By Kirstie McKenzie-McHarg, Clinical Psychologist and founding member
I work as a clinical psychologist and manage a perinatal psychology service in the UK. A basic dilemma that exists when treating PTSD following childbirth (PTSD FC) is that of whether the presentation of PTSD in the perinatal population the same as, or different from, PTSD caused by other events? If the presentation is the same, we can utilise existing approved treatments. If it is different, we may need to adapt our approaches to allow for these differences. Trauma-focused cognitive behaviour therapy (CBT) is a PTSD treatment recommended by NICE guidelines. A paper by Ayers, McKenzie-McHarg & Eagle (2007) presents case studies which suggest that standard CBT approaches to women experiencing PTSD FC are effective and appropriate to use with this population.
However, the context of PTSD FC differs from that of PTSD following other events. In PTSD FC, women are expected to take home a dependent newborn and to care for the baby. For some women, the baby is a lasting reminder of their traumatic birth experience, and bonding and attachment may be affected. There are significant postnatal hormonal changes for women. Childbirth itself is considered by society to be a positive event, unlike any other stressor leading to PTSD such as war, assault or traffic accident. Therefore women may experience others as lacking in understanding, making comments such as ‘aren’t you lucky, you have a beautiful baby’. There are very often sexual problems for women experiencing PTSD FC. All of these specific difficulties are in addition to the normal postnatal background of extreme fatigue, increased social isolation, decreased independence and increased responsibility. As such, it is important that the postnatal context of women with PTSD FC is taken into account when intervention is planned.
Clinicians working with PTSD in the perinatal context therefore need to consider how to work effectively when the mother may need to bring the baby to every session; for example, if the mother is highly anxious and therefore cannot leave her baby, or if she is breastfeeding. There is also a need to recognise that some women will experience a tension between significant anger and resentment at the changes in her status and health, and simultaneously experiencing an overwhelming and confusing protective instinct for an infant she may resent.
The clinical space therefore must provide a safe and containing environment in which new mothers can express their conflicting emotions, and admit to potentially shaming or even dangerous thoughts about themselves and their baby. While the creation of this safe space presents a challenge when working clinically with any individual with PTSD (due to their avoidance of discussing the trauma) it is additionally difficult in a postnatal population. This is because many women fear that admitting negative emotions towards their baby may result in a referral to social services and the subsequent loss of their baby. In summary, while the broad therapeutic approach we use for intervention for PTSD may remain the same, consideration of the perinatal context is critical.