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By Emma Svanberg
[Photograph by Phil Taylor]
There can still be some confusion around what birth trauma means, and as a result also some confusion about the best available therapies and treatments to resolve symptoms of trauma. Birth trauma in essence refers to symptoms which relate to the experiences of birth and around birth. So this may be the birth itself, or there may be symptoms of trauma related to the pregnancy journey, the postnatal period, feeding experiences. The key link is that, at some point in these experiences, an individual felt that they or a loved one were fundamentally unsafe. This is why not only women and birthing people may experience symptoms of trauma, but birth partners, health care professionals and wider family members. One can also experience symptoms of trauma through hearing about traumatic events, leaving ripples that can span through a whole family, group of friends or team of healthcare providers. What’s key here is that the experience of trauma is entirely subjective, and can’t be defined by anyone else1. If a person feels that they have been negatively affected by a traumatic event around their birth, even if on paper it may look like a straightforward experience, then listening with an open heart and lack of judgement to their experiences can be a significant first step on the road to recovery.
For some, their symptoms may meet the criteria for a diagnosis of Post Traumatic Stress Disorder (PTSD). Currently around 4% of women who give birth are being diagnosed with, or thought to be suffering from, PTSD2. Or, as is the case for about a third3 of women, there may be some symptoms of trauma but not the cluster of symptoms that defines a diagnosis of PTSD. Whether or not a diagnosis exists, such symptoms can have a far reaching impact on daily life, on relationships with our babies, partners, family, friends, and health care services, on our sense of confidence, our mental and physical health.
When we feel traumatised, our brains get ‘stuck’ in fight or flight mode. It’s as if our bodies haven’t quite registered that we are now safe. Many of the symptoms therefore revolve around reminders of the traumatic event, avoiding such reminders, feeling vigilant to threat and inevitable mood changes that result from this.
So what can we do about traumatic symptoms? At Make Birth Better4, we are working as a collaboration of parents and professionals to examine the systemic causes of birth trauma and campaign, alongside our colleagues at AIMS, for wider cultural change. But until that happens, what can help those women, birthing people, partners, family members and healthcare professionals who are affected by trauma?
There are a range of different therapeutic options available for those who have symptoms of PTSD, many of which will also be suitable for those with sub clinical (below diagnosis) symptoms. All of them target the continued feeling of being unsafe – particularly in changing the ways that traumatic memories are stored in our brain. The feeling of continued threat experienced after trauma is due to the traumatic memory being stored in a part of the brain called the amygdala, which is our ‘alarm system’. Treatments tend to focus on exploring the traumatic memory and allowing it to be processed, so that it can be stored in the hippocampus alongside our other long-term memories.
The National Institute for Clinical Excellence (NICE) guidelines, which are research based guidelines for health practitioners, suggest Trauma Focused Cognitive Behavioural Therapy (TF-CBT) and Eye Movement Desensitisation and Reprocessing (EMDR). The majority of people in the UK who are offered treatment are offered TF-CBT. Other treatments have also been evaluated but not recommended by NICE, however psychiatrist and trauma specialist Bessel van der Kolk suggests in his book ‘The Body Keeps the Score’ that many people will benefit from a range of different approaches, and that these may change over time.
TF-CBT and EMDR are both manualised approaches (approaches which follow a defined protocol), which therapists are encouraged to adhere to strictly. Both begin with a lengthy process of teaching the client ‘grounding’ techniques. These are techniques which ‘ground’ a person in the here and now, reminding them that they are safe. These might be focusing on breath to bring a person back to the present (particularly when they might be experiencing flashbacks), looking at all of the blue objects in a room, counting the number of circles you can see, asking questions about the day, date, what is happening in the news and so on.
These treatments directly combat the trauma memory by enabling someone to quickly return to a sense of safety. It is useful to note that, in brief therapy of 6-12 sessions– which is what most people are offered from local NHS psychological therapies services – this grounding part of therapy may be the only technique used to ensure that someone is left feeling safe. In brief therapy, moving too quickly to exploring and resolving the traumatic memories themselves can feel very destabilising.
Trauma expert Babette Rothschild emphasises the need for clients to feel able to ‘put on the brakes’ before tackling any memories of trauma. She says “…I never help clients call forth traumatic memories unless I and my clients are confident that the flow of their anxiety, emotion, memories and body sensations can be contained at will. I never teach a client to hit the accelerator, in other words, before I know that he can find the brake.”5
This can be frustratingly slow when you are desperate to free yourself of trauma symptoms, but it is imperative that, when accessing traumatic memories, a person is able to feel deeply relaxed so that a feeling of safety can be held on to. The risk of going too quickly is that you can re-traumatise a person, and leave them with more distressing symptoms. This may mean that therapy may be accessed a number of times before symptoms are resolved, or that a request for therapy from another source is made. Within the NHS, services follow a ‘stepped care’ model so that if symptoms are not resolved by the first therapeutic option offered, further support should be requested. However, in reality many people find it hard to access support and knowing the recommended treatments of choice can be helpful when requesting help. These can be found by looking at the NICE guidelines on Post Traumatic Stress Disorder6 and Antenatal and Postnatal Mental Health (section 1.9.4)7.
Cognitive Behaviour Therapy (CBT)
During Trauma Focused CBT, once the client and therapist both feel that it is safe to do so, they will begin to explore the traumatic memory together focusing specifically on the meanings that were made at the time and the parts of the memory that feel particularly emotionally raw (called ‘hotspots’). They will then work together to create new meanings, and go through the memory together (called ‘reliving’) introducing some of these new meanings to the traumatic memory. In this way, the old traumatic memory is updated with new information that affirms the person’s safety and begins to make the memory feel less powerful. TF-CBT may also include exposure, such as taking small steps to visit the hospital in which the trauma occurred. This can be particularly useful when any avoidance symptoms are stopping the person from living their daily life. With birth trauma, some people feel that the baby themselves can be a reminder of the traumatic memory, and put strategies in place to create a buffer between them and the baby (such as feeling unable to be left alone with the baby), so exposure may also involve gradually building up confidence in this way too. Other CBT models, including mindfulness and shame-focused interventions are sometimes used in addition to this model.
Eye Movement Desensitisation and Reprocessing (EMDR)
While EMDR looks quite different, it works in a similar way in processing the traumatic memory. EMDR follows a protocol of eight phases. The first three phases overlap somewhat with TF-CBT; a thorough assessment is carried out to learn about the traumatic event and also any current difficulties, grounding techniques are practised and the process of therapy is discussed, and a particular traumatic memory is described alongside the symptoms it brings up. Where EMDR then diverges is that the therapist will use a particular tool, such as a finger movement, using tones or tapping, to create a dual awareness. This means that the traumatic memory can be processed while attending to something else, removing the intensity of the memory. A more positive or hopeful belief or meaning is then added to the memory. The body is also attended to, and any feelings of tension are targeted as trauma can so often be held in the body. During every session, progress will be reviewed, and each session will end with using techniques so that the client leaves feeling calm and grounded.
Alongside these therapies, some people also choose to take medication (according to the NICE guidelines, medication should not be offered unless one of these therapeutic interventions has been declined, but in the realities of the NHS this is not always the case). Many are offered Birth Afterthoughts or Birth Reflections sessions – these are different according to each Trust and most are not grounded in evidence based practice (see the article in the AIMS Journal Vol 30 No 4). It is useful to note that one off debriefs are advised against for PTSD in the NICE guidance as this may also heighten symptoms of trauma if the traumatic memories are left unresolved. NICE also recommends that therapists should be flexible about the treatments that are offered, and acknowledge that symptoms of trauma may themselves make it challenging to attend appointments.
What we hear from women who contact us at Make Birth Better is that they also find other strategies helpful – such as breathing exercises, yoga and massage. Peer support can also be beneficial, and groups such as the Birth Trauma Association’s peer support Facebook group or local face to face peer support groups can normalise the often distressing experience of birth trauma. However, some people find that hearing others’ stories can add to their distress so it is useful to access such groups with additional support (this may be from a friend or family member, or a health professional).
What’s key is that you find something that works for you, with someone you trust and who has the appropriate skills and experience to work with you. It can be frightening to take that first step towards seeking help, but the effectiveness of these treatments means that birth trauma is something you absolutely can recover from.
Many people do find it difficult to find the most appropriate help. For this reason, we have created a number of free-to-download crib sheets8 on the Make Birth Better website, including information about birth trauma, possible treatments and therapeutic techniques, which you are welcome to print off and share with any healthcare providers. There is also a crowd-sourced map of local services9 on the website, including both NHS and independent services. Many people find that a range of different techniques is what helps them to recover and – like birth trauma itself – what can help is as individual as you are.
If you would like to access support for a traumatic birth, or would like to support a client, friend or family member, the first option is always to speak to your GP or another healthcare provider. There is still misunderstanding around birth trauma so taking a crib sheet from the Make Birth Better website to explain your symptoms and what you are entitled to can be helpful. Depending on your symptoms and the age of your baby, you may be offered access to a brief psychological therapies service, to a Perinatal Mental Health Team or to a Trauma service. Sometimes there are long waiting lists, or you may have to see a number of people before you find the right support. Do take a look at the Make Birth Better website and Why Birth Trauma Matters for ideas about supporting yourself as you wait. You are always welcome to contact us at Make Birth Better if you have any questions about this process.
1. Tatano Beck, Cheryl. (2004). Birth trauma: In the eye of the beholder. Nursing research. 53. 28-35
2. Dikmen Yildiz, Pelin & Ayers, Susan & Phillips, Louise. (2016). The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. Journal of Affective Disorders
3. Slade, P. (2006). Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics and Gynecology, 27(2), 99-105.
5. Rothschild, Babette (2004) Applying the Brakes. Psychotherapy Networker
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services. From the beginning of 2018, the journal has been published online and is freely available to anyone with an interest in pregnancy and birth issues. Membership of AIMS continues to support and fund our ability to create the online journal, as well as supporting our other work, including campaigning and our Helpline. To contact the editors, please email: email@example.com
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