EMDR Therapy and Pregnancy

EMDR Therapy and Pregnancy 
by Bethany Warren, LCSW, PMH-C

A few months ago, EMDRIA asked long-time PHA member and supporter (and past PHA President!), Bethany Warren, to write a blog about EMDR therapy and pregnancy. In her interview, Beth talks about the benefits of this type of therapy with pregnant clients, and debunks some common myths and misconceptions associated with EMDR therapy and pregnancy.

Tell us a little bit about you, your experience becoming an EMDR therapist, and your experience using EMDR therapy with clients during pregnancy.  

Becoming a parent is one of the largest developmental shifts one can experience. There can be layers of revisiting raw attachment wounds while also simultaneously forging attachments to a baby, and all in the midst of great physical, emotional, and biological changes.  Any traumatic distress experienced throughout this time can be deeply layered and nuanced. 

I’m a psychotherapist in private practice in San Diego, California, certified in EMDR therapy and Perinatal Mental Health and have worked in the field of reproductive / perinatal mental health for over two decades. I have found EMDR therapy to be absolutely foundational to my practice. 

Before I was trained in EMDR, I found insight and cognitive-oriented approaches to be lacking in full and complete healing for my clients, particularly as perinatal clients often present with such complexity. Many clients who experienced reproductive trauma seemed to hit a “ceiling” of recovery, despite their best efforts in therapy. It was like they were trying to talk themselves into believing the distress to be over, believing themselves to be good parents, or not permanently broken, etc., but they did not actually fully feel it to be true and the trauma triggers continued to happen. In retrospect, I didn’t understand the concept of the AIP model, but I certainly knew I needed something different for my clients.

Becoming trained in EMDR therapy blew the lid off my practice, so to speak. Clients found relief, many with such complex layers of attachment wounds, multiple traumas from childhood, and current day Perinatal Mood and Anxiety Disorders and reproductive traumas. 

Are there any myths you’d like to bust about EMDR therapy during pregnancy?

There are several widespread myths and misconceptions about the use of EMDR therapy during pregnancy. I get asked these questions a lot from consultees and colleagues, so I am very grateful for the opportunity to address this here.

One common myth I hear is that EMDR during pregnancy is contraindicated, or should only be used after the first trimester. 

Another common myth is that clinicians should only target perinatal-specific targets when doing EMDR with pregnant clients (such as distress around pregnancy complications, preparation for birth, processing a prior traumatic birth, triggers around OB visits, etc.) and avoid any childhood trauma or non-perinatal related distress. 

And the other misconception I frequently hear is that if you are currently doing EMDR therapy with your client and they become pregnant, that you should stop EMDR and either do talk therapy or “resourcing” because of the pregnancy. 

I truly think these concerns are coming from folks who are well intended and acting from an abundance of caution in thinking about the wellbeing of the pregnancy. However, a lot of the information I hear, particularly the “gatekeeping” aspects of waiting to start EMDR until later in the pregnancy, or stopping EMDR therapy once a client is pregnant, is often rooted in misinformation and fear. An example is that because the majority of pregnancy losses occur in the first trimester, some folks believe it is better that the client not have any doubts that EMDR may have contributed in any way to their loss, if a loss occurs.

Here’s what I would love you to know about EMDR therapy during pregnancy: there is no evidence to support concerns that EMDR therapy during pregnancy is unsafe.  Instead, to the contrary, research now shows us that pregnant clients who receive EMDR therapy experience decreased distress and PTSD symptoms, reduced fears of childbirth, less intrusive thoughts and overall increases in confidence about their upcoming delivery (Baas, et al., 2022; Baas, van Pampus, Braam, Stramrood, & de Jongh. 2020; Sandstrom, et al., 2008; Stramrood, van der Velde, Weijmar Schultz, & van Pampus, 2011; Stramrood, et al., 2012; Zolghadr, Khoshnazar, MoradiBaglooei, & Alimoradi, 2019). Reducing the mother’s fear of her upcoming childbirth, while aiding her in symptom reduction and grounding skills increases the likelihood of her creating a secure and positive attachment with her baby. And as prenatal bonding increases, so does the postpartum attachment. This is particularly the case as we aid the client in processing and healing from her own deep attachment wounds, and as she builds adaptive attachment skills to now aid in her own ability to parent.

I have found, time and time again, this to be the case with my clients, and have seen this to be true with my colleagues’ and consultees’ experiences as well.

The more informed and educated we are as providers, we are then not withholding a viable therapy as an option to a client due to our own anxieties and fears. A parallel pattern occurs in psychiatry, with many clients reporting that they were advised by their prescribing physicians to stop their psychiatric medications upon becoming pregnant.  This too is often advised out of an abundance of caution, but it may not take into account the impact of untreated mental illness on both the pregnant person as well as a developing baby.  We know so much more now than we used to about how to support both mother and fetal health simultaneously, rather than forgoing mother’s health care in order to protect the pregnancy. A prescribing provider who specializes in perinatal mental health will have updated research and knowledge of treatment options and be able to weigh both treatment benefits and risks, as well as the risks of untreated mental illness symptoms on both the pregnant person as well as a developing baby. Similarly, as EMDR therapists, once we are informed and empowered with information, we can thoroughly inform our clients of their options, collaborate with their providers, and then obtain an informed consent based on evidence.

Another way to look at this is to consider other psychotherapy recommendations and norms. There is not a community standard of care recommendation to stop any other types of trauma-informed therapy when a woman is pregnant (i.e. TF-CBT), so why would we do this with EMDR? We know from the research that EMDR provides symptom and cortisol level reduction (George, Thilly, Rydberg, Luz, & Spitz, 2013; Gerardi, Rothbaum, Astin, & Kelley, 2010). By providing EMDR therapy to a pregnant client, this is helpful to both her, as well as the developing baby and has positive impacts on the baby’s lifetime trajectory. What we know about pervasive and chronic heightened distress during pregnancy is that this has a negative impact on the developing baby, negative impacts on the eventual bond between mom and baby, and there are higher risks of preterm delivery and small infant birthweight (Cortizo, 2020; Daglar & Nur, 2018; Kinsella & Monk, 2009; Zietlow, Nonnenmacher, Reck, Ditzen, & Müller, 2019). There can be significant impacts on the child later in their life as well, from emotional and stress regulation, to higher rates of mental illness. In the pregnant person, there are also increased risks of postpartum PTSD and Perinatal Mood and Anxiety Disorders when there are prior histories of untreated trauma.  All of this speaks volumes about the importance of not only addressing the pregnant client’s prior trauma history, but current distress as well. 

How can using EMDR therapy during pregnancy help? What successes have you seen?

In addition to all the benefits we’ve already discussed (such as distress reduction, improved wellbeing of both the mother and the developing baby’s nervous system), EMDR therapy can be incredibly beneficial with pregnant people in healing past attachment wounds, better preparing them for parenting differently than how they were parented. With the standard protocol, EMDR is often quite successful. I say this, because it’s important to highlight that we don’t have to have restricted processing during pregnancy. We can help them heal unresolved past events that are currently impacting them in the present, and aid them in preparing for the future. What this often looks like is processing unresolved prior reproductive traumas such as infertility, prior pregnancy losses, birth trauma, pregnancy complications, etc., as they are currently impacting and triggering them during this pregnancy. And then we turn our focus to future templates as each trigger is processed, to aid the client in preparing for more optimal ways of coping with this issue instead (such as preparing for a more empowering birth, feeling more capable with interactions with their OB, managing distressing body sensations, etc.). 

Some of my favorite work with these clients is processing unresolved attachment wounds from childhood such as neglect from a cold/detached mother as they themselves are preparing to become a mother, as parenting can often bring up terror and feelings of overwhelm. Or perhaps they’re triggered by current family interactions, or are grieving the changes in their identity, shifts in relationship dynamics, feelings of overwhelm and powerlessness, etc. This is why it’s important not to restrict processing to only perinatally-focused content, but do a thorough history taking based on whatever our client is experiencing. I find many new parents simultaneously grieving their past life while also eagerly anticipating their changing world. Holding this ambivalence is paramount in this work of working with new parents. 

I have found recent event protocols to be incredibly useful as well, of course, when a client presents with more recent (or ongoing) infertility trauma, pregnancy loss, or birth trauma. And there have been powerful successes at processing and breaking multigenerational patterns of trauma when thoroughly assessing for themes of neglect, abuse, and of course, racism and microaggressions.

There are certainly nuances when using EMDR therapy with pregnant and postpartum clients, which is why it is important to work with a consultant specializing in this population. For example, infertility treatment experiences and traumatic births often have so many layers, not only from the standpoint of the sheer amount of time that can pass during these events, but also the various “trauma points” that can occur. These are often not easily processed as one complete event, as a result. For example, for one person’s birth experience, an undesired epidural can have a NC of “I failed”, while a negative interaction with a particular provider can have a NC of “I don’t have agency”, prolonged labor can be internalized as “I’m not capable”, and breastfeeding difficulties interpreted as “I’m broken”.  These can be intermixed with numerous positive experiences of feeling victorious and capable throughout the labor as well.  

Are there specific issues that might apply regarding the use of EMDR during pregnancy in multicultural populations?

Perinatal Mood and Anxiety Disorders, including Perinatal PTSD disproportionally impacts BIPOC and LGBTQ+ parents, with these communities experiencing 3-5x the rates of these disorders than those of White parents (Blustain, 2019; Lara-Cinisomo, Wisner, Burns, & Chaves-Gnecco, 2014; Ross, Steele, Goldfinger, & Strike, 2007). Parents in marginalized communities also face disproportionally higher rates of maternal mortality and infant mortality rates, which also of course impacts higher trauma rates in these communities (MacDorman, Thoma, Declcerq,  & Howell, 2021). And yet, these folks are screened less frequently by their providers, and are less likely to be offered mental health treatment. This is an ongoing cry to action for our mental health community to remain aware of these systemic issues and how implicit bias and racism impact mental healthcare, and perinatal mental healthcare, in particular. It’s vital for those of us working in this field to continue to take implicit bias and cultural competency trainings, work on our own triggers through therapy, seek consultation and support, and continue to strive to be the safest clinicians we can be.

It’s important to be aware that your client may have had numerous negative experiences with their prior providers, feel cautious to work with you, and that their triggers and targets may likely include multigenerational and racist trauma. For example, if a woman of color felt overpowered, coerced or unheard during her prenatal doctor visits, she may likely have experienced these similar patterns before throughout her life, and this can become a part of her treatment plan and target sequencing. Thorough explanations about our work together, obtaining trauma informed consent and allowing the client to have agency and autonomy is so crucial in our work together.

As you explore history taking and case conceptualization, I recommend using the following resources in addition to your standard perinatally-focused intake questionnaires (such as the Edinburgh Postnatal Depression Scale and the Perinatal Anxiety Screening Scale). This helps us to explore beyond symptoms and delve into themes, strengths, resources, support, etc.:

-EMDR Phase 1: Client History Identity, Race, & Culture Interview 

-Cultural Competence and Healing Culturally Based Trauma With EMDR Therapy by Mark Nickerson, Editor

-Birthing Justice: Black Women, Pregnancy and Childbirth Edited by Julie Chinyere Oparah and Alicia Dr. Bonaparte

(This is only a sampling of some of the resources I draw upon and suggest doing advanced trainings and seeking out consultation for additional resources.)

Anything else you’d like to add?

Working with perinatal populations can be incredibly fascinating and deeply rewarding, seeing multigenerational patterns changing, and watching new parents learn how to reparent themselves and heal while simultaneously caring for their new little one. It also truly is a specialty requiring knowledge of how to treat the various Perinatal Mood and Anxiety Disorders and symptoms during this developmental period. For example, you may find it interesting to know that upwards of 90% of pregnant and postpartum women experience intrusive thoughts that are ego dystonic, yet can be quite visceral and distressing. Clinicians who are not trained in perinatal mental health can sometimes be overwhelmed by the content of these vivid thoughts shared by their clients, be fearful of intent (to harm baby, for example), and have a difficult time distinguishing these thoughts from postpartum psychosis. Knowing how to treat these thoughts while also supportively reassuring their client that thoughts do not equal intention is an example of just one important aspect of this work. 

It’s also really crucial you do thorough history taking with these clients, and pay close attention to attachment themes, family of origin issues, multigenerational patterns as discussed above, and ensure you are screening thoroughly for dissociation. Some of my clients with the most significant presentations of severe structural dissociation have self-presented with “Perinatal Mood and Anxiety Disorders” and were actually so much more complex.

Whether you are interested in working more with the perinatal mental health population, or want to learn more about how to manage care with a client who might become pregnant while you are working with them, please know you are not alone and there are great resources to support you. Please seek out consultation from an approved consultant who specializes in perinatal mental health and consider joining the SIG for EMDR for Perinatal Mental Health as well! It’s important to seek support so you don’t feel afraid to do this work. Treating from a space of empowerment and information is exponentially preferable to treating (or stopping or withholding treatment) out of fear.

I’m so thankful for this space, for the opportunity to share on this blog, and for our community of extraordinary EMDR clinicians. I hope we can all continue these conversations and share helpful information with each other. Thank you very much.

References and Research:

Baas, M., van Pampus, M. G., Braam, L., Stramrood, C., & de Jongh, A. (2020). The effects of PTSD treatment during pregnancy: systematic review and case study. European journal of psychotraumatology, 11(1), 1762310. https://doi.org/10.1080/20008198.2020.1762310

Baas M.A.M., van Pampus M.G., Stramrood C.A.I., Dijksman L.M., Vanhommerig J.W, & de Jongh, A. (2022) Treatment of Pregnant Women With Fear of Childbirth Using EMDR Therapy: Results of a Multi-Center Randomized Controlled Trial. Front. Psychiatry 12:798249. doi: 10.3389/fpsyt.2021.798249

Blustain, R. (2018, July 13). The Paradox of Postpartum Depression. Colorlines. https://www.colorlines.com/articles/paradox-postpartum-depression

Cortizo, R. (2020). Hidden trauma, dissociation and prenatal assessment within the calming womb model. Journal of Prenatal and Perinatal Psychology and Health, 34(6), 469-481

Cortizo, R. (2020). Prenatal and perinatal EMDR therapy: Early family intervention. Journal of EMDR Practice and Research, 14(2), 104-115. https://dx.doi.org/10.1891/EMDR-D-19-00046

Daglar, G., & Nur, N. (2018). Level of mother-baby bonding and influencing factors during pregnancy and postpartum period. Psychiatria Danubina, 30(4), 433–440. https://doi.org/10.24869/psyd.2018.433 

de Divitiis, A. M., & Luber, M. (2016). EMDR therapy protocol for the prevention of birth trauma and postpartum depression in pregnant woman. In M. Luber (Ed.), Eye movement desensitization and reprocessing (EMDR) therapy scripted protocols and summary sheets: Treating anxiety, obsessive-compulsive, and mood-related conditions (pp. 365-364). New York, NY: Springer Publishing Co

EMDR Phase 1: Client History Identity, Race, & Culture Interview Adapted from Alter-Reid, K., Angelini, C., Chang, S., Gattinara, P., Grey, E.,Hearting, J., Heber, R., Juhasz, J., Levis, R., Levis, R., Lutz, B., Marich, J., Masters, R., McConnell, E.,

Monteiro, A., Nickerson, M., O’Brien, J., Onofri, A., Robinson ,N., Royale, L., Seubert, A., Shapiro, R., Siniego, L., & Yaskin, J. In Nickerson, M.I. (Ed.), Cultural Competence and Healing Culturally-Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. New York, NY: Springer. Edited in consultation with Chaffers, Q., Hamilton, H., Kase, R., Marich, J., & Urdaneto Melo, V. and the EMDRIA Diversity, Community & Culture SIG (personal communication, July 2020). Promoted by Diane Desplantes, LCSW and developed by Colette Lord, PhD & Susanne Morgan, LMFT ~ EMDR Readiness Academy (Updated 9/2021)Open Permission Granted to Share and Reprint

George, A., Thilly, N., Rydberg, J. A., Luz, R., & Spitz, E. (2013, March). Effectiveness of EMDR treatment in PTSD after childbirth: A randomized controlled trial protocol. Acta Obstetricia et Gynecologica Scandinavica, 22(7), 866-868. doi:10.1111/aogs.12132

Gerardi, M., Rothbaum, B.O., Astin, M.C. & Kelley, M. (2010) Cortisol Response Following Exposure Treatment for PTSD in Rape Victims. Journal of Aggression, Maltreatment & Trauma, 19:4, 349-356, DOI: 10.1080/10926771003781297 

Kinsella, M. T., & Monk, C. (2009). Impact of maternal stress, depression and anxiety on fetal neurobehavioral development. Clinical obstetrics and gynecology, 52(3), 425–440. https://doi.org/10.1097/GRF.0b013e3181b52df1

Klabbers, G., van Bakel, H., van den Heuvel, M., & Vingerhoets, A. (2016). Severe fear of childbirth: Its features, assessment, prevalence, determinants, consequences and possible treatments. Psychological Topics, 25(1), 107–127

Lara-Cinisomo, S., Wisner, K. L., Burns, R. M., & Chaves-Gnecco, D. (2014). Perinatal depression treatment preferences among Latina mothers. Qualitative health research, 24(2), 232–241. https://doi.org/10.1177/1049732313519866

MacDorman, M.F., Thoma, M., Declcerq, E. & Howell, E.A. (2021). Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017. American Journal of Public Health 111 (9), 1673-1681

Nickerson, M.I. (Ed.), Cultural Competence and Healing Culturally Based Trauma With EMDR Therapy: Innovative Strategies and Protocols. New York, NY: Springer

Oparah, J.C. & Bonaparte, A.D. (Eds.), Birthing Justice: Black Women, Pregnancy and Childbirth. New York, NY: Routledge.

Ross, L. E., Steele, L., Goldfinger, C., & Strike, C. (2007). Perinatal depressive symptomatology among lesbian and bisexual women. Archives of women’s mental health, 10(2), 53–59. https://doi.org/10.1007/s00737-007-0168-x

Sandstrom, M., Wiberg, B., Wikman, M., Willman, A.K. & Hogberg, U. (2008).  A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth. Midwifery, 24(1), 62–73. https://doi.org/10.1016/j.midw.2006.07.008

Format:

Stramrood, C. A. I., van der Velde, J., Doornbos, B., Paarlberg, K. M., Weijmar Schultz, W. C. M., & van Pampus, M. G. (2012). The Patient Observer: Eye-Movement Desensitization and Reprocessing for the Treatment of Posttraumatic Stress following Childbirth. Birth-Issues in perinatal care, 39(1), 70-76. https://doi.org/(…)23-536X.2011.00517.x

Stramrood, C. A. I. (2013). Posttraumatic stress following pregnancy and childbirth. (Doctoral dissertation, University of Groningen). Retrieved from http://irs.ub.rug.nl/ppn/357967046. Dutch

Stramrood, C., Paarlberg, K. M., Vingerhoets, A. J., van den Berg, P. P., & van Pampus, M. G. (2012, March). Posttraumatic stress following childbirth: Diagnosis, treatment and prevention. Poster presented at the 70th annual scientific meeting of the American Psychomatic Society, Athens, Greece

Stramrood, C., van der Velde, J., Weijmar Schultz, W. C. M., & van Pampus, M. (2011, March). A new application of EMDR: Treatment of posttraumatic stress following childbirth. Poster presentation at the American Psychosomatic Society 69th Annual Scientific Meeting, San Antonio, TX

van Deursen-Gelderloos, M., & Bakker, E. (2015). Is EMDR effective for women with posttraumatic stress symptoms after childbirth? European Health Psychologist, 17(S), 873

Zietlow, A-L., Nonnenmacher, N., Reck, C., Ditzen, B. & Müller, M. (2019). Emotional Stress During Pregnancy – Associations With Maternal Anxiety Disorders, Infant Cortisol Reactivity, and Mother-Child Interaction at Pres-school Age. Frontiers in Psychology, 25(9). https://doi.org/10.3389/fpsyg.2019.02179

Zolghadr,N., Khoshnazar, A., MoradiBaglooei, M., & Alimoradi, Z. (2019). The Effect of EMDR on Childbirth Anxiety of Women With Previous Stillbirth. Journal of EMDR Practice and Research, 13(1). 10.1891/1933-3196.13.1.10

For more information and trainings on Perinatal Mental Health and EMDR:

EMDR & Perinatal Mental Health (Podcast Episode on the Mom & Mind Podcast – basic information for the general public) https://momandmind.libsyn.com/107-emdr-for-perinatal-mental-health-with-bethany-warren-lcsw

EMDR & Pregnancy with Dr. Mara Tesler Stein (YouTube Video) https://www.youtube.com/watch?v=9DIp35n6nB4&t=393s

(Dr. Stein also offers EMDRIA approved trainings on EMDR and Perinatal Mental Health!)

Dancyperinatal.com (including courses on EMDR and perinatal mental health, Impacts of Transgenerational Trauma and Racism on Maternal Health) 

Postpartum Health Alliance: postpartumhealthalliance.org (PMADs 101 course and other resources)

Postpartum Support International: postpartum.net (Become further trained in PMADs, receive a certification in Perinatal Mental Health, resources)