The travails and pleasures of psychoanalytic training while mothering small children is a subject I know well. Upon completing a psychiatric residency at U.C.L.A., I entered private practice and began attending seminars at the Los Angeles Psychoanalytic Institute. At the end of the first year of seminars, my second child was born. My daughter now is nearly five, my son, two, and I am in my third year at the Institute. Engrossed in parenthood and career, I recognize how mutually enhancing they are; yet I feel an essential conflict in how I can be immersed in both worlds, as each pulls me away from the other.
To begin with, a woman whose priority is motherhood is not considered the most serious of careerists. In our field, a woman's professional development is a highly individualistic and potentially lonely process. We suffer from a dearth of women who have achieved the goals we hold out for ourselves, women who function simultaneously as training analysts, psychiatrists, and mothers, to whom we might turn for supervision and role modeling. Many women candidates I know have expressed demoralization over the lack of senior women analysts and faculty. Perhaps because mothers working part-time are unable to amass the requisite number of clinical hours, the likelihood of their becoming training analysts is low.
The disturbing truth is that sometimes it is difficult to make good on our determination that the needs of our babies and young children come first—perhaps more so for those of us who are, like myself, at the very beginning of our careers. I find myself ardently yearning for clinical experience and the completion of training, and yet mothering my children is the greatest honor of my life and I have known no greater joy. I was fortunate in having been able to spend many delightful and illuminating months at home with my daughter after her birth, and much time at home with my son during his first year of life. I have been pregnant or nursing for four of these last five years, enjoying my babies, while, perforce, being able to advance my clinical experience only part-time. Getting to know the children of my friends and belonging to an assortment of play groups (a necessity of urban life) has afforded me additional opportunity to be with little ones, and to understand the growth and development of human beings in interaction with the significant figures in their lives. At the same time, I have continued my training analysis and didactic course work.
Despite all difficulties, however, my experience of parenthood, my analysis, and my forays into psychoanalytic theory have been mutually enhancing. I have gained an enormous respect for the rapidly unfolding capacities of infants and toddlers, and am awestruck by their potential. Watching the evolution and maturation of my children's memory, reality testing, and language, as well as many other developmental progressions, has been a wondrous experience. My reading from Freud through contemporary infant researchers has reinforced and dovetailed with direct experience and observation of my own and other children's normal patterns, including separation anxieties, transitional phenomena, the development of object permanence, and a tendency toward mastery of the environment. By virtue of this experience, the primacy of the relationship of parent and child is more real to me, as is an understanding of the conflicts inherent in triadic relationships. My experience of several thousand breast-feeds affects my views of psychoanalytic formulations regarding the breast and the mother-infant relationship in the context of breast-feeding. For example, not yet within my experience is the concept of biting as an oral-aggressive, envious attack on the breast: when my son was twelve months old, he began biting, while maintaining eye contact, during mutually pleasant and calm feeds. He learned quickly, and with apparent glee, that I would respond to the contact that he initiated in a characteristic and predictable way. I experienced this as a playful, communicative, assertive exchange, one that demonstrates well the concept of effectance pleasure. Such experiences, I feel, enrich my capacity to assess psychoanalytic constructs.
Adopting an analytic stance is helping me to detect, appreciate, and utilize the subtleties of language, behavior, and nonverbal communications with my patients, as well as my children. A potential danger, of course, in this appreciation of the similarity between patient and child, is the emergence of a tendency to label feelings in either: the intrusive belief that the mother/analyst knows what the child/patient thinks and feels. But I find I am developing a greater tolerance for my own doubts and frustrations, as well as those of my children and patients. I am becoming more aware of labile moods and rapid affective shifts. Seeing inexplicable leaps in my children's development gives me an appreciation for how being in the background must sometimes contribute to being “good enough”; it appears that a communicative matrix always exists. This realization helps relieve the performance pressure novice analysts often feel with patients, and the need for establishing a holding environment for some patients has been rendered more meaningful to me. In addition, experience with my children has enlivened concepts for me that might otherwise have remained constructs. This extends into my training analysis, where I have the benefit of working through personal issues I have read about (and might therefore intellectualize) as these issues emerge and become more realized in the amalgam of motherhood and training.
But, despite the evident joys, rewards, and educational value of mothering, there are dilemmas and conflicts inherent in being a practicing clinician while child rearing. These involve primarily loyalty and devotion. The most difficult is the feeling of abandoning one's children for one's patients and vice versa. I believe that for many women the crux of the conflict lies in managing one's omnipotent feelings. The dependency of child and patient increases the analyst's sense of importance and commitment to the other. The act of apportioning one's time and energy leads to feelings of anxiety and guilt about cheating one's “dependents.” Conversely, being relied upon may heighten one's feelings regarding one's own capacities. This leads to conflict about cheating oneself, of not realizing one's own potential, and of not having one's own dependency needs met. Renouncing one's omnipotence and working through one's personal deprivation in order to strike a comfortable balance is of the utmost necessity here.
I believe that “quality time,” as conceived by some mothers, is a myth. One needs to be present, if only in the background. Yet it is not always easy even to be “good enough.” For example, the painful reality of making commitments to our patients is that we cannot
readily cancel several sessions, or even whole days, in order to stay at home with a child who is ill. Periodic cancellations with patients we see once or twice a week are easier to reschedule, and are therefore less disruptive, than are cancellations with analytic patients, with whom missing consecutive sessions can disrupt the analytic process. On the other side of the conflict, a real scheduling difficulty may occasion offering someone an hour we had planned to spend with our children; sometimes such offerings of precious family time are necessitated by the urgency of the patient's situation. For example, a recent clash in schedules with a long-term psychotherapy patient required that I offer her a late afternoon hour. She declined, stating that she needed to be home with her small children after school. The irony did not escape me, and I felt guilty for having my actions conflict with my ideals. I have recently heard a number of similar vignettes from others who agree that so much of what we learn while away from our children is about how we should be at home with them. Conversely, if the patient takes the hour we offer, we struggle with feelings of resentment toward them or toward our children for complicating our lives and choices. We all harbor some ambivalent feelings towards our children, and yet no one really likes talking about them. Sometimes we joyfully leave the demanding pace of needy, cranky babies, all the while wondering if and how we are failing them. Yet we also feel that our work is an important and satisfying dimension of our lives that enables us to be better mothers upon our return home.
Those who leave small children all day offer them a potentially meager compensation by obtaining what is rationalized as the best available in-home child care. Some women have no choice in the matter and must work full-time for financial reasons. Those who work part-time and feel strongly about taking children to school and being home after school refuse categorically to see patients before or after school hours. As a result, they are quite compromised in their flexibility to schedule control cases. Others, despite attempting to impose such limits on their working hours, succumb to the temptation of needed control cases or full-fee patients. Either way, we are fortunate when compared with other professional women, since most analysts are self-employed and therefore determine their work schedules. The result is that some mothers in training may take longer to get started with cases or choose to take their seminars on a part-time basis. Fortunately, in my institute the administration and faculty have been very flexible with my requests and of those of colleagues with whom I have communicated. Recent changes implemented to accommodate parents include changing postseminar conferences from evening to daytime, and offering enrollment in seminars on a part-time basis. Perhaps this flexibility will become commonplace as the pressure for reform mounts from a growing body of women trainees (and from fathers as they become more interested in preserving family time).
The issue of pregnancy in the analyst/therapist is a complicated one. Both of my children were born before I had any control cases, so I avoided this issue as an analyst. But I had hospital and psychotherapy patients as a resident during my first pregnancy and an outpatient practice during my second. The patients were often quite ill and expressed many primitive fantasies. My babies were named and their genders pondered. A myriad of fantasies were projected into my growing abdomen. Each person seemed to have his own unique reaction or an obvious lack of a response; the latter often signified unconscious fears of abandonment and a variety of sibling fantasies. Those were stressful times; I understand why some women analysts deliberately wait until the end of training to have children, in order to postpone the issues a pregnancy may generate with control cases. Some of us would consider having more children were it not for a wish to avoid introducing the stress of pregnancy into the treatment setting. From the outset, the way pregnancy is handled by the therapist/analyst is varied. Some choose to tell their patients early on, so as to avoid generating feelings of betrayal or mistrust, while others opt to wait for the patients' reactions, maintaining a more classical technical approach. I would hope that most inform their decision by considering each patient individually. The discussions that can be generated about this issue are complex, especially for the candidate for whom the introduction of parameters necessitates thoughtful consideration.
I want to address one final complication which, like many others I have addressed, has implications for men as well as women. I imagine that balancing a general psychiatric practice with motherhood (and parenthood in general) would be a difficult challenge in and of itself. For the young practitioner, contending with psychiatry and psychoanalysis, both complex, multifaceted disciplines, further complicates matters. Developing as a psychiatrist/analyst is an arduous, inspiring, and impelling task partly because it is difficult to belong to two groups, each with its own identity and each claiming expertise regarding similar phenomena. These days, especially, psychiatry and psychoanalysis contradict some of each other's most fundamental tenets. For example, the belief that symptom relief through medication undermines motivation for analysis is worthy of investigation. I have knowledge of medications and have observed their utility in treating signs and symptoms in a variety of disorders. The psychiatrist/analysts of my generation, whose education includes pharmacotherapies and a multimodal approach to patient care, are confronted with such issues. Gaining knowledge of the psychoanalytic literature and deciding which criteria to use in their evaluation requires much time, effort, and thought. Striving to keep abreast of changes in both disciplines, while integrating aspects that are clinically useful, requires continual review and the questioning of key concepts from each.
Overall, my career, training, and mothering experience is exciting, challenging, and rich. My children are thriving and adorable. I believe that combining a psychoanalytic career with motherhood is a superb choice as long as one does not expect to do so with perfection, aplomb, and grace. I confidently expect that as long as I can tolerate confusion, doubt, and bungling then the combination of motherhood and a psychiatric/psychoanalytic career will prove both manageable and rewarding.