The Benefits of Integrative Wellness During and After Pregnancy

Dr. Muskal has been helping women for more than 30 years to manage the challenges, transitions, uncertainties, joys, and loss of pregnancy. Taking a mindful approach in her clinical practice, Dr. Muskal believes that clinicians should be aware of the issues that arise during and after pregnancy to optimize the woman's experience throughout the perinatal period including birthing. In this column, Dr. Muskal discusses some of the challenges women face during and after pregnancy and how an integrative and wellness approach can help improve outcomes for both mom and baby.

Q: You have worked with women for many years. What are some of the major areas of focus/interest in your practice over the years and particularly now? What are the main reasons people seek you out as a clinician?

Robin Muskal, PhD, PMHC, LPC: My interest began early on in the field of attachment and bonding, and I worked exclusively with adopted children and their families. I noticed a trend in the state of mind of the adopted mother as she would often feel very similar to pregnant women with a postpartum mood shift. So once the child was adopted, many women would fall into an anxious or depressed state of mind. That in turn had an impact on the attachment to the child and the child's attachment to the adoptive parent. There were times when these adoptive moms would become pregnant after adopting a child and that was the transition point for me to move forward and work with pregnant women. For more than a decade, I have focused on the peri- and postnatal transition to motherhood, where many issues and challenges arise including the unfortunate occurrences of intrauterine loss. I also see women because they are experiencing anxiety, depression, intrusive thinking, and/or fear during either their pregnancy and/or postpartum. In fact, one out of six women will experience some perinatal mood response, whether purely hormonal or because they have historically suffered from mood conditions. These are some of the main reasons that people seek me out as a clinician.

Q: What are some of the major challenges that women face in the peri- and postnatal phase of their pregnancies?

Dr. Muskal: One of the major challenges is a lack of social support. For example, that would be feeling embarrassed about their feeling state. Even though there could be social support, they feel embarrassed to share what they are feeling. Society and most women feel that pregnancy should be a joyful happy experience with a perfectly implemented birth plan and the best time of their life postpartum. If the pregnant woman does not feel this way, this leaves her wondering if something is wrong and, therefore, she may not seek help or talk to friends or family for fear of judgment. No one wants someone to think they are bad mothers or not excited about the birth of their new child.

Another challenge along the same line is intrusive thinking and that can occur during pregnancy and postpartum, and some women have intrusive thoughts about something happening to their child. For example, they may become obsessive about the foods they eat, and if they eat a certain ingredient, that woman may literally become obsessed that the child will be ill-affected because of their eating “mistake.” They get caught in a loop of thinking this way. This can create a perfect storm for mood disorders such as anxiety, depression, and obsessive compulsive disorder, which as I mentioned are common in pregnant women. Clinicians should be aware whether their pregnant patients have had prior experiences with mood disorders outside of pregnancy because their risk for recurrence may be higher, and this is important to know early on and even before pregnancy. Psychiatrists, mid wives, obstetricians and gynecologists, and primary care clinicians including internists, pediatricians, and family practitioners need to be aware of their patients' and family history and past pregnancies and should ask questions about social support such as “Do they have family and friends surrounding them?”

Intrauterine loss is another significant issue I see in my practice. These moms and partners often come to me with a birth trauma story—many have had to go through a birth where they knew the child was not going to live or the baby was born and died imminently. They already may have a child, and that makes it even more complicated because they feel they have disappointed their living child who thought they would have a sibling. This significant loss creates a life time of grappling in stages. Many coupled families today have reminders in the home such as an urn in a central location or a holiday ornament with the name of the baby on it. Holding a place for this child in their life allows for ongoing recognition and integration of that child.

We need to be aware also of the inequities that exist in our world, which significantly increase the rate of birth traumas including fetal and maternal deaths for minorities and the underserved. There has to be a movement toward better care before, during and after pregnancy for all women. An important resource regarding this issue is Evidence Based Birth (https://evidencebasedbirth.com/) because it addresses the fact that birth is medicalized, and there is gross inequality between those who can afford and those who cannot afford quality care.

Q: Why is a preventive and integrative approach so important for pregnant women?

Dr. Muskal: There is not one single modality that works for almost anything. Humans are complex. The same is true for pregnant women. When you take a preventive and integrative approach, you improve birth outcomes, emotional outcomes of both the mother and the child, and a sense of mastery for the parents so they can make the transition into parenthood with confidence. The insight and awareness of the parents then lend itself to being open to different modalities to achieve better outcomes for everyone.

Q: What are some of the main integrative and wellness approaches you use in your practice to help women through their pregnancy?

Dr. Muskal: There are several approaches that I use in my practice that are very much dependent on the individual client and the integrative therapy. This is not a one-size-fits-all approach. The approach must be specific to each client because they have to feel comfortable with the approach and recommended complementary therapies. For example, there may be a woman who benefits greatly from drawing or painting her current experience. There may be someone who has difficulty relaxing, and so that person will be taught specific yoga poses to reduce her anxiety and increase her parasympathetic response so that her stress level decreases. A greater sense of calm also increases their ability to manage things that come up, and decreased stress also improves birth outcomes including birth weight and the incidence of colic, for example. In addition, high levels of cortisol in the pregnant woman have been known to cross the placenta and affect the baby in myriad ways.

One thing that is very helpful is a cognitive approach for the moms who tend to be obsessive or fearful about things going wrong. So it is very important that women identify their fears and are able to share their story line. For example, mom had a sip of wine, and then her fears increase, but often her fears are not realistic. So the cognitive piece is critical because it teaches them to get out of the hamster-cage thinking loop and catch the story loop and bring it back to the present moment awareness and focus on the reality, which may be that “I am 5 months pregnant and everything is fine.” Catching the story line and bringing it back to the reality of the now is critical. They may catch that story line immediately or after a bit of time, which helps stop catastrophizing way down the timeline. What matters is that they catch it and then they can come back to more realistic thinking. I have patients give me an example of what their fear is and have them tell me what their thoughts or images are and then tell me what they have imagined will happen. Then I teach them at that moment to learn to stop the story and come back to present moment awareness. Sometimes, I have them accomplish that by putting their hand on their belly, where the baby is thriving and kicking and come back to the reality of the healthy baby.

Regarding yoga, there are poses that target anxiety and depression and also target tension. Although there are precautions for pregnant women and yoga, I have found that certain poses can help people shift and make these uncomfortable feelings and sensations decrease. ¹ I do a lot of teaching of breathing and meditation. We practice that together in the office, so that when they get home they can practice appropriately on their own.

I also refer my pregnant patients to acupuncture, chiropractors, massage therapists, and group therapy. One of the most well-known and respected organizations within the field is Postpartum Support International (PSI). This organization focuses on education, and support and they offer free services, group therapy, help lines, and facilitators and coordinators that can refer women to services including clinical and complementary providers around the world. PSI has chapters in many states in the United States, and those chapters are mirroring the larger organization and are a local resource for clinicians and pregnant women.

Bibliotherapy is an excellent therapy I use, where my patient and I talk about a book together that covers strategies for intrusive thoughts or explores dialectical behavioral therapy, etc.

Another critical aspect of the integrative approach to pregnancy when working with pregnant clients is that clinicians should be teaching the client what to do when they are not in the office. The therapies I use in my office are therapies that have to be learned in my office so that they can be used at home. Practicing 50 minutes a week in my office will not be enough to truly help the client.

The complementary therapies are hands-on in the office and are action based including journaling. For example, in the early postpartum weeks, I help parents come up with a calendar for night-shift feeding, who is buying the groceries, etc. so that the expectations of each other are clear, and we incorporate time so that each has her own respite.

Q: Any further advice for clinicians who are seeing patients and what they should be on the lookout for regarding their pregnant patients who might benefit from further integrative/wellness support?

Dr. Muskal: When clinicians see patients who have recently given birth, they should always review how the pregnancy was physically and emotionally and hands down review the birth story—how was the hospital, the mid-wife, the nurses, the doula. Equally important is whether the mother felt she had choices, was being heard, and understood. The birth story is a significant element of launching into parenthood. It is helpful to have specific training to work with this population, and there is a two-day training through PSI offered to be able to explore, explain, and educate clinicians regarding different areas of the peri- and postnatal phases of pregnancy. Any clinicians working with pregnant patients can and should take this course.

Then of course as previously mentioned, clinicians should be on the lookout for history of mood disorders and work with the appropriate specialists to help ensure their patients receive proper treatment. There is an entire industry of reproductive psychiatrists who can be very helpful in this area and are frontline prescribers.

Many clinicians who are not obstetricians/gynecologists may assume that the patient's wellness plan is fully covered by the specialist, when in fact primary care clinicians should be interactive and proactive in helping pregnant women make healthy lifestyle choices to ensure a healthy mom and baby. ▪

To Contact Dr. Robin Muskal

Robin Muskal, PhD, PMHC, LPC

Psychotherapist, Owner, Postpartum Wellness Counseling, LLC, Florham Park, New Jersey, USA

E-mail: www.postpartumwellness.net/contact

Website: www.postpartumwellness.net/