Are trauma-focused psychological therapies safe for pregnant women?
During a pregnancy, the health and wellbeing of the mother and unborn child are of paramount importance, so it makes sense that therapists often worry about using trauma-focused treatments. Undeniably, there is often short-term distress associated with working on trauma memories, and a physiological correlate to that in the body’s arousal response. Many therapists we have worked with have been advised against treatments like TF-CBT or EMDR with pregnant women for these reasons. However, delaying treatment also confers a risk of harm. Untreated PTSD is associated with various negative outcomes for both mother and baby, including lower neonatal birth weights (Cook et al., 2018) and has been shown to impact on mother-infant bonding (Suetsugu et al., 2020). Not treating pregnant women also means they have to live longer with the distressing symptoms of PTSD. For those where their PTSD relates to a previous traumatic childbirth or child loss, often a reason women come forward for treatment when they are pregnant, this will make the subsequent pregnancy and birth particularly emotionally difficult.
Whether the risks of treatment outweigh the risks of non-treatment is an empirical question which has not been fully answered by the literature. However, a recent review (Baas et al., 2020) of 13 studies of trauma-focused psychological treatments for PTSD with pregnant women found no adverse outcomes (and most reported reduced PTSD symptoms) and concluded that treatment was most likely safe, although more, better quality research is needed for a definitive answer. These findings echo an earlier review that supported the use of exposure treatments in pregnancy for anxiety disorders more generally (Arch et al., 2012).
Overall, therefore, we usually offer trauma-focused treatments to our pregnant clients. As with everyone, this is from a position of informed consent – discussing the relative risks and benefits with the client and giving them as much information as they need to make a decision. If they wish, we support them to seek advice from their midwife or GP. This is particularly important if there are any risks associated with the pregnancy. Another reason where we would be extra cautious is if the client uses any high risk coping strategies to cope with their PTSD symptoms, such as drugs, alcohol, self-harm, or other forms of risk-taking, or if they are at significant risk of suicide or harm to others. There is a possibility that these behaviours would increase in response to short-term distress related to trauma-focused work, so require detailed assessment and management before proceeding (we’ll write a future blog on high risk behaviours).
The other area to consider carefully is timing. Ideally, we want to aim to complete treatment before the baby is born, although of course sessions thereafter are possible and may be advisable, especially if the index trauma was birth or early childhood related. So we need to consider the stage of pregnancy and the number of sessions we are likely to need to make sure we have sufficient time. Very late in pregnancy, our clients will be physically uncomfortable and understandably very focused on the imminent birth, plus there is always the chance that the baby will come early, so we cannot count on being able to offer sessions right up until the due date. If your service can support it, time-intensive treatments or at least twice weekly sessions might help get through treatment in time for the birth. Also be aware that you might need to be flexible in how treatment is delivered depending on your client’s needs. For example, physical symptoms like fatigue, morning sickness and pain may impact on concentration and availability – discuss with your client how to make treatment work for them e.g. time of day, length of sessions, remote delivery etc.
If the index trauma related to a previous pregnancy or birth, then the current pregnancy will necessarily be a feature of your treatment. For example, fears about similar events occurring will be common and helping your client develop realistic appraisals of risk may be important. Liaising with your client’s midwifery team can be helpful – often a midwife with a specialism in mental health can be allocated to their care, and can often offer birth planning meetings as well as advice on possible risks. Planning for the birth will form an important part of the blueprint, in particular how to use trigger discrimination, and visiting the birthing centre to practise these skills if possible. Involve your client’s birthing partner in these discussions, if both consent.
Trauma-focused treatments can lead to short-term distress and physiological arousal, often leading clinicians to be concerned about causing harm to unborn children
There are also negative potential consequences to delaying treatment
Research to date has not shown negative effects of trauma-focused therapies on pregnant women or their babies so these are generally considered safe
Advice can be sought from medical professionals, especially if the pregnancy is higher risk
Careful assessment and management of any high risk behaviours are also important as these may increase in response to treatment
Timing should be considered, ideally to ensure that treatment can be completed before birth
If the trauma related to a previous pregnancy or birth, the current pregnancy and planning for the birth will be important parts of treatment
Arch, J. J., Dimidjian, S., & Chessick, C. (2012). Are exposure-based cognitive behavioral therapies safe during pregnancy?. Archives of Women's Mental Health, 15(6), 445-457.
Baas, M. A., van Pampus, M. G., Braam, L., Stramrood, C. A., & de Jongh, A. (2020). The effects of PTSD treatment during pregnancy: systematic review and case study. European Journal of Psychotraumatology, 11(1), 1762310.
Cook, N., Ayers, S., & Horsch, A. (2018). Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review. Journal of Affective Disorders, 225, 18-31.
Suetsugu, Y., Haruna, M. & Kamibeppu, K. A longitudinal study of bonding failure related to aspects of posttraumatic stress symptoms after childbirth among Japanese mothers. BMC Pregnancy Childbirth, 20, 434 (2020).