Perinatal Mental Health Through a Different Lens: What is That Lens?
Through a trauma informed looking glass
Let’s begin with the first principle of trauma informed care - Ask not ‘what is wrong with that person’, but rather, ‘what happened to them’. When we lead with this lens as we approach the landscape of perinatal mental health, it opens a different conversation and thus, a different storyline. As someone who has worn many different hats within the arena of childbirth prior to specializing as a perinatal trauma therapist, I believe that I can offer a unique perspective to the maternal mental health conversation.
The introduction of social media has resulted in an explosion of awareness around postpartum mood disorders and it has attempted to normalize and highlight the challenges mothers face throughout the entire childbearing continuum. For example, less than ten years ago few people were talking about birth trauma; now it is a buzz word. Many suffered in silence and isolation as they grieved either from miscarriages, infertility, or late stage loss; now there are support groups popping up all over online. Mothers vented about how hard the postpartum was (often harder than they had expected) to their core group of friends or swallowed their complaints for fear of sounding negative or worse, being labelled as having postpartum depression or anxiety; now there are millions of voices online to be related to. On one hand, social media is connecting voices and experiences which can reduce the isolation factor, normalize the struggles of the perinatal period, fuel advocacy and change, and increase support systems. On the other hand, although we have access to more information than ever before and can ‘connect’ at the click of a button, we continue to see a rising rate in perinatal and postpartum mood disorders (PPMD).
Thanks for reading Therapy For Moms! Subscribe for free to receive new posts and support my work.
Why is this?
First, a few descriptions to get us started. The perinatal period encompasses the entire continuum from conception to postpartum. And, when we talk about perinatal mental health we are referring to the women’s and/or person-with-a-uterus’s mental and emotional experience as it spans the spectrum. For purposes of this article, the word ‘woman and women’ are used to denote anyone who has a uterus and is actively participating in the reproductive phase of one’s life.
Perinatal mental health, as a blanket term, also takes into consideration the challenges that can present during this timeframe such as infertility, loss, unwanted pregnancies, pregnancy risks, high risk interventions, birth trauma, postpartum distress, insomnia, and the day-day struggles of parenthood. It is important to note that throughout the perinatal journey there are many obstacles that can lend to the presentation of what mainstream psychology calls mood disorders. In this article, I will zero in on the postpartum period.
I was afraid that I was going to catch postpartum depression;
I spent most of my pregnancy trying to avoid this.
So often I hear this statement from my clients. With so much focus on prevention, it is no wonder. Sobbing, my clients expose their deepest fear - to be diagnosed with a PPMD. With so much attention trying to avoid ‘catching’ this ‘thing’ in the postpartum, or normalizing PPMD as part of the experience of becoming a parent, we have collectively created a ‘monster under the bed’ that we are afraid to look at. When we label the symptoms that can present in the postpartum as ‘disordered’ we can’t help but turn them into something bad or wrong. As well, when we normalize distressing symptoms in the postpartum as ‘just part of the grind’ we can miss or ignore important cues that could result in harming behaviour. And, if we glorify the postpartum as if we are living in la-la land, hiding all of our distressing feelings and thoughts, we are running away from reality. It is as if we are stuck in a damned if we do, damned if don’t, paradigm.
Let’s step out of this mindset for a moment and take a wider gaze that includes all experiences, with less fear.
Circling back to the opening trauma informed statement: It is not what is wrong with them, but what happened to them. In other words, let’s take a systems approach to understand the challenges of the postpartum. As well, let’s look at the build up of stressors and traumatic stressors that influence the mothers window of tolerance (capacity to tolerate life’s stressors). Finally, let’s look at resilience, post-traumatic growth, grit, brain health, and relational living. And, let’s focus all of these points through the lens of the biological nervous system.
A Systems Approach
Through a systems approach we understand that we are a part of a larger system and that we are in a dynamic relationship of energy and information exchange with the outer and inner environment that we inhabit. Let’s call this exchange that happens between you and the outer, and you and the inner, as experience. Each unique experience influences how you think, feel, and behave. In other words, how you show up for life. Without getting too philosophical, for the sake of the point of view that this article is taking, can we agree on the assumption that you are an individuated system that composes of your biology, your emotional and cognitive processing centres, ego/personality, energetic and relational self (I call this your: body home, heart centre, cognitive brain centre, and energetic soul-self). This system, let’s call it ‘Self’, is in a dynamic exchange with its external and internal environment at all times. There are many external forces that impose energetic pressure or force, and influence the health and wellbeing of your unique system.
Listed below are some systems that influence the perinatal spectrum:
Extended family system
Nuclear family system
Religious or spiritual system
Without unpacking each system, take a moment to imagine the potential influence of all the external factors that can have an impact on your unique experience. Each of these systems hold at its core a belief structure, and we can bump into these belief structures. Some of which might be supportive. Others can be harmful, resulting in the increased risk of a traumatic stress injury. These stress injuries, that can result in trauma (but not always), are at the root of the ‘disordered’ symptoms. However, when we neglect to take into consideration the whole picture of influence, the mother who is suffering often turns the pain inwards and blames herself and holds the belief that there is something wrong with her, rather than something wrong with the external systems. I am known to say that we can only adapt so much to a toxic environment before we tip out of balance and the ship starts to sink. Taking this point of view into context, what is toxic about the external perinatal environment you might be asking?
There are many factors that can be experienced as traumatic stressors for a woman throughout the perinatal period. Not all stressors are traumatic, however, an accumulation of stress in which the woman is in a prolonged state of survival stress with no reprieve can result in what I call, a toxic stress load (TSL). This TSL will be experienced differently per each unique individual because every postpartum mother has a unique window of tolerance (WOT) - how much stress you can tolerate before you tip out of balance and hit the internal mayday ‘alarm’ button. When the personal system is stuck in an alarm state (survival stress) with no end in sight, the system is vulnerable to symptoms of distress. These symptoms can flair up and they present along a spectrum, in which we label, as either depressive, anxious, or bipolar. Due to the uniqueness of each individual system you can’t predict what symptoms will become problematic or destructive to the health and wellbeing of the mom and her relationships. In a very simplistic way, what I am saying is that the symptoms of a PPMD tells us something about the mothers state of survival stress, and that something likely happened to trigger her alarm system throughout the perinatal period. Leaving us to question: What triggered the alarm system? What influences the health of the mothers system? What influences the WOT? What helps to restore and regulate a system? Can a stuck system, presenting with a distress call (i.e., symptoms of PPMD) shift towards coherence?
A few potential traumatic stress factors, but not limited to, are as follows:
Previous miscarriage or loss
High risk pregnancy factors
Induction and/or medical interventions
Unplanned cesarean birth
Emergency during labour and/or delivery
Overwhelming pain without reprieve
Medical micro agressions
Harmful protocol or painful procedures
Lack of support in the pp
Active substance abuse
History of abuse or oppression; current abuse or oppression
Unplanned or unwanted pregnancy
Lack of informed consent
Substantial blood loss
Infection or sever illness
There are many potential stressors that can pile onto the individual system resulting in dysregulation of the wellness of the mother. We know that our biological system does not thrive in a prolonged stress state. As such, the perinatal period if full of external stressors that can contribute to the risk of a stuck alarm system. For some of us, living in survival stress is base line - it is familiar. Just because it is familiar doesn’t mean it is normal or healthy. For years now, I have been deeply invested in what supports the health and wellbeing of the individual and the collective. In other words, how do we/you/I thrive even under chronic survival stress?
Typically, when I explain this to one of my clients they let out a huge sigh of relief. A shift occurs internally in which they begin to see their ‘symptoms’ as a result of prolonged survival stress rather than, a disorder or failure on their part. Without going into great detail about how external systems, with differing beliefs or worldviews, can cause harm, I hope you can begin to see a broader picture as it pertains to postpartum mental health. One that shifts the gaze away from the individual as being ‘disordered’ and moves towards a compassionate embrace of carrying the burden of too much survival stress imposed by too many stressors throughout the childbearing continuum.
Resilience, Post-traumatic Growth, and Relational Living
Finally, to enter the up and out phase of trauma recovery, the article would not be complete without speaking about the intelligence of our individual system that seeks to thrive. Without this core assumption, one can get lost in the weight of trauma and crisis. Identifying the root contributing factors and naming them and understanding how they influence the health of a mothers system is one thing . This step alone can increase the compassion quota, which is remarkable to witness. However, we need to go one step further. Although it is true that acceptance of one’s symptoms is helpful; no longer fighting with reality. I propose that we can go further towards a belief or hope, that a system can shift from surviving to thriving.
Most of modern evidence based mental health modalities such as CBT, ACT, DBT, for example, assert that we can change our relationship with our distressing symptoms by first accepting them and looking at them head on. These approaches require some foundational elements to be effective. First, the client has to be motivated to change and take charge of their wellbeing - commitment. Second, the client seeks to embody the foundational skills of regulation (being with emotional material) and reflection (becoming aware of thinking, feeling, and sensations). These two important steps lay the foundation for almost all therapy. This is often where therapy can seem like it failed.
If a mother is coming to therapy in the postpartum hoping that the therapist will ‘cure’ them with a magical technique, they will be terribly disappointed and likely internalize that they wasted their money. Hence why the medical model of mental health focuses much of their attention towards symptom management via pharmacology. Sometimes, the support of psycho-pharmaceuticals enhances the mothers capacity to engage in the two steps mentioned above. Without medical intervention, a mother might find herself trapped and immobilized to such a degree that there is no shifting out of the ‘alarm’ state. Therefore, there is room for medical management as a tool to support this shift towards coherence. Once a mother embodies these primary steps - commitment, regulation, and reflection - she is well on her way towards stepping out of the dreaded state that she finds herself in as a result of a toxic stress load.
I have encountered push back towards this individualistic point of view in which there is an expectation that the mother willingly chose to be an active participant in their mental and emotional health. In particular, the concern is that if the mother ‘fails’ at learning these ‘skills’ that it will further embed an already negative belief that there is ‘something wrong’ with them, or that they are ‘permanently damaged’ and can’t be helped. Due to fear of failing at applying these new skills, many will choose to not engage at all and thus, remain trapped in a prolonged survival stress state.
This foundational step is a key factor in therapy and is akin to choosing to work out, eating healthy nourishing foods, consuming healthy media production etc for the sake of health. We know that these factors above influence the health of the body and mind. We also know that learning the foundational skills of regulation and reflection fosters more coherence, and thus, greater overall mental health.
Shifting from a state of survival stress towards one that is coherent, and thus, thriving requires the aforementioned steps before diving into the next phase of therapy. I argue that much of talk therapy spends most of its time focusing on the above skill development. Embodying those skills is one thing, applying them when life is turbulent is when it really matters. And, the postpartum is a raw time full of vulnerabilities and stressors that require any mom to hold steady while the waters throw her around. So when we are talking about prevention we are talking about practicing the skills of regulation and reflection to start, and building our inner and outer resources. After this, however, when we are hit with the tsunami of life after birth, we often need something more.
That something more is where nervous system informed, trauma informed and transpersonal psychology enter the conversation. Foundational to these paradigms is a belief that the body wants to heal and the psyche wants to heal; that our systems are designed to heal. From a transpersonal perspective, each individual has an internal healing intelligence that knows how to support the health and wellbeing of the system. Through a nervous system informed lens, our biology houses both a survival system and a thriving system. Innate is a drive to thrive. From a trauma informed lens, there is a belief that traumas cloud our essential self and block the ‘sun’ from shining through. In all of these paradigms, the key factor is to remove the debris that is blocking the full expression of the essential self - which is one of vibrancy and love.
How does a mother remove those blocks? What is in the debris? What is supportive or required for her system to thrive? How does she do this while also adapting to new motherhood? What guides the process? These are the questions that lends to a deeper investigation into the world of mental health and opens up the conversation around healing and transformation. However, for the purpose of this article, I will give you a very basic answer to these supportive questions.
First, it is said that we don’t have a mental health crisis, we have an emotional health crisis. Removing the blocks usually occurs through an embodied emotional release process; one in which the mother stays in her body throughout the felt experience of the emotion. And generally speaking, the debris comprises of undigested emotional and cognitive material like grief, anger, or fear and the story that follows. Typically, what we resist in therapy is feeling these emotions and hearing the story we are telling ourself about the stressful events. This is where we can stay stuck and therapy can feel scary and impossible. Therefore, leading with what supports the system to release this stuck emotional material is critical. And, according to attachment theory and polyvagal theory, we do this relationally. In other words, we need another calm, anchored, and connected nervous system to help us in this process; we were never intended to do this alone. Hence, therapeutic relationship is even more important than we thought. If a mother doesn’t feel safe therapeutically, she will not shift out of survival into thriving.
There are many external contributing toxic stressors that layer upon the mothers experience. In the vulnerable state of the postpartum during which time the mother’s entire sense of the world has been blown wide open and she is collecting all her cells and reorganizing them after birth (no matter the way in which she birthed), she is expected to just ‘handle’ it all with grace and ease (most often alone); Often left surprised by how challenging the fourth trimester stage is. Therefore, is it any wonder why we continue to see rising rates of PPMD?
I am proposing that we have reached a collective tipping point in which the mother can no longer bear the burden of the postpartum in this way - alone and ‘toughing it out’ - as if all that she is experiencing is ‘normal’. There is nothing ‘normal’ about our rapidly changing global climate (literally and figuratively) and the stressors that today’s mother is burdened with outweighs, in my opinion, the stressors of the past mother. Thus, more moms are trapped in the ‘alarm’ state resulting in the expression of a ‘mood disorder’. Although I presented you with an approach to therapy and framed postpartum mental health through a trauma informed systems lens, I conclude with a bigger question: If the collective is dysregulated and toxic, are we supposed to continue, as mothers, to ‘just’ adapt a little bit more? Or does there come a time when we push back and say, enough, something is terribly wrong, and it is no longer me that has something ‘wrong’? Sometimes I question if our symptoms are in fact a healthy response to an unhealthy culture around birth and motherhood?
Thanks for reading Therapy For Moms! Subscribe for free to receive new posts and support my work.