Source: 123rf.com/Verapol Chaiyapin

Meeting Monica and Bobby was hard from the start. I knew from her phone message that they had lost their dear son after nine months gestation, during delivery. No matter how much experience we gather and how many years we refine our craft, it never gets any easier, hearing one very sad story after another.

“He was perfect,” she sat close to her husband in my office and shook her head in disbelief, “Perfect. He was eight and a half pounds of solid boy.” Monica tried to stop herself from crying while she reached for her husband’s hand.

The three of us sat together waiting for the details of the story to unfold. Planned, uneventful other than a late delivery, two weeks post term. No history of or difficulties related to reproduction. Married for three years, both to start a family and anticipated no problems. Monica was referred to me by her obstetrician who was worried about Monica’s “prolonged ” suggesting she should be “over it by now, after all, it’s been five months.” Monica did have a history of , so she agreed that it could be helpful to find a safe place to talk about her huge loss.

“It’s hard to talk about this to anyone. My family is also suffering, so, honestly, I don’t want them to feel bad about how bad I’m feeling. My friends have their own problems and don’t need to hear about mine. Besides, many of them have a new baby which isn’t a place I want to be right now.

“I don’t know what happened,” she continued. “No one has given us an explanation that makes any sense. All I know is…that…I don’t know…it’s not supposed to happen like this. One minute I was pregnant with a big healthy boy and the next minute they tell me he’s dead. When they put him in my arms, he didn’t look dead. He looked perfect.”

She cradled her arms and gazed into the emptiness. In a flash, I could see her baby there, in her mind and in mine, plump and perfect as she had described him. Unexpectedly, I was overcome with a feeling that brought me way too close to home, and, for an instant, I was transported back to the birth of my son, sixteen years earlier.

My pregnancy was also uneventful. I loved being pregnant and the bigger I got, the better I felt. When my due date came and went, no one was particularly concerned other than anxious relatives who called for hourly updates. After three weeks post due date (hard to believe this was so long ago it was before doctors were doing routine ultrasounds), and a failing placenta, a C-section was the only way my baby was going to come out. We packed, we prepped, and we let the doctors do their thing given that nature’s course had stalled.

Though memories of the moments after delivery are vague as my aging brain rummages through the past twenty four years, I remember the hurried response and the flurry of scrub-clad, nameless figures around me. My baby was whisked away to an undisclosed, oh-my-god-what’s-wrong-with-my-baby location as my belly was meticulously stitched closed. After what seemed like forever due to either my altered, medicated state or my panic, I’m not sure which—my baby boy was brought to me, swaddled neatly and capped with the sweet striped infant hat that today is packed away in a box of things with which I simply cannot part. He embodied perfection to me, apart from his misshapen head that resulted from being overcooked and pelvis-squeezed for too long. I would later learn that the critical moments just before he was perfect were, in fact, life-threatening. When they wiggled his big head out of my tiny incision they saw he wasn’t breathing. His Apgar score was 2 at one-minute. Scores below 3 are generally regarded as critically low and above 7 are generally normal. To this day I don’t know which specific criteria he fell short on, but I do know that when the test was repeated at five minutes, his score was 8. All was well.

But for an instant, he wasn’t breathing. He had aspirated on meconium, a risk to post mature babies, and thanks to split-second intervention had an endotracheal tube down his little throat to suction his mouth and airway. Before I knew what was happening, he had been intubated, observed closely, cleaned off and literally within minutes, returned to my swollen chest which was yearning for the warmth of my newborn baby. He was, as Monica had just described her baby boy, perfect.

In addition to aspiration, another risk of post maturity is intrauterine fetal demise or stillbirth.

The ache I felt in my chest as Monica recounted the events of that heartrending evening at the hospital was too deep and too personal to ignore. I took in a full slow breath as Monica pulled out a picture of her son, “Can I show you a picture of Mathew?”

“Of course,” I said, digging deep for the most soothing and tender voice possible.

The moment of silence while she looked for her one enduring keepsake of his precious self seemed eternal. The room felt still and empty. Then, the emptiness started to throb, as if in sync with my rushing heart beat. What would I see? How would he look? Could I separate this from my own experience? Would I be able to stop thinking of my son? Would I be able to hide what I was feeling? Could I remain neutral in my response?

Bobby bent forward to grab a peek at the photo before she handed it to me. I leaned toward her, accepting the picture as a delicate gift she was sharing, as if she were handing me a sacred piece of herself. I looked at Mathew. He was just as she had described him, big and gorgeous. His eyes were closed. He looked peaceful, and, as we so often hear, as if he was . I remember being bothered by my quiet thought that she was right, he didn’t look dead. The dull pain in my heart grew sharper as images of my own son’s birth flooded into my vision. I could almost feel my objectivity vanishing.

“I’m so sorry,” I looked at Bobby and Monica, “It’s so awful, sweet Mathew, he’s so beautiful.” Another moment, in as in life, when the right words are nowhere to be found. Her eyes filled with tears, “I miss him so much.” Her sobs became heavy with unimaginable grief.

My instincts led me to sit quietly after saying, “I know you do.”

One of my students asked me when the pain is that excruciating, is it ever okay to go over and sit with her or hug her? In general, it’s better not to. Without knowing the particular client, her degree of healthiness, the severity of her symptoms, the strength of her personal boundaries, what she needs and what the therapeutic relationship means to her is at that moment in time, it’s hard to know what impact that level of might have on her.

When the pain is that great, and that palpable, two things are certain: 1) she needs to express it, and 2) she needs to know we can tolerate it. The space we create between the client and ourselves during such time of incredible emotion is as important as our desire and ability to comfort her. Bear in mind that a loved one who responds to her weeping might hold her and console her in the hopes of helping her control the pain to some extent and perhaps cry less. Loved ones unite against the unbearable pain hoping to lessen it, even if only slightly. If you stop crying you won’t be in so much pain, they might think.

Our job, on the other hand, is to let her know that no matter how bad she feels, how hard she cries and how much it hurts, it’s okay. The message is that she has permission to express the inexpressible and that it will not unnerve us, nor will we try to inhibit the process. To the contrary, although we too want to be consoling in our response, the difference is that we want her to stay in that painful space for a bit longer than she might like, so she can say the things she needs to say and feel the things she needs to feel in order to get some relief and make room for healing.

I am not saying a hug is always inappropriate. I am saying that sometimes, with some women, a hug can be misinterpreted as I’m here for you, but I’d feel better if you stop crying and that’s the last message we want her to get. Moreover, it can violate an important boundary, one of . Clinicians need to be mindful of their own emotional response and perhaps reassess whether giving her a hug would be the best thing to do at that moment. Timing is crucial. At another moment, such as when she’s leaving the session, I do believe a hug is not only an appropriate gesture of comfort, it can also provide closure on a difficult session that tells her all is okay; that she is safe here.

I confess that the feeling I struggled with while listening to Monica and Bobby explore their sadness was one of tremendous . I thought about our similar tales of pregnancy and post term deliveries and, still, any way I looked at it, my baby lived and their baby died. Any time a strong emotional response invades the therapeutic setting we have the ingredients of material that can be 1) useful to the session, 2) harmful to the session, or 3) incompatible with the work we are doing. In this case, it had honestly never occurred to me that my son had been so close to death, until I sat along side their anguish.

introduced the concepts of transference and countertransference within the therapeutic relationship as labels for the irrational, stereotypical, and patterned responses that are inappropriately transferred between the client and the therapist. Just as we expect some clients to project some of their emotional responses into our relationship, we must also be prepared for the possibility that this intimate work with new mothers will provoke strong emotional responses of our own.

Using a broader definition than originally conceived, countertransference has evolved over the years to apply to any emotional reactivity on the part of the therapist, not just the inappropriate ones. The construct applies to both positive and negative experiences which are more often than not, currently seen as tools for deepening our understanding of the therapeutic experience. When countertransference problems arise, though not surprising to us, they should be attended to and dealt with, as they emerge. Honest introspection and ongoing supervision can safeguard against potential intrusions into the therapy. This may seem obvious to many but the slope is slippery, and the scrutiny of emotional truthfulness cannot be emphasized enough.

When we are moved beyond words and overflowing with emotional resonance it can be one of the most authentic moments of our work. If mindful, the degree to which we allow ourselves to experience these emotions, understand them, and use them in our work enables us to move through the process with finesse and proficiency. It can inspire therapeutic action that makes sessions richer and more meaningful for both the clinician and the client.

Monica and Bobby observed my sadness on a number of occasions during our work together. They later told me it was a part of what made it so meaningful for them. I was constantly moved by how poignantly Monica expressed her grief and the shattering of every one of her . She would describe hearing her baby cry or phantom movements in her belly. She often dreamt that Mathew was alive and recalled vivid tales of things they did together in the middle of her deep sleep. Early in our work these were hard for her to talk about, later they became a source of comfort to her.

The death of a child must be the most difficult to mourn.

My own sadness needed to be understood within this context and saved for future sessions without them ever hearing a word about my son’s birth. We must remember that we are there for our clients and for our clients only. They are entitled to every fragment of our . When it wanders off course we are obliged to regroup, focus, and cast aside our temporary diversion for later inspection. We do that on our own time with our own supervisor or therapist.

That moment in time, locked within their nightmarish sorrow and the awareness of my own blessing stays with me today as a reminder of how to get in and get out of the vortex of pain. We can step inside only so far. Then we stay, we empathize and we leave. It was a single bittersweet moment that unveiled life’s cruelest sorrow and its utmost .

Adapted from "Therapy and the Woman" by K. Kleiman (Routledge, 20)