risk internal consistency for a fluidity that favors complexity. She demonstrates this in her discussion of “a kind of transitional space in theory,” a stance that can accommodate more than one description of a phenomenon (p.

7). Benjamin says, “it is important to put aside how a particular point of view is exclusive of another, to defer the contradiction in order to entertain more than one idea” (p. 7).

Benjamin introduces the Hegelian concept of recognition as a building block of subjectivity. Recognition is defined as,

51 that response from the other which makes meaningful the feelings, intentions, and actions of the self. It allows the self to realize its agency and authorship in a tangible way. But such recognition can only come from an other whom we, in turn, recognize as a person in his or her own right (1988, p. 12).

Presaging Jessica Benjamin’s use of the concept of recognition, the poet Adrienne Rich (1976/1981) wrote about her personal experience of motherhood and mentioned recognition stating, “I don’t know how we made it from their embattled childhood and my embattled motherhood into a mutual recognition [italics mine] of ourselves and each other” (p. 13).

Recognition of the child’s increasing subjectivity as she or he matures is an indispensable maternal task. Likewise, Benjamin declares that the recognition of the mother’s subjectivity by the child (as well as society) is equally necessary. This kind of recognition is the negotiation of a relationship that shifts from the mother’s recognition of the baby’s subjectivity to an increasingly mutual recognition of their two subjectivities.

Recognition waxes and wanes as a two-way process depending on the moment and the capabilities of mother and child. This type of recognition is not pandering to the mother’s unhealthy narcissistic needs, nor is it the hyperbolical admiration of the child’s developing capabilities. It is a salubrious give and take, affected not only by the mother’s competency, but also by the baby’s characteristics. Mother must, relinquish her fantasy that she can be perfect and provide a perfect world for her child, a blow to her narcissism—she must accept that injuring the child’s complete control over her is a step on the road to the child’s recognition (Benjamin, 1995, p. 89).

52 Likewise, the culture must relinquish this fantasy of the mother (and at times the father) in order to recognize her subjectivity. Recognition, whether in theory or practice, is a work in progress, a narrative of development, and an ongoing negotiation.

Until this important revision of theory, there was little theoretical or actual space for the mother’s subjective aims independent of her functions on behalf of the infant/child. Most developmental models remain infantocentric and they do so at the mother’s expense. As Benjamin states, “we may wish to take some distance from a paradigm that grants the mother so much responsibility and so little concern for the conditions of her own subjectivity” (1995, p. 88).

The traditional mother-as-object position buttressed an idealized maternal role while continuing to render the mother as a subjectless functionary. For Benjamin, it is the “struggle for recognition” that “inevitably breaks up the ideal, expresses and brings forth aggression and separation, and so helps foster a symbolic space within the early maternal dyad between mother and child . . . “ (1995, p. 19). Benjamin’s reference to aggression and separation concerns the expected failures in recognition that keep it from becoming an ideal or a smoothly operating system. The inevitability of failure, manifested as the inability to sustain tension between “subjects of differentiation” creates opportunities for repair (1995, pp. 22-23). Growth in human development as well as in the psychotherapeutic encounter is facilitated by these repairs. This dynamic of rupture and repair is a key element of relational and intersubjective psychotherapy.

53 Intersubjective Theory: Stolorow and Atwood According to intersubjective theorists Stolorow and Atwood (1992), the developmental models of Freud, Mahler, and Kohut are all based on a faulty premise they call the “isolated mind.” This faulty premise skews developmental theory toward the “idealization of autonomy” (1992, p. 13). Intersubjective theory contends that the mind is not a self-contained reified entity and must always be considered as part of an interpersonal context. Another faulty premise challenged by Stolorow and Atwood relates to the principle of conatus inherent in developmental theory. They say, A second remnant of the myth of the isolated mind that persists . . . can be seen in the idea that the self possesses an innate nuclear program or inherent design (Kohut, 1984) awaiting a responsive milieu that will enable it to unfold (1992, p.

17).

Instead, what Stolorow and Atwood offer is an interactional process that begins in infancy and continues throughout the lifespan: With regard to psychological development . . . we . . . have proposed that the organization of the child’s experience must be seen as a property of the childcaregiver system of mutual regulation . . .[and] it is the recurring patterns of intersubjective transaction with the development system that result in the establishment of invariant principles that unconsciously organized the child’s subsequent experience (1992, pp. 23-24).

Unlike other developmental theorists, Stolorow and Atwood eschew the use of age-related phases of development, as well as concepts dealing with reified intrapsychic structures or complexes. Instead, it is the history of one’s relationships, and the manner in

54 which those relationships create unconscious organizing principles, that determines psychological health or pathology.

The intersubjective approach would seem to lessen the bias toward mother blaming by relinquishing the developmental arrest model that attributes culpability to the mother’s faulty interaction with the infant. Instead, it treats development as the product of interaction between two minds. It cannot escape the cultural bias completely, as the mother’s ability to attune to her infant/child takes center stage as the major building block of development. This raises the question, where do these attuned mothers hail from in a society that fails to attune to them in a healthy way?

Daniel Stern One of the most notable changes in the theory of development is related to the exciting field of infant observation studies. Previously, theories about child development were derived from the cases of adults being treated for maladies and dysfunction. In lieu of relying on the infant “reconstructed” through the interpretation of adult psychology and behavior, the burgeoning field of neuroscience used infant observation. This changed our understanding of infant capacities and led to greater comprehension of the interactive process taking place between infant and caregiver (mother). There are too many contributors to the field to be reviewed here (Beebe 2002; Emde, 2014; Lieberman, 1993; Tronick, 2007) and others). I have selected Daniel Stern as representative because of the impact of his groundbreaking work chronicled in The Interpersonal World of the Infant (1985).

55 Classical theory posited a neonate wholly undifferentiated at birth, unable to distinguish inside from outside, itself from another. This undifferentiated oneness had been the keystone to Mahler’s (Mahler, Pine & Bergman, (1975/2000) popular developmental theory and has served as an explanation for regressive psychodynamic functioning in which there is a failure to recognize oneself or the other as separate entity/subjectivity. Stern presented a neonate with nascent abilities in the area of differentiation. This is a momentous change in thinking because the infant is no longer a completely passive actor in the interactive field. In this model the infant not only possesses some aptitude for interacting with its environment, but also shapes that interaction to some degree.

Stern’s work is relevant to this study because changes in our understanding of infants change our expectations regarding mothers. Stern says, “These working theories . . . determine how we, as parents, respond to our own infants, and ultimately they shape our views of human nature” (1985, p. 4). While infant observation studies do not remove the onus from the mother regarding the manner in which she interacts with her baby, it does emphasize the interactional quality of the relationship and eliminates the passive “neutral” infant being totally shaped by the mother. This is a “relational” infant, coming into the world ready to interact. In order to be truly relational, there must be at some point two subjectivities interacting. Thus this view opens the door to the mother as subject as well as the infant as subject, reformulating the object to subject position.

Stern does not throw out the psychoanalytic view of the baby “with the bath,” but combines two forms of collecting and interpreting data. He writes, “I have tried to infer the infant’s likely subjective experiences by considering the newly available experimental

56 findings about infants in conjunction with clinical phenomena derived from practice” (p.

275). These “newly available experimental findings” improve the accuracy of theorists’ inferences about the mental life of infants. Stern concentrated his focus on the development of the infant’s self, which he divided into four aspects: the emergent self, the core self, the subjective self, and the verbal self. Subsumed within these aspects are the following functions: “the sense of agency, the sense of physical cohesion, the sense of continuity, the sense of affectivity, the sense of creating organization, and the sense of transmitting meaning (pp. 5-6). According to Stern self-development takes place preverbally, i.e. “prior to self-awareness and language” (p. 6).

Perhaps what is also appealing in Stern’s work and applicable to this query is the manner in which he regards his own theory building. Stern does not put forth his ideas with codified finality, but considers them a “working theory,” “a hypothesis to be explored” and “a clinical metaphor to be used in practice” (p. 275). He ends The Interpersonal World of the Infant stating, “Just as infants must develop, so must our theories about what they experience and who they are” (p. 277).

The Impact of the Therapist’s Life Experience “Progress in psychoanalysis can only be made the hard way, by including ourselves and our difficulties. If we remain static and averse to change, our theories are bound to become barren and dogmatic” (Horney, 1945/1992, p. 7).

The preponderance of the literature regarding the significance of the personal life of the psychotherapist has had little to do with the impact of motherhood on the clinician or vice-versa. Although the topic of pregnancy has been addressed in the literature, the focus has been on the impact of the psychotherapist’s condition on the client (Fenster,

57 Phillips & Rapport, 2015). Furthermore, classic positions in psychodynamic theory have historically treated the intermingling of the personal and the professional as problematic.

This may have reinforced reluctance for women clinicians to describe what they were experiencing after becoming mothers. As the negative association between the personal and professional shifted with the advent of the two-person theoretical model, the acknowledgment of issues arising from private life, whether in the form of countertransference or other changes in the thinking and practice of the clinician, became more acceptable, and even the norm. Clinicians became freer to describe and speculate more openly about the meanings of their personal reactions and circumstances. Papers were more revealing about these effects on the psychotherapist and his or her practice (Adams, 2014; Basescu, 1996; Farber, 2017). Despite this change, only a small number of works have dealt directly with the experience of the mother/clinician.

The adoption of a two-person model of psychotherapy as fostered within relational and intersubjective psychoanalysis, has generated an interest in acknowledging and describing the impact of the psychotherapist’s personal life on clinical practice.

Changes in theory have led to changes in attitudes towards self-disclosure within the consultation room and in clinicians’ willingness to share aspects of their personal lives.

Clinicians’ first-person accounts offer a bridge between “real life,” theory, and practice.

Contemporary professional literature now includes more of the psychotherapist’s selfreflection and examination of the effects of their personal life on practice (Adams, 2014; Gerson, 1996; Kuchuk, 2014; Farber, 2017). In addition, feminist theory, also promotes the examination of the personal sphere in order to unmask unrecognized interpersonal dynamics and the power relationships contained therein.

58 In The Myth of the Untroubled Therapist, author Marie Adams (2014) suggests that, The more we know of how other therapists faced difficulties, how they might choose to do things differently next time, or what was positive about the way they tackled their personal crisis, the better equipped we may be to manage our own (p.

3).

In concert with Adams, relational analyst, Steven Kuchuk makes the observation that, By expanding psychoanalytic study beyond theory and technique to include a more careful examination of life events and other subjective phenomena, readers will have an opportunity to explore specific ways in which these events and crises affect the tenor of the analyst’s presence in the consulting room, and how these occurrences affect and interact with clinical choices (2014, p. xviii).

This stance is a far cry from the profession’s earlier position of anonymity and neutrality.

Classical psychoanalysis was based on the premise that the analyst should provide a blank screen upon which the analysand, through free association, could project the contents of their unconscious. This neutrality was meant to prevent the analyst from contaminating that content with his or her own subjectivity. It was also thought that the analyst’s revelation of personal information would be gratuitously gratifying to the patient as well as the analyst, and further interfere in the treatment.

The majority of the literature dealing with the therapist’s mindset is focused on the reformulated position regarding the recognition of the therapist’s subjectivity. The

59 interactions between two subjectivities are seen as an inevitable source of change. The clinician’s cognitive, emotional, and somatic responses are taken as data to be used in service of the treatment. This view of countertransference has the potential to free the therapist from an unsupportable ideal of objectivity. Marie Adams (2014) remarks that, “Therapists are often expected to be immune to the kinds of problems that they help clients through” (p. 1). This expectation may serve to reinforce a clinician’s unrealistic ego ideal, with possible negative consequences for the psychotherapy.

Although the literature on the therapist’s life experience includes accounts of various types of crises and noteworthy personal circumstances, there is very little written about the female clinician’s experience of motherhood and its impact on her professional identity or vice versa. Marie Adams (2014) considers this issue stating, “We cannot leave our experiences outside the room. Even if not at the foreground of our minds, our tensions and pleasures, the rumbling envies and unresolved issues of archaic experience, are always with us” (p. 2).

In The ‘Crisis’ of Parenthood (1996), psychoanalyst, Claire Basescu also comments on the absence of motherhood in the professional literature noting, In terms of what was in the literature, once the children were born . . . it was as if they were no longer an issue . . . Perhaps there is so much more literature on pregnancy because pregnancy is a literal physical ‘intrusion’ . . . . (p. 105).

There is likely no single explanation for this occurrence. One possibility has to do with the demarcation between personal life and working life in Western society: personal life, for the most part, must be kept out of the workplace. This contributes to a persistent pressure on women to manage the interference of their maternal duties

60 privately, lest they appear “unprofessional.” In What Female Therapists have in Common (1990), Laura Brown refers to this as, “attempts to degender ourselves and to conform to an androcentric model of relating that is presented to us in our professional training” (p. 228). The difficulties inherent in keeping the private sphere separate from the public sphere of employment has disadvantaged women and contributed to their exclusion from full participation in the public domain of work. This situation has influenced the choices available to women, which are further affected by ethnicity and class.

Regarding the impact of motherhood on the therapist’s clinical work, the literature offers both positive and negative consequences. Positive consequences include greater empathy and understanding of the nuances and intricacies of child rearing, greater familiarity with child development, and an appreciation for the unique characteristics of a particular parent-child dyad. A client may perceive that the parent-therapist is in a better position to understand the vicissitudes of childrearing and therefore have more insight into the client’s issues. Penelope Campling (1992) thinks that the experience of parenting teaches clinicians that, “development is often very erratic and does not proceed in a straight line” (p. 77). This is in contrast to the progressive trajectory in most developmental theories. Campling’s insight enables the therapist to be more openminded in their conceptualization of diagnosis and treatment.

On the negative side, the profession’s investment in deficit-oriented explanations of psychological and behavioral problems sets up an implicit bias toward the therapist’s perception of her client’s difficulties as directly traceable to faulty parenting (Mitchell, 1984; Rutter, 1972/1991; Lombrozo, 2014). This may cause the clinician to overlook

61 other salient factors such as temperament (Kagan, 1998/2000), experiences with siblings and peers, and socio-economic factors. A focus on mal-parenting can also manifest in splitting. This can occur when the therapist identifies herself as the more ideal parent, while the client’s parent represents the bad or lesser parent. Although this splitting occurs in the private domain of the therapist’s office, it reflects the idealization and devaluation of women/mothers in the culture at large.

Relevant Research and Literature Only a small number of writings deal directly with the subjective experience of the clinician/mother. I will briefly describe below the three most relevant works.

In New Directions in Feminist Psychology (1992), author Paula S. Derry looks at motherhood and “clinicianhood” not as problematic, but in terms of the perceived effects the former has on the latter. Derry’s paper is based on her research in which she interviewed 25 clinician/mothers in single face-to face interviews. The majority of interviewees (88%) identified themselves as psychodynamically oriented. Derry considers her most significant finding a nearly universal change in thinking that came about through the experience of motherhood. Although her participants often believed that they did not change their clinical interactions or interventions subsequent to becoming mothers, a difference in thinking appeared in the data and lent itself to the following findings: idealism regarding parenthood diminished; expectations regarding the success of interventions were reduced; greater empathy lessened the tendency to pathologize the parent; there was a deepened understanding of child development; clinicians identified more with the parental point of view and children were considered

62 active agents and not simply passive recipients of parental behavior. Derry also suggests that her study implicates one other possible factor, the tendency to identify with the child and not the mother, as a contributing factor in mother-blaming.

Laura Carter Robinson’s (2012) dissertation investigated the experiences of nine psychoanalyst-mothers concerning the reciprocal influence of the clinician-parent role.

This qualitative study revealed four leitmotifs: “motherhood changes everything; insight changes everything; therapists’ experiences of motherhood are complex; and therapists have a worldview that encompasses their parenting and professional lives” (p. ii). Dr. Robinson further separated these categories into fourteen sub-themes that described in greater detail the types and qualities of the changes the majority of her respondents discussed. These included changes in boundaries, career plans, and increases in empathy and understanding. Robinson concludes that rather than thinking about being psychoanalytic with their children, psychoanalyst/mothers have absorbed a particular worldview that becomes part and parcel of who they are in the maternal role (p. 91).

Susan Scholfield Macnab details the interaction between her personal and professional experiences as a mother-clinician in her contribution to A Perilous Calling: The Hazards of Psychotherapy (1995). Her chapter is humorously titled, Listening to your Patients, Yelling at Your Kids: The Interface between Psychotherapy and Motherhood. Dr. Macnab, a social worker and a psychologist, finds that there is, “a continuous interplay between my role as a mother and as a psychotherapist” (p. 37). This interplay takes many forms, from changes in her identifications with patients to beliefs and expectations regarding her capabilities as a mother. Motherhood has increased her empathy with parents and made her more aware of how therapy can “encourage” mother-

63 blaming. Until she became a mother, she tended to distance herself from the “culpable” mother/client and identify more with the “innocent” child. After becoming a mother, empathy for the parental position increased and Macnab developed a greater appreciation for the complexity in parent-child relationships. In reference to her own self-regard as a clinician/mother, she writes that she held the belief that “my years of training and psychotherapy would protect me and my child from almost all the pain I had heard from my patients or had experienced in my own family” (p. 39). She found that her training could be helpful, but also leave her more vulnerable to internalized expectations of “near perfect” mothering (p. 37).

Macnab traces some aspects of distortions in her professional belief system to her exposure to psychodynamic theory. She states, Psychodynamic theories focus intensely on the pernicious influences of mothers and fathers, or their emotional and physical absences. The therapist encourages the patient to explore the roots of painful feelings and their early childhood origins. Destructive patterns are often traced to the frightening, angry, unfeeling, or humiliating ways that patients experienced their parents. We may have moved away from mother blaming—but not far enough. (p. 41).

Macnab identifies “Overreliance on psychological theories to explain everything about children’s needs and behaviors” as another problematic aspect of the psychotherapy profession (p. 40). She does, however, also value her professional expertise remarking that, “my clinical work brings important knowledge to my family life; that is, the inevitability of suffering and the immense healing capacities of compassion for myself and my family” (p. 44).

64 As demonstrated in the literature review, theory has evolved and even redressed some of the grievances regarding feminine development and character, and yet, the focus on the contribution of maternal care to child development and psychopathology has grown, for better or worse, toward creating a hyperfocus that raises questions about how women as therapists and how mothers perceive themselves in these dual roles. While much has been written about mothers and mothering in the professional and lay literature, there is a notable absence of the voices of the subjects of this literature. This study intends to provide the opportunity for those voices to be heard for the purpose of understanding more about the interaction of the clinician/mother roles.

65

Chapter III

Methods and Procedures This research explored the potential interaction or relationship between a woman’s dual roles as mother and psychotherapist. Recognizing the absorption of sociocultural gender bias into theory regarding female development and identity, it explored how clinician/mothers experienced their acculturation into the role of psychotherapist and whether this had an impact on their experience of motherhood and/or changed their way of practicing psychotherapy. I was interested in discovering whether the attitude of mother-blame or stereotypical notions regarding female gender characteristics and development, posed challenges to women psychotherapists in the evolution of their identities as clinicians and mothers.

Methodological Approach and Design A grounded theory design (Glaser & Strauss, 1967/2006; Corbin & Strauss, 2008) was selected to investigate the interrelationship between the psychotherapist’s identity as clinician and mother. Grounded theory is a qualitative approach employing in-depth interviews and a small sample size to produce data that can be systematically reviewed, compared, and contrasted to generate themes found in the data. In contrast to quantitative designs, there are no preconceived categories in qualitative approaches which emphasize description and interpretation rather than numerical analyses. Qualitative design, in the

66 form of grounded theory, is frequently used to provide a meticulous understanding of a specific phenomenon. The information elicited by this design can contribute details and perspectives through the addition of “lived experience” to the understanding of extant theories and concepts.

Corbin & Strauss, (2008) point out that qualitative approaches assume a world that is complex and in flux, and thus suited “to examine problematic as well as routine situations and events” (p. 6) Also, quantitative approaches, represented by means-ends analytic schemes, are usually not appropriate to understanding action and interaction because “they are much too simple for interpreting human conduct (2008, p. 7).

Relevant to the influence of the larger matrix in which research is conducted, philosopher, John Dewey declares, “Neither inquiry nor the most abstractly formal set of symbols can escape from the cultural matrix in which they live, move and have their being” (1938, p. 20). Qualitative studies assume that an inquirer is not an objective observer. Similar to the role of the psychotherapist in the consulting room, the inquirer is a participant/observer. As Corbin and Strauss (2008) indicate, “The experiences of whoever is engaged in an inquiry are vital to the inquiry and its implicated thought processes” (p. 3). The observer is also subject to the influence of the greater social matrix from which they derive their interests, attitudes, and questions for investigation.

The greater social matrix influences not only the personal interests of the observer, but what topics of inquiry the research community favors over another. This context is present whether research is conducted in a controlled laboratory setting or a more informal setting. Acknowledgement of the interactive impact of the inquirer/subject

67 relationship removes the misapprehension of “pure” objectivity often associated with quantitative designs.

According to Brown (1990) the little that has been written on women as therapists and the literature that exists is based on assumptions rather than analysis. She further notes that theory is most often based on the dominant social group and therefore missing the voice of other segments of society, in particular, regarding “race, class, sexual orientation, age, and able-bodiedness” (1990, p. 229). A qualitative approach is wellsuited to adding those voices to the literature because of its use of in-depth interviews and a small number of participants, whose voices might be lost in a larger, quantitative endeavor.

I conducted individual interviews with women who were established as clinicians prior to becoming mothers. An interview guide (See Appendix A) containing topic areas to be explored was used in lieu of a formal questionnaire, with the goal of obtaining the personal accounts of clinician/mothers and their subjective experiences of being acculturated into the clinician/ mother roles. This format follows the guidelines set out by Mischler (1986) and favors open-ended questions and an interview arrangement that is partially structured. The intent was to generate discussion, record and transcribe the interview, and utilize a systematic form of analysis known as “constant comparative analysis” as outlined by Strauss and Corbin (2008), for the purpose of identifying common and unique themes that underlie the experiences of therapists/mothers as a group.

68 Validity and Reliability Individual interviews and subjective experience can be relied upon to provide useful data, even in a scientific environment that favors “objective measures and results” This is accomplished through by establishing validity and reliability. The term validity refers to whether the query is measuring what it intends to measure. The concept of reliability is concerned with the accuracy of measurement in a given study. Patton (2002) summarizes a set of criteria for safeguarding the quality of qualitative research, which he claims depends on the integrity of the researcher. His list includes: acknowledging subjectivity, trustworthiness, authenticity, triangulation (capturing and respecting multiple perspectives), reflexivity, praxis, particularity (doing justice to the integrity of unique cases), enhanced and deepened understanding (Verstehen), and contributions to dialogue (p. 544).

Corbin (2008) contests the use of the terms reliability and validity when applied to qualitative research and prefers the concept of “credibility,” (p. 301) which she defines as research that, resonates with readers’ and participants’ life experiences. It is research that is interesting, clear, logical, and makes the reader think and want to read more. It is research that has substance, gives insight, shows sensitivity, and is not just a repeat of the “same old stuff” or something that might be read in a newspaper. It is research that blends conceptualization with sufficient descriptive detail to allow the reader to reach his or her own conclusions about the data and to judge the credibility of the researcher’s data and analysis. It is research that is creative in its

69 conceptualizations but grounded in data. It is research that stimulates discussion and further research on a topic (pp. 301-2).

Furthermore, qualitative research, according to Corbin and Strauss (2008), is represented by the following characteristics: methodological consistency, clarity of purpose, self-awareness, a researcher trained in doing qualitative research who has “feeling” and “sensitivity’ for the topic, a researcher who will work hard, a researcher who can access their creativity, a researcher with the awareness to anticipate criticism and resolve methodological problems and a desire to do research for its own sake (p. 303).

Participants Nature of the sample/data collection/criteria for selection.

I interviewed eight women who had been practicing clinicians for a minimum of five years prior to becoming mothers. The rationale for this criterion was that this temporal relationship was likelier to show an effect of being a clinician on the participant’s experience of motherhood. The minimum of five years was to ensure acculturation into the role of psychotherapist. The ages of the participants’ children ranged from early toddlerhood (one year) to high school so that the participants’ children were still physically present in the home. The aim was to provide a sample of participants who were actively engaged in their dual roles. There were no restrictions as to the age or ethnicity of the participants, and it was hoped that individuals from differing backgrounds could be brought into the study. Prospective participants had to possess the appropriate California licenses and degrees to practice psychotherapy. The study included Licensed

70 Clinical Social Workers (LCSW), Marriage and Family Therapists (MFT), and one Psychologist (PhD).

Recruitment.

I created documents that described the research to prospective referral resources and participants (See Appendices B & C). I drew from the local Northern California psychotherapy communities and specifically from the California Society for Clinical Social Work. I posted a description of the study and request for participants on professional listservs, such as the California Society for Clinical Social Work and The American Association for Psychoanalysis in Clinical Social Work. I also contacted the California Association for Marriage and Family Therapists (CAMFT) and the American Psychological Association (APA). Through the use of the “snowball technique” as described by Patton (1990), I used “word of mouth” by personally engaging with peer professionals, and through their referrals, to other referral and participant sources, in order to expand the recruitment network.

Data Collection: The Interview Data was collected from one-on-one recorded interviews using an interview guide with open-ended questions and covering selected topics relevant to the research question. I personally transcribed some of the interviews and hired a professional transcriber to transcribe the rest. Participants were given pseudonyms and all identifying information was edited to preserve anonymity.

71 Procedure.

Prior to the interview a statement was shared (See Appendix A) with the participant explaining the purpose of the study and their options should they become uncomfortable or decide to withdraw. The Participant was asked to sign an informed consent form (See Appendix D). Participants were re-consented (asked to sign new consent forms), when this study was transferred to the auspices of ICSW, due to the dissolution of The Sanville Institute, the originating academic source (See Appendices H, I & J). I estimated that the interviews would range from one to two hours with breaks as needed. All interviews lasted approximately one hour. The interview guide (See Appendix A) covered selected topics for exploration relevant to the purpose of this study.

It also served as a prompt for the Researcher and Participant as needed, thereby providing flexibility in the interview process.

Topics of the interview guide.

Areas covered by the interview guide (See Appendix A) include the following categories: •

Professional education and training,

•

The clinician thinks about motherhood/the maternal role,

•

Contributions of the role of clinician to the subjective experience of becoming a mother,

•

Contributions of the role of motherhood to the subjective experience of being a clinician,

72 •

Mother-blame, and

•

Final thoughts.

In order to ease the participant into the interview process, I began by reading a brief statement (See Appendix A) to orient them to the purpose of the interview, the safeguards for confidentiality, and provide an opportunity to ask any questions or state any concerns they have before proceeding.

The format of the interview guide was designed to put the participants at ease before launching into the specific aspects of the research question that I would like to explore with them. I obtained their demographic information, including their family status and some information about their current practice in the Prospective Participant Questionnaire (See Appendix E) prior to the interview.

Professional education and training.

I was interested in knowing when they entered their education and training and what ideas/theories/methods of treatment they were exposed to along the way. Theories come into vogue and then fade or transform in some significant ways, so it was relevant to know whether they were formally exposed to those models reviewed in the Literature Review or to others. What did they recall as most influential to their way of conceptualizing and practicing psychotherapy? What thoughts did they have about their education and training in terms of any deficits or ideas that they found problematic?

73 The clinician thinks about motherhood/the maternal role.

Motherhood and how it is characterized as an institution and experienced on an individual level, is a fraught topic in Western culture. Views and values of motherhood are therefore context dependent at both macro and micro levels. In order to elicit data that might inform the gap between theory, cultural attitudes, and lived experience, participants were asked to talk about their experience of motherhood, beginning with childhood recollections of either attraction, ambivalence or rejection of mothering as a potential part of their identity. Identifying or dis-identifying with the maternal role can be present early in childhood and transform throughout one’s development. Following this inquiry, I asked what did they remember thinking about the maternal role, both personally and professionally before becoming a mother. What did the participant remember looking forward to, and/or what concerns might they have had? This line of inquiry was intended to reveal the changes that were influenced by their professional path and/or their experience of being a mother.

The contributions of the role of clinician to the subjective experience of becoming a mother.

As clinicians, we are often exposed to numerous ideas about the mother-infant dyad and its influence on early development, as well as its influence throughout the later stages of childhood development and beyond. Regarding motherhood, what expectations, ideas or even feelings did participants have about the maternal role, related to their practice that came from their education and training as a therapist? In what ways

74 did they think their education, training and practice experience have an effect or multiple effects, positive or negative on their experience of mothering?

The contributions of the role of motherhood to the subjective experience of being a clinician.

I was interested in learning how the real “lived” experience of motherhood influenced the clinician’s ideas about human development and the way they think about and respond to mothers and mothering (parenting) issues in their practice. I asked if they could talk about how they were affected as professionals after experiencing their own motherhood.

Mother-blame.

Given that this concept is part of the social matrix with which clinicians are acculturated into their profession, I asked if the participants have heard this expression and if they relate to it any way. I saved this question after gathering information in the topic areas noted above, so that I avoided influencing the participant’s responses regarding negative stereotyping of mothers and mothering.

Final thoughts.

In keeping with the rationale for a semi-structured format, it is important to provide opportunities to the participants to share material that might not be accessible using other types of approaches. Since the emphasis in this qualitative study was to elicit themes from the interviews, providing the means to allow them to share something that

75 may have been missed or overlooked by the researcher could prove valuable. For that reason, upon near completion of the interview, I asked was there anything I missed that the participant would like to add. I also provided an opportunity to debrief the participant by inquiring how did they feel or how was it for them to discuss these topics. Ultimately, I looked to this research to fill the gap between theory and lived experience in the effort to provide a more realistic and nuanced view of each.

Data Analysis I used Corbin and Strauss’s (2008) “constant comparative method” as a systematic way for analyzing the data. This approach allowed themes to emerge from the interviews and was useful for illuminating subjective experience.

I took notes after the interviews and listened to the recordings soon thereafter, making further notations of my responses to the material and any aspects that stood out. I started to transcribe the interviews myself in order to be as familiar with the data as possible prior to formal analysis, but became bogged down in the process and hired a professional transcriber. I created a structure that follows Patton’s (2002) recommendation of “identifying, coding, categorizing, classifying, and labeling the primary patterns in the data” (p. 463). This required several readings of the transcripts, as well as listening to the recorded interviews several times. I took extensive notes in order to identify emerging themes for categories. These were used to make comparisons, further extract and refine themes and subthemes.

76 Presentation of Findings In keeping with the grounded theory approach to research, I created a structure of relationships among the categories, defining and illustrating each with data quotes and developing a narrative that described the relationship between themes generated by the data. Anonymity of the participants was preserved by the use of pseudonyms and by only discussing in general terms the overarching and specific aspects of the categories that are derived from the interviews.

Chapter Five of this study focuses on the relationship between the data and the research question. Commonalities as well as unique findings are described as they relate to the literature relevant to this topic. Limitations of this query are presented as well as suggestions for further research.

77

Chapter IV

Findings This qualitative study examines the interrelationship between a woman’s dual identities as psychotherapist and mother, with a particular interest in the phenomenon of “mother-blame’” Mother-blame can be defined as a cultural attitude which hyperfocuses on maternal contributions to psychopathology which has been absorbed by several theories that have influenced the practice of psychotherapy. I hope to shed light on the ways that clinician-mothers understand and reconcile their personal and career identities in a profession with historical roots derived from a biased way of regarding female development and character. I describe the characteristics of the participants and the major categories that emerged from their interviews. Quotations originate from the verbatim content of face-to-face or online interviews and unnecessary verbalisms have been edited from the material for the purpose of clarity and continuity. These edits are not intended to change the meaning contained within the content.

Description of the Participants I interviewed eight female clinicians face-to-face either in-person or by using an online audio-visual platform which was twice augmented by telephone call when the audio signal was compromised. They have been given the following pseudonyms to protect their privacy: Lisa, Fran, Lucy, Taylor, Ella, Tonya, Ava, and Jen. The participants represented the following professions; five are licensed clinical social

78 workers, two were licensed marriage and family therapists and one was a licensed clinical psychologist. All participants had children ranging in age from one to eighteen years old.

Ethnicities included six Caucasian women, one Asian and one Latina woman. Four of the women were married, two were divorced and two were single mothers. Participants were from Northern and Southern California, and one lived and practiced in North Carolina.

Although a participant might have a single preferred theoretical orientation, all mentioned at least two kinds of approaches that they used in their assessments and interventions with clients. These included Freudian theory, unspecified psychodynamic theories, object relations, cognitive-behavioral therapy, family systems, manualized prevention strategies, sensorimotor therapy, a Rogerian/humanistic approach (unconditional positive regard), the person in the environment, unspecified developmental theory, Ericksonian developmental model, EMDR and attachment theory.

All of the participants in this study consciously chose to become mothers, though for some the decision was more easily arrived at than for others. Seven respondents became mothers after working as clinicians for a minimum of five years. An eighth interviewee incorrectly filled out the participant form and during her interview revealed that she had become a mother prior to becoming a therapist. Although this did not meet with my criterion of five years clinical experience prior to motherhood, her interview showed no remarkable differences from the content of the other seven participants other than the timing of her becoming a clinician. This material was also richly descriptive and illustrated the themes found in the other interviews and is therefore included in the findings.

79 A second participant, though licensed for over five years, was actually doing very little psychotherapy. During the interview she disclosed that she performed short-term triage types of interventions in a medical setting and provided supervision to other professionals. I included her interview and found some similarities and differences when comparing her responses to the other participants, which will be further described.

All of the participants had to be re-consented, i.e. fill out new consent forms because this research was initially approved and conducted under the auspices of The Sanville Institute for Clinical Social Work in Berkeley, California. Stewardship was shifted to Chicago’s Institute for Clinical Social Work after the dissolution of Sanville in the fall of 2018. A re-consent form was reviewed and approved by the dissertation chair and ICSW’s IRB chair. All participants signed and submitted the new form.

Overview The findings and analysis of my data collection reveal significant and often profound interactions between a woman’s role as both a clinician and a mother. There was a duality often noted by participants, i.e. that being a clinician and a mother was both “a blessing and a curse.” This refers to factors associated with either role that were identified as helpful as well as burdensome. Such factors, which are derived from professional education, training and practice, include having information, knowledge, awareness, and understanding beyond that of the general public regarding child development. Participants experienced a number of changes after becoming mothers.

These included an increase in empathy, a greater identification with parents, deepened emotional intensity, and changes in boundaries that tended toward greater self-disclosure

80 with clients. Some individuals revealed that their personal childhood experiences and relationships with their mothers exerted a strong influence on their desires to “parent differently.” Several dealt with high self-expectations and perfectionism in their role as parent. A distinctive problem was the way in which professional jargon and images of specific types of attunement failures, such as shown in the Still Face Experiment (Tronick, 2007), could arise as specific guilt-inducing ideations, especially when there was a conflict between the needs of the mother and the child.

The following five major categories emerged from the interviews and are described below under the headings Becoming a Clinician; Being a Clinician: Impact on Motherhood; Being a Mother: Impact on the Clinician; Mother Blame, and Unique Issues. Unique Issues is so labeled because each of its three sub-categories describes a topic that was specific to a particular participant and was not mentioned by other interviewees.

Becoming a Clinician Becoming a clinician requires advanced degrees and additional post-graduate training, no matter the initial degree or license. Participants’ choice to become a psychotherapist came from four intertwining experiences: the impact of their own personal psychotherapy, an affinity for relating to others, a general interest in psychology, and a desire to help others derived from their own childhood traumas and difficulties.

Regarding personal psychotherapy, Lisa said, “I started my first therapy experience and I got to rethink about what I wanted for my life, and the therapist said,

81 ‘You’re very empathic and you’re very compassionate. You should be a therapist.”

Similarly, Fran was inspired to become a clinical social worker based on her fondness for her own psychotherapist. She disclosed that, “I think the therapist I was seeing was like a mother figure . . . she was just so gentle and nurturing.”

The second factor related to becoming a clinician involves the individual’s interest in and desire to interact with others. Unlike Lisa and Fran, Lucy came to her choice, “having never even been in therapy.” Lucy illustrated this second factor stating, “I was always someone that was around people . . . I enjoyed knowing about people and people confiding in me, so I became a psychology major and somewhere along the way I decided I wanted to be a therapist . . .”

Some participants envisioned themselves working with children or adults prior to becoming a clinician. Taylor said, “So I knew, I think, for a long time, I wanted to be a psychologist . . .” and after Ava discovered how much she enjoyed working closely with children, she risked her parents’ disapproval regarding the career they had envisioned for her and chose to become a child therapist.

The clinician’s childhood came up spontaneously in several of the interviews, though it was not a topic of my interview guide. Childhood experiences of trauma or difficulty influenced several of the participants choice of profession. In this regard, Tonya described her motivation for becoming a child therapist, stating, I had a mother who couldn’t attend to me at all. There was a lot of physical deprivation. She also had a lot of cognitive problems and a lot of psychological problems and probably her own trauma. I became a child therapist to sublimate, to

82 understand, to heal. When I work with others, I’m healing myself. I think that’s one of the gifts parenting can give . . .

Lisa also had a difficult childhood. She and her brother were abused by her mother, i.e. “there was a lot of hitting and screaming.” In the aftermath of these experiences she eventually became empowered, concluding that, “It’s been a healing process for me to become a therapist . . . I know that I can heal people from things that I have healed myself.”

Tonya raised another point regarding the impact of the therapist’s childhood on her choice of profession. Based on her own healing experience as a formerly abused and neglected child, she thought it was important to assist women in stopping the cycle of abuse. She was critical of the common association that is often made between having suffered abuse as a child and becoming an abuser. From the vantage point of her own experience she concluded that, I think there are many women who have been traumatized physically, emotionally, who have been neglected, sexually traumatized that have no interest in harming their children and with the right kind of help and support can become wonderful mothers. And I am one of them.

Whether the participant was originally attracted to the field of mental health or not, the choice to become a psychotherapist was influenced by their exposure to a positive role model in their own personal psychotherapy. In addition, their experience of and recovery from traumatic or fraught relationships in their families of origin motivated them to choose a profession in which they could help others.

83 Being a Clinician: Impact on Motherhood This category encompasses the participants’ perceptions of the impact of their education, training, and practice on their thinking, feeling, and behaving as mothers. One of the notable findings of this study is the paradoxical effect of the participants’ professional background on the maternal role, as summed up by Taylor who declared that being a clinician-mother “is a blessing and a curse.” Blessings are those aspects of being a clinician that are seen as most beneficial to the maternal role and curses are the unintended consequences of being a clinician that involve having “too much knowledge” and thus contributing to self-doubt, insecurity, and worry. Blessings and curses are represented by the following sub-categories: Knowledge, Attunement and Repair, Exposure to Problems, Exposure to theory, Occupational Hazards, and Expectations.

Knowledge.

Knowledge is defined by the online Oxford Dictionary as, “facts, information, and skills acquired through education or experience.” Knowledge was cited several times by the participants as an important benefit of their clinical background and training. Those who came to motherhood with a background in developmental theory or by working with families and children, perceived, at least initially, that they held an advantage over nonclinician mothers in their ability to contextualize their child’s behavior and respond appropriately. But knowledge can have a two-sided nature, functioning both as a blessing and a curse.

Ella referred to the self-assurance in her maternal skills that she derived from her professional knowledge, while also hinting at the anxiety this raised. She declared that,

84 I had a lot of theoretical knowledge going into trying to become a parent. You know I had training in positive discipline, in parenting theory, and I had worked for a long time on helping parents to parent. So, I was simultaneously confident in that I knew what I was doing for the most part, and terrified that even though I can say I know this theoretically is good, will it actually work for my kid, and will I be consistent?

Taylor described the impact of her professional background as follows: I feel like I just have this wealth of knowledge and awareness and information and understanding that most people don't have. Coming from all my training and my professional work, and I just . . . see hundreds of families and all the different scenarios and what works and what doesn't, so I know so much. Both . . . intellectually from training, and experientially and clinically. I hope [it] helps me to be a better mom and informs me and I also find that it torments me and it’s gotten in the way I think, if I’m totally and brutally honest.

When I inquired of Taylor how being a clinician has “gotten in the way” she responded, “It’s like I know too much . . . it’s just made it difficult sometimes to just be a mom.”

For Jen, being a therapist had the following positive impact on her experience as a mother.

I think it’s helpful to have an understanding of developmentally where she’s [her daughter] at and adjusting my expectations accordingly . . . and not personalizing some things that maybe sting or hurt in the moment and remembering that this is

85 really normal . . . I think that’s what’s good about being a therapist . . . I think I’ve done a good job honoring her [daughter’s] feelings.

Both Tonya and Lisa mentioned the positive impact of being a clinician on their experience of motherhood. Tonya spoke about the pragmatic effects saying, “I think I was more prepared when it came to having a baby about what stages to be aware of and what to look for, and what would be typical or what would be atypical.” Lisa summarized her experience as a mother, stating that, “I think that being a therapist has been a blessing and it has saved me.” Moreover, she believed that her background as a clinician allowed her “to be more of the mom that I want to be.” She ascribed this achievement to her training as a sensorimotor therapist saying, “So this modality has given me a framework of how to be, not just as a therapist, but also as a mom, so I’m really grateful for that.”

In contrast to the positive effects of having a professional background as a clinician, Fran felt that her knowledge should have made childrearing easier. She reflected that, I thought it would be a little easier because I was educated or I’ve worked with children, I’ve worked with family, so I didn’t realize there’s a lot of stuff you can’t control . . . I thought, ‘Oh I love kids and it’ll be great’ and . . . how much I studied child development . . . so I know a lot, so that should help me. That should make it easier, but it doesn’t.

When asked about the impact of being a therapist on motherhood, Lucy shared that, I think before my first was born I imagined [being a clinician] would be helpful, and maybe it is . . . but in the throes of infanthood it was not helpful because I was

86 panicked . . . I had too much information, I was really afraid that I was doing it wrong.

A different concern expressed by Jen was a tendency toward overconfidence or “cockiness” that she attributed to her background as a clinician. Regarding sensitive issues like drugs or sex, she questioned whether she had a false sense of security because she had, “talked about all of these things and explored all of these things” with her daughter. Being a therapist also shaped her dystopian view that the world was “a monstrous place” which she attributed to working with a particularly troubled population.

Her outlook was reinforced by “the just really catastrophic choices that I’ve seen some of these adolescents and children go through.”

Attunement and repair.

The term attunement emerged from this study as a word used by some participants to describe a deep or concentrated focus on a feeling, condition, or need, and the ability to effectively address it. The term is associated with several contemporary models of psychotherapy and can be defined as, “the ability to see, hear, sense, interpret and respond to the client’s verbal and nonverbal cues in a way that communicated to the client that he/she was genuinely seen, felt, and understood” (Wylie & Turner, n. d.). It may also be thought of as a process of feeling one’s way into the psycho-emotional state of a client or a child. If the psychotherapist or mother is attuned, repairs can be made to remedy misattuned or dysregulating interactions. These repairs can be restorative or regulating not only to the client or child, but also to the clinician or mother. Repairs are the catalysts for healing. The act of repair helps to mediate conflicts between therapist

87 and client, mother and child. The concepts of attunement, repair, and healing recur in several of the participant interviews Tonya considered her education and experience with children as factors that “deepen” her attunement as both a clinician and a mother. Because of her professional background she was able to identify a developmental delay in her son that had been missed by her pediatrician. She asserted that, “My attunement to that [delay] and my awareness really helped me in serving my son.”

Several participants spoke about their faith in the powerful act of repair to mend grievances or hurts. Lisa said, There’s no faster and better healing that happens when you as a mom healed your son directly or your daughter . . . right? It’s better than being years in therapy . . .

I mess up and everybody messes up and everybody will mess up, and yes, we do have a big effect on our kids, but that is also very reparative. You can do that no matter how old they are, and the quicker you do it the better.

The following two quotes are also about attunement and repair, but their impact extends to the participants’ roles as clinicians and mothers. Ella spoke about the kind of repair she employs as a mother and in her work with clients saying: The . . . thing that I think is really important is the repair, it’s much more important than any conflict that happens. You know, especially when I work with moms who have older kids who when they yell at their kids there’s this incredible

88 guilt and this shame. So, we work on how you repair this with your kid, because you’re human, you’re gonna lose your temper.

Ava described the way in which she applied her clinical skills to her practice, but also to her own children, observing that, there’s [sic] so many parts to my understanding of kids that kind of translates to how I understand my kids. . . . So the way in which I work with kids is trying to get a sense of just sort of what they are like, their strengths, their weaknesses, and how we can really shore up their strengths, how we can manage the areas that are weak or the areas that they need help in. So, I feel like I do the same thing with my kids.

Occupational Hazards Being a clinician is a unique role in which one is exposed to a variety of stress inducing situations, sometimes life threatening, as well as to difficult feelings that require the support of ongoing training, education, supervision, consultation or one’s own personal psychotherapy. While psychotherapists may rely on the such supports, dealing with the impact of exposure to client difficulties does not end with a degree, a license or certificate, but is an ongoing process that can become more complicated when the clinician becomes a mother. The types of occupational hazards raised by participants consisted of the following subcategories: •

Exposure to Problems,

•

Exposure to Theory,

•

Expectations and Perfectionism.

89

Exposure to problems.

For several participants becoming a mother increased their vulnerability to anxieties about potential hazards, both emotional and physical, that could affect their children. They viewed this as a result of their exposure to the kinds of problems that they witnessed in their professional capacities. According to Fran, “being more aware of what could happen . . . causes anxiety about what could happen.” Similarly, Taylor made the observation that: I see hundreds of families and all the different scenarios and what works and what doesn’t. I also find that it torments me and it’s gotten in the way . . . I just feel like a lot of times I know too much . . . it’s just made it difficult sometimes to just be a mom.

Sometimes these fears are very specific. For Jen, working with sexually abused children had a strong impact on how she saw the world. “I went through this feeling like the world was a monstrous place. I would have to keep re-centering myself.” She continued, “I was always afraid to have a boyfriend, because of all the children that are molested that I have worked with. So, I think I maybe worry more being a therapist.”

Lucy described the unintended negative consequences of her exposure to client problems saying: I think I was hyper-vigilant and hyper-aware of all the ways in which I could screw him [her son] up. I worked in a program with actively borderline people where there was a lot about “goodness of fit” and invalidating environments that

90 create horrendous outcomes . . . so, I do feel very afraid that I’m accidentally invalidating . . . that it’s not a goodness of fit. I’m still worrying about that.

Lisa, who was a mother prior to becoming a psychotherapist, ended up second guessing herself in the maternal role as she became educated in the profession. This occupational hazard is similar to reading a medical text and imagining that one has the illness described therein. As Lisa studied attachment theory, she became concerned about her connection with her children saying, “Oh my goodness, I think I’m one of those moms that cannot fully connect. I must be messing [sic] my kids wrong.” Despite this difficulty, Lisa went on to say that being a therapist was also helpful, commenting that, “It was hard for me . . . getting the education, but it also helped me be more aware as a mom.”

Exposure to theory.

I found that participants were exposed to a wide variety of theories in their education and training with varied emphases from psychoanalytic to cognitivebehavioral. Clinician/mothers also had differing responses regarding the importance of theory in their professional and personal lives. Theories had a paradoxical influence, i.e. they could be helpful and provide guidance to mothers in their interactions with their children or they might also exert a negative influence that diminished maternal selfesteem.

One example of a negative effect originates in the phrase, “goodness of fit,” derived from attachment theory. This term echoed painfully in Lucy’s mind as a guiltinducing reproach that was produced as she struggled with her reactions to a difficult-to-

91 soothe child. Another participant, Ella, found herself in a negative echo chamber the first night she came home with her newborn, after a high-risk pregnancy that was preceded by four miscarriages and a lengthy hospitalization. She shared the stress of that night: She [her newborn daughter] was finally home in the bassinet and she was fussing, and I was so tired, and I was sleeping. All I could think about, ‘cause I just wanted to sleep . . . was the Still Face Experiment and how I didn’t want her to be affected by that. So, it was one of those things where too much information was fueling some of my anxiety . . . I didn’t want her to have an insecure attachment [because] I wasn’t coming to get her when she was fussing.

The clinician/mother, sensitized by her training to the identification of dysfunctional traits and dynamics, often worries about finding these dynamics in herself.

The following example demonstrates how Tonya’s knowledge of attachment theory contributed to increased anxiety regarding her bond with her child. She said, I really cared a lot about attachment, so I was really paying attention to the things that were important to me, like nursing and bonding . . . I think I felt an enormous amount of pressure and probably still do to not cause any damage.

Similarly, Lucy mentioned Erikson’s Trust versus Mistrust phase (1950,1993), declaring, I had too much information. I was really afraid that I was doing it wrong, that there was a right way that I didn’t know . . . I think before my first was born I imagined it [being a therapist] would be helpful, and maybe it is . . . but in the throes of infanthood it was not helpful because I was panicked. Trust versus mistrust, my baby’s crying and I don’t know how to soothe her . . .

92 Lucy’s use of the phrase “trust versus mistrust” is an indication of how terminology, rather than the lived process described by Erikson, can be internalized by the clinician/mother as a standard against which she critically measures herself.

The concern with doing no harm or fear of causing damage was repeated in several of the interviews. This apprehension was also expressed by Lisa, the only participant who became a clinician after motherhood. She declared that, When I started reading about the effects that moms have on kids and all of that, I would say, “Oh my God,” I’m still doing everything wrong.” And so, it was really hard for me as a mom to become trained as a clinician, because I was reading everything, how I could affect my kids and everything that I had already done wrong.

Not all responses to being exposed to theory were negative. As previously described in the Knowledge subcategory, participants expressed a general appreciation for those aspects of their professional backgrounds that gave them an understanding of phases of development and guidance regarding emotion and behavior. For instance, after being exposed to and rejecting several modalities, Lisa chose to practice a somatic form of treatment and remarked that, “this modality has given me a framework of how to be, not just as a therapist but also as a mom.”

In response to my query about what is helpful about being a clinician, Ella referred to attachment theory and responded that, I think having a theoretical base that I want to be following . . . It helps me frame the way that I want to talk to her [daughter]. So instead of just saying no, don’t do

93 that, it’s correcting her and saying what I do want her to do . . . I don’t know if I would have known to do that without the knowledge that I had previously.

Expectations and perfectionism.

This sub-category deals with the clinician/mother’s self-appraisal in the performance of her maternal role. Concomitant with being a professional who has indepth knowledge of child development and expertise helping people, is the implicit assumption that clinician/mothers should be exemplary parents, and as such, able to raise model children. It was therefore surprising to some participants that they experienced a disconnect between their professional selves and the actual practice of parenting. In the following example, Fran illustrated this schism which she attributed to unconscious processes: I thought it would be a little easier because I was educated, or I’ve worked with children. I’ve worked with families, so there’s a lot of stuff that you can’t control . . . Stuff comes up from my childhood . . . so that affects the kids and it’s all unconscious and . . . I didn’t think that would happen.

Taylor recalled thinking about how she would balance motherhood and career recalling that, I had this . . . almost sort of fantasy about, oh we would commute and then he’d come home with me, but the reality is I was bringing a little baby home in the evening at night and it was late, and you know he was just downstairs [at daycare] and so I was thinking about him all the time and going down and nursing which

94 again, in the fantasy version was wonderful, but . . . I think, it was hard in some ways.

Lucy also had the expectation that being a therapist would be helpful, but found that, “I was unequipped for some reason, I couldn’t access my own instincts or if I did, I discounted them as wrong.”

In addition to the clinician/mother’s own expectations, participants mentioned the influence of society in general on the standards to which mothers are held. Regarding social pressures Jen said, There is a sense, I think, that women somehow can have this endless bunch of internal resources and energy and put everyone else’s needs before anything that they might need . . . I think men get excused for a lot of behavior that’s not tolerated in women.

Tonya also believed that the emphasis on being a good mother is partially rooted in society’s expectations. She asserted that, “I think in general women have a lot of pressure to be good mothers . . . you know, societal expectations . . . a lot of things about doing it right.” The phrase, “doing it right,” hints at the concern clinician-mothers have about not meeting social standards as well as the precepts of their own profession when it comes to parenting.

In order to “do it right,” Tonya rises at 5:30 AM to make breakfast and watch half a television show with her son. She does not do evening appointments and tries not to over- schedule activities, while still carving out time for herself. She is also a writer and devotes a specific time to her writing on a weekly basis. All of this is in addition to a fulltime psychotherapy practice. When I mentioned that it sounded like she needed more

95 than a 24-hour day, the themes of exhaustion and perfectionism emerged. Tonya was trying to do everything to the best of her ability or in her words, “I’m just overcommitted to the idea of being a really good mother.” When I asked her what she meant by “overcommitted,” she responded, “Well you know, not letting myself off the hook if I mess something up . . .”

These apprehensions are amplified by the trait of perfectionism, in which high goals can often lead to self-deprecation. Participants who mentioned perfectionistic strivings held themselves personally accountable for those traits or at the very least questioned their personal accountability. They also remarked about the kinds of external influences, such as social media, that were potential contributing factors, in addition to particular psychotherapy models and exposure to client problems. For instance, Fran stated, “I resented the pervasive messaging of needing to be perfect, selfless, responding to every need. Social media, it’s a real problem, this kind of curated lifestyle that we’re all privy to.” Ella acknowledged herself as, “very much a perfectionist. I’m very hard on myself. I expect a lot out of myself and those around me.” She further questioned herself wondering, “What would it be like if I wasn’t happy with something that I had done as a parent, would I be able to sit with that?” In a similar vein, Lisa, spoke about becoming self-critical when clinical reading material and wondered about her own perfectionistic tendencies, observing that, Even now when I read something psychodynamic or anything, I think, “Oh my goodness, this is where these beliefs are coming from. I was not there enough for my kids” . . . You know, it has to do with my own perfectionism, maybe.

96 When it came to mothering, Tonya held herself personally accountable for being perfectionistic saying. “Well, I may be overdoing it . . . certainly perfectionism would be one of my traits,” while Lucy reacted to expectations she believed were unfairly placed on women saying, “You know, I think that there’s a double standard, the expectation of the mom being omnipotent and perfect, perfect life, perfect mother, perfect employee, house is perfect. I think that is pervasive.”

Being a Mother: Impact on the Clinician This category looks at the way motherhood changes the clinician in terms of her clinical practice and self-appraisal in the performance of her maternal role. Clinicianmothers take motherhood seriously. They think about the deleterious effects of poor parenting, either witnessed in their practices or experienced in their personal lives and make strenuous efforts to avoid causing harm to their offspring. Participants also worry about being unaware of the ways in which they might unintentionally cause harm. Some regard themselves as perfectionistic, a trait that exemplifies the high expectations they place on themselves as psychotherapists and mothers.

For the purposes of this study, the multidimensional experience of being a mother has been divided into the following sub-categories: •

Work-life Balance,

•

Boundaries,

•

Growth and Development,

97 Work-life balance.

Work-life balance is a commonly identified challenge for many working mothers and is also a reality for the clinician/mother. Though work-life balance can be conceived of as an attainable ideal, it is more realistically viewed as a dynamic process that requires frequent retooling. Work-life balance contains within it the implication that its two elements can be manipulated to achieve a type of equilibrium that maximizes both personal satisfaction and professional fulfillment. While this may be desirable, it is a goal that presents with numerous dilemmas.

There are universal aspects of work-life balance as well as specific factors that apply to clinician/mothers. Universal problems cluster around time management, the complexities of running a household, maintaining a career, and finding time to spend with children, a partner or even one’s self. Recovery from childbirth varies among women, but the resulting physical changes, lack of sleep, and fatigue plague most new mothers.

Like many mothers, the clinician/mother experiences the lack of time and energy to spend with her own children as a major concern in negotiating the challenges of family and career. Referring to this universal dilemma, Ava remarked, I would feel guilty about not having enough quality time with my kids at home . . . I’m always trying to do something; it’s the laundry or it’s cooking or cleaning . . . I’m not sitting and devoting a full hour [to them], at least a full hour, and then I would feel guilty about that.

While “quality time” with the children versus “getting things done” illustrates one aspect of the many conflicts that arise, another area of struggle concerns the ability to

98 serve as both a resource to one’s children and to one’s clients. Who then gets the “best version” of the clinician-mother, her clients or her children? Both types of relationships depend on some of the same qualities being available to each. What kinds of feelings does this raise for the clinician-mother and how does she handle them? In this regard, Jen articulated her disappointment at having to return to work before she was ready: The hardest part has most definitely been the resource of time. One of my life’s biggest regrets is that I had to go back to work fulltime very early . . . she [her daughter] was about seven months old . . . I feel like the person who means the most to me gets the most exhausted, depleted, unfun version of me.

She continued, I’m just really tired and by the end of the day craving something nurturing . . . I’m always longing for this feeling that everything’s done . . . Now, now is the time to relax and just enjoy being together, but there’s usually not any time left.

While Jen expressed worry about shortchanging her daughter and the lack of quality time, Ella shared her apprehension about shortchanging her clients due to interferences from her responsibilities as a mother stating, I want to be that predictable, reliable person in their [clients’] lives and to provide that safe place where they know what they’re walking into. Having my daughter makes it where there’s that element of uncertainty.

This element of uncertainty is the tension Ella felt when she anticipated her daughter getting sick. She expressed this apprehension saying, “I think one of the hardest parts about being a parent on my practice is the constant fear that she’s gonna get sick and I’m gonna have to stay home and cancel my clients.” Despite this strain, Ella found

99 that both roles were very rewarding in that, “These are the two really rich parts of my life right now, my work and my motherhood, and I love everything about those two things. I wouldn’t want to give up either.”

While most clinician-mothers felt they didn’t get enough time at home with their children, others had a different experience. For Fran, being an “at home” mother didn’t satisfy her in the way she imagined it would. She reflected that, “Staying home with them was harder than going to work for me. I went back to work and I thought, ‘Oh wow, there’s adults here I can talk to’ . . .” Fran felt that she was able to adjust and return to work because she received support from peers who were also returning to work after having children. She did so with some reservations, questioning the impact of her choice on her children. She wondered, “How was that affecting them and what did I think about [it]? A little bit about my bonding with them and what would happen . . . am I still their mother?

Boundaries.

The term boundaries refers to the implicit or explicit constraints that determine what can take place in the therapeutic relationship. There are three features of boundaries relevant to the practice of psychotherapy. First are the pragmatic arrangements, such as time and place, under which the therapy is to be conducted, as well as billing arrangements, cancellation policies, and the like. Second, there are the aspects of boundaries that comprise the ethical framework for the conduct and interaction of the professional vis a vis the client. This would include restrictions regarding the types of personal information a psychotherapist may disclose to a client or provisions against dual

100 relationships. The third facet concerns the clinician’s ability to adaptively self-regulate in the face of provocations or disturbances, i.e. the permeability or impermeability of the therapist’s personal boundaries. This was the aspect that I was most interested in exploring.

Because psychotherapists have responsibilities for maintaining a highly specialized relationship with a person or persons rather than a project or material type of work, an especially sensitive management of boundaries is required. Though absences can create disruptions in any type of work, a clinician’s absence or loss of focus due to her maternal responsibilities has meaning for both the client and the psychotherapist that can influence the therapeutic environment, alter the narrative of psychotherapy, and the equilibrium of both therapist and client. Consequently, with motherhood there may be some unavoidable effects or even ruptures in the therapist-client bond. Crises and emergencies may arise in either the home or at work that are particularly draining physically and emotionally and that require more time than traditional nine-to-five working hours.

Psychotherapists of all types are generally cautious about boundaries. This is especially true coming from the influence of psychoanalytic/psychodynamic thinking in which proper boundaries establish a secure, stable and safe clinical space and maintain the clinician’s neutrality. Ideas about therapist neutrality have evolved with a notable shift to cautious acknowledgment of the therapist’s actual presence and characteristics.

These are recognized as having an impact on the client and the client-clinician relationship. This may involve a more relaxed attitude about self-disclosure on the part of the therapist when it is seen as beneficial to the client. Motherhood, for the clinicians in

101 this study, often had the effect of changing their willingness to self-disclose, particularly when it comes to parenting issues. A veil is lifted, and a more practical way of thinking elicits a shift toward concrete support rather than symbolic meaning-making and interpretation. This speaks to a recognition on the part of psychotherapists that their clients are already so anxious about their parenting, that concrete examples or a revealing personal story related by the therapist can be more helpful than the stereotypical exploration of the client’s anxiety.

Lucy noticed that prior to having children the boundaries between work and personal life were blurred. She noticed a shift in her boundaries post-partum. As she recalled, I used to bring a lot home with me emotionally, worrying about people, thinking about caseload, cases, things I had done, things I had to do, just work overall. I had dreams about clients, weird, you know, all that weird stuff. [My] perspective is different. I’m not all things to my clients. I have a family that needs me and that I need. I feel like . . . when I leave work, work is done.

For Fran, motherhood also created a better boundary between her personal and working life. She explained that, My kids have tested me, and the experiences that I’ve had have just made me a stronger person overall to where things that I think earlier in my career that have bothered me or things people have said . . . yes I have my work and I have my job and I’m here to take care of and help people, but there’s just that boundary of, yes, but I have this other job [motherhood]. . . it’s just different being a mother versus not being a mother.

102 Boundaries can shift over time, especially as the therapist progresses through the lifecycle. For some clinician/mothers, self-disclosure seems to be more restricted prior to having children. Therapists who might never or rarely share a personal anecdote with a client, found that sharing some of their own maternal experiences can be helpful. Ella offered the following observation: I think I was more guarded with personal experiences with clients before having my daughter . . . So, with new moms that I work with I think sometimes I’ll tell them anecdotes of things that have happened to me to normalize their experience or to connect with them.

Another issue involving boundaries was shared by Taylor, who spoke about the dilemma of seeing child clients who are the same age as her own children. She remarked: I think it’s sort of a boundary issue in both directions. I think I wouldn’t want my experience as a mom going through something with my child to bias my work with kids at work in any way. . . I think the bigger concern is more what’s happening with me as a mom influencing my work with my client . . . that somehow it would make me less objective . . .

Growth and Development While the study of human development is often centered on the earliest years of life, the process of maturation can also be understood as a continuous progression extending into the farthest reaches of adulthood. Consequently, it is not surprising that parenthood is a phase of adult development that offers a myriad of opportunities for learning and growth. One of the primary effects of being a mother found in this study is

103 its impact on the personal and professional growth and development of the individual.

The impact of this growth and development is manifest in the acquisition of the following attributes: an increased sense of competence and confidence, increased identification with and empathy for parents, and an increased range and depth of feeling. Sub-categories include Strengths Gained and Shifts in Thinking and Feeling.

Strengths gained.

This sub-category describes several of the positive changes that result when clinicians become mothers. These transformations are a consequence of the participants contending with the various challenges that motherhood poses. “Strengths Gained” encompasses the acquisition of or fortifying of personal qualities, the resulting constructive changes in self-perception, and a greater sense of agency in navigating personal and professional relationships.

The maternal role can alter the multiple ways a woman may experience herself as an individual and a clinician. In Fran’s case, she noted that motherhood infused her with a sense of “confidence” and “mental toughness.” She described herself using the word “stronger” several times during the interview. Fran defined strength in terms of the fortification between her personal and professional boundaries, stating that it meant, “having a thicker skin . . . not taking things as personally.” She also asserted that, “[being a mother] has given me the strength to understand somebody better.”

Ella appreciated the increase in her professional self-esteem that she attributed to her experiences as a mother. This gave her a sense of legitimacy that was lacking in some of her work with parents. She shared that, “I had some bad experiences, well, with

104 one family very much cutting me down and my expertise down because I didn’t have children. I was looking forward to putting that behind me and having some . . . authority.” “Real lived experience” proved a worthy addition to her theoretical knowledge. Moreover, her personal experience with multiple pregnancies and losses motivated Ella to develop a specialty in pregnancy-related trauma, further enhancing her clinical skills.

Another aspect of strength is embodied by Lucy, who reported that she gained the confidence to be more self-directed when she became a mother for the second time. She observed that, Sometime after my second was born I was much better able to decide I could be my own mom; I didn’t have to be like my mom was, I didn’t have to be like my friends or social media where everyone only shows the good side.

This reflection indicates how Lucy has grown through motherhood in her ability to attune to herself in a more accepting way, rather than allowing herself to be negatively affected by others.

Tonya offered a poignant observation regarding her personal growth that she attributed to working through the struggles she experienced in becoming a mother. She shared that, I was able to re-parent in a way in which I hadn’t been parented . . . to see that I could respond and meet the need or correct failures, you know, on my part, and understand them and to see the benefit and the growth has been really rewarding.

The “benefit and growth” she mentioned related to her personal evolution as a clinician and a mother, as well as to the development of her child. Being a mother, going

105 through trauma and everyday difficulties, has resulted in her ability to be more present with clients. Tonya identified with the vulnerability parents feel when they are bringing their child for therapy. She spoke to the idea of the idealized parent and the therapists who think that “there’s a perfect parent out there somewhere and that parents are only good parents when . . . they have their whole lives together.” She concluded that this was a myth, saying, “And that’s just not true.”

Tonya demonstrated further gains in response to the significant life challenges posed by being a clinician/mother. She shared how she used those experiences to arrive at the following outlook: My own sorrows provide an opportunity. As I continue to appreciate myself and my own struggles without expecting them to be different [from her clients], I see how much that enriches my presence and availability. Because I think what my office really needs to be, is it needs to be a place where people can come who feel broken.

Shifts in thinking and feeling.

There are several noteworthy shifts in thinking and feeling that take place when a clinician becomes a mother. This sub-category reflects the reciprocal or overlapping relationship between thoughts and affects and details the most frequently reported effects.

On the positive side these are a deepening of emotion, an increase in empathy, an appreciation for the complexity of human behavior, and increased vulnerability. Being a mother also introduces the individual, regardless of profession, to new worries. More troubling feelings such as guilt and a sense of inadequacy are also part of the changes that

106 participants described. For the clinician/ mother there is an added burden because of her theoretical and direct knowledge of what can go wrong in childrearing. The consequences of these changes can feel profound.

Although Ava was trained in psychoanalytic and psychodynamic modalities, becoming a mother modified her approach to psychotherapy. First, she acknowledged that she had become more pragmatic saying, “I bring that [pragmatics] in quite a bit when I work with parents,” and added that, “I probably wouldn’t think about that if I weren’t a mom.” She also noted that, “humor is a large part of how I work with kids and with parents.” She made two further observations revealing shifts in thinking and feeling, stating, “I think I’m much more flexible” and “I’m much more understanding and empathic.”

Jen revealed how being a mother affected her countertransference with clients “who are complaining a lot about their mother.”

Sometimes I worked with a couple of clients who said, “Well, my mother was never there. She was always at work and she then went to school . . . so she can get a better job.” And I, and in my mind I’m thinking, “Gee, that must of have been super fun for her. Obviously she was doing that because your dad was a deadbeat and she was feeding you and keeping you alive!”

Certain emotions, especially those related to a sense of love or feeling of care for children, are experienced with an intensity not previously felt. This strength of emotion is often unanticipated and can take the clinician mother by surprise. Ava expressed the intensity of emotion that arose from being a mother noting that, “When I had my first son, I was just obsessed with him . . . I think my whole life I just wanted to be a mom.”

107 In Jen’s case, prior to giving birth to her daughter, she had already experienced a new depth of feeling when her nephew was born. She said, “It kind of broke my heart open . . . I don’t think I had known that a love like that could exist.” To feel so deeply, even about someone else’s child, was a surprise and a precursor to another significant change in Jen’s thinking and feeling.

Preceding her own motherhood, Jen entertained thoughts about the difficulty that she might have sharing limited resources with a child. She was therefore unable to predict the sense of generosity and joy that she would feel toward her own baby. Jen noted that, I used to think these really self-centered thoughts like, “Wow, if I only had $50 left at the end of the week and then I have to buy all these kid things, I won’t ever be able to take care of myself.” And then when I had a child, I was like, you just don’t care, you just want this child to have all their needs met . . . if anything I’m in danger of over-indulging my daughter because it brings me so much joy.

This feeling of joy, representative of deepened emotion, also stood out in Ella’s interview when she described picking up her toddler after work: And when I go to pick her up at daycare, it is just that moment, and people remark on this all the time, what that moment is between us where she is like, her entire body is like, vibrating with excitement. And she comes, now she, she's crawling, she comes barreling over, and she shrieks, and is so ex[cited] and to me that is just with all of my attachment knowledge, it just, it is just the best feeling in the whole world.

Taylor also acknowledged that being a mother had a significant impact on her clinical work, particularly in relation to empathy. She commented that:

108 For me personally it’s made a huge, huge difference in terms of my empathy, my ability to truly understand what parents are going through, what kids go though at every developmental stage . . . Now I have teenagers and I see teenagers differently and I see parents of teen differently. I think I am much, much less judgmental . . .

Tonya exemplified the maturity in thinking that the maternal role can marshal in the following reflection: I think my day to day struggles, like everybody else, limits and boundaries and figuring things out . . . my own troubles in my own life, it’s really helped me to continue to see that the depth of who I am and the depth of who people are is not really about their trouble—it doesn’t define them.

Along with the deep, rich, and positive feelings that motherhood can bring, there are other less pleasant emotions that are evoked. Motherhood also introduces the clinician to greater anxiety in the form of worries about her offspring and guilt regarding her performance in the maternal role. This is an added burden for the psychotherapist, who, because of her theoretical and direct knowledge of what can go wrong in childrearing, holds herself to a very high standard. Referring to her professional role, Tonya remarked, “a lot of it allowed me to create a good environment . . . but it also made me feel under a lot of pressure that perhaps not the average mother brings into her parenting.”

Ava expressed feelings of guilt in response to changes in her work-life balance remarking that,

109 I would feel guilty about not having enough quality time with kids at home . . . I have these patients who I spend a full hour with . . . where they have my undivided attention . . . At home I’m always trying to do something; it’s the laundry or it’s cooking or cleaning . . .

Furthermore, Ava also experienced guilt when she failed to provide a resource for her children. She worried that, “If I missed something or I didn’t have something already there, available, then I would feel guilty about that.”

Guilt is also present for Jen, who worried about the impact of her divorce on her daughter, relating that, I was very aware that my mother was really unhappy and my father always seemed angry, so I had this fantasy of how incredibly different my own family life was going to be. And then here I have a very unhappy and brief marriage and get divorced very early on. . .

She somberly added, “I feel very sad she [her daughter] did not get to grow up in an attached nuclear family . . . so I wonder all the time what kind of impact that will have.”

Another shift involves the participants’ expanded recognition and acceptance of complexity in human behavior, specifically that which is related to family dynamics. This was made evident in the repeated comments by participants regarding their increased capacity for empathizing with parents, even those who may act inappropriately. For example, when dealing with parental anger Fran explained, I can understand sort of the frustration that people have . . .not that it’s okay to ever hurt your children, but I can understand sort of that there is that frustration

110 and you just have to figure out how to cope with that frustration. I can sympathize more . . . it’s [being a mother] given me strength to understand somebody better.

In the following comment Lucy indicates that since becoming a mother she is more able to consider the factors contributing to abusive parenting stating that, I also remember after becoming a mom having more empathy for this idea of child abuse. It’s not that far-fetched to see how someone can’t take it anymore . . .

There’s so much more gray than we would like to believe.

Tonya revealed that her perspective had changed regarding parenting when she spoke to the idea that, “there’s a perfect parent out there somewhere and that parents are only good parents when . . . they have their whole lives together. And that’s just not true.”

Similarly, Jen observed, It’s been very helpful working with parents. Having a child makes me do better at family therapy work. I think I can have additional compassion for parents in family work now and have a better understanding of their fears and worries when their child is engaging in destructive behavior.

Another example of an unexpected change in emotion is experienced by Lucy in the form of greater vulnerability. Despite her previous involvement in making child protective service reports, she recalls this surprising instance after returning from maternity leave saying, “I can remember the first child abuse case I was involved in after my kids were born and [I was] needing to excuse myself to cry, which had never happened to me before.”

111 When it came to appreciating and working with parents, Fran thought that her maternal experience offered her something more than her clinical education and training.

For example, when dealing with parental anger she shared that she can “understand” how frustrating childrearing can be and that her own maternal experience has increased her ability to better comprehend parental feelings.

Along with a preponderance of increased empathy for parents and recognition of complexity, the experience of motherhood can occasionally lead to stronger feelings of criticism toward parents. To illustrate, Jen disclosed that, I also think I maybe expect a little more than that too in a way. I certainly worked with people whose needs came way before their child’s and I guess since becoming a parent and seeing what an incredibly powerful position it is, I guess I don’t have as much tolerance for that. You can do so much damage.

This response was rarely expressed in any other interviews and did not fully represent Jen’s thoughts on the subject. At times she also experienced a greater identification with the mothers saying, “Sometimes I have some counter-transference when I’m working with a client who is complaining a lot about their mother.” The countertransference in this instance signifies Jen’s identification with the mother.

Tonya spoke to the depth of feeling and profound shifts that come from the experience of motherhood. She commented that, “I feel like I have this presence I would have never had, had I not become a mother.” Her presence combined with “a tremendous amount of empathy” has led Tonya to a greater understanding of the complexities involved in being a parent. This includes her recognition of the vulnerability of parents in seeking help and a shift from the belief she held prior to becoming a mother, namely that,

112 “I had this very false idea that parents were solely responsible for all of their children’s successes or failures.” Tonya as well as other mother/clinicians in this study appear to have an enhanced recognition of the complexity of family dynamics, which they applied to themselves as well as to their clients.

Mother-Blame Mother-blame is the tendency toward a singular focus on the negative maternal contributions to child development and/or psychopathology. It is an unacknowledged mindset that restricts the conversation about human behavior and emotion to the mother’s influence alone. Addressing this bias is not intended to minimize the mother’s contributions, but to recognize that this focus is not simply a matter of mothers as the dominant figures in childrearing, but is also a reflection of the social arrangements and distribution of power in Western society. Human development and growth are more complex than is acknowledged in the dissemination of childrearing expertise that is often oversimplified for public consumption.

While a clinician’s personal experience of motherhood may increase her empathy for the difficulty of the maternal role, it can also increase the psychotherapist’s tendency to be judgmental. Thus, clinician/mothers may perceive that they are the recipients of mother-blame, but may also be its purveyors. Most participants in this study shared their increased empathy toward mothers and only one mentioned feeling more judgmental at times. All but one participant was able to make some association to the term motherblame.

113 Taylor, saw mother-blame as a relic of the past. She remarked that, “I don’t hear that term that much, but that was so often kind of the explanation for so many problems with kids for a long time.” On the other hand, she articulated the current atmosphere of high expectations for parents, declaring, “There’s so much worry and fear you know, and I think it’s increasing, not decreasing. The anxiety that parents feel, the pressure that they feel to somehow raise a kid to be a certain way.”

Lucy had a very different response to the term mother-blame: I think of it clinically as a therapist who’s intent on understanding their client’s problems as resulting from a mothering failure issue . . . I think of it more as a layperson, being similar, but maybe not used so specifically. I think we call it “mama drama”.

Her view was that mother-blame came from the culture at large. As she described it, I don’t think it is very present in the culture of psychotherapy. I think this idea of expecting mothers to be perfect is very prevalent culturally. You know, I think that there’s a double standard, the expectation of the mom being omnipotent and perfect . . .

Furthermore, Lucy identified one of the difficulties in dealing with the issue of mother-blame, namely that, “Your mother is a significant figure in your life, for better or for worse—and sometimes it’s worse!”

Ella’s opinion about mother-blame was in agreement with Lucy regarding the profession’s current stance regarding mother-blame. Referencing her graduate education, she declared, “I think the way they [theories] were taught is that those were very outdated

114 ideas and that we didn’t really believe that [mother-blame], so it really wasn’t a thing.”

Despite this view, Ella associated mother-blame with early psychoanalytic theory and the theory of the schizophrenogenic mother, stating, The first thing that comes to mind, well there are two things . . . one is Freud and one is the idea that schizophrenia was from a frigid mother, or the idea that all of the problems come back to, “It’s your mom’s fault.”

Regarding the impact of mother-blame on the individual mother’s self-esteem, Ella offered an additional thought, “I think it’s important to look at where these ideas that we have about ourselves come from, and a lot of times they do come from our moms, things that our moms have said and done.” Her point underscored the difficulty in simultaneously recognizing the mother’s importance to child development without succumbing to blame.

Jen took a different position on the profession’s contribution to mother-blame, acknowledging that, “The main person who was responsible for pathology was the mom, and I had some feelings and thoughts about that, especially when I became a mother,” adding, “You’d be hard pressed not to notice that the mother gets the wrath for just about anything that goes awry with the child.” She also associated to the term mother-blame in the following way: It certainly has some connotations . . . I think of the schizophrenogenic mother and how the mother had created this incredibly tragic situation. I think there’s a perception that the mother pulled the emotional life of the family, so if that’s not going well, then it’s on her.

115 Jen thought the tendency to blame mothers could be offset by a particular theoretical orientation and the therapist’s years of practice. For example, she maintained that, I think people who have some expertise in systems . . . might have a broader understanding of the choice that sometimes women have to make, whereas I think maybe more inexperienced clinicians or certainly in the beginning of their careers . . . I think there’s a lot of, Well, why doesn’t she leave? Well, why would she stand for that? Well, why did she stay there if she suspected her boyfriend was molesting her child?” I think that that’s an incredibly complex situation that a woman can find herself in. So, I think we’re in a position to facilitate a tremendous amount of healing, but I don’t think all clinicians do a great job of suspending judgment.

Unique Issues I have included in the findings several issues that though were unique to specific participants, still relate significantly to the primary question exploring the interaction between the role of clinician and mother; the •

Non-Clinician Parent,

•

Real-life Motherhood

•

High Risk Pregnancy, and

•

Undiagnosed Postpartum Anxiety.

116 The non-clinician parent.

The mother is seen as the expert parent in our society, the one who is most responsible and most knowledgeable about child rearing. Mothers are often viewed as the ones who naturally have that expertise based on a combination of biology and socialization. Being a psychotherapist adds an additional level of expertise and can lock the clinician mother into a position of being the one who knows or is expected to know.

How then does being a clinician affect the dynamics in a couple? Taylor broached the issue of the therapist/non-therapist parent couple in this way: “I think a factor that comes in that’s kind of really complicated is my partner—am I the expert? Am I not the expert?

And is that a positive or a negative?”

Being the expert comes with certain benefits and risks. Having one’s expertise respected by a partner is gratifying, but it can also lead to shouldering most of the blame should something go wrong. Conversely, if that expertise is ignored, it can lead to “complications,” as Taylor framed it, by creating tension between the partners.

Real life motherhood.

“Real life motherhood” is a term coined by Lucy, who used it to identify a dilemma she experienced as a mother, namely, that there was a lack of honesty about sharing the negative aspects of being a parent. For Lucy, “real life motherhood” involves the ability to recognize and be able to talk freely about the negative as well as the positive aspects. She believed that social media has contributed to a “curated lifestyle” that depicts motherhood unrealistically and thereby raises the bar and anxieties regarding maternal performance. For example, Lucy described her difficulty with breastfeeding and

117 the pressure she felt to continue as an illustration of how the current bias toward nursing made it difficult for her to stop. Breastfeeding is currently represented as essential for the baby’s health and mother-child bonding. Any acknowledgment of a downside is underrepresented. Lucy described the impact of this partiality stating that, I had a really hard time breastfeeding, I wanted to stop. My mom and my husband and society at large pressured me to keep going. It wasn’t good for me or the baby. I think that there’s a lot that we don’t talk about . . .

Lucy suggested one way to redress this: We need more places . . . where people can just talk about how much it sucks, that it’s not what they expected . . .What I missed in my own journey is having people who could be honest about real life motherhood with me, which was part of what was hard for me. To feel alone or particularly deficient because people didn’t have the same struggles that I had. So, I’m honest, honest with my friends, I’m honest with people, colleagues at work who are pregnant and have questions. It’s real life!

High risk pregnancy.

In each interview the participant was asked about her experience of becoming a mother. For Ella, this question brought up the trauma she underwent in her efforts to conceive. She shared that, “I didn't know about any of the infertility world. It's like this dark world, this dark underground that you don't know about until you have to know about it.” Ella had four pregnancies that resulted in miscarriages and her fifth pregnancy,

118 though successful, required a protracted hospital stay prior to delivery. She described this difficult time: I was on IV, I was on magnesium sulfate for a month, um, which they typically do for 48 hours tops. I had, um, contractions they couldn't control otherwise, so I was on that. And I had placenta previa and some bleeding. So, I spent a couple of weekends in the hospital and then a full month. And so, she was born at 34 weeks and taken immediately to the NICU and she did pretty well. She was only there for 11 days and then came home. But you know, none of that is easy . . . no NICU experience is, even if they're there for an hour . . . there's still difficulty in it.

Ella remembered thinking that, “I always hated when people said to me, ‘You don't know what it's like until you've been there.’ But I think with infertility and with pregnancy loss, there really isn't a way to understand it until you've been there.” She noted that she is more open with clients since becoming a mother. For example, she mentioned that, “with the new moms that I work with, I think sometimes I'll tell them anecdotes of, of things that have happened . . . to normalize their experience or to connect with them.” Ella’s experience led her to change the focus of her practice. She now concentrates on women’s issues related to infertility, pregnancy, and post-partum adjustment.

Undiagnosed postpartum anxiety.

In the past three decades there has been an increasing recognition of post-partum adjustment responses (Bennett & Indman, 2006, Kleiman & Raskin, 1994, Miller, 1999).

119 While there has been an acknowledgement of the “baby blues,” as a normal response to initial hormonal changes and lack of sleep following birth, the more serious postpartum responses, such as debilitating anxiety or depression, were not commonly identified. This omission has left women without the support and treatment that they required. This situation had serious consequences for Lucy, who disclosed that, “I had really terrible anxiety. I resent that my ob-gyn missed it, my daughter’s pediatrician missed it. I needed help.” She described this nightmarish condition in the following way: “I wasn’t sleeping even when the baby slept. I was worrying all the time; my mind was racing. I was agitated. I lost a lot of weight.” This condition lasted for “well over a year.”

As a psychotherapist, Lucy shouldered an additional burden which she expressed in the following question; “How did I not know that as a mental health professional?”

Summary of Findings The findings revealed a reciprocal interaction between the participants’ experiences as clinicians and mothers. The data also corroborated the findings of the few extant studies and writings related to this topic. Parsing of the interviews uncovered factors that exerted a paradoxical influence by contributing either positively or negatively to the clinician mother’s self-appraisal and performance in both roles. This was reflected in the various subcategories in which societal and professional values came into play. The manner in which these factors were internalized, both supported and undermined clinician/mothers. For all participants motherhood wrought significant changes in their personal and professional lives. These adaptations were the result of complex challenges, some foreseen and others unforeseen, that called upon each individual to adapt and grow.

120

Chapter V

Discussion of the Findings The purpose of this qualitative study was to explore the interrelationship between the roles of mother and psychotherapist in eight clinician/mothers using a semi-structured one-on- one interview. The main objective was to gather information in response to the question, “What are the effects of being a clinician on motherhood and the effects of being a mother on the clinician?” My intention was to discover whether the participants’ thought that their experiences as clinicians contributed anything significant to their personal experience of motherhood, and how they felt about themselves in the role.

Similarly, I was also interested in learning if their experiences as mothers changed anything about their role as a clinician in terms of how they thought about and worked with clients. I wanted to know if exposure to any particular clinical or developmental theory played a part in the clinician’s self-appraisal as a mother. This exploration also considered the concept of mother-blame, a hypercritical focus on the contributions of the maternal role to psychopathology and dysfunction and whether it had any relevance for the way in which the participants thought and felt about their dual roles.

The findings demonstrate a rich and complex interaction between a woman’s identity as a clinician and a mother. Although this connection might seem obvious, there is a dearth of literature that explores the nature of this interaction and its profound effect on both roles. The interviews revealed that this interrelationship is both positive and negative in its multiple effects.

121 This chapter is divided into the following sections; my motivation for conducting this research, my interpretation of the study findings, a discussion of the data’s relationship to the literature, limitations of the study and thoughts regarding future research.

Motivation for the Study “My self-recognition in the . . . testimonies of others was part of an attempt to understand and analyze both a personal conflict and some of its social and ideological components—for example, the role of normative psychoanalytic theories in devaluing, or positively ignoring, the mother’s subjectivity and voice; or the absence of adequate social and material support for mothers in contemporary American society” (Suleimon, 1994, p. 7).

The choice of topic was motivated in part by my personal and professional experiences as a clinician-mother. When I became visibly pregnant in 1989, I felt as though I had become a projection screen for society’s attitudes and expectations regarding mothers. I experienced a steady stream of messages that suggested I could easily damage my child regardless of my love or intentions. A confluence of external and internal factors impinged upon my changing identity. The external factors included all of the news reports, magazine articles, books, and talk shows with what seemed an incessant focus on the mother’s negative contribution to any problematic behavior in her child.

There was a constant stream of advice from experts coupled with the changing trends in childrearing—ranging from “children should be seen and not heard” to the childcenteredness of the self-esteem movement, helicopter parenting, “tiger mothering” and the like. Each trend seemed to recommend one approach, only to critique it several years later. These fluctuations are to some extent unavoidable since new information and

122 discoveries will change ideas and practices. However, each new trend was promoted in such a way that it often repudiated rather than modified its predecessor, leaving mothers vulnerable to further criticism as the trends changed.

Regarding the theories I was exposed to as a clinical social worker in the early 1980s, I learned that as a mother I could fail my child by the sin of commission as well as by the sin of omission. (Kohut, 1971). I could cause havoc in my infant with my anxiety (Sullivan, 1953/1997). I could fail to soothe in a timely manner or soothe too much and inhibit growth (Mahler, 2000). I could, because of unresolved unconscious processes, unknowingly inflict harm on my child (any psychodynamic theory). This phase of my life repeatedly challenged my tolerance for ambiguity and the ability to emotionally and physically endure. I grappled with the mirror that I felt society held up to women; a mirror that too often reflected mothers as toxic influences. As I continued my studies as a PhD student, and deepened my understanding of the inter-relationship between theory and practice, I wondered how my peers experienced the interaction between being a clinician and a mother. What versions of motherhood did we believe in before having children? What did we think was true after having children? Furthermore, what had our professional backgrounds contributed either positively or negatively to our self-appraisals as mothers and clinicians? My intention is to introduce a more complete way of thinking about the interaction between motherhood and clinical culture. In this regard psychiatrist Robert J. Lifton (1999) writes that, No adult is a mere product of childhood. There is always a forward momentum to the self that does not follow simple cause and effect. Each self becomes a constellation or a collage that is ever in motion, a ‘self-system’ or ‘self-process.’ .

123 . . outcomes depend upon evolving combinations of experience and motivation that are never entirely predictable. (p. 12) Complexity refers to the recognition that numerous factors influence the mother/child interaction. It requires the ability to perceive that both positive and negative factors can exist simultaneously. Looking at the world complexly can require a certain forbearance in foregoing appealing but overly simplistic formulations regarding the human condition. In this vein, the evolutionary biologist, Richard Lewontin (2001), cautions that, Saying that our lives are the consequences of a complex and variable interaction between internal and external causes does not concentrate the mind nearly as well as a simplistic claim; nor does it promise anything in the way of relief for individual and social miseries (p. 207).

The “relief of individual and social miseries” is the purview of clinical social work. It is our obligation as professional helpers to ask the question, “Do our current ways of conceptualizing human behavior and treating clients add to or reduce this misery?” An investigation into how clinician/mothers experience and navigate both roles seeks to counteract the tendency to oversimplify or use obsolete tropes by incorporating the details of lived experience into the claims of theories and belief systems.

When I began this research, I assumed that psychodynamic or neo-Freudian theories might be cited by clinician/mothers as having a negative impact on their selfregard in the maternal role. I imagined others would feel the same as I did, that theory contributed to their sense that mothers were too often blamed by therapists. As I reviewed the data, I came to the realization that whether a participant had exposure to a particular

124 theory or not, depended on the time period in which they were trained and the orientation of their graduate institution. In recent years evidence-based theories, chiefly cognitivebehavioral therapy, have come into vogue, thereby replacing much of the emphasis on psychodynamic thinking. Therapists, particularly clinical social workers, do not come up through the Freudian ranks as they once did, therefore some participants considered traditional psychoanalytic views regarding female development as “old hat.” Several were never directly exposed to psychoanalytic or even neo-Freudian theories, therefore it is not surprising that they did not bring up traditional psychoanalytic principles as having much of an effect on their self-regard as mothers.

In general, clinicians are exposed to multiple theories, some emphasizing the mother’s impact and others having different foci. Along with this trend, the field of infant studies has recast developmental theory (Beebe & Lachmann, 2002; Stern, 1995; Tronick, 2007). This is significant because previously infants were characterized through the adult imagination or reconstructed from adult clinical material, which delimited understanding and interpretation of psychological functioning of both infants and adults.

Infant studies have changed our ideas about neonatal capacities, both highlighting the sensitive nature of the maternal/infant interaction and offering a correction to the singular focus on the mother in its acknowledgment of the infant’s role in shaping the mother’s responses. The environment also plays a significant role because it may either “hold” the mother adequately, a la Winnicott (1960), it may be inconsistent, or altogether fail to do so.

Despite psychodynamic thinking losing its centrality, the data revealed that it was the rare clinician who altogether escaped this influence as psychodynamic thinking has a

125 powerful imprint, both mirroring and shaping Western culture. Also, there were those clinician/mothers who directly cited theory as a source of negative bias toward mothers.

It became apparent that the manner in which theory is adopted into the clinician/mother’s personal ideals creates a sense of apprehension or worry about her motherly capacities.

The bar for being an exemplary mother is set high given the clinician/mother’s knowledge of child development, communication techniques, psychological insight, and experience working with people. These attributes imply that clinician/mothers should, therefore, raise exemplary children, an assumption that is reflected in Agrawal’s (2017) opinion that therapists “are disenfranchised in the imagination from common conflicts, behavior, and feelings” because of their training which makes them “psychosophisticated mothers” (p. 3).

In contrast to the difficulties posed by the impact of theory on the clinician/mother, participants also identified a more positive effect, namely that having a theoretical foundation provides a secure base as a parent because it offers an explanation of what a child might be feeling and doing. Consequently, theory makes its appearance in this study both positively and negatively, as it covertly and overtly threads itself through the experiences of the participants as described in the sections below.

Discussion of the Findings Clinicianhood/motherhood.

Our notions of the maternal and its relationship to female development cannot be unbound from motherhood as a socio-cultural phenomenon. For all of the clinician/mothers in this study, becoming a mother was a choice. The centrality of

126 motherhood is captured in the response of one of the participants who said, regarding becoming a mother, “It was never unimagined.” Becoming a mother is so intertwined with views of female development that it is often seen as an inescapable part of female identity and desire (Benjamin 1988, 1995, 1998; Zakin, 2011). The interaction of motherhood as a private, personal experience with the institution of motherhood is, as Rich (1981) has stated, inevitable, profound, and subjected to a specific form of idealization and devaluation. That the conceptualization and performance of the maternal role has taken place in the context of a pervasively masculinist ideology can affect our ability to think about it in new ways. Motherhood is shaped by trends which include the fluctuating ideas about what creates psychologically healthy, well-functioning human beings. It is also under the influence of our increasing knowledge of genetics, neurobiology, and the rise and fall of sociopolitical and religious ideologies. Like their non-clinician counterparts, clinician/mothers swim in the same cultural stream that most mothers navigate. This generalization recognizes that the stream diverges according to multiple sociocultural factors such as ethnicity, class, religion, and geographical location.

These multiple factors provide the context in which the individual clinician/mother experiences the benefits and burdens of her dual roles.

In conducting these interviews, I was struck by how eager the participants were to talk to me. Of course, this was a self-selected group, which might suffice to explain this phenomenon, but they shared their experiences openly and eagerly, sometimes with an intensity suggesting that clinician/mothers had much to share about their experiences in their dual roles and that there weren’t sufficient outlets to enable these conversations. By granting permission for individuals to speak openly and honestly about their conflicts and

127 struggles they find that they are not alone. Susan Suleimon underscores this point in her book, Risking Who One Is (2014), writing that, “My self-recognition in the . . . testimonies of others was part of an attempt to understand and analyze both a personal conflict and some of its social and ideological components” (p. 7).

Accounts of personal and professional experiences counterbalance a dominant public narrative that often leaves out a diversity of voices and viewpoints. Expanding the conversation regarding the professional/maternal experience is valuable both to our clients and ourselves.

Use of the self in service of another is the occupation of the clinician, an occupation which was once described to me by a psychotherapist as “a calling” rather than a job. A calling speaks to a greater level of meaning, sense of purpose, synchronicity with one’s identity, and overall level of investment. To whom this profession “calls” is a study in itself, beyond the scope of this paper, but it is worth looking beyond demographics to consider some of the characteristics of the interviewees that emerged from the data.

Becoming a psychotherapist.

Becoming a psychotherapist is distinct from many other professions because it requires the use of the self in a unique way, namely as the instrument through which a process of discovery and healing takes place. A psychotherapist requires extensive and perhaps lifelong learning. This involves exposing oneself to myriad human difficulties and requires a close monitoring of one’s own internal world while interacting with and monitoring the internal world of another.

128 Each participant in this study mentioned that they had undergone some form of personal psychotherapy. This experience proved significant in their choice of career path and is mentioned in the literature as a significant motivation to enter the field. Buesken (2014) makes the observation that, “After experiencing a rich transference relationship in their own (training or personal) therapy many women wish to recreate this role and become therapists themselves, identifying not just with the role or position of their therapist but with her person . . .” (p. 100).

It is interesting to note that personal psychotherapy has often been used as a common gibe directed at clinicians who are said to choose their careers as a means to address their own problems. This over-simplification reproduces the split between personal difficulties and professional competence—assuming the presence of one negates the presence of the other. A clinician is not a person free of problems or beyond problems. That is a faulty view which contributes to the creation of an unrealistic ego ideal and overlooks the possibility that grappling with problems can lead to growth. It ignores the value of self-reflection and the commitment it takes to work through difficulties, qualities that are fundamental in becoming a skilled clinician. Overall, the main theme in the choice of profession is reflected in the value the individual places on understanding herself and others. Clinicians have a strong sense of curiosity and are often catholic in their interests, traits that serve them as they encounter a wide variety human behaviors and difficulties in their practices.

129 Approaching motherhood.

Clinicians/mothers are likely to approach motherhood with the same attitudes and values that they possess as professionals. Self-reflection and growth are prominent among these, although not the sole provinces of clinicians. The clinician/mothers in this study placed a high value on knowing and managing their emotions and behaviors. They were greatly motivated to recognize and work through issues that surfaced in the conduct of their personal and professional lives.

The tasks of motherhood and clinicianhood can appear very similar.

Psychotherapy, often referred to as a corrective emotional experience, is sometimes considered a “redoing” of selected aspects of the mother-child relationship. If it is indeed a redoing, the clinician’s role can still be differentiated from the maternal.

Like “clinicianhood,” motherhood also places a demand upon the individual to navigate between self and other. Unlike clinicians, mothers have the additional responsibility to provide for their offsprings’ basic biological needs. Mothers are often the fulfiller of needs. Clinicians, for the most part, explore or address needs rather than fulfill them. Clients come into psychotherapy with a history; a child’s history is cocreated with the parent. In general, mothers are fulltime providers of care while psychotherapists offer their service within a proscribed framework of time limitations and specific settings and rules. Motherhood is unpaid labor. Clinicians are fee for service or salaried. Motherhood requires no training, but clinicians must obtain formal training and a license. Both involve limit setting, but this is often carried out differently. For example, regarding a dangerous or unwise situation, the mother might tell her child “No, you can’t do that,” while a psychotherapist would explore or address what was going on in the

130 hopes of facilitating the client’s self-awareness and redirecting their behavior. By definition the parent is the authority figure and the younger the child the greater the power differential. A psychotherapist might be seen as an authority because of professional expertise and transference, but they do not have the legal or moral authority to determine the course of their client’s life. In short, the stakes are different in parenthood as compared to clinicianhood.

In spite of these differences, some of the similarities are compelling. Clinicians and mothers provide guidance, facilitate growth and learning, are role-models, and provide emotional support. But it is the context, the type of emotional investment, and the kinds of boundaries that distinguish the two roles.

The upside.

The clinician/mothers in this study found their knowledge and background as psychotherapists very helpful for raising their own children. The foundation provided by this background fills a gap that exists in contemporary society due to the increased isolation of and disruption to the nuclear family unit. As family configurations change and become more varied, old models of childrearing may no longer apply and the availability of relevant role models for mothers may be lacking. The latest findings garnered from neuroscience and other disciplines add to the rapidly evolving mores, values, and understanding of human development that requires constant adaptation to ever-changing precepts and pronouncements regarding childrearing. Even something as simple as the placement of the infant in a crib has shifted from stomach to back to side in the last 30 years, accompanied by serious warnings from the medical establishment for

131 failing to place baby in the correct position. It is therefore advantageous to have the grounding in human behavior and development that is provided by clinical education and training.

Findings from the current study suggest that being a psychotherapist helps the clinician/mother in several ways. Knowledge of child development assists her in setting appropriate expectations regarding the timing and type of behaviors and capacities that their children will display. It aids in interpreting the meaning of their children’s behavior and provides ways of communication that are less reactive and more positively focused.

Therapists are generally encouraged to develop empathy, self-awareness, and respect in their dealings with others and this carries over into their approach to parenting.

The clinician/mother’s clinical knowledge provides her with insight into how deeply children are affected by their parents. She recognizes that the way a thought or feeling is expressed makes a significant difference in the way it will be received, therefore proficiency in verbal communication further assists clinician/mothers in communicating with their children.

Psychotherapy training and experience provide techniques and methods for addressing behavior in the consulting room as well as at home. For instance, if the provocative behavior of a teenager is seen as age appropriate and illustrating a desire for separation rather than an attack on the mother, the response is less likely to be an unproductive counterattack. It also serves to take the personal sting out provocative behaviors that might otherwise elicit untoward maternal reactions.

The interface between the clinician/mother roles produced an effect that was profoundly moving for the participants in this study. After becoming mothers, they

132 reported a depth of feeling that they had never experienced before. All of their education and training regarding human relationships could not prepare them for the felt experience of being a mother. This new identity created an enhanced sense of empathy and connection with the daily struggles of other parents. This was an unanticipated aspect of motherhood. For some, motherhood could be said to function similarly to a kind of spiritual journey. Being open to the experience in all of its wonders and trials became an opportunity for the kind of adult growth and learning that parallels the intense development of the child.

For all of the clinician/mothers in this study there was a predominantly beneficial interaction between their clinical knowledge and their real-life maternal experience, which expanded their competence and positive self-regard in the maternal role.

Ironically, the very background and knowledge that are perceived as beneficial also serve to undermine self-confidence and intensify anxieties.

The downside.

The data suggest that the manner in which the clinician/mother internalizes her training and background informs her self-appraisal as a mother. This influences her expectations and aspirations in the maternal role and sets in motion an internal dynamic that can bolster or diminish self-esteem. In Freudian vernacular this dynamic is represented by the concept of the ego ideal. The ego ideal can be thought of as the accumulation of internalized standards to which the clinician/mother aspires. These standards form an idealized mother imago or internalized object. The consequences of

133 meeting the ego ideal result in a sense of confidence and competence. Failing to meet the ego ideal results in anxiety and self-doubt, even a sense of failure.

The difficulty of balancing attention to self and other is a core challenge of motherhood that infantocentric models complicate by overlooking the subjectivity of the mother and the context in which she parents. One example of this is described in Chapter IV, in which Ella vividly recalled how the Still Face experiment (Schulte, 2013) haunted her when she could not respond quickly enough to her baby’s cries. She declared, “I didn’t want her to have an insecure attachment [because] I wasn’t coming to get her when she was fussing.” Although legitimately exhausted from a high-risk pregnancy that required hospitalization, the fear of causing harm outweighed the consideration of her own trying circumstances.

This dynamic is closely related to the expectations clinician/mothers identify in Chapter Four. The role of theory in these instances, particularly deficit models such as self psychology and other matrifocal theories, can amplify feelings of guilt, inadequacy, and self-doubt in the maternal role. This is a complex interaction that depends on environmental factors as well as personal traits and therefore necessitates caution in ascribing these effects only to the influence of theory.

It is interesting to note as the individual mother proceeds through her experience of mothering, the lens through which she imagined or anticipated that experience is challenged by the reality of the experience. This creates the condition through which she may acquire greater empathy for mothering, and perhaps her own mother. But this is not an inevitable outcome. Excelling in ways that one’s own mother failed can also result in a solidifying of judgmentalism and a harsher lens with which to judge other mothers.

134

The prevalence of guilt.

One of the most common responses that clinician/mothers communicated regarding their self-appraisal in the maternal role was the fear of unintentionally harming their children psychologically. Such responses, like Tonya’s “I think I felt enormous pressure, and probably still do to not cause any damage,” indicates a perception of the parent-child interaction as particularly fraught and the child as exquisitely vulnerable.

While it is important to recognize that children have an active mental life and are affected by their caretakers, this sometimes results in clinician/mothers being particularly sensitive to their child’s unhappiness or discomfort.

Because the evolution in our understanding of children brings strongly held beliefs into conflict with new information and insights, changes can be extreme, as the shift from “children should be seen and not heard” to “helicopter parenting” shows. One trend is valued and later discredited without synthesizing what might be valuable in each.

For instance, child-centeredness is a response to counter the unheard/unseen child--which advances a more complete and wholesome understanding of child development.

Unfortunately, it has also led to some blurred distinctions between short-term, tolerable discomfort that is growth producing or essentially benign, and the type of distress that results in long-term damaging effects. For some clinician/mothers it has had the effect of their feeling obligated to “fix everything.”

In a recent personal conversation with a retired clinician/mother, I was told that she had waited until her mid-thirties to have children because she “didn’t want to f* them up”. When I asked her what she meant, she expressed her concern about the fear of

135 damaging her future children. She decided to wait until she felt mature enough to be a good mother, i.e. avoid the numerous pitfalls she had become aware of in the process of becoming a psychotherapist. This unsolicited revelation exemplifies how the clinician/mother, sensitized by her training to the identification of dysfunctional traits and dynamics, often worries about finding these dynamics in herself and inflicting them on her children. Although there is a normative aspect to this concern for one’s impact on their child, it is the overestimation and exposure to numerous examples of unfortunate consequences that make this a special case for clinician/mothers. There are also mitigating factors such as the inclusion of the mother’s subjectivity in theory or the acceptance of the concept the “wounded healer.” (Adams, 2014; Farber, 2017; Gerson, 1996; Kuchuk, 2014), a shift in thinking that normalizes what at one time was considered shameful or unworthy behavior. Despite these changes, this worry persists.

The high expectations held by clinician/mothers regarding their performance in the maternal role are derived from the interaction of internal and external forces. Factors such as socioeconomic status, ethnicity, culture, education, and training intersect with the personal traits and the lived experience of the individual. It is the clinician/mother’s struggle to meet her expectations or exemplify them in her maternal conduct, that can set forth a harsh self-critical reaction. One of the external factors that influences this reaction is a Western culture that privileges individualism. With the exception of systems theory, individualism permeates the foundational thinking in the mental health field. But even systems theory cannot wholly avoid the influences of individualism. Psychopathology is still mainly considered to be a result of individual characteristics though it may be abetted by environmental circumstances. Given this cultural context, it is not hard to imagine that

136 clinician/mothers have assimilated this mindset and therefore assign themselves an inordinate amount responsibility for the way their children turn out. For example, attunement, a means of affect regulation, is highly valued by psychotherapists and can be experienced as gratifying not only to the child, but also to the mother. But failure in achieving attunement not only leads to difficulties for the child, but to dysregulation for the clinician/mother. This distress, which can be experienced by any mother, is compounded for the clinician because she has internalized images of the myriad negative consequences that can result from misattunement. Furthermore, the more highly valued the response or expectation, the more negative is the impact in failing to achieve it.

Mother-blame.

“It is as if, for psychoanalysis the only self-worth worrying about in the mother-child relationship were that of the child. How this exclusive focus affects the mother is something we are only now becoming aware of, as mothers begin to speak for themselves” (Suleimon, 1994, pp. 16-18).

“Despite claims that psychology has moved beyond mother-blame (Seeman 284), many mental health professionals have confessed that mother-blaming messages are embedded in their training” (Caplan, 1994, p. 21).

How and why we feel so guilty can be linked to an internalized sense of blame.

Blame appears as a frequent response to cultural ills and human failings. The first definition that appears in an online search for the word blame is, “to assign responsibility for a fault or a wrong.” Blame is further defined as “an expression of disapproval or reproach, responsibility for something believed to deserve censure” (https://www.merriam-webster.com/dictionary/blame). These definitions, however, leave us with a conundrum; how do you differentiate accountability from blame?

137 Accountability is likelier to create an openness to learning, while blame often invokes censure that leads to shame and “shutting down.” The task of navigating through blame and accountability is one that clinicians must manage in their practices in order to avoid the negative consequences that follow from blame. This same issue is one that clinician/mothers also wrestle with in their personal lives. The tendency to slip into selfblame for perceived deficiencies as a parent, illustrated by Lucy’s remark that “something was wrong with me,” is a common thread among clinician/mothers.

Whether the clinician’s training included overt or covert mother-blaming messages, or these impressions were absorbed from the culture at large, all but one of the participants acknowledged that mother-blame had some impact on them as clinicianmothers. There were two significant concerns expressed by participants related to this phenomenon. The first concern relates to how the clinician imagines she appears to the public in her maternal role. In other words, would she be “blamed” and discredited as both a mother and a clinician if her children were known to have some form of behavioral or emotional problem. The second concern involves the fear of doing something “wrong” or untherapeutic that might distress and ultimately harm her own child. This elicits a personal sense of guilt, shame, or inadequacy in the maternal role and relates to the expectations clinician/mothers have regarding their parenting.

The concern about how she appears to the public may have a portion of its origins in the historical evolution of the psychotherapist role and its comportment. A doctrinaire approach to psychoanalysis in the United States contributed to an expectation that the analyst, having passed through his or her own successful analysis, would be free of major neurotic dynamics. Additionally, the idea that the analyst was a neutral figure and did not

138 contribute to what took place in the consulting room, gave the psychotherapist a one-up position vis a vis the analysand. As a result, analysts, as well as the other psychodynamic therapists, were under pressure to maintain a circumscribed professional persona since disclosing or acknowledging their personal life and traits would flout the norms of the clinical community. Until the advent of the two-person model of psychotherapy, very little personal information was overtly disclosed by the clinician.

Another source of internalized mother-blame may stem from the high expectations clinician/mothers have of themselves as mothers. These expectations may originate from the individual’s personal traits, but are also are subject to the influence of cultural and environmental factors. One such factor, the digital age, has brought about the erosion of privacy, thereby contributing to an environment that heightens the threat of public exposure. Several of the clinician/mothers cited social media as an insidious form of social pressure to perform as exceptional mothers. One participant opined that many of our personal circumstances can be made public through cyberspace’s erosion of privacy.

The internet can be put to ill use by posting distorted or damaging information which can be accessed by scores of viewers. Anyone can be “googled” and information that was previously inaccessible is now available. Thus, the sensation of “being under the microscope” has taken on new meaning in the digital age. As Lucy shared in our interview, “It’s a whole different world, the results of our parenting are so public. I feel tremendous hypocrisy all the time.” This loss of control, in terms of what a clinician wishes to be made known or kept private about herself and her children, contributes to the sense that one is “under the microscope.”

139 One noteworthy factor related to mother-blame, involves having a history of a disturbed relationship with one’s own mother. Among the participants who related significant difficulties in this area, there was a tendency to see some validity in the use of mother-blame. Their mothers had indeed been lacking or inappropriate in significant ways and this contributed to their sensitivity to the negative impact of poor mothering.

Ironically, this predilection exists side by side with greater empathy toward parents in general. At times this empathy can extend to an abusive or negligent mother, as the clinician uses her own stressful experiences of motherhood to connect with clients. For some clinicians, being a mother reduces the need to defensively maintain an unrealistic maternal ideal for self and other.

While there has been real progress regarding sexism in society, this has occurred unevenly, and the residual and institutional effects of sexism remain. It is often harder to grasp their effects as they become more covert, especially when it fits with our values to think we have recognized and sufficiently worked through these issues. It is ironic that even in the wake of the improvement in the rights and social status of women that the focus on mothering has contributed to an atmosphere of anxiety. As noted in an article in the New York Times Book Review, “political progress doesn’t always translate to selfacceptance” (Smith, 2020, p. 9). Perhaps this explains in part why clinician/mothers are particularly vulnerable to worries about their parenting.

Buesken (2014) points out that, “People have multiple identities across competing and conflicting categories . . .” with the consequence that “our particular structural positions and psychological identifications are subject to greater flux than ever before” (pp. 92-93). This social “flux” adds another layer of uncertainty to modern life that

140 creates an ever-shifting perception of human relationship norms. Women have to negotiate the range of parenting expectations that have moved from “Spare the rod” to child-centeredness, to helicopter parenting and to whatever new is waiting in store. While there is a positive value in being open to and assimilating new information, it is also difficult to be without a solid base upon which to rely.

Contradictions and complexity.

It may appear in the results of the data that the observations regarding clinician/mothers are contradictory As Taylor mentions in her interview, being a therapist is “a blessing and a curse.” I believe this reflects current sociocultural stresses. Women are more liberated, yet current and residual effects of gender discrimination still exist.

Societal definitions regarding identity and gender and therefore womanhood and motherhood, are subject to continual change. They are more anxious about harming their children and yet they are more prepared and confident in the professional knowledge that can be used in their maternal role. They are more empathic toward parents and yet, more judgmental toward mothers who are negligent or hostile toward their young. I think this attests to the complexity of interaction between the two roles. Rather than finding that it is either an advantage or a disadvantage to be a clinician/mother, it is more likely that it is both. What seems indisputable in this study is that there is a profound interaction between the two roles and that this interface is corroborated in the literature.

141 Findings with Respect to the Literature In Chapter II I reviewed the literature in the following areas: (a) the contribution of foundational theories that have played a key role in our conceptualization of the etiology and treatment of mental health problems, (b) the theories that followed and contributed to the evolution of that clinical thinking, and (c) the three studies that most closely resembled my inquiry. In this section I am re-introducing the formerly reviewed study by Paula S. Derry (2017) because I have gained a greater appreciation for the relevance of her data as I have gone through the process of completing my study. I am also including new literature that I discovered after writing the first literature review. This includes Petra Bueskens’s (2014) discussion of psychotherapy as a form of mothering and Gillian L. Sheridan’s (2017) master’s thesis, Exploring the Psychology of Being Both a Psychologist and a Mother: A Psychosocial Study. I will also be focusing on motherblame and the reflections of clinician/mothers on the “real-life” of their dual roles.

One of the keys to understanding the beliefs and values currently held by Western society is the evolving view of motherhood. As portrayed by biology, religion, philosophy, sociology, and psychology, motherhood has been determinative of a woman’s place in the social structure, but actual mothers have had little to do with how the maternal role has been characterized by the helping professions. While there is a body of literature on the impact of the psychotherapist’s pregnancy, little has been written on the impact of motherhood. According to Claire Basescu (1996), Perhaps there is so much more literature on pregnancy because pregnancy is a literal physical ‘intrusion,’ which even analysts committed to a model of analytic anonymity cannot ignore or deny. When the children are just in the therapist’s

142 head and heart, it may become more possible for patients or even for therapists to imagine that they are no longer there in a relevant way. As clinical theory expands to include what is in the therapist’s head and heart, it becomes necessary to consider how more aspects of the therapist’s identity are relevant to the clinical encounter (p. 105).

There is only a small body of literature that looks directly at the impact of motherhood on the clinician and vice-versa, which was the focus of my study. There are, however, many works about motherhood as a sociological, political and psychological phenomenon. There were less than a handful of available dissertations on the topic and a number of books about the psychotherapist’s personal life were compendiums containing a chapter or two in which a clinician/mother wrote about the intersection of her professional and personal experience. The remainder of the relevant articles were located in professional journals and in the lay press. The scant number of works dealing specifically with the interface between being a clinician and a mother were often consonant with the themes that emerged from this study’s data. This congruence offers strong support for the categories that emerged from my interviews.

Although not directly related to the findings, it is useful to look at a common conception that equates psychotherapy with a specialized form of mothering. In Is Therapy a Paid Form of Mothering? (2014), author Petra Bueskens reflects on clinical practice as, “a specific, trained way of engaging in meaningful relationship [italics hers] with a person who is suffering or simply growing, and in that sense as more of an art than a science . . .” (p. 98). She answers her own question by concluding that, “maternal care does provide a potent metaphor” for psychotherapy (p. 86) and that, “Psychotherapy is

143 ‘motherly work’ because its theories and practices are consonant with women’s relational selves” (p. 100).

Buesken takes a broad sociological view that clinical practice is a predominantly “female enterprise” shaped around “an ethic of care” (p. 87). Buesken’s use of the term “ethic of care” refers to the movement in psychotherapy toward relationality, which she considers one reflection of the “feminization” of clinical practice. Bueskens believes that psychotherapy mirrors the emotional labor that women have provided to society as the major caretakers of others.

Feminization is a phenomenon in which men tend to occupy the highest echelons in society and commerce, while women are predominantly in “the rank and file” (Bueskens, p. 87) There is a regressive connotation attached to this concept that includes all of the negative stereotypical characteristics associated with the feminine, i.e. weakness, softness, less rigor, illogical or fuzzy thinking, and excess emotionality.

Buesken, however, chooses to embrace feminization as a positive force in psychotherapy on the ideological grounds that the shift to relationality, which she associates with a feminine orientation, is a progressive evolution in theory and practice. She describes some of the obvious negative consequences of feminization, such as diminished status of the profession and lower remuneration for services. This is especially true in clinical social work where women predominate.

Empirical research.

It wasn’t until I began work on this, the fifth chapter, that I randomly came across an article relevant to this study I had previously overlooked. The title of the article, There

144 is No Longer Room for Me on Your Lap (Shaw & Breckenridge, 2014), had appeared to be similar in theme to another paper, The Therapist’s Pregnancy, Intrusion into the Analytic Space (Fenster, Phillips, & Rapoport, 1985). I assumed that the former was another description of the client’s difficulties with the therapist’s pregnancy, as this was the predominant theme of most of the literature. As I read further, I observed that Breckenridge and Shaw were asking a similar research question to mine, namely, “Does being a therapist inform and influence mothering?” (p. 139) Their study of nine clinician-mothers used a qualitative approach, collecting data from written, semi-structured interviews. In addition to their focus on the interaction between the roles of mother and clinician, they also explored the impact of the clinician’s pregnancy on the practice of psychotherapy. The authors’ motivation for undertaking their study also paralleled mine in that their personal experiences as mothers and professionals influenced their desire to explore the interaction of those two roles. The authors also noticed, as I did, how little was written about the interaction between the maternal and psychotherapist roles, stating that, Even when therapists do write about pregnancy and motherhood, much of the focus remains on the transference and countertransference aspects, rather than an exploration of the therapist’s personal experience and the practical and real aspects that intrude on the role and into the therapeutic space (Shaw & Breckenridge, 2014, p. 141).

Their main findings can be summarized as follows: Being a therapist is extremely important to the participant’s identity; for all participants becoming a mother resulted in career sacrifices or changes . . .; all therapists . . . need to think about when to tell clients; how to stage disclosure;

145 how to think about and explore the impact of pregnancy on individual clients; how to manage transference and countertransference (pp. 145-146).

Furthermore, other changes included “exposure to clients, increased empathy for their patients and their patients’ mothers, deepening knowledge, self-understanding and potential for greater understanding and connection with clients” (p. 150).

Regarding pregnancy, the authors point out that “there are so few other events that will so obviously intrude into the therapy and defy the established boundaries” (p. 146).

Their data showed that participants were “positive about being mothers” and indicated a “desire to foster particular skills and qualities in their own children” (pp. 145-152).

Some of their results echo my findings, specifically: “increased empathy for their patients and their patients’ mothers,” “deepening knowledge, self-understanding and potential for greater understanding and connection with clients.” The main exception is the lack of identification of any disadvantages from the interaction of roles. In the Breckenridge-Shaw study they reported only a few pragmatic concerns regarding worklife balance. In contrast, my participants did speak to the negative impact of either being a mother or a clinician, identifying psycho-emotional issues as well as practical concerns.

In her master’s thesis, Exploring the Complexity of Being a Psychologist and a Mother: A Psychosocial Study, Gillian Sheridan (2017) interviews nine psychodynamic clinician/mothers, focusing on the manner in which their dual identities “inform, shape, enrich and conflict with each other” (p. 7). Sheridan’s primary discovery is that motherhood is a transformative state that affects the psychologist/mother’s multiple identities. She concludes that the resulting shifts in identity are continuous and challenge

146 the clinician to acknowledge positive and negative effects, reflect on these, and constructively re-integrate them into the self.

Several of Sheridan’s finding concur with data from my study. She found that in general, being a clinician is both helpful and detrimental to the role of motherhood. This duality or complexity manifests in her findings in the following ways: being a psychotherapist is more of an identity than a job and therefore involves a mindset that exists in the personal and professional speres. Psychologist/mothers struggle with the high standard that they set for themselves as mothers and take themselves to task for failing to meet those standards. Being a psychotherapist deepens the capacity for empathy and creates a greater ability to be relatable in their clinical practices, while knowledge of theory and child development is both beneficial and inhibiting in the performance of the maternal role.

Sheridan observes that psychologist/mothers are, “both supported but also constrained by their knowledge of psychological theory around child development and mothering . . .” (p. 19). She describes her psychologist/mothers as particularly thoughtful and reflective regarding their maternal role, but that these qualities can serve to diminish spontaneity in childrearing. These discoveries are similar to my findings that theory provides the scaffolding and direction that gives a clinician/mother confidence and a sense of knowing what to do, while also serving at times as an internalized judgmental, punitive, and inhibiting force.

Sheridan further describes the way in which theory is processed by the psychologist/mothers and produces multiple kinds of effects. She explains as follows:

147 Evident in the narratives was that each psychotherapist has a unique relationship with theory and it is postulated that each of their relationships with theory are likely influenced by their internalised object relations, based on their own childhood experiences of being parented as well as their personalities. It would appear that how objects and theory have been internalised – what has been internalised and what is transferred onto theory in particular moments – determines whether theory is experienced as predominantly punitive or protective (p. 34).

Thus, Sheridan has offered a plausible explanation of how theory functions in positive or negative ways, depending on the individual, her experiences, character, and circumstances.

In accord with the adverse impact of theory, Sheridan’s participants reported an intense, “pressure to get mothering right” (p. 23). This pressure is also located in a discourse alluded to by participants in both of our studies; namely, that as clinicians, participants have exceedingly high expectations of themselves as mothers and also believe that the public holds them to this higher standard. Regarding this detrimental aspect of being a clinician, Sheridan asserts that, The pressure experienced by these mothers . . . seemed to be exacerbated by their role as psychotherapists. Their professional roles as ‘experts in mental health and/or child development’ added additional pressure to be ‘perfect’ and to be seen to raise a healthy child (p. 36).

148 Similarly, the theme of perfectionism emerged from my interviews. Comments such as, “I’m very much a perfectionist” or “I’m very hard on myself” typify the kinds of responses my participants shared.

In terms of the positive effects of motherhood on the clinician, Sheridan’s data indicate that participants found that motherhood “enhanced, deepened, softened and broadened their engagement with their clients as well as with psychological theory” (p.

36). Her findings illustrate the intensity of thought and feeling that emanate from the interaction of the clinician/mother roles and convey the richness with which motherhood informs the clinician’s sense of empathy. This, in turn, further augments the ability to be more relational in the practice of psychotherapy. Sheridan’s psychologist/mothers illustrate the profound intersection and overlap between their personal and professional lives as a complex source of challenges, growth, and adult development.

In the Chapter II literature review I briefly summarized Paula S. Derry’s study, but I am reintroducing it here in order to provide a more detailed analysis of how it relates to my findings. In Motherhood and the Professional Life (1990), Derry provides one of the few resources that is an actual study of the effects of maternity on the psychotherapist’s professional identity. Though our two studies possess a similarity of intention and theme, there are significant differences in methodology. Derry used personal interviews and structured questionnaires to obtain her data. She then submitted these to several quantitative forms of analysis. She employed a framework utilizing three concepts to assess and describe her findings. Despite the differences between our studies, the results and interpretation of the data hold many similarities.

149 A brief description of Derry’s three-factor conceptual framework follows. The first factor considers the interaction between roles as inherently conflictual, the second, is that accommodation or “active coping” occurs to help in managing multiple roles, and the third refers to a “synergistic” dynamic in which multiple roles are thought to enhance one another (1990, pp. 1-2). Derry concluded that no single concept explained her data and that clinician/mothers differed very little from non-mothers in their relationship to work.

Some of Derry’s findings do not fit the categories derived from my data, but the following are examples of those results which do corroborate mine.

According to Derry, the most common and generally expressed change for clinician/mothers was greater empathy for parents. This manifested in: increased identification with the perspective of parents, less judgmental attitudes towards parents, greater understanding of the sresses of parenting, greater appreciation of the strength of affects and behavior of parents as variants of a universal or normal experience, or decreased identification with the perspective of the child (1990, p.53).

In addition, her respondents (and mine as well) reported “an increased understanding of child development” (p. 52). Derry also found that because of the addition of motherhood as a second role, working-life lost some of its “centrality” (1994, p. 156). Her data suggested that maternity created new limits on the professional role. As she indicates, “The more roles a person plays, the less important or central might be any one of the roles” (1990, p. 12). This corresponds to one of my participant’s comments that, “I’m here to take care of and help people, but there’s just that boundary . . . I have this other job [motherhood].” She no longer wanted to take her work home; she wanted a

150 stronger boundary between her work and personal life, though she did not feel that she had a reduced commitment or interest in work. Derry mentions a reduction in the number of hours worked and a somewhat decreased amount of professional aspirations during the first year that clinicians were taking care of their infants (1990, p. 29). The amount of working hours and thought that can be devoted to work is a universal issue for many working mothers, no matter the type of work they perform.

Another of Derry’s findings was that motherhood increased the value of focusing on personal rather than work-related experiences (p. 158). This echoed the accounts of deepening emotional capacity and an appreciation for life that clinician/mothers expressed in my interviews. These factors were felt to be profound and were often poetically articulated in the interviews like Tonya’s comment that, My own sorrows provide an opportunity. As I continue to appreciate myself and my own struggles without expecting them to be different [from her clients] I see how much that enriches my presence and availability. Because I think what my office really needs to be, is it needs to be a place where people can come who feel broken.

In both studies clinician/mothers do not perceive themselves as changing their way of practicing, yet the changes in empathy and identifications that result from motherhood would be likely to affect countertransference or other clinician responses.

Likewise, preferences for particular theoretical orientations may not have changed, but the accumulation of knowledge linked to lived experience recalibrates orientations to theory and how theory is understood and applied. If this were not so, the experience of motherhood, as well as other life experiences, would have little or no effect on the

151 clinician. In The Myth of the Untroubled Therapist, Marie Adams (2014) reminds us that, “We cannot leave our experiences outside the room. Even if not at the foreground of our minds, our tensions and pleasures, the rumbling envies and unresolved issues of archaic experience, are always with us” (p. 2).

In general, clinician/mothers do think and feel differently post-partum. The results of Derry’s study and my own indicate that there is an attitudinal change even though theoretical orientations and styles of psychotherapy may not alter.

The prevalence and type of maternal anxieties in contemporary society may also be indicative of a wider social phenomenon not limited to clinician/mothers, but affecting mothers in general. In 1977 the author Eda LeShan wrote, “I have just finished reading about 30 recently published or soon‐to‐be‐published books on child care and, if I were a young parent today, I might cut my throat”. This dramatic response is understandable as it reflects how the maternal advice “industry” promotes a confused message to mothers, exemplified in the following quote: “Trust your instincts and train your insight, follow your baby’s nature and spare no effort on her nurture—relax and enjoy those first years and don’t forget for a minute that your child’s future is at stake” (Hulbert, 2003, p. 314).

In that one sentence there are seven verbs exhorting the mother to both “trust” herself and “relax” while everything she does will either secure or destroy her child’s future. With this kind of contradictory and anxiety provoking pronouncement about the good mother permeating our media, it is incumbent upon clinicians to help their clients navigate a sea of information and disinformation, while they are simultaneously being bombarded by the same messaging. As seen in the data, being a clinician/mother does not provide immunity from the Achilles heel of doubt and guilt that mothers in general experience.

152 In Chapter Two, prior to conducting my study, I briefly reviewed Laura Carter Robinson’s dissertation, Therapist as Mother and Mother as Therapist (2012). The focus of her qualitative study was the subjective experience of nine psychoanalyst/mothers regarding the interface between their dual identities. Robinson’s “master themes” appear to mirror and support several of my findings. She found that being a mother was “life changing” (p. 81), that personal psychotherapy was highly valued and was related to a desire to “parent differently” (p. 84). Her participants also experienced the duality inherent in being clinicians and mothers; on the one hand there is a beneficial effect of being a clinician on the maternal role, but it can also add to anxiety and unhelpful selfscrutiny (p. 85). Robinson also focused on a few areas that were not part of my study.

She identified her participants as having a psychoanalytic “world view” which they applied to their professional and personal lives (p. 88). In addition, she noted that becoming a mother was disruptive to her participants’ career paths and required them to make various adjustments to compensate for the loss of time available to devote to career. (p. 82). In summary, Robinson’s study, like this one, reflects the complexity of the maternal experience and the mutual influence of the analyst/clinician identities (p. 88).

Mother-blame redux.

In Penelope Campling’s “On Being Good Enough, Bad Enough, and Never Getting It Right,” (1992) she uses her experience as a mother and as a clinician to offer a critique of the negative consequences that result from the idealization of both roles. She begins by focusing on the unrealistic views about motherhood that were perpetuated by what she describes as, “male definitions and judgements based on the remembered

153 position of the helpless and vulnerable child . . . discrepant with the raw and earthy experience of being a mother . . .” (p. 73). This observation refers back to my earlier discussion of Jessica Benjamin (1988, 1995, 1998) and the mother’s function as an object rather than a subject in developmental theory. Campling shares her personal experience as a clinician/mother, stating that, “I found it difficult to switch from the empathic, identifying mother so much described by psychoanalysts to the busy parent, running a home and family and managing the complexity of relationships involved” (p. 74).

Campling cites research that shows a high rate of “intense emotional distress” in mothers with young children, specifically in the first year after giving birth (p. 75). She critiques the response of the mental health system which views an increased vulnerability to emotional difficulties in mothers, “as an illness or judgement on the individual, rather than a cultural experience of everyday mothering” (p. 75). The results of my study raise the question whether the volume of anxiety experienced by clinician/mothers (as well as by mothers in general) is an inevitable part of the maternal role and, if so, whether there is some way to mitigate this effect. Campling responds to this concern by declaring that, If we don’t constantly root ourselves in the reality of our experience, we succumb to pressures from society, reflected deep within ourselves, to idealize both motherhood and the caring professions . . . this can leave individuals isolated with their doubts and fears, their mistakes and disillusionment as they share only what they feel is acceptable (p. 75).

The “reality of our experience” that she refers to is the acknowledgment of our imperfections and vulnerabilities vis a vis the vicissitudes of being clinicians and mothers. The consequences of failing to acknowledge this reality are that “we isolate

154 individuals with their doubts and their fears, their mistakes and disillusionment, as they share only what is acceptable” (p. 75). Sharing “only what is acceptable,” whether you are a clinician in peer consultation or a mother talking to the pediatrician, continues the cycle of idealization. A romanticized view of motherhood raises the performance bar unrealistically high, and the less than perfect experiences that might be beneficial to share with others are left out of interchanges.

The judgementalism that characterizes attitudes toward mothers in general and clinician/mothers in particular is derived from what Campling calls, “persecutory comparisons” (p. 76). These comparisons represent the intersection of internal struggles and societal expectations. Campling’s thinking suggests that what is missing in our attitudes toward motherhood is the ability to individualize what is “best” based on the particular mother and her circumstances. She writes that, Bogged down by all these conflicting pressures, the question of what feels right for that particular mother and particular baby and why, does not get the priority it deserves, gets answered superficially and leaves mothers with a seed of uncertainty which has to be kept small and manageable and strongly defended (p. 76).

Campling personally experienced that pressure in the form of seminars she took that focused on “early mothering” in which, “every seminar, everything I read and everything my patients said insinuated that I should be at home with my baby” (p. 76).

She goes on to say that, Nothing I’ve read really prepared me for what it was going to feel like. Much of the literature encourages a sense of guilt and failure in the mother, unless she can push her baby into whatever the latest psychological trend suggest is healthiest.

155 There is also a problem for mothers who do succeed in making themselves and their babies fit the fashion. For them the sense of guilt and frustration with what trend they followed is repudiated to be replaced by the next (p. 79).

Campling concludes her paper by encouraging the reader to “learn to live with the idea that we’ll never get it quite right” (p. 81). Perhaps this is what Winnicott originally intended in his concept of the “good enough mother.” The difficulty however, for clinician/mothers, is how to come to terms with this murky ideal.

In 2014 Sara S. Richardson et.al published a paper in the science journal Nature, entitled “Society: Don’t Blame Mothers.” She and her colleagues looked at the way in which findings from the field of epigenetics, the study of changes in gene expression, were being described in journals and in the media. The main thrust of the piece was that a lack of context regarding discussions about epigenetics and pregnancy led to “exaggerations and over-simplifications in making scapegoats of mothers.” Warning that this trend could increase “the surveillance and regulation of pregnant women,” the authors referred to a general practice of historical “over-reach” when it came to reporting potential dangers to fetal development and the etiologies of mental illness conditions.

They recommended a fourfold approach to mitigating this problematic trend: First, avoid extrapolating from animal studies to humans without qualification.

The short lifespans and large litter sizes favoured for lab studies often make animal models poor proxies for human reproduction. Second, emphasize the role of both paternal and maternal effects. This can counterbalance the tendency to pin poor outcomes on maternal behaviour. Third, convey complexity. Intrauterine exposures can raise or lower disease risk, but so too can a plethora of other

156 intertwined genetic, lifestyle, socio-economic and environmental factors that are poorly understood. Fourth, recognize the role of society. Many of the intrauterine stressors . . . correlate with social gradients of class, race and gender. This points to the need for societal changes rather than individual solutions (para 16).

All of these considerations can be applied to the belief systems we create, subscribe to, and promote that contribute to the phenomenon of mother-blame. This view is supported by philosopher and science critic, John T. Bruer (2014), who urges that, If our intent is to use science and research to form policy, to guide educational practice and to give parents assistance, it's incumbent on people putting forth those arguments to get the science right. If they choose not to get the science right, if they choose to misinterpret it or over-simplify, we just have another instance of political rhetoric . . . (para 3)

The clinician/mother: Realities.

In The Therapist as a Person (1996), author Barbara Gerson gathered a variety of essays in order to, “provide a place for thoughtful clinicians to talk to others about the ways they think and work amidst and with their struggles” (p. xviii). Her thinking, similar to what emerged from my data, is that the individual analyst’s (psychotherapist’s) life experiences, which include not just pregnancy, but the entirety of motherhood, have effects on the clinician and her analysand/client. Although her book does not contain actual studies, one of the essays, The Ongoing, Mostly Happy ‘Crisis’ of Parenthood and its Effect on the Therapist’s Clinical Work by Claire Basescu (1996), is particularly relevant to the theme of my work. In Gerson’s words, this essay illustrates the ability for

157 “detailed clinical inquiries . . . to enliven and deepen our understanding of the general questions of how our lives affect our interactions with patients” (Gerson, p. xv).

Basescu’s observations mirror the advantages and disadvantages that emerged from my data that were a result of the dual mother/clinician roles. Even though this is a personal account based on private and professional experience, she captures in parallel the essence of some of my study’s themes in a very descriptive and relatable manner. She identifies her sense of the dual roles having a positive and negative effect by the following remark: “My vulnerability at this time in my life was double-edged for my patients and myself— both useful and disruptive, growth-promoting and growth-inhibiting” (Basescu, p. 112).

In regard to meeting the needs of her children and shortchanging her clients or vice-versa, Basescu says, “I . . . felt guilt towards my patients at this time. My children were more important. Their needs were all-encompassing. I worried about short-changing my patients. I wondered whether I should work at all” (p. 111). This dual role interaction clearly shows in the consulting room as Basescu’s thoughts take the form of questioning her own performance as a mother. She notes, When patients talk about their childhoods and the impact of their parents, I sometimes find myself thinking, oh, I have to remember never to do that or that’s something to try to do. I find myself thinking about my children at a case conference or in a session . . . (p. 114).

Although this might appear to be a negative consequence, Basescu goes on to say that it can have a positive effect as well. In her estimation it is useful, “because it gives me a developmental context with which to evaluate the event being described. It can also

158 be distracting, excruciating, and anxiety-provoking as I think about my own child’s vulnerability” (p. 114).

Basescu’s reaction brings up the issue of transference and countertransference, which is alluded to in my study, but not addressed using those terms. Instead, I asked whether participants felt they experienced changes with their work after becoming mothers, and although they did not shift in terms of their orientations or methodology, there were, a la Basescu, changes in thoughts feelings, and attitudes toward clients.

According to Basescu, “There can be feelings of comraderie and shared pleasure and pain, feelings of competitiveness . . .” (p. 114). These feelings speak to the shift in identifications on the part of the clinician/mother from the child to the parent and include greater empathy, compassion and understanding of the complexity of family life. Along with increased tolerance for parental behavior, my participants shared that they sometimes experienced, though to a lesser degree, greater difficulties in tolerating negative or harmful parental behaviors. Basescu recognizes that, “the immersion in family life and parent-child relations at home can inform one’s understanding of transferences and countertransferences at the office” (p. 103). Her thinking matches well with the responses from my study as she clearly articulates the continuous interplay between the dual roles and identifies the varying countertransference responses. Basescu writes that, The most troubling countertransference arises when I feel something in a patient’s parenting is wrong or damaging or abusive . . . I more often feel my patients are too hard on themselves, or they are honestly struggling with a difficult issue . . . (p. 114).

159 The Myth of the Untroubled Therapist (2014) by Marie Adams, is based on her study of 40 psychotherapists regarding the relationship between their personal and professional lives. Although it is not specifically about mother/clinicians, and includes men as well as women, there are numerous observations that coincide with my findings.

Adams’s work is more of a presentation of her thinking than a reporting of data. The areas that relate to my thinking and data have to do with her understanding of the personal motivations underlying the choice of clinical work and both the positive and the negative consequences of being a parent and a clinician.

First, Adams articulates the validity of researching and writing about the clinician’s personal life. She believes that, We cannot leave our experiences outside the room. Even if not at the foreground of our minds, our tensions and pleasures, the rumbling envies and unresolved issues of archaic experience, are always with us (p. 2) Thus, she takes on the canard of the “fully analyzed” clinician, i.e. the therapist who is “often expected to be immune to the kind of problems that they help clients through” (p. 1). As indicated by my data, this expectation is as likely to be held by the clinician herself, as well as imagined as coming from the client or lay population. One of my participants, Lucy, assumed she would be better prepared to parent than a layperson, saying: “I think before my first was born I imagined it [being a therapist] would be helpful, and maybe it is . . . but in the throes of infanthood it was not helpful because I was panicked.” Touching on the desire that clinicians have to meet a sometimesunrealistic ego ideal, Adams says, “Perhaps we want to be seen as having conquered

160 life’s traumas, proving somehow that therapy works. If we can embody that success, we can prove to ourselves and others that what we do for a living has validity” (p. 7).

The theme of healing emerged from my data and it was also present in Adams’s discourse. Several of my participants shared that being a clinician/mother gave them the opportunity to heal from their own childhood traumas. In the performance of their maternal or professional roles they were able to redress the negative experiences from the past. Ella experienced this in a powerful way, sharing that, “Being a mother has been able to help me mother myself and to teach other people to do it. And I did not inflict the same trauma on my child as has been done to me.” This would lend support to Adams’s claim that, “We may work to help others, but our main, unconscious objective may be to save ourselves” (p. 8). Whether in the office or at home, the act of being able to “redo” experience via motherhood or clinicianhood can be powerful. Adams considers motherhood as “transformational,” but recognizes that it does not always result in positive feelings and empathy for clients. Again, this supports the duality that emerged in my findings regarding the “pros and cons” of being a clinician/mother.

Regarding the various motivations for becoming a psychotherapist, Adams gives space to the shadow side; those unconscious narcissistic aims that depend on gratification from clients that may adversely affect the psychotherapeutic relationship. She shares a personal insight into this dynamic, stating that, I am entirely human, and I bring with me every single day into the therapy room a wealth of imperfections. How I use my humanity is up to me, hopefully in the service of my clients, but sometimes it is bound to interfere. Like most people, I sometimes want to be seen as better than I am (Adams, 2014, p. 3).

161 Her observation also relates to the difficulties that some of my participants experienced when faced with abusive or neglectful parents. Although on the whole they felt a deeper understanding and empathy for their clients, this was occasionally tested by their knowledge of how much children are affected by a mother’s perceived lack of competence in providing physical and emotional care. While they may have experienced some negative feelings toward “harmful mothers” before becoming a parent themselves, those feelings and a concomitant critical attitude can be amplified after becoming a mother. Adams identifies this effect commenting that, “What might promote a deeper capacity for empathy, may also evoke sadistic tendencies” (p. 30). Those “sadistic tendencies” may serve as a partial explanation for the competitive and judgmental attitudes at play in the tendency, both on an individual and societal level, that leads to mother-blaming.

Although a synopsis of the humorously titled, “Listening to Your Patients, Yelling at Your Kids” (1995), by Susan Scholfield MacNab is included in Chapter Two, I decided to return to describe it in greater detail after parsing my data. MacNab writes about the interaction between her experience of being a psychotherapist and a mother.

Her self-reflections demonstrate the formidable positives and negatives that align with those that emerged from my data and are the result of the interplay between these dual roles. Overall, clinical education and training are experienced as helpful in parenting and in understanding clients, while high expectations and a desire to be better than “good enough” accentuate worry and self-doubt.

MacNab identified aspects of her clinical thinking that she experienced prior to and after becoming a mother. Before becoming a mother, she thought that it was “easier

162 to join the patient in his or her blaming of parents,” and that she had a “more linear and simplistic understanding of human development” (p. 40). These observations closely resembled the comments made by my participants as described in Chapter Four. For instance, Taylor acknowledged: For me personally it’s made a huge, huge difference in terms of my empathy, my ability to truly understand what parents are going through, what kids go though at every developmental stage . . . I think I am much, much less judgmental . . .

After becoming mothers, the tendency to identify more easily with children shifted, and the participants, like MacNab, became more understanding of the complexities of family relationships, finding it easier to identify and empathize with parental figures.

MacNab also held the expectation that she should be “near perfect” as a mother, echoing the high standards that the clinician/mothers in this study expressed. This striving for near perfection is partially derived from the fear of unknowingly inflicting harm. The issue of unintended harm emerged from my data and was repeated in MacNab’s observation that, I continued to be unwilling to be just a ‘good enough’ parent. This was particularly unacceptable because my patients’ stories suggested that what one might assume was ‘good enough’ was nowhere near it. They complained that their talents were not fully developed, and their familial relationships were often permeated with conflict, blame, and guilt. Many of my adult patients seemed to have many regrets and little peace. I wanted to spare my children such struggles and this stunted potential. All of this made it very hard not be overinvested in

163 having an intensely empathic understanding of my children that, I thought, would keep them happy (pp. 41-42).

The high expectations held by clinician/mothers are mirrored in Macnab’s belief that she had, “an inside track on parenting,” because of her own personal psychotherapy and because she was a clinician (p. 38). She elaborates the origins of this high ideal in the following statement: Some of my unrealistic expectations originated, not in personal family experiences, but from distortions that grew during my two decades of psychotherapy practice and several years of my own psychotherapy and psychoanalysis. Psychodynamic theories focus intensely on the pernicious influences of mothers and fathers, or their emotional and physical absences. The therapist encourages the patient to explore the roots of painful feelings and their early childhood origins. Destructive patterns are often traced to the frightening, angry, unfeeling or humiliating ways that patients experience their parents. We may have moved away from mother blaming—but not far enough (p. 41).

MacNab concludes that there is a direct connection between theoretical principles that overly emphasize maternal influence and the ego ideal that she struggled to achieve.

Thus, MacNab links the mother-blame as a social and personal phenomenon to theory.

One interesting note is that MacNab experienced a novel form of countertransference infrequently mentioned by my participants, i.e., that patient complaints about their parents made her question her behavior with her own children (p.

38). She would reflect for hours about the impact of her behavior, wondering if she had erred in the very same ways cited by her clients. Another change she noticed was that

164 despite being psychodynamically oriented, that the provision of “real support” was as important for new mothers as some of the other verbal interventions she employed in her practice of psychotherapy (p. 39). Her description of “real support” is somewhat lacking, as she only refers to questions or comments that she might make regarding the new mother’s experience. There is no verbatim exchange and it is hard to know specifically how that support differs from her usual therapeutic discourse. Perhaps support refers to concrete suggestions as well as the clinician’s increased willingness to share more personal experiences with clients. The latter certainly emerged from my interviews as a common response to becoming a mother.

MacNab identifies physiological difference as one of the factors overlooked by clinicians. She declares that, the physiological differences among children may be obscured by an overreliance on psychological theories to explain everything about children’s needs and behaviors. With the birth of our second child, who was a more difficult baby and child, I was brought face to face with the power of physiological differences (p.

40) The recognition of physiological differences enabled MacNab to understand more fully some of the “negative” maternal behaviors that had an impact on her clients. She gives the example of an adult client who was not diagnosed with attention deficit disorder until later in life and how this helped her to understand why she may have been so impatient with her son.

MacNab references the issue of psychotherapy and its resemblance to a specialized form of maternal care. The comparison between psychotherapy and

165 mothering has long been part of clinical vernacular (Bueskens, 2014; Firestone, 2010).

For example, psychotherapy has been called by some a “corrective emotional experience,” (Alexander & French, 1946), one in which the therapist, like the mother, supplies the self-object functions that were missing or disordered in the upbringing of the client. These functions are restored in the clinical relationship through the person of the psychotherapist acting as the “good mother.” Although there are similarities in the competencies held by clinicians and mothers, MacNab finds it useful to differentiate the two in an effort to modify her high expectations of herself in the maternal role. The expectation that she performs at home similar to way that she does in the office can be counterproductive. MacNab recognizes the following differences between the two roles.

She has a therapeutic agreement with her patients, but not with her children; she notes that, “being a participant and observer in therapeutic change . . . gives me opportunities to feel more competent, more compassionate and more knowledgeable than in everyday family life,” she is able to be “a more consistent listener” in the office, recognizing that “family life seems to move at a more unpredictable pace than therapeutic work,” and has learned “ to respect the resistances, fears, and differences in my children” appreciating that this “is a greater challenge than understanding and responding to these issues in clinical work” (p. 43). MacNab’s recognition of the ways in which family life is different, combined with a less controlled setting and a therapeutic contract, remind her how challenging childrearing can be. This enables her to be more compassionate with herself, thereby modifying her expectations of herself as a mother. This may prove to be a useful exercise for clinician/mothers who are also besieged by the demands of an unrealistic ego idea.

166

The clinician/mother: Universal experiences.

The seven and a half pages of MacNab’s writing is one of the shortest pieces reviewed for this study, yet it contained the most examples of thinking that matched those of my participants. Even her final words closely mimic one of the participant’s quotes. In her summation MacNab states, “I also believe that my clinical work brings important knowledge to my family life; that is, the inevitability of suffering and the immense healing capacities of compassion for myself and my family” (p. 44). Likewise, one of the participants in this study, Ava, stated, I can meet with people who have traumas like mine or who have stories that are not mine but have deep sorrow about the journey of their lives. And as I continue to travel on mine, I respect my patients more than I think I ever could have. I think my patients are very lucky for my troubles and also, just for my parenting.

From these two quotes, similar in outlook and depth of feeling, the major connection between the literature and this study emerges; namely, the universality of experiences and responses that clinician/mothers are subject to in their dual roles.

Motherhood and clinicianhood set the groundwork for profound encounters with the individual’s self-regard, strengths, limitations, and capacity for growth. Being a clinician both enhances and supports the experience of being a mother, while simultaneously elevating the sense of risk and apprehension in the performance of that role. Being a mother adds depth of knowledge and empathy to the clinician, increasing the flexibility of her belief system, while shifting her identifications and sensitizing her to the nuances in her clients’ developmental experiences. Mother-blame has a role to play in this too;

167 whether it is derived from theory, social conditions, gender discrimination or internalizations based on personal experience, its residual effects were acknowledged by all but one of this study’s participants.

Unexpected Findings There was one participant in my study who became a clinician after motherhood and I did not find that any of her responses could be attributed to that one difference. I had originally thought that being a clinician would demonstrate more clearly the impact of being a professional on the personal experience of being a mother, but this was not the case. Also, unexpectedly, I found that psychoanalytic/psychodynamic theory did not have the dominant place in the participants’ education and training, as it had in mine. That orientation had been superseded by other approaches. The participants mentioned some of these theories, but they were not necessarily central to the clinician/mother’s experience.

Conclusions In this examination of the interrelationship of the clinician/mother roles, I explored the issue of mother blame, curious whether its continuing presence in our culture had any effects on clinician/mothers. Specifically, I wondered how mothers think and feel about their mothering in a culture that often fails to provide the necessary holding environment for them. How can we, in the helping professions, avoid a blaming mentality in our thinking and approaches to understanding and treating our clients?

168 My thoughts regarding these key questions were adroitly addressed by Dr. Alicia Lieberman, a professor and researcher in trauma and infant mental health at the University of California, San Francisco (personal communication, 8/17/20). She offers three suggestions to remedy the mother-blame attitude in our culture and counteract the therapists’ tendency to blame. First, she recommends understanding the role of the intergenerational transmission of trauma, second, she favors a multidisciplinary approach for assessment and treatment, and lastly, she advocates for the pursuit of social justice.

Inclusion of the intergenerational transmission of trauma supplies a context that goes beyond the individual’s personality traits and history, providing a fuller picture of the factors that have contributed to their current situation. A multidisciplinary approach offers a safeguard from the danger of becoming ideologically entrenched in a “one size fits all” manner of assessment and treatment. Lastly, attention to social justice recognizes and works to ameliorate the socio-cultural obstacles that interfere with human health and well-being. These recommendations can serve as a guide to clinicians and the culture-atlarge in reframing the ways that have shaped our single-minded focus on mothers and tendency toward blame.

It has been a privilege to be allowed entrée into the personal and professional lives of the participants. This has given me the opportunity to consider the various responses to the question of interconnectedness and influence between their dual roles, and how their experiences mimicked or differed from each other and my own. The motivation for this study originated in my personal and professional history and the curiosity I harbored regarding the experiences of my peers. Adams (2014) writes that, “Therapists are created, not born, and it is through our histories that we find ourselves

169 unconsciously gravitating, by whatever route, towards the profession” (pp. 125-6). This proved to be validated by the data as the choice of being a clinician was most often related to something significant in their personal histories. While theories contain our best understandings of human behavior and emotion at a particular point in history, they cannot fully represent the nuances and vagaries of real lived experience. The interviews suggest that as clinicians gain experience in life, the opportunity to use theoretical understanding in a more fluid way becomes possible. This is unsurprising given the evolution of thinking and accumulation of knowledge regarding human development, emotion and behavior.

Limitations The small sample size requires caution in attributing findings to any specific individuals or groups of clinician/mothers. Thus, the study cannot claim to be representative of the range of ethnicities that comprise the practitioners of clinical work, nor does it represent the contributions of minority perspectives to the field.

Suggestions for Further Research I have mentioned the necessity for recognizing the influence of dominant cultural voices, this study, but did not specifically seek out and feature the voices of underrecognized socio-economic groups of clinician/mothers. Future studies having this specific focus could provide a fuller picture of the various ways in which women are affected in these two roles.

170 I did not directly inquire about the nature of the clinician/mother’s relationship with her own mother, but this was brought up spontaneously by participants and would be an interesting area to pursue. Participant references to these relationships were focused on deficits, leading to the question, what role does the transmission of intergenerational trauma play in becoming a clinician negative is more easily accessed than the positive?

Woundedness, broadly speaking, if its traumatic effects are adequately dealt with, can also function as a source of growth and creativity. Another possibility is that fraught mother/child relationships are disproportionately represented in the clinician population.

That begs a line of inquiry beyond this study.

Another intriguing issue that surfaced during the interviews was the dynamic between a non-clinician parent and their clinician partner/spouse. How does being an “expert” in human psychology and behavior affect the couple in their parenting roles?

Does the non-clinician cede authority to the psychotherapist mother, and if so, how does that play out in terms of the balancing the couple’s responsibilities and sense of efficacy as a parent? What is it like to be in a personal relationship with a clinician in general?

What advantages and disadvantages result?

Recognizing that the clinician/mother interrelationship is meaningful, future studies might explore how to apply this knowledge to redress the biases that have shaped our approach to assessment, diagnosis, and treatment. The valuable insights expressed by clinician/mothers can thus be employed on behalf of the profession, but also on behalf of all mothers.

171

172

Appendix A

Interview Guide

173 Interview Guide Thank you for meeting with me and participating in my research. I am going to record our interview which should last anywhere from 60-90 minutes. We can take breaks as needed and if anything being discussed becomes problematic for you please let me know so we can pause and address it.

I would like to briefly go over the issue of informed consent and confidentiality.

(Have participant sign Informed Consent Form) I have both a professional and personal interest in the topic at hand. As a clinician and a mother, I am sensitive to the ways the maternal role has been viewed in the theory and practice of psychotherapy. So much has been written about mothers, but without the benefit of their actual lived experience. What is it like to be a clinician and later, become a mother? How does one experience influence the other? This is my interest in interviewing you today, to hear about your thoughts related to your own experience of being a clinician and a mother.

Professional Education and Training Can you talk about your educational experience, when did you decide to become a psychotherapist? What do you think led you to choose your profession?

What kind of theories or training were you exposed to?

What ideas have been most influential in your development as a psychotherapist?

Are there any theories or approaches which you have found problematic, and if so, can you talk about what you found objectionable and why?

How would you describe your current theoretical orientation or stance regarding diagnosis and treatment?

174 The Clinician Thinks about Motherhood/the Maternal Role When I was growing up, I remember playing the role of mother with my dolls and later thinking that I would have six children when I got married! What do you recall of any childhood or adolescent thoughts or feelings you had about being a mother or motherhood? How did becoming a clinician impact your thinking or feelings about motherhood?

What did you look forward to about becoming a mother? Can you talk about any concerns you might have experienced when thinking about becoming a mother? (such as physical changes, work-life balance, status in society, etc.)

The Contributions of the Role of Clinician to the Subjective Experience of Becoming a Mother In what ways do you think your education, training and practice experience have had an effect or multiple effects, positive or negative on your experience of mothering?

What has been most helpful in being a clinician to your personal experience of being a mother?

Has there been anything about being a clinician that has made your personal experience of motherhood more challenging?

The Contributions of the Role of Motherhood to the Subjective Experience of Being a Clinician

175 I am interested in learning how your experience of motherhood may have influenced your ideas about child development. How has being a mother informed your understanding of childhood, of parenting?

Can you talk about how being a mother has affected how you respond to mothers and mothering (parenting) issues in your practice? how do you think you were affected as a clinician after becoming a mother?

Mother-Blame Is the term mother-blame familiar to you? If so, what does it mean to you? If this term is unfamiliar to you, what do you think it might refer to? Has it been a factor in your experience of being a clinician or a mother?

Final Thoughts Was there anything I did not ask or cover in our discussion that you would like to add?

How was it for you to discuss these issues today?

176

Appendix B

Sample Recruitment Letter: Mail and Email to Personal Contacts

177

Dear ______________________________, In order to complete my doctoral studies with the Sanville Institute for Clinical Social Work and Psychotherapy, I am embarking upon the final phase of my PhD, a qualitative study entitled, The Subjective Experience of Clinician/Mothers. I am contacting you to request your help in obtaining participants for this study.

The primary focus of my research is to explore the relationship between the experience of being a clinician and a mother. I’m interested in what effects clinician/mothers believe their experience of motherhood and of being a psychotherapist have had on one another.

Participation consists of a 60-90 minute face-to-face semi-structured interview.

Participants will be asked to describe their experience of being/becoming a psychotherapist and their experience of motherhood. All participants should be licensed and have a minimum of 5 years clinical experience. I am seeking individuals who became mothers after working as therapists.

All measures will be taken to insure confidentiality of the participant and any identifying material they share about themselves or others.

If you know anyone who might be interested I may be contacted by email: gerigold@yahoo.com or by telephone (650) 369-9309. I am also willing to contact potential referrals directly if that is desired.

Thank you for your consideration of my request.

Sincerely,

Geri Goldmann, LCSW Doctoral Student, The Sanville Institute

178

Appendix C

Recruitment Posting for Listserv/Professional Publications/Newsletters

179

Request for Research Participants Given the centrality of the maternal role in clinical theory, I am interested in exploring what has been the actual lived experience of women who are clinicians and later became mothers? What has each role brought to the other?

Seeking licensed individuals (LCSW, MFT, PhD, PsyD, MD) with 5 years clinical experience for a study on the reciprocal effects being both a clinician and a mother. The study is aimed at understanding how these two roles have affected one another and will consist of a brief screening phone call and a 60-90 minute face-to-face interview. All measures will be taken to insure confidentiality.

If interested, please contact Geri Goldmann, LCSW, doctoral candidate at The Sanville Institute for Clinical Social Work and Psychotherapy at (650) 369-9309 or gerigold@yahoo.com.

180

Appendix D

The Sanville Institute Informed Consent Form

181

I, _____________________________________________ hereby (print name of research participant) willingly consent to participate in the study: An Exploration of the Subjective Experience of Clinician/Mothers.

This doctoral research project will be conducted by Geri Goldmann, LCSW under the direction of Sylvia Sussman, PhD, Principle Investigator and faculty member, Whitney van Nouhuys, PhD, and under the auspices of The Sanville Institute.

I understand that my participation in this study will involve the following: A brief introductory phone call to determine my eligibility for the study. I will participate in one or two 60-90 minute audio-recorded interviews which will be conducted in a private, confidential setting to be arranged between the researcher and participant. I will be discussing my experience as a mother and clinician and the impact of these two roles on each other. I am aware that I am only required to share what I determine. I am aware that these audiotapes may be transcribed by a service and that the researcher will strive to omit any identifying information on the recorded interview. I am aware that the audiotape will have an identifying number rather than my name. The researcher will use numbers instead of names for data analysis and reporting of results.

A brief follow-up phone call may be necessary for any clarification.

I understand that the potential risks and benefits of my participation are as follows: I am aware of the time requirements for the interview and any potential follow up. I understand that a discussion of my subjective experience may elicit issues or feelings of which I was unaware and that might evoke some emotional discomfort.

To minimize these risks, the Researcher will make every effort to conduct the interview in a comfortable and private setting. The Researcher will advise the Participant of the time required for participation and the order and manner in which the interview may proceed. If the Participant experiences any discomfort during the interview, the Researcher can pause the interview and collaborate with the Participant through a discussion to find a solution.

If I experience emotional discomfort during the interview, I will advise the Researcher so that appropriate steps can be taken to collaboratively resolve this. If I have any misgivings or discomfort post interview from my participation, I may contact the Researcher for assistance in dealing with these residual effects together and/or by receiving a referral to a therapist or other appropriate resource if desired.

Potential benefits to participation may include: The opportunity to think about and explore this topic may result in increased sense of clarity and appreciation for one’s

182 experiences. In addition, the Participant may gain a sense of satisfaction by making a contribution to understanding the interplay of these two very important roles in a woman’s life.

I understand that my participation in this study is completely voluntary and that I may withdraw from the study at any time by doing the following: I may stop the process at any time during the project by informing the researcher that I would like to withdraw.

I understand that this study is being conducted as a qualitative research dissertation. My information and any information pertaining to other persons I might discuss will be treated as confidential and all persons will remain anonymous. This confidentiality and anonymity will extend to any future article, presentation, published or unpublished work that is derived from this research. The Researcher will require that any naming of clients be disguised through the use of pseudonyms and identifying details also be disguised to ensure anonymity and confidentiality. In situations in which detailed scenarios could potentially provide identifying information, those descriptions may be summarized to preserve anonymity and confidentiality. The audio-recording of my interview will be erased six months after completion of the dissertation. Only the Researcher, the Principle Investigator the additional members of the Dissertation Committee, and Transcriber will have access to the oral interview.

I understand that my anonymity will be protected unless I give specific written consent for disclosure. This applies whether or not the study is published.

INFORMED CONSENT FORM My signature below indicates that I have read the above explanation about my participation in this research study, that I understand the procedures involved and that I voluntarily agree to participate.

Participant Name: _________________________________________ Participant Signature: ______________________________________ Date: _______________

Researcher Name: ________________________________________ Date: _______________ Researcher Signature: _____________________________________ Date: _______________ ___________________________________________ ____ If you would like a copy of the results of this study, please provide your name and address:

183 Name____________________________________________ Address__________________________________________ Email __________________________________________

184

Appendix E

Prospective Participant Questionnaire

185

Name: _______________________________________________________ Address: ______________________________________________________ Email: _____________________________________________________ Phone: Home___________________ Cell____________________ Work________________ Preferred method to reach you: _________________________ I volunteer to participate in the study, The Subjective Experience of Clinician/Mothers and would be available for the 60 to 90 minute face-to-face interview.

Yes______ No_______ Number of years practicing psychotherapy: (minimum of 5 years) _______________________ Professional License: ________________ Year of Initial Licensure: ____________________ Name of Graduate School and Degree: ___________________ Year Graduated: ____________ The study requires that the participant be a practicing psychotherapist prior to becoming a mother. Do you meet this requirement? Yes: _________________ No ____________ Are you willing to discuss your background and educational experience as a clinician as well as your personal experience of motherhood and how those two roles may have affected one another?

Yes: __________________ No: ________________ Need more information: _______________ Marital Status: _________________ Number of Children (living at home full or part-time):__________________ Ages of Children: _______________________

186 Thank you for your interest in participating in what I hope will be a worthwhile experience. I will contact you shortly regarding the possibility of your participation. You may contact me at gerigold@yahoo.com or (650) 369-9309 if you have any questions.

Best Regards, Geri Goldmann, LCSW, Doctoral Student, The Sanville Institute

187

Appendix F

Sample Letter/Email for Prospective Participants

188

Dear_________________________, Thank you for your interest in participating in my doctoral research on The Subjective Experience of the Clinician/Mother. Or: I am reaching out to you today at the suggestion of _____________________ as a potential participant in my doctoral research on The Subjective Experience of the Clinician/Mother.

This study is being conducted for the completion of my doctorate through The Sanville Institute for Clinical Social Work and Psychotherapy and under the auspices of Principal Investigator and faculty member, Sylvia Sussman, Ph.D. and Whitney Van Nouhuys, Ph.D., faculty member.

I am seeking individuals who are licensed psychotherapists (LCSW, MFT, PhD, PsyD, MD), have a minimum of 5 years clinical experience and became mothers after becoming a practicing psychotherapist. Given the focus on the contributions of the maternal role/relationship to healthy or compromised child development, what can the actual lived experience of clinician/mothers contribute to our clinical concepts and practices? This is a topic about which little is written, so your participation would provide a valuable contribution.

Participation involves the following: Filling out and returning the attached questionnaire to determine eligibility; if accepted, scheduling a brief phone call to answer any of your questions about your participation and arrange the time and location of the in-person interview. There may also be a brief follow-up telephone call post-interview if clarification of the interview material is needed.

Please review the enclosed Consent Form. I will also review this form at the time of the face-to-face interview and ask you to sign it. I will take measures to ensure the anonymity and confidentiality of any of your identifying information or any that is discussed in the interviewed. This is applicable to the actual dissertation, and includes any future presentations or publications based on this interview. If you might wish to discuss clients, please use pseudonyms and disguise any identifying information.

Please complete and send the attached questionnaire via regular or email as soon as possible. gerigold@yahoo.com or 152 King Street, Redwood City, CA 94062. (650) 3699309 Again, thank you for your time and interest.

Sincerely, Geri Goldmann, LCSW, Doctoral Student, The Sanville Institute

189

Appendix G

Sample Letter/Email for Prospective Participants Ineligible for the Study

190

Dear ____________________________, Thank you for your interest in my research on the Subjective Experience of Clinician/Mothers. I am pleased to say that I have the requisite number of eligible participants and therefore will not be scheduling any more interviews at this time. OR: I am sorry that you do not meet the criteria for my study (state which criteria) and thank you for responding to my request for participants. If you would like a summary of my findings, please feel free to contact me at gerigold@yahoo.com or leave a message at (650) 369-9309.

Again, I appreciate your responding to my request for participants.

Best Regards,

Geri Goldmann, LCSW Doctoral Student, The Sanville Institute

191

Appendix H

Re-Consent Information Letter

192 Dear Thank you for participating in my qualitative research dissertation on The Subjective Experience of the Clinician/Mother. I sincerely appreciate your participation and I am working on the final three chapters. I hope to complete the study within a year’s time. I am writing to apprise you of a change which I may have mentioned to some of you at the time of our interview, namely, that I have transferred my doctoral studies to the Chicago Institute for Clinical Social Work (ICSW). This has come about due to a recent change in California legislation under which Sanville Institute, after 45 years of service to the community and the profession, had to close its doors.

This qualitative research dissertation is still being conducted under the auspices of Principal Investigator, Sylvia Sussman, Ph.D., one original committee member, Whitney Van Nouhuys, PhD. and ICSW faculty.

In order to meet ICSW’s accreditation requirements I am asking that you sign this revised consent form. ICSW has an in-house Institutional Review Board with a Federal Wide Assurance (FWA). A Federal Wide Assurance is the documentation of an institution’s commitment to comply with federal regulations and maintain policies and procedures for the protection of human research participants.

An institution must have an FWA in order to receive Department of Health & Human Services (DHHS) support for research using human participants. This is the principal mechanism for compliance oversight by the Office for Human Research Protections. The FWA number for ICSW is IRB0007789 and valid through 10/12/2021. If further interested, their profile can be viewed at http://ohrp.cit.nih.gov/search/IrbDtl.aspx .

Minimal changes were made by the ICSW IRB panel to my original application and consent form. The panel designated my study at below minimal risk.

To use your interview and complete my study, I must receive the attached consent form. If you have any questions regarding this change you may contact me directly or call Dr. John Ridings, ICSW IRB Chair, at (773) 263-6225 Please review the enclosed Consent Form. I will take measures to ensure the anonymity and confidentiality of any of your identifying information or any that is discussed in the interview. This is applicable to the actual dissertation, and includes any future presentations or publications based on this interview. If you might wish to discuss clients, please use pseudonyms and disguise any identifying information.

Please complete and send the attached questionnaire via regular or email as soon as possible to gerigold@yahoo.com or 152 King Street, Redwood City, CA 94062. (650) 369-9309 Again, thank you for your time and interest.

Geri Goldmann, LCSW, Doctoral Student, Institute for Clinical Social Work

193

Appendix I

Re-Consent Form

194

Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research The Subjective Experience of the Clinician/Mother I, ______________________________________, acting for myself, agree to take part in the research entitled An Exploration of the Subjective Experience of Clinician/Mothers This qualitative research dissertation will be conducted by Geri Goldmann, LCSW under the direction of Sylvia Sussman, PhD, Principle Investigator, Whitney van Nouhuys, PhD, and under the auspices of the Institute for Clinical Social Work (ICSW), Robert Morris Center, 401 South State Street, Suite 822, Chicago, IL 60605 (312) 935-4232.

PURPOSE: This grounded theory research dissertation explores the interaction between a woman’s experience of her dual identities as a clinician and a mother with a particular interest in the topic of mother-blame as a cultural phenomenon. Data will be collected during single in-person or online interviews from seven licensed psychotherapists who became mothers after 5 years of clinical experience.

I understand that my participation in this study will involve the following: A brief introductory phone call and/or email to determine my eligibility for the study, filling out and returning the attached questionnaire to determine eligibility; I will participate in one 60-90minute audio-recorded interviews which will be conducted in a private, confidential setting to be arranged between the researcher and participant. I will be discussing my experience as a mother and clinician and the impact of these two roles on each other. I am aware that I am only required to share what I choose. I am aware that these audiotapes may be transcribed by a service and that the researcher will strive to omit any identifying information on the recorded interview. I am aware that the audiotape will have an identifying number, letter or combination thereof, rather than my name. The researcher may use pseudonyms instead of actual names for data analysis and reporting of results.

A brief follow-up phone call may be necessary for any clarification.

I understand that the potential risks and benefits of my participation are as follows: I am aware of the time requirements for the interview and any potential follow up. I understand that a discussion of my subjective experience may elicit issues or feelings of which I was unaware and that might evoke some emotional discomfort.

To minimize these risks, the Researcher will make every effort to conduct the interview in a comfortable and private setting. The Researcher will advise the Participant of the time required for participation and the order and manner in which the interview may proceed. If the Participant experiences any discomfort during the interview, the Researcher can pause the interview and collaborate with the Participant through a discussion to find a solution.

If I experience emotional discomfort during the interview, I will advise the Researcher so that appropriate steps can be taken to collaboratively resolve this. If I have any misgivings or discomfort post interview from my participation, I may contact the Researcher for assistance in

195 dealing with these residual effects together and/or by receiving a referral to a therapist or other appropriate resource if desired.

Potential benefits to participation may include: The opportunity to think about and explore this topic may result in increased sense of clarity and appreciation for one’s experiences.

In addition, the Participant may gain a sense of satisfaction by making a contribution to understanding the interplay of these two very important roles in a woman’s life.

I understand that my participation in this study is completely voluntary and that I may withdraw from the study at any time by doing the following: I may stop the process at any time during the project by informing the researcher that I would like to withdraw.

I understand that this study is being conducted as a qualitative research dissertation. My information and any information pertaining to other persons I might discuss will be treated as confidential and all persons will remain anonymous. This confidentiality and anonymity will extend to any future article, presentation, published or unpublished work that is derived from this research. The Researcher will require that any naming of clients be disguised through the use of pseudonyms and identifying details also be disguised to ensure anonymity and confidentiality. In situations in which detailed scenarios could potentially provide identifying information, those descriptions may be summarized to preserve anonymity and confidentiality.

The audio-recordings of my interviews will be erased six months after completion of the dissertation. The transcripts will be destroyed six months after completion of the dissertation.

Only the Researcher, the Principle Investigator the additional members of the Dissertation Committee, and Transcriber will have access to the oral interview.

I understand that my anonymity will be protected unless I give specific written consent for disclosure. This applies whether or not the study is published.

INFORMED CONSENT FORM My signature below indicates that I have read the above explanation about my participation in this qualitative research dissertation, that I understand the procedures involved and that I voluntarily agree to participate.

Participant Name: _________________________________________ Participant Signature: ______________________________________ Date: _______________ Researcher Name: ________________________________________ Date: _______________ Researcher Signature: _____________________________________ Date: _______________ _______________________________________________

196 If you would like a copy of the results of this study, please provide your name and address: Name/Address/Email______________________________________________________ ___

197

Appendix J

Signatures for Re-Consent

198 For the Subject I attest that I have been given a letter that explains the changes made to Geri Goldmann’s IRB application. I have read and understand the contents of the letter. (must respond)

Yes: _____ No: ______ I understand that I am reconsenting into this study under the auspices of the Institute for Clinical Social work and give full permission to Geri Goldmann to use any data previously collected by her prior to her affiliation with the Institute for Clinical Social Work. (must respond) Yes: _____ No: ______ Would you like a summary of the results of this study?

Yes: _____ No: ______

I have read this consent form and I agree to take part in this study as it is explained in this consent form.

Participant Name: ____________________________________ Participant Signature: _________________________________ Date: _____________ For the Primary Researcher I certify that I have explained the research to _____________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Researcher Name: ___________________________________ Researcher Signature: ________________________________ Date: _________

199

References

Adams, M. (2014). The myth of the untroubled therapist: Private life, professional practice. New York, NY: Routledge.

Ades, R. (2016). Winnicott: the ‘good-enough mother’ radio broadcasts. Oxford University Press blog. Retrieved from https://blog.oup.com/2016/12/winnicottradio-broadcasts/ Aidenbaum, A.M. (2014) Mother-blaming and the rise of the expert. Retrieved from https://michiganjournalhistory.files.wordpress.com/2014/02/aidenbaum_ ashley.pdf Ainsworth, M. D. S., Bihar, M. C., Waters, E., & Wall, S. (2015). Patterns of attachment: a psychological study of the strange situation. Hillsdale, NJ: Erlbaum. (Original work published in 1978).

Alexander, F. & French, T. M. (1946). Psychoanalytic therapy: Principles and application. New York, NY: Ronald Press.

Ambert, A. M. (1992). The effect of children on parents. Binghampton, NY: The Haworth Press.

Aries, P. (1962). Centuries of childhood: A social history of family life. New York, NY: Vintage Books.

200 Balsam, R. H. (2016). The war on women in psychoanalytic theory building. Retrieved from file:///Users/gerigold/Downloads/balsampages83-107.PSOC-69_MASTER61.pdf Bartky, S. L. (1990). Femininity and domination: Studies in the phenomenology of oppression. Abingdon, OX: Routledge.

Basescu, C. (1996). The ongoing, mostly happy “crisis” of parenthood and its effects on the therapist’s clinical work. In B. Gerson (Ed.), The therapist as a person: Life crises, life choices, life experiences, and their effects on treatment. (pp. 101-117).

Hillsdale, NJ: The Analytic Press.

Beebe, R. & Lachmann, F.M. (2002). Infant research and adult treatment, New York, NY: The Analytic Press.

Benjamin, J. (1988). The bonds of love: psychoanalysis, feminism, and the problem of domination. New York, NY: Pantheon Books.

Benjamin, J. (1995). Like subjects, love objects. New Haven, CT: Yale University Press.

Benjamin, J. (1998). Shadow of the other. New York, NY: Routledge.

Bennett, S. S. & Indman, P. (2006). Beyond the blues: A guide to understanding and treating prenatal and postpartum depression. San Jose, CA: Moodswings Press.

(Original work published 2003).

Berzoff, J. (2004). Psychodynamic theory and the psychology of women. In Berzoff, Flanagan, J. M. & Hertz, P. (Eds.), Inside out and outside in: psychodynamic clinical theory and practice in contemporary multicultural contexts.(pp. 247-260).

Lanham, MD: Rowman and Littlefield. (Original work published 1996).

201 Bettelheim, B. (1967). The empty fortress: Infantile autism and the birth of the self. New York, NY: The Free Press.

Bollas, C. (1989). The shadow of the object: psychoanalysis of the unthought known.

New York, NY: Columbia University Press.

Bowlby, J. (1982). Attachment: attachment and loss: Volume one. New York, NY: Basic Books. (Original work published 1969).

Bowlby, J. (1973). Separation: Anxiety and anger. New York, NY: Basic Books.

Bowlby, J., Robertson, J. & Rosenbluth, D. (1952) A two-year-old goes to hospital. The Psychoanalytic Study of the Child. 7 (1), 82-94.

Brown, L. (1990).What female therapists have in common. In D. Canon (Ed.), Women as therapists: A multitheoretical casebook. (pp. 227-242). New York, NY: Spring Publishing.

Bruer, J. (4/19/2016). Inside the teenage brain. Frontline. PBS. Retrieved from: http://www.pbs.org/wgbh/pages/frontline/shows/teenbrain/interviews/bruer. html Bueskens, P. (2014). Mothering and psychoanalysis: Clinical, sociological, and feminist perspectives. Bradford, ON: Demeter Press.

Campling, P. (1992). On being good enough, bad enough, and never getting it right—a comparison of motherhood and the experience of working in a therapeutic community. Therapeutic Communities. 13 (2), 73-81.

Caplan, P. J. & Hall-McCorquodale, I. (1985). Mother-blaming in major clinical journals.

American Journal of Orthopsychiatry. 55 (3), 345-353.

202 Caplan, P. J. & Caplan, B. J. (1994). Thinking critically about research on sex and gender. New York, NY: Harper Collins.

Caplan, P. J. (2000). The new don’t blame mother: Mending the mother-daughter relationship. New York, NY. Routledge.

Caplan, P. J. (2013). Don’t blame mother: Then and now. In Hobbs, M. & Rice, C. (Eds.), Gender and Women’s Studies in Canada. (pp. 99-194). Toronto, ON: Women’s Press.

Chodorow, N. (1978). The reproduction of mothering: Psychoanalysis and the sociology of gender. Berkeley, CA: University of California Press.

Chodorow, N. & Contratto, S. (1982). The fantasy of the perfect mother. In B. Thorne & M. Yalom (Eds.), Rethinking the family (pp. 54-75). New York, NY: Longman.

Collins, P. H. (2007). The meaning of motherhood in black culture and mother-daughter relationships. In A. O’Reilly (Ed.), Maternal theory: Essential readings. (pp. 274289). Toronto, ON: Demeter Press.

Corbin, J. & Strauss, A. L. (2008). Basics of qualitative research. [Kindle version].

Retrieved from Amazon.com Derry, P. S. (1990). Motherhood and the professional life: the case of women psychotherapists. Bristol, IN: Wyndham Hall Press.

Derry, P. S. (1992). Motherhood and the clinician/mother’s view of parent and child. In J. C. Chrisler & D. Howard (Eds.) New directions in feminist psychology: Practice, theory, and research. (pp. 26-39). New York, NY: Springer.

203 Derry, P. S. (1994). Motherhood and the importance of professional identity in psychotherapists, women and therapy. Women and Therapy. 15:2, pp. 149-163.

Doi: 10.1300/101/v15n02_12 Dewey, J. (1938). Experience and education. New York, NY: Touchstone.

Dinnerstein, D. (1999). The mermaid and the minotaur. New York, NY: Other Press.

(Original work published 1976).

Doane, J. & Hodges, D. (Eds.). (1993). From Klein to Kristeva: Psychoanalytic feminism and the search for the good enough mother. Ann Arbor, MI: University of Michigan Press.

Dyer, K. A. (1997-2001). The importance of telling (and listening to) the story: Journey of hearts (A healing place in cyberspace). Retrieved from http://www.journeyofhearts.org/kirstimd/tellstory.htm Emde, R. N. (Ed.). (2019). Early parenting and prevention of disorder. New York, NY: Routledge.

Farber, S. K. (2017). Celebrating the wounded healer psychotherapist: Pain, posttraumatic growth and self-disclosure. New York, NY: Routledge.

Fenster, S., Phillips, S. B. & Rapoport, E. R. (2015). The therapist’s pregnancy: Intrusion in the analytic space. New York, NY: Taylor and Francis. (Original work published 1986).

Ferber, R. (1985). Solve your child’s sleep problems. New York, NY: Touchstone.

Freud, S. (1965). New introductory lectures on psychoanalysis. New York, NY: W. W. Norton. (Original work published 1933).

204 Fromm-Reichmann, F. (1948). Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry. Retrieved from (http://www.psychodyssey.net/wp-content/uploads/2012/05/Fromm-ReichmannPsychiatry1948.pdf Gerson, B. (1996). Introduction. In B. Gerson (ed.), The therapist as a person: Life crises, life choices, life expriences, and their effects on treatment (pp. xii-xxiii).

Hillsdale, NJ: The Analytic Press.

Glaser, B. G. & Strauss, A. L. (2006). The discovery of grounded theory: Strategies for qualitative research. New Brunswick, NJ: Aldine Transaction. Retrieved from http://www.sxf.uevora.pt/wp-content/uploads/2013/03/Glaser_1967.pdf (Original work published 1967).

Hammack, P. L. (2015). Theoretical foundations of identity. In K.C. Maclean & M. Syed (Eds.) The Oxford handbook of identity development. (pp. 110-130). Oxford: Oxford University Press.

Hays, S. (1996). The cultural contradictions of motherhood. New Haven, CT: Yale University Press.

Horney, K. (1964). The neurotic personality of our time. New York, NY: W. W. Norton.

(Original work published in 1937).

Horney, K. (1992). Our inner conflicts: A constructive theory of neurosis. New York, NY: W.W. Norton. (Original work published 1937).

Horney, K. (1993). Feminine psychology. New York, NY: W. W. Norton. (Original work published in 1967).

205 Hrdy, S. B. (2003). Mother nature: A history of mothers, infants, and natural selection.

New York, NY: Pantheon. (Original work published in 1999).

Hulbert, A. (2003). Raising America: Experts, parents, and a century of advice about children. New York, NY: Alfred A. Knopf.

Kagan, J. (Rev. ed.). (2000). Three seductive ideas. Boston, MA: Harvard University Press. (Original work published 1998).

Kanner, L. (1943). Autistic disturbances of affective contact. Retrieved from http://simonsfoundation.s3.amazonaws.com/share/071207-leo-kanner-autisticaffective-contact.pdf Kaplan, G. & Main, M. (1984). Adult attachment interview protocol. Unpublished manuscript, University of California at Berkeley.

Kleiman, K. R. & Raskin, V. D. (1994). This isn’t what I expected: Overcoming postpartum depression. New York, NY: Bantam Books.

Klein, M. (1975). Love, guilt and reparation. New York, NY: The Free Press.

Kohut, H. (1971). The analysis of the self: A systematic approach to the treatment of narcissistic personality disorders. Chicago, IL: Chicago University Press.

Kuchuk, S. (Ed.). (2014). Clinical implications of the psychoanalyst’s life experience.

New York, NY: Routledge.

Lancy, D. F., (2015). The anthropology of childhood: Cherubs, chattel, changelings.

(Rev. ed.) Cambridge, UK: Cambridge University Press. (Original work published 2008).

LeShan, E. (1977). Child care. The New York Times. Retrieved from http://www.nytimes.com/1977/02/20/archives/child-care.html? r=Q

206 LeVine, R. A. (2014). Attachment theory as cultural identity. In H. Otto and J. Keller (Eds.), Different faces of attachment: Cultural variations on a universal human need. (pp. 50-65). Cambridge, UK: Cambridge University Press.

Lewontin, R. (2001). It ain’t necessarily so: The dream of the human genome and other illusions. New York, NY: The New York Review of Books.

Lieberman, A. F. (1995). The emotional life of the toddler. New York, NY: The Free Press.

Lifton, R. J. (1999). Destroying the world to save it: Aum Shinrikyo, apocalyptic violence, and the new global terrorism. New York, NY: Metropolitan Books.

Lombrozo, T. (2014). Using science to blame mothers. Retrieved from http://www.npr.org/sections/13.7/2014/08/25/343121679/using-science-to-blamemothers-check-your-values Macnab, S. S. (1995). Listening to your patients, yelling at your kids: the interface between psychotherapy and motherhood. In M. B. Sussman (Ed.), A perilous calling: The hazards of psychotherapy practice (pp. 37-44). New York, NY: John Wiley & Sons.

Mahler, M. S., Pine, F., & Bergman, A. (2000). The psychological birth of the human infant. New York, NY: Basic Books. (Original work published 1975).

Mazzoni, C. (2002). Maternal impressions: Pregnancy and childbirth in literature and theory. Ithaca, NY: Cornell University.

Miller, J. B. (1986). Toward a new psychology of women. Boston, MA: Beacon Press.

Miller, L. J. (1999). Postpartum mood disorder. Washington, DC: American Psychiatric Press.

207 Mishler, E. G. (1986). Research interviewing: context and narrative. Cambridge, MA: Harvard University Press.

Mitchell, S. A. (1984). Object relations theories and the developmental tilt.

Contemporary Psychoanalysis. 20: 473-499. Retrieved from http://www.wawhite.org/uploads/PDF/SMitchell-Object_Relations_Theories.pdf Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Boston, MA: Harvard University Press.

Mitchell, S. A. & Black, M. J. (1995). Freud and beyond. New York, NY: Basic Books.

Morrison, T. (2004). Beloved. New York, NY: Vintage Books. (Original work published 1987) Murphy, K. (2017). Yes, it’s your parents’ fault. The New York Times. 1-5. Retrieved from http://www.nytimes.com/2017/01/07/opinion/sunday/yes-its-your-parentsfault.html O’ Reilly, A. (Ed.). (2007). Maternal theory. Toronto, ON: Demeter Press.

Patton, M. Q. (1990/2002) Qualitative research and evaluation methods. Thousand Oaks, CA: Sage Publications.

Pfister, J. & Schnog, N. (Eds.). (1997). Inventing the psychological: Toward a cultural history of emotional life in America. New Haven, CT: Yale University Press.

Reimer, S. & Sahagian, S. (Eds.). (2015). The mother-blame game. Bradford, ON: Demeter Press.

Rich, A. (1981). Of woman born. New York, NY: Bantam Books. (Original work published 1976).

208 Richardson, S., Daniels, C. R., Gillman, M. W., Golden, J., Kukla, R., Kuzawa, C. & Rich-Edwards, J. Society: Don’t blame mother. Nature. 512, 131-132. doi: 10.1038/512131a. Retrieved from https://www.nature.com/news/society-don-tblame-the-mothers-1.15693 Robinson, L. C., (2012). Therapist as mother and mother as therapist: The reciprocity of parenting and profession for female psychoanalytic psychotherapists. (Doctoral dissertation, Rutgers, The State University of New Jersey). Retrieved from http://rucore.libraries.rutgers.edu/rutgers-lib/37577/ Rutter, M. (2nd ed.). (1991). Maternal deprivation reassessed. New York, NY: Penguin Books. (Original work published 1972).

Schafer, R. (1974). Problems in Freud’s psychology of women. Journal of the American Psychoanalytic Association. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/000306517402200301 Schulte, B. (2013). Effects of chld abuse can last a lifetime: Watch the ‘still face’ experiment to see why. The Washington Post. Retrieved from https://www.washingtonpost.com/blogs/she-the-people/wp/2013/09/16/affects-ofchild-abuse-can-last-a-lifetime-watch-the-still-face-experiment-to-see-why/ Shaw, E. & Breckenridge, J. (2014). There is no longer room for me on your lap. In P. Bueskens (Ed.), Mothering and psychoanalysis: Clinical, sociological, and feminist perspectives. (pp. 139-57). Bradford, ON: Demeter Press.

Simpson, D. E. (Director). (2003). Refrigerator mothers [Motion Picture]. http://www.snagfilms.com/films/title/refrigerator_mothers

209 Smith, C. (2020, June 9). What if a shaman could solve all your problems, in three days?

The New York Times. Retrieved from https://www.nytimes.com/2020/06/09/books/review/sam-lansky-brokenpeople.html Stearn, P. N., (2003). Anxious parents: A history of modern childrearing. New York, NY: New York University Press.

Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York, NY: Basic Books.

Stevens, J. (2006). Pregnancy envy and the politics of compensatory masculinities. The Women and Politics Research Section of the American Political Science Association. 265-296. doi: 10.1017/51743923X05050087 Stolorow, R. D. & Atwood, G. E. (1992). Contexts of being: The intersubjective foundations of psychological life. Hillsdale, NJ: The Analytic Press.

Stone, A. (2014). Feminism, psychoanalysis, and maternal subjectivity. New York, NY: Routledge. (Original work published in 2012).

Suleimon, S. (1994). Risking who one is: Encounters with contemporary art and literature. Boston, MA: Harvard University Press.

Sullivan, H. S. (1997). The interpersonal theory of psychiatry. New York, NY: W. W. Norton & Company. (Original work published 1953).

Tietze, T. (1949). A study of mothers of schizophrenic patients. Psychiatry, 12(1), 55-65.

Wing, L. (1997). The history of ideas on autism: Legends, myths and reality. Autism, 13, 23. DOI: 10.1177/1362361397011004

210 Winnicott, D. W. (1960) The theory of the parent-infant relationship. The International Journal of Psychoanalysis. 41:585-595. Retrieved from http://icpla.edu/wpcontent/uploads/2012/10/Winnicott-D.-The-Theory-of-the-Parent-InfantRelationship-IJPA-Vol.-41-pps.-585-595.pdf Wylie, M. S. & Turner, L. (n. d.). The attuned therapist. Retrieved from https://www.drdansiegel.com/uploads/The-attunded-therapist.pdf Wylie, P. (2007). Generation of vipers. McLean, IL: Dalkey Archive Press. (Original work published 1942).

Zakin, E. (2011). Psychoanalytic Feminism. In E. N. Salta (Ed.), The Stanford encylopedia of philosophy (Summer 2011 ed.). Retrieved from: https://plato.stanford.edu/archives/sum2011/entries/feminism-psychoanalysis/ Zelizer, V. (1985). Pricing the priceless child: The changing social value of children.

New York, NY: Basic Books.