Amy Wenzel, Ph.D., ABPP
Beck Institute Faculty
Perinatal distress is defined as depression or anxiety experienced by women who are pregnant or who are in the first postpartum year (Wenzel, 2015). Those of you who have attended the Core 2 CBT for Anxiety Workshop at Beck Institute know that I do not include this issue as a part of the curriculum; nevertheless, questions pertaining to work with perinatal women are frequently asked once workshop participants know my background, and lively discussion usually ensues. Thus, we thought it would be of interest to address this topic in this e-newsletter.
On many occasions, I have encountered negative attitudes toward CBT in the community of mental health professionals (the vast majority of whom identify with other theoretical orientations) who treat perinatal women. Examples of these attitudes include:
- Attention to the therapeutic relationship is paramount, and cognitive behavioral therapists place little, if any, significance on it.
- Session structure is too rigid and cold for a perinatal woman in substantial distress, who needs to be provided with a “holding environment” (a Donald Winnicott construct) that provides nurturance, reassurance, and a sense of safety.
- There is no way that a new mom who is frazzled and sleep-deprived can do homework in between sessions.
When I encounter these myths in conversations with colleagues, I treat them as assumptions that should be tested prospectively, rather than factual information that must be followed without critical evaluation in one’s clinical work. When I open up dialogue with these colleagues, they are pleased to learn about the central importance that cognitive behavioral therapists place on the therapeutic relationship and the high-quality research that has been published on the topic in the past decade. They are also surprised to learn that CBT with perinatal women (or with any clients, for that matter) should not be practiced in a mechanistic way, according to a checklist, but instead should proceed in a flexible, collaborative manner that is driven by the individualized case conceptualization and the client’s preferences. In contrast to the experience of some of my non-CBT colleagues, many perinatal women have expressed gratitude for CBT’s session structure and tangible exercises, remarking that it is precisely because they are frazzled and sleep-deprived that they respond well to CBT’s organized approach. Moreover, newer technology such as Mobile phone apps allow perinatal women much flexibility in completing homework; for example, many of my clients have completed the equivalent of a thought record or an activity log while nursing their infants to sleep.
Interestingly, unlike the literature on CBT for a host of adult mental health problems, there is mixed evidence for CBT’s efficacy with perinatal women (with postpartum depression being the perinatal mental health problem that has received the vast majority of the attention). Authors of meta-analyses on this subject generally conclude that there is strong evidence for the efficacy of interpersonal psychotherapy (IPT) and weak to moderate evidence for the efficacy of CBT for this population. However, in my recent comprehensive review of psychotherapy for perinatal mental health problems (Wenzel, 2016), I concluded that a true “Beckian” approach to CBT—one in which the case conceptualization lies at the heart of the treatment and informs intervention in a flexible, individualized, and collaborative manner—has not yet been evaluated with perinatal women. The majority of the “CBT” treatment packages evaluated to date are heavily focused on psychoeducation and specific techniques (e.g., relaxation) delivered at prescribed times throughout the course of treatment. Although these packages are thoughtfully designed and often theoretically driven, in many instances they did not fare better than usual care in outcome analyses. Thus, I recently published a manual that describes a case conceptualization-driven approach to CBT with perinatal women (Wenzel, 2015), and I look forward to empirical research that evaluates this approach to treating perinatal distress. I will also call your attention to an excellent article written by Arch, Dimidjian, and Chessick (2012) that refutes myths about the dangers of exposure therapy with pregnant women and provides guidelines for conducting exposures with this population in a safe but effective manner.
Arch, J. J., Dimidjian, S., & Chessick, C. (2012). Are exposure-based cognitive behavioral therapies safe during pregnancy? Archives of Women’s Mental Health, 15, 445–457.
Wenzel, A. (2015; with K. Kleiman). Cognitive behavioral therapy for perinatal distress. New York, NY: Routledge.
Wenzel, A. (2016). Psychotherapy for psychopathology during pregnancy and the postpartum period. In A. Wenzel (Ed.), Oxford handbook of perinatal psychology (pp. 341-365). New York, NY: Oxford University Press.