From a Pea to a Pumpkin: A Prenatal Psychotherapy Group for Women with Eating Disorders

By Angela R. Wurtzel, MA, MFT, CEDS

During the past year three of my long term clients became pregnant. One expressed a strong interest in being a part of a psychotherapy group with other pregnant women to talk about their emotional and psychological lives during pregnancy and preparing to become mothers and parents with their partners. So, I set out to create From a Pea to a Pumpkin: A prenatal psychotherapy group for women with eating disorders and within a few weeks, my first group was formed. This article will highlight and incorporate these women, their experiences in the group and how we have continued as a group postpartum. All of my clients’ identities have been protected in the following article.

The main purpose of the group is to address the conscious and unconscious expectations of pregnancy and motherhood paying particular attention to the dynamics at play for women with or who have struggled with eating disorders. The eating disorder component of the group focuses on the eating disorder of the patient and how it developed in relationship to her early attachment and how this may have an impact on her attachment process with her infant. Most importantly, the group’s underlying frame is to provide a therapeutic holding environment for the women to become and be able to talk openly about their pregnancy experience and how the process of putting thoughts and feelings into words allows for greater insight and potential change.

The prenatal conscious scenario: beginning to speak of the pregnancy experience.

Each woman has a story of how she became pregnant and I believe that the outset of the pregnancy is very impactful on the pregnancy and birth of the child. Containing and articulating this experience into words for women with eating disorders is very important because often the eating disordered woman, even with years of treatment, may have limited self reflection and as a result may reenact their own childhood experiences to express their feelings. For instance, Janice initially became pregnant by secretly going off her birth control and not telling her husband. In the group, Janice was able to voice her wishes of becoming pregnant and she how she always wanted “a kid” and knew that when she married her husband he did not want children. Janice said she couldn’t take no for an answer, and secretly stopped taking her birth control and is now pregnant. Janice clearly explained that she felt justified in wanting what she wanted. The group members and I validated her feelings and added that acting on these feelings was much different from feeling her wanting and subsequent frustration. Through the group process, Janice decided to talk with her husband and together decide what to do about her secret pregnancy. Janice had been seeing me individually for more than two years for binge eating disorder. At the root of her eating disorder is a hunger that is all consumptive; she is determined to acquire what she wants with a strong dissociative quality that allows her to avoid realistic consequences and outcomes of her behavior, urges and fantasies. She came by her all consumptive nature honestly as she was nicknamed in her family the “garbage disposal” because she was encouraged and teased about eating all the leftovers. Janice grew up in a home with no boundaries, no limits and very little protection. At the same time, Janice reports a childhood and adolescence marked with loneliness, fantasy and daydreaming. Devoid of true emotional attunement from her parents and a tremendous amount of verbal abuse from her three sisters, Janice took to taking care of herself into her own hands and found refuge and soothing by over feeding herself. When she decided to become pregnant without her husband’s knowledge it was a reenactment of her childhood experience of being in charge, the one to take care of herself even if someone else’s life might be greatly affected by her own self gratification. When she did tell her husband that she was pregnant he was angry. Her greatest concern was that he would want her to abort the baby. However, he conceded and they went ahead with the pregnancy. At 8 weeks into her pregnancy, Janice miscarried. She was devastated and suffered from a severe grief reaction. This traumatic event unleashed a well of emotion in Janice. We used this experience and time to explore some of her underlying tendencies related to want, frustration and boundaries. She was very concerned that her husband would not be willing to impregnate her again and she began talking about her urges to trick him and stop her birth control. While this was happening inside Janice, she and her husband were also talking directly with each other about the possibility of getting pregnant. Janice was like a little child asking her parent/husband if she could do something, waiting for him to give her the only answer she wanted. She would not take no for an answer and was terribly frustrated. She felt like she was coming out of her skin and actively binged to manage her feelings of frustration and anger. She expressed her anger at me, too, because I held the line with her in her mind, and the group also provided a real frame of reference for her. Janice became pregnant and was happy and relieved. However, she expressed in the group her fear about having another miscarriage.

Janice was binge eating to help regulate her emotions and express that which she had yet to find words for. She maintained a primitive process of using her body as the stage for her emotional expression. Even though she was pregnant and becoming full she felt an urge to take extra care of herself and her unborn baby. Out of fear, she tried to contain her behaviors and talk more openly about her feeding processes. Loss is a very big trigger for eating disorder symptoms, be they real, perceived or anticipated losses. For Janice, her eating disorder failed as a true transitional object during this time of loss because it instead bound her to her excessively gratifying internalized mother. Janice is so ashamed of how she feeds herself. This is a very tender area for her to talk openly about and she usually can only find very concrete words to describe her feeding style. Understanding her urges driving her pregnancy became an important reality for Janice, her child and her family.

The prenatal unconscious scenario: Beginning to speak of the unacceptable pregnancy experience

The unconscious hunger that operates in most women with eating disorders develops from an emotional deprivation during their own infancy. Eating disorders are a means later in life to get rid of the mother and to maintain a tie to her at the same time. Through the process of group therapy, it is possible to uncover these unconscious motivations that can lead to insight and change over time. The intention of providing this type of therapy to prenatal women is to help them become aware of their unconscious hunger in relationship to feeding and attachment. By beginning with the hunger for a pregnancy and then a baby, the story begins to tell itself. By no means should these underlying hungers negate the wish for the pregnancy or a baby, but rather to shed light on what else may be going on with each woman in the group during their pregnancies.

Janice clearly had unconscious hunger and fantasies in becoming pregnant and having a baby. She wanted what she wanted and was driven by an insatiable hunger in which she had even been willing to overstep the rights and wishes of her husband and their vows to consume what she wished for. Her dissociative capacities allowed for this and her unconscious need to fill herself would surpass any ethic or value she may consciously uphold. Because she was so mistreated as a child Janice had very little value of herself. To some extent, Janice and her mother still share the same mind for two. Janice brought herself to therapy to address her eating disorder and to explicitly separate from the destructive effects of her mother. She felt she had lived for her mother’s needs and she could not breathe her own air. She said she knew she would continue to binge eat if she didn’t come to therapy. During the group, Janice had the opportunity to explore and reveal her wishes to have a baby for her self. She wanted someone to love and who would definitely love her. She never pictured an infant, just a friend who she could play with. When she found out she was having a boy, she started thinking about the future, when he would get a girlfriend and leave her. She felt angry and jealous thinking of him leaving her. Her hunger to maintain a narcissistic fusion with her child has been at work and fueling her bond with him before she even conceived him. Her pregnancy fantasies revolved around her own introjected narcissistic demands of her mother.

Another tenet of the group is to help each participant gain insight and sensitivity about her own mother’s early attachment and how it may affect her own internalized expectations of pregnancy and motherhood. At the core of most eating disorder behaviors is a narcissistic fusion with one’s primary caregiver in which the then patient/now mother to be has very little sense of self and the development of the eating disorder becomes her means of separation and individuation. This dysregulated yet persevering attempt at survival will undoubtedly color her interpersonal relationships and her unconscious motivations and attachment tendencies with her own child. Providing a platform for discussing and exploring the attachment tendencies with pregnant women who have eating disorders is essential and therapeutic in helping them develop more attuned and empathic attachment styles. Beginning this process during pregnancy can help the patient bring dissociated thoughts to their conscious awareness with an opportunity to consider other ways to think about how to be with their baby when the baby is born.

Terri had a very intrusive mother. Terri had to sleep in her mother’s bed, spooning her, until her teenage years. She became her mother’s lover and receptacle. Terri remembers as a child repeatedly urinating in her bedroom and spreading her feces on her walls. When she talked about these memories in-group it was clear how severely neglected and used Terri had been by her mother and totally unprotected by her father, who divorced her mother and abandoned Terri. Her brother and sister also abused Terri. There are countless letters and exchanges between Terri and her family of origin that define a narcissistic fusion. Over the years of therapy, Terri weaned herself from her family, physically, emotionally and financially. However, she still maintains a strong wish for a good, decent family to share her life with. During her moments of aloneness in her pregnancy, Terri talked in-group about feeling urges of desire to fuse again with her family and for her daughter to have relatives. She feels jealous and angry that her baby will only have relatives on her father’s side. She wants to give her daughter relatives even if they are bad ones. Terri still continues to struggle with having her own mind and own body. When she impulsively decided to tell her family that she was pregnant, the response from her mother was classically narcissistic. In an email subject: I am going to be a grandmother and this is the best day of my life! Yet, there was no acknowledgment of Terri, how she is doing, who the father is, etc. At first read, Terri felt relieved and satisfied because she pleased her mother and received praise for making her mother happy. During the group she explored her father’s response as well, which was to send her all the quarters he had saved in a jar, she could have those to help with her baby. Terri accepted the quarters and then realized that he consistently sent her “ leftovers and second hand type gifts, not ones that were really chosen for me.” Terri realized, too, that earlier in our group sessions when she had talked about hogging and hoarding her baby that this was how her mother had been with her and that she was reenacting this unconsciously with her own baby. 

The Holding Environment: Attune to each participants potentiality of depressed and anxious mood and body dissatisfaction and provide a framework for therapeutic intervention.

When we ask what the body is, attachment theory can help us understand how internalized attachments can find a voice in the body. Attachment theory can help us to understand how unspoken narratives can take the form of psychosomatic processes or illnesses. This is especially true for people who react to psychological stress through somatic manifestations and pregnancy can affect this process. As these mothers begin to think about their attachment to their baby they have only to call upon their own blueprint of attachment with their mothers and primary caregivers. As we have already explored, one’s own attachment process becomes deeply internalized and is a major factor in the development of eating disorders. Overall, most of the members of this group reported very little body dissatisfaction during pregnancy and some depression of mood and definitely anxiety. Postpartum has been more concerned with body dissatisfaction and the dissatisfaction with the therapist mother who has become the shared skin for each member. I can’t help but think that during the early months after the birth of their babies when the eating and feeding disturbances with each of these women’s babies becomes more possible, the group has been more focused and concerned with their own feeding and body images. It is true that that the only sense of power these babies have in a world that they are entirely dependent on their mothers is in the arena of eating and elimination. Mothers attempt to breast-feed during group and they each coo their baby to feed when sometimes the baby doesn’t seem hungry. Often the mother thinks the baby should be fed and should eat. Sylvia’s baby falls asleep. Terri’s’ baby doesn’t like her right breast, and Alisa’s baby is just a little bit underdeveloped still to get all of the milk from her mother’s breast. It is the battle to get a child to eat that is being reenacted here, and, in the process, these babies may internalize the experience of their bodies being their mother’s for her control, not unlike what was certainly true for each of these mothers. Providing a frame for the mothers in this group to put words to what is happening in these group experiences will prove to be helpful.

Sylvia expressed loving being pregnant and loving her body more than she ever had despite her gestational diabetes and the self control she had to exercise to provide a safe in utero environment for her baby. She stated that when she looked in the mirror she liked her image and hadn’t felt that way in a long time. When it came to giving birth and going into labor, Sylvia talked in the group about her resistance to giving birth. She did not want to not be pregnant. She wanted to keep her baby inside of her. Due to her gestational diabetes it was possible that she may have her baby a few weeks early. This was not the case for Sylvia. She was two weeks late in delivering her baby and needed to be induced. When she went to the hospital, she was in labor for 48 hours and needed three epidurals. Sylvia’s wish to keep her baby inside perhaps was very much at play and giving birth disrupted the fusion she wished to maintain with her baby. Since the birth of her baby, Sylvia has expressed very high body dissatisfaction and a strong unwillingness to make any adaptable changes like the ones she made during pregnancy. Her resistance may be related to having wanted to stay pregnant. Sylvia may have something inside of her that she has yet to find words to express.

The curative effects of speaking about ones’ pregnancy experience

The pea to a pumpkin group process of finding one’s words makes possible a communication within each group member’s dissociated parts of each of their inner worlds. This process has strengthened each of the women’s more tenuous sense of reality by weaving together various parts of each of their personalities to form a more cohesive fabric. Each woman has the chance to understand not only what happened in their past but also how events from their past have become the template for organizing internally all subsequent experiences, in this case, pregnancy and motherhood. By conducting the pea to a pumpkin group in this way, meaning for each of these women and their histories of eating disorders is constructed out of what could be overwhelming chaos. Words become the means for expressing and regulating affect.

The power of the pea to a pumpkin group demystifies destructive behaviors and decreases shamefulness and allows these mothers to appreciate the adaptive aspects of their eating disorders, mood concerns and traumatic attachment issues. Working through the enactments in a group setting and understanding them enables both the mothers and the therapist to know through experience that each can feel whatever they may feel with the other without destruction of the relationships and abandonment. Even intense emotion can be contained. The group is both supportive and mutative. For example, I made an offhanded comment regarding Terri’s OCD tendencies with her baby and she returned the following week and expressed to me calmly that she was angry, hurt and confused by my comment. “I didn’t know I had OCD tendencies.” This led to an open discussion in the group that began with me apologizing for hurting Terri’s feelings in any way. This then led to a discussion about anxiety, OCD and Terri’s wish to not treat her baby the way she was treated: neglected and uncared for. While at the same time, we could explore her over compensatory and intense reaction to her baby becoming ill and how this reaction may also be accommodating to her needs rather than her baby’s needs. Terri did not want to feel sad or responsible for her baby being sick. There was a resolution and understanding.

The psychoeducational aspect of the pea to a pumpkin group can help members to recognize and identify certain attachment patterns, behaviors and emotions while providing links between their eating disorder and attachment with their mother and developing attachment with their infant. This group develops a common history together of being pregnant and having their babies. They each identify with me, not as harsh and punitive as they are to themselves. They also see themselves in each other, a powerful means for altering their own attitudes and feelings toward themselves. There becomes a greater capacity for self reflection when eating disorder behaviors diminish and the focus of the group can shift to one that is more interpersonal and psychodynamic, geared toward attachment and becoming a mother.

The pea to a pumpkin group becomes an alternate family as they move through their pregnancies and become mothers and become better mothers to themselves and to each other. Combined with individual therapy the holding environment is greatly expanded. This a powerful tool for change and it allows for delicate interpretations to occur using prior knowledge from individual work. The pea to a pumpkin group eases aloneness and allows trust to develop over the lifetime of the group. All the members of the group report feeling alone at times and how the group has substantially helped fill this void. The group has also been a place where each member can explore the feeling of being alone.

The pea to a pumpkin group developed cohesion that was promoted through identification with each other and the common goal of developing the capacity to move through pregnancy with emotional regulation, awareness and develop the most possible healthy attachment with their babies. This cohesion has led to these women continuing their group therapy with their babies! Each week we meet, three mothers and three babies, each born one month apart in tandem, and so the story will continue.

Even with all of their struggles, these women maintained a sense of hope for a full life and family. The Pea to a Pumpkin Group developed out of this sense of hope and wish for ongoing growth and a sense of peace and freedom. In closing, I wish to quote S. Louis Mogul, M.D., who authored a paper “Sexuality, Pregnancy and Parenting in Anorexia Nervosa.” He ends the paper with a beautiful and poignant paragraph that resonated with me and the intention of the pea to a pumpkin group.

“Most clinicians who know patients with anorexia nervosa are impressed with how completely love relationships, and, even, loving feelings are squeezed out of the patients’ lives as the disease progresses and the whole emotional life becomes focused on food and body weight. Even in the phase of recovery from weight loss many anorectics are still too preoccupied with these to experience real loving feelings. It is the argument of this paper that the powerful, even if narcissistic, experience of falling in love with a baby and a child can provide, in some cases, an opening for the anorectic in therapy to be active in restructuring the sense of self based on a new, positive mother – child relationship that is, probably, in turn based on the parallel experience of finding a positive relationship in the therapy. The patient needs the capacity, often impaired anorectics, for a strong investment in building and using a positive therapeutic relationship – stronger than the investment in thinness. The therapist needs to be able and willing to foster the growth of such a relationship and help the patient find the opportunity in being a good parent of mastering some of the specific deficits and conflicts that are central in the psychotherapy of anorexia nervosa.”

Mogul, Louis S., “Sexualtiy, Pregnancy and Parenting in Anorexia Nervosa,” Psychoanalysis & Eating Disorders. Bemporad, Jules R. MD & Herzog, David B. MD, 1989; The American Academy of Psychoanalysis.