Perinatal therapy — what is it?

Pregnancy, childbirth and puerperium are associated with the body rather than with the spirit. You have to deal with the ailments, slow down, go to the doctor and for examinations more often. If that time is associated with therapy, it is mainly with medicines supporting pregnancy, or urogynaecological therapy. Perinatal psychotherapy is still a novelty in Poland. What is it all about? How can it help? I asked psychotherapists running workshops for pregnant women, Iwona Wojtan and Barbara Sławik.

Joanna Piekarska:Everyone knows that pregnancy is a time of huge physiological changes. The body prepares for childbirth and childcare, but what happens in the psyche during this time? This knowledge is much less common. The common conviction is probably that it is only joy and bliss…

Iwona Wojtan:Pregnancy is a time of dynamic psychological changes. A woman withdraws into her own interior, is absorbed in dreams, feelings and fantasies. A future mother dreams of her child. She imagines what it will look like, what its character will be. Sometimes she gives it a caressing nickname, talks with the child as if it was an imaginary friend. It is a peculiar relationship, in which one body is closed inside another. Feeling the movements of the fetus, the woman realizes that she has a resident with its own daily rhytm, not necessarily predictable. It is also a time to return to memories and experience from the times when we were little girls ourselves. They can relive difficult memories of relationship with parents. Sometimes it makes the bond stronger. The fact that body ceases to be the exclusive property of a woman and undergoes many changes also has an emotional meaning. The reflection in the mirror may turn out to be surprising, it becomes difficult to lean, and in the third trimester you can only dream of seeing your own feet. All of this makes woman sensitive and defenceless during this period.

Barbara Sławik:I will come back to what we started with, that the stereotype speaks of pregnancy as mere joy and bliss. This is the first thing that makes it difficult for a pregnant woman to accept different feelings. But there is also a lot of calming, dropping everything on the instinct. When a woman has doubts or is afraid of something, she is told: “You will know after giving birth”. Only after the birth it turns out that a small “alien” appeared, and the instinct is lacking… I very much agree with Justyna Dąbrowska [one of the precursors of perinatal therapy in Poland – my footnote] that there is no such thing as maternal instinct. An instinct is called a mixture of what was done to us, what we hear from others, and what is in the cultural message. It is mixed up and only all these elements together are called the instinct. It is to make everything with the newborn so “sensitive”, hoping that this is the right thing to do. Then it turns out that this is not quite the case. We start taking care of the baby and we don’t like what we do. And what then? Despite the fact that perinatal care is getting better and better, that there are such actions as “Rodzić po ludzku”, many important things are not mentioned, there is not even a way to find out about them. Women after childbirth are surprised by many things, even though they have already had a good care, a trusted doctor, an approved hospital… We still don’t know much about our rights and what is crucial for the future relationship after the childbirth. (And this is known from research into the attachment of Mary Ainsworth and others). There are moments, milestones that are worth taking care of, such as first contact with the baby “skin to skin”, first feeding. And the way it happens can make it much easier or more difficult for us later on. That is why it is worth considering beforehand: what support do I want and from whom, what am I ready for, who do I want to allow myself in the puerperium? Afterwards, various things can happen quickly and there is no room for reflection.

Pregnancy and childbirth are times when you lose control or, in other words, your ability to do something. You are very dependent on the others: doctors, family, especially in case of some complications, e.g. after the C-section. If you don’t know what is important, what to demand and what you can forgive, it can be difficult to do so later. That is why it is worth thinking about the relationship with the child, when he or she is still in our body, in order to better prepare for the time when the child will leave the body. These are very big changes and in order to have contact with yourself and with your child at this moment, you have to have support in such a belief that I know how I want it to be. This thought was the foundation for the idea of a workshop for pregnant women. We wanted to create a space for common reflection. We don’t want to say how it should be, but to pay attention to what is important for the relationship with the child, so that the participants can think about what they would like to include in their relationship with the child and in what form, and have the opportunity to choose the path that suits them.

J.P.: It seems to me that there is a little talk about what is emotional in pregnancy, more about physiology and all the technical details, what to eat, what not to eat, in what position to sleep and so on. And it may be that pregnant women experience various things that are natural in this state, and they worry that maybe something is wrong with them, since there are not only pleasant feelings. So to deny the myth that pregnancy is just a joy, I will ask – what fears are most often experienced by future mothers?

I.W.:Regardless of whether the woman did not plan to become the mother, or whether the pregnancy was preceded by long efforts, the fact of conception arouses various fears and mixed feelings. When it becomes clear that the symptoms of the body mean that a separate being is living within it, doubts, feelings of loss and grief, or contradictory desires may arise. 9 months is the time to mentally prepare for the new role. This involves, among other things, the loss or significant reduction of many activities such as work and social life in order to concentrate on the child. Focusing on tasks related to future motherhood entails the loss of part of one’s freedom.

J.P.: And it’s very fast because from the beginning of the pregnancy you can’t drink alcohol, do some sports, carry shopping…

I.W.: Life is changing irreversibly. A woman can experience mourning, saying goodbye to her previous lifestyle, feeling inner disagreement or enjoying the changes she experiences. Or everything at once. It is important for her to be aware that all her feelings are natural and can be spoken about openly. Unfortunately, the widespread idealization of pregnancy and motherhood, sanctioned socially and culturally, does not help.

B.S.: I would add a few things to that. First of all, it is difficult to be pregnant and to be aware that it is already happening, that it is somehow irreversible. You can’t just stop being pregnant – it can end up in different ways, but it’s already a fact.That brings us into contact with the various fears of a new role, of how it will be, but also of returning to our own childhood experiences. Especially if they were difficult. When I think about what kind of mother I want to be, I automatically think about what kind of mother I had. Then I ask myself if I want to do the same, or maybe in a different way – and what, and how in a different way? On the other hand, we sometimes know that we want it differently, but we don’t know how. We have no other example. And then, there is a need for support. I am very happy that nowadays it is becoming more and more difficult to say that a pregnant woman should not be in therapy. Once, we were used to avoid it. Women were afraid that if she gets very emotional, she could miscarry. Today, I have patients with whom I work until giving birth. And this is great because it allows a woman to get in touch with different emotions, including difficult ones. An invaluable thing is also a possibility of continuing the therapy after the birth of a child, already together with him/her in the office. If there are any problems with establishing a bond, or if the woman is somehow difficult with this child, or if she has not been flooded with a wave of happiness in the delivery room and is worried, she can come to the therapist’s office with the child (up to 10 months old) and work on the bond, receive the necessary support. This cultural coercion, that a small child should cause only waves of happiness and joy in us, is very strong. On the other hand, there is a great pressure on naturalness and it was terrible when I read on the Internet the discussion about the fact that mothers who had a C-section cannot say that they had given birth to their children… Just that these children were excavated.

J.P.:For real?

B.S.: Yes, and there was a verbal argument as to whether these children have the right to celebrate their birthday, or whether they should celebrate “mining”. Indeed, there are women who want to have a C-section on request, but that does not make them less mothers. There are also many C-sections with medical indications.

J.P.: I’m really glad that I didn’t get lost in this corner of the Internet. But since we are already talking about such non-supportive hate-speech, let’s turn the subject a little bit, let’s talk about support. What kind of support does a future mother need from her loved ones?

B.S.: I think there are no specific guidelines. The most important thing for a woman is to think about her own situation and be aware of what she needs. Whose help does she want and to what extent. If she doesn’t know because she didn’t think about it earlier, then it turns out that the loved ones either help too much, or too little, or differently than she would like to.

I.W.: When asked what support a pregnant woman needs, I would answer that all of it (laughs). Support of the partner is the key. As life develops inside a woman, man’s attitude also changes.Partners are beginning to change and these changes are moving in the direction of becoming parents. It is often associated with a partial withdrawal from activities outside the home, focusing on satisfying needs, getting closer to each other in tandem. The supportive attitude of the future dad consists of increased sensitivity and empathy towards his partner. Mutual understanding is built by discussing fears, frustrations and ideas about how it will be. This is helped by not denying the difficult emotions that occur during pregnancy and openness to a sincere exchange of thoughts and feelings.

J.P.: You spoke about psychotherapy in pregnancy. What emotional difficulties can make a pregnant woman need therapy?

I.W.: Emotional suffering after childbirth is not uncommon. In Western societies almost half of women feel a mild state of depression after birth, most often manifested by sadness, nervousness, problems with sleep and concentration of attention, fatigue. Post-natal sadness, commonly referred to as baby blues, is a temporary phenomenon as passes by itself with appropriate support from the family. Specialist help should be sought when a woman’s emotional state takes the form of disease. Mental suffering disrupts everyday life, exceeds to ability to cope with it. In our country, about 20% of women suffer from postnatal depression. The things that should be disturbing are: the feeling of complete failure to cope with the role of mother, lack of hope, sadness, helplessness, strong anxiety or guilt. It should be remembered that postnatal depression can affect any one of us. Even when a child is longed for and awaited. That does not means that a woman is a bad mother. Properly provided therapeutic or pharmacological help is an effective way to deal with the disease.

B.S.: It does not have to be just postnatal depression. It can be a difficulty of accepting the pregnancy, even when it was planned and efforts were made. Sometimes a woman who sees these two lines on the test thinks that if she were to make the decision today, she wouldn’t want to be pregnant at all.

J.P.: The other side of this desire, fear, uncertainty, comes to the fore?

B.S.: Yes, then it turns out that it has already happened, and the woman suddenly does not want it at all, or wants it much less than before. And then you can work on these feelings, see where they come from and what processes accompany them. Sometimes pregnancy is complicated. Then a woman experience a lot of anxiety and she may need support. Sometimes the reaction of the environment or the father of the child is not as expected, the woman can stay alone with the pregnancy, and this can lead to different reactions in the family. And then it is worth having the support of a therapist who helps the patient to better understand what she is experiencing.

J.P.: In addition to therapy, what else can be helpful when it is emotionally difficult to get pregnant? I understand that workshops can be such a thing?

I.W.: Our workshops „Gotowa na rozwiązanie” are aimed primarily at supporting women in this difficult period, which is pregnancy and the initial stages of caring for the baby. We want to draw attention of mothers to important issues related to the creation of ties in the first year of a child’s life. To sensitize them to their own internal emotional states, which, when well read, will help to read the child’s needs. We want a greater awareness of hidden beliefs coming from family or cultural messages, to allow women to become more aware of motherhood.

B.S.: We offer workshops also because it is an opportunity to meet other women, listen to different perspectives, hear someone’s ideas or experiences. It can inspire. Besides, not everyone is convinced of the therapy, not everyone needs it. A workshop is such a form of development and experience.

J.P.: And it probably gives something that we today often don’t have – the experience of being in the circle of women.

B.S.: Today, because families are nuclear rather than multi-generational, they are women who have never had contact with a pregnant woman or a small child. They are pregnant and never held a newborn baby. There is a feeling of loneliness and confusion in them because not enough that this is a new role, it is even more difficult for someone who has not had contact with small children. When you meet other women, you can find understanding and support.

J.P.To sum up a little: how to take care of one’s emotionality during pregnancy?

B.S.: The point is to accept one’s own different states, such ambivalence, a swing of moods. This is absolutely normal. These states may be different, doubts may arise and we will not always feel happy. It should be noted that this is OK. At this time, it is worth thinking about yourself as a friend, with greater tenderness and empathy.

J.P.: I like it. Thank you for the interview.

February 25th 2019

text: Joanna Piekarska photo: daiga ellaby

originally, the interview was published on August 13, 2018 on the Notatki Terapeutyczne blog