EMDR During Pregnancy: To Process or Not to Process?
It is a common debate in the therapy field: Should pregnant clients be offered trauma re-processing as an intervention? For the purposes of this blog, I will focus on Eye Movement Desensitization and Reprocessing therapy which is a well-known and evidence based trauma treatment, and it’s safety and efficacy in pregnancy and beyond.
Common Myths About EMDR Therapy During Pregnancy
I have heard many different takes on EMDR therapy during pregnancy. That it is “too stressful” on the pregnant woman and baby. To only do stabilization strategies or “resourcing”. In the contrary, the idea of “getting it done as quickly as possible” to protect the attachment relationship between the mother and baby or to make a consecutive labour and delivery experience less intrusive.
The truth is that many of these thoughts are just that, thoughts, and not rooted in any compelling evidence. The intention is positive in that we want to make sure that any intervention, especially in pregnancy, is safe and worthwhile. As part of my EMDR certification process, I completed continued education specifically in complex trauma and the perinatal population. I was able to delve further into this topic and what I learned was reassuring.
One of the main concerns about trauma treatment in pregnancy is inducing stress that can result in harm to the pregnant person or the baby. “Toxic stress”, after all, can have physiological consequences for the unborn baby. Fortunately, there are differences in “types” of stress. A weekly, one hour, therapy appointment that looks to help resolve and make meaning of a traumatic experience or set of experiences would be categorized as “positive stress” or what we would consider adaptive, which can actually have positive outcomes for both mother and baby.
Trauma, when untreated is still “playing in the background” and taking up space. To say that withholding trauma treatment due to pregnancy has no impact, is false. Ongoing patterns of toxic stress due to trauma symptoms can negatively impact pregnancy, postpartum and beyond. The evidence is clear that all phases of EMDR therapy, including the re-processing phases, are safe in pregnancy.
The same assessment for readiness should be applied to pregnant individuals as the general population. For example, if someone is ready to get started with re-processing and finds out they are newly pregnant, this is not a reason to not proceed. In the same breath, if someone is not ready to start re-processing we would not rush to start because of pregnancy. Whether EMDR re-processing is offered should have nothing to do with whether the client is pregnant or not and more to do with the individual client’s readiness (are they consenting and wanting to move forward) and preparedness (the clinician’s assessment of their readiness to tolerate and benefit from the treatment).
Prevalence of Trauma in Pregnant People
Between 20% and 40% of pregnant people have experienced trauma. Common trauma experiences in the perinatal population might include their own childhood trauma (which is most likely to resurface during the perinatal period than any other time), sexual assault trauma and/or prior birth and/or loss trauma. Postpartum depression is the most common perinatal mental health condition. Trauma, especially complex trauma, is strongly linked to depression. From a trauma therapist’s view, prolonged hyper-arousal can lead to a hypo-arousal “crash” causing depressive symptoms. Treating trauma during pregnancy may protect against postpartum depression and other perinatal issues.
Omission Bias
Omission bias exists largely in the medical field. This idea of “if we can’t be sure, don’t do it”. This rhetoric largely originates from concerns about liability. However, sometimes NOT doing something can be more harmful than doing something. Lack of intervention has its own set of consequences. Although liability is a valid consideration for healthcare professionals, we need to start to look at benefits and risks of both acting and not acting equally. Withholding treatment and the choice to engage in treatment, could equally be considered doing harm.
Benefits of EMDR Treatment in Pregnancy:
When treated, some of the benefits of EMDR treatment in pregnant people include:
Reduction in PTSD symptoms and overall distress
Decreased fears of childbirth
Decreased intrusive thoughts
Increased prenatal and postnatal bonding and attachment with baby
Overall well-being of mother
Positive influence on developing baby’s nervous system
Decreased postpartum mental health concerns including postpartum anxiety and depression
Safety
It is now clear that EMDR therapy including all phases of treatment are NOT contraindicated in pregnancy. There are no safety considerations that don’t otherwise exist already in the regular population.
To quote Bethany Warren, LCSW, PMH-C in her guest blog with EMDRIA:
“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. Research now shows us that pregnant clients who receive EMDR therapy experience decreased distress and PTSD symptoms, decreased 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 deep attachment wounds and as she builds adaptive attachment skills to now aid in her own ability to parent.”
Take-Aways
Pregnant people are the least likely to be researched. This comes from a place of protection, but in the absence of information, it is assumed that not doing something is always safer than doing something. Often times, the consequences of not acting can be far more detrimental than acting. The evidence is now clear that pregnancy is not a contraindication for EMDR re-processing. EMDR therapy is safe and can have major long-lasting benefits for the pregnant mother, baby and the family as a whole. The same assessment for readiness in re-processing phases of trauma treatment should be applied in pregnant individuals as non-pregnant individuals. EMDR therapy is specialized and so is working with the perinatal population. Care should be put into finding an equipped provider for this specialized population.
EMDR and Perinatal References
Peer-Reviewed Articles
Baas, M. A., Stramrood, C. A., Dijksman, L. M., de Jongh, A., & van Pampus, M G. (2017). The OptiMUM-study: EMDR therapy in pregnant women with posttraumatic stress disorder after previous childbirth and pregnant women with fear of childbirth: design of a multicenter randomized controlled trial. European Journal of Psychotraumatology, 1293315. Open access: https://doi.org/10.1080/20008198.2017.1293315
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. Open access: https://doi.org/10.1080/20008198.2020.1762310
Baas, M. A., 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. Frontiers in Psychiatry: Psychological Therapies, 12:798249. Open access: https://doi.org/10.3389/fpsyt.2021.798249
Chiorino, V., Cattaneo, M. C., Macchi, E. A., Salerno, R., Roveraro, S., Bertolucci, G. G., . . . & Fernandez, I. (2019). The EMDR recent birth trauma protocol: A pilot randomized clinical trial after traumatic childbirth. Psychology and Health, 1-16. https://doi.org/10.1080/08870446.2019.1699088
Chiorino, V., Roveraro, S., Cattanio, M., Salerno, R., Macchi, E., Bertolucci, G., . . . Fernandez, I. (2016). A model of clinical intervention in the maternity ward: The breastfeeding and bonding EMDR protocol. Journal of EMDR Practice and Research, 10(4), 275-292. Open access: https://doi.org/10.1891/1933-3196.10.4.275
Cortizo, R. (2020). Prenatal and perinatal EMDR therapy: Early family intervention. Journal of EMDR Practice and Research, 14(2), 104-115. Open access: http://dx.doi.org/10.1891/EMDR-D-19-00046
Cortizo, R. (2020). Prenatal broken bonds: Trauma, dissociation and the calming womb model. Journal of Trauma & Dissociation, 22(1), 1-10. Open access: https://doi.org/10.1080/15299732.2021.1834300
de Bruijn, L., Stramrood, C. A., Lambregtse-van den Berg, M. P., & Rius Ottenheim, N. (2019). Treatment of posttraumatic stress disorder following childbirth. Journal of Psychosomatic Obstetrics & Gynecology, 41(1), 1-10. https://doi.org/10.1080/0167482X.2019.1593961
Forgash, C., Leeds, A. M., Stramrood, C. A. I., & Robbins, A. (2013). Case consultation: Traumatized pregnant woman. Journal of EMDR Practice and Research, 7(1), 45-49. Open Access: https://doi.org/10.1891/1933-3196.7.1.45
Furuta, M., Horsch, A., Ng, E. S. W., Bick, D., Spain, D., & Sin, J. (2018). Effectiveness of Trauma-Focused Psychological Therapies for Treating Post-traumatic Stress Disorder Symptoms in Women Following Childbirth: A Systematic Review and Meta-Analysis. Frontiers in Psychiatry, 9, 591. Open access: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00591/full
George, A., Thilly, N., Rydberg, J. A., Luz, R., & Spitz, E. (2013). Effectiveness of eye movement desensitization and reprocessing treatment in post-traumatic stress disorder after childbirth: A randomized controlled trial protocol. Acta Obstetricia et Gynecologica Scandinavica, 92(7), 866-868. Open Access: https://doi.org/10.1111/aogs.12132
Hendrix, Y. M. G. A., Sier, M. A. T., Baas, M. A. M., van Pampus, M. G. (2022). Therapist perceptions of treating posttraumatic stress disorder in pregnancy: The VIP study. Journal of Traumatic Stress,Online. https://doi.org/10.1002/jts.22842
Hendrix, Y. M. G. A., van Dongen, K. S. M., de Jongh, A., & van Pampus, M. G. (2021). Postpartum early EMDR intervention (PERCEIVE) study for women after a traumatic birth experience: Study protocol for a randomized controlled trial. BMC Trials, 22, 599. Open access: https://doi.org/10.1186/s13063-021-05545-6
Kranenburg, L. W., Bijma, H. H., Eggink, A. J., Knijff, E. M., Lambregtse – van den Berg, M. P. (2022). Implementing an eye movement and desensitization reprocessing treatment-program for women with posttraumatic stress disorder after childbirth. Frontiers in Psychology: Psychology for Clinical Settings, 797901. Open access: https://doi.org/10.3389/fpsyg.2021.797901
Krupnik, V. (2015). Integrating EMDR into a novel evolutionary-based therapy for depression: A case study of postpartum depression. Journal of EMDR Practice and Research, 9(3), 137-149. Open access: http://dx.doi.org/10.1891/1933-3196.9.3.137
Madrid, A., Skolek, S., & Shapiro, F. (2006). Repairing failures in bonding through EMDR. Clinical Case Studies, 5(4), 271-286. https://doi.org/10.1177/1534650104267403
Okawara, M., & Paulsen, S. L. (2018). Intervening in the intergenerational transmission of trauma by targeting maternal emotional dysregulation with EMDR therapy. Journal of EMDR Practice and Research, 12(3), 142-159. Open access: http://dx.doi.org/10.1891/1933-3196.12.3.142
Poel, Y. H. M., Swinkels, P., & de Vries, J. I. P. (2009). Psychological treatment of women with psychological complaints after pre-eclampsia. Journal of Psychosomatic Obstetrics & Gynecology, 30(1), 65-72. https://doi.org/10.1080/01674820802545990
Sandstrom, M., Wiberg, B., Wikman, M., Willman, A. K., & Hogberg, U. (2008). A pilot study of eye movement desensitization 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
Stramrood, C. A., van der Velde, J., Doornbos, B., Marieke Paarlberg, K., Weijmar Schultz, W. C., & van Pampus, M. G. (2012). The patient observer: Eye-movement desensitization and reprocessing for the treatment of posttraumatic stress following childbirth. Birth, 39(1), 70-76. https://doi.org/10.1111/j.1523-536x.2011.00517.x
Taylor Miller, P. G., Sinclair, M., Gillen, P., McCullough, J. E. M., Miller, P. W., Farrell, D. P., Slater, P. F., Shapiro, E., & Klaus, P. (2021). Early psychological interventions for prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in post-partum women: A systematic review and meta-analysis. PLOS One, 16(11): e0258170. Open access: https://doi.org/10.1371/journal.pone.0258170
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), 10-19. Open access: http://dx.doi.org/10.1891/1933-3196.13.1.10
Videos/Podcasts
Evans, K. (Host). (2022, March 23). Episode 35: Can you do EMDR with a pregnant client? Clinical reasoning in the perinatal period with Dr. Mara Tesler Stein [Audio podcast episode]. In Zero Disturbance. https://www.zerodisturbance.com/podcasts/zero-disturbance/episodes/2147703777
Kaeni, K. (Host). (2018, July 9). Episode 107: EMDR for Perinatal Mental Health with Bethany Warren, LCSW [Audio podcast episode]. In Mom & Mind. https://momandmind.libsyn.com/107-emdr-for-perinatal-mental-health-with-bethany-warren-lcsw
Marich, J. (2021, March 1). EMDR & Pregnancy with Mara Tesler Stein (and Jamie Marich). YouTube.https://www.youtube.com/watch?v=9DIp35n6nB4&t=393s
Books/Chapters
Caterina Cattaneo, M., Chiorino, V., Roveraro, S., Salerno, R., & Fernandez, I. (2019). The EMDR recent birth trauma protocol. In M. Luber (Ed.), EMDR therapy scripted protocols and summary sheets: Treating trauma in somatic and medical-related conditions, (pp. 377-412). New York, NY: Springer Publishing
Chiorino, V., Roveraro, S., Caterina Cattaneo, M. Salerno, R., & Fernandez, I. (2019). The breastfeeding and bonding EMDR protocol. In M. Luber (Ed.), EMDR therapy scripted protocols and summary sheets: Treating trauma in somatic and medical-related conditions, (pp. 427-454). New York, NY: Springer Publishing.
de Divitiis, A. M., & Luber, M. (2019). EMDR therapy protocol for the prevention of birth trauma and postpartum depression in the pregnant woman. In M. Luber, (Ed.), EMDR therapy scripted protocols and summary sheets: Treating anxiety, obsessive-compulsive, and mood-related conditions, (pp. 325-357). New York, NY: Springer Publishing.
Klaus, P.H. & Simkin, P. (2011). When survivors give birth: Understanding and healing the effects of early sexual abuse on childbearing women. Seattle: WA, Classic Day Publishing
Kavakci, O. (2019). EMDR therapy, nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) in pregnant women. In M. Luber (Ed.), EMDR therapy scripted protocols and summary sheets: Treating trauma in somatic and medical-related conditions, (pp. 355-370). New York, NY: Springer Publishing
Luber, M. (2019). Summary sheet: EMDR therapy, nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) in pregnant women. In M. Luber (Ed.), EMDR therapy scripted protocols and summary sheets: Treating trauma in somatic and medical-related conditions, (pp. 371-376). New York, NY: Springer Publishing
Luber, M. (2019). Summary sheet: The breastfeeding and bonding EMDR protocol. In M. Luber (Ed.), EMDR therapy scripted protocols and summary sheets: Treating trauma in somatic and medical-related conditions, (pp. 427-454). New York, NY: Springer Publishing.
Luber, M. (2019). Summary sheet: The EMDR recent birth trauma protocol. In M. Luber (Ed.), EMDR therapy scripted protocols and summary sheets: Treating trauma in somatic and medical-related conditions, (pp. 413-426). New York, NY: Springer Publishing.
Other Articles
Morelli, K. (2012, Oct 12). EMDR part two: Clinical opinions regarding the safety of using EMDR to process traumatic material during a subsequent pregnancy to treat PTSD (childbirth onset) [blog post]. Retrieved from: https://www.lamaze.org/Connecting-the-Dots/emdr-part-two-clinical-opinions-regarding-the-safety-of-using-emdr-to-process-traumatic-material-during-a-subsequent-pregnancy-to-treat-ptsd-childbirth-onset
Rusnak, K. (2021, March 4). How to treat grief and pregnancy loss: An interview with a certified EMDR therapist. Psychology Today. https://www.psychologytoday.com/ca/blog/happy-healthy-relationships/202103/how-treat-grief-and-pregnancy-loss
Schraer, R. (2021, April 6). Mental health: More help for new and expectant mothers in England. BBC News. https://www.bbc.com/news/health-56639858
Vantage Point Contributor. (2021, March 30). Improving Reproductive Health for Women with PTSD. Vantage Point: Blog of the U.S. Department of Veterans Affairs. https://blogs.va.gov/VAntage/86691/improving-reproductive-health-women-ptsd/
West, C. (2014). Can I do EMDR if I am pregnant? [Webpage]. Retrieved from https://www.colleenwest.com/for-clients/can-i-do-emdr-if-i-am-pregnant/