Applications of Pre- and Perinatal Psychology: An Overview
The basic tenet of Pre and Perinatal (PPN) Psychology is that the baby is having an experience from conception onward and that this experience will have an influence on her for the rest of her life. While PPN therapy is becoming increasingly well known and accepted, the notion that it applies only to prenates, infants and mothers is still all too common. Even more so, the idea of working with babies in the womb is too foreign to grasp for many people. When I talk to peers or potential clients about what I do, their first question usually is: "So you work with pregnant moms?" And I reply: "Yes, I do work with pregnant moms - and with everybody else too". Most PPN therapists are very familiar with this kind of exchange, but those of us who have been practicing in the field understand that PPN therapy is really about the following: Supporting our clients to integrate early somatic imprints, and that anybody - no matter which phase of their lifespan they are in, from conception to the dying process - can benefit from this integration.
A Crucial Developmental Period
Let's look at why the PPN period has such a strong influence on us: The PPN period was long disregarded by psychologists, medical doctors and scientists alike. As mentioned above, this has been steadily changing: The impact of PPN influences on life-long health is now scientifically accepted (Gluckman et al., 2008), and developmental theories are embracing the significance of the PPN period (Wade, 1996; McCarty & Glenn, 2008). It has long been understood that the earlier a developmental phase, the stronger and more fundamental its impact on the individual throughout their life. Therefore, since the PPN period is the earliest of all developmental phases, we can safely assume that its influence is also one of the most significant throughout the lifespan. As Perry et al. (1995) state: "Experience can change the mature brain - but experience during the critical periods of early childhood organizes brain systems". As a matter of fact, since the foundations for all aspects of our being (physiological, emotional, energetic and even later developing cognitive patterns) are being laid down in this period, everything that happens during this time affects our overall capacity and health. This includes attachment patterns, functional organ health, and nervous system resilience, etc. The PPN period can thus be likened to the foundation of a house: If it has a crack it will affect the whole building. No matter how much one tries to solve the problem on the fifth floor, the only permanent solution is to repair the foundation. Similarly, many PPN therapists find that once issues from the PPN period have been addressed, many other issues that appeared to have developed later in life can dissolve more easily.
Case example: Layers of PPN trauma
Sue* was a client of mine who sought somatic PPN therapy for moderate depression, anxiety and relationship problems. She had been in therapy for several years and had tried various approaches, including couples therapy and anti-depressive medication. While she had made some progress, she felt that at the core her problems had not changed. She felt lonely, disconnected from her husband of over 15 years and reported strong spikes of anxiety at various times. During our therapy sessions, she began to notice a general sense of contraction and "feeling frozen" throughout her system. Sometimes she felt unable to move her arms and reach out for the connection she desperately longed for. This was reflected in her marital relationship as well – her husband complained that she was not affectionate or warm. The first early imprint that surfaced during the therapy process was about separation from her mother immediately after her Caesarean birth, with all the usual factors: Being swaddled tightly and kept in a nursery for two weeks before being allowed to go home with her parents. Her symptoms were beginning to make sense to Sue: The anesthetic effects from the C-section along with the immediate and prolonged separation had prevented her from bonding with her mother during and right after birth, a period that we know to be crucial to attachment and bonding (Uvnäs-Moberg, 2003). The daily swaddling and the separation also seemed to be causing the sense of not having access to her arms and not being able to reach for her primary attachment figure. When Sue was in the nursery, she had given up on getting her needs for connection and nurturing met. After several sessions of working on these experiences, Sue began to feel more connected to her husband and more general vitality. However, as therapy progressed she still reported feeling a deep sense of contraction in her system and sometimes a deep shivering would start to emerge from her body during sessions. As her depressive symptoms decreased her anxiety levels were rising. She reported not feeling safe in her body and problems sleeping. After several sessions the next layer of her PPN experience surfaced: During one session the shivering turned to shaking and Sue felt the impulse to pull her legs up and all her life-force toward the top of her body. As the session proceeded she realized she was feeling as if her survival was threatened. Sue likened this to "the earth shaking and I am in danger of falling off the earth into outer space". At the end of the session she had a very clear sense that somehow she had experienced an episode of existential threat in the womb. (However, this did not feel like her mother had attempted to abort her, something many PPN practitioners are familiar working with). When Sue talked to her mother about this experience, she learned that there had indeed been a threatening event her mother had never shared with her: Around 25 weeks of gestation her mother had witnessed a store robbery at gunpoint. She had hidden at the back of the store with several other people and had not been directly threatened herself. Deeply shaken, Sue's mother had found herself shivering in shock for some time. She told Sue that she had been afraid to lose her baby at this point. When Sue shared this new information with me, she said that everything felt like it was making more sense. As the pieces of her story were falling into place and she had a safe place to process the somatic aspects of her history over several sessions, Sue reported dramatic changes: She was experiencing a sense of safety and being present in her body that she had not known before. She felt more available in her relationship with her husband and her sleeping issues disappeared. Sue completed therapy some time later.
* The name of the client was changed to protect her identity and permission to share this case was obtained.
Early Somatic Imprints & Attachment
Before we move on to the applications, let's take a moment to look at what the central components of PPN therapy are. While there are many important skills a PPN practitioner needs, two of them are crucial: Working with early somatic imprints and early attachment ruptures.
The term "early somatic imprints" usually refers to preverbal imprints that are encoded via implicit memory as opposed to explicit memory. Implicit memory is formed in the subcortex/amygdala and does not involve the hippocampus. The memories are formed subconsciously (without conscious awareness), and include behavioral, emotional, perceptual, and bodily memory. Implicit memory formation begins in utero. Explicit memory on the other hand begins in the second year of life, is cortex and hippocampus based, and requires conscious attention for formation. Another crucial differentiating feature is that with explicit memories, the person remembering them is aware that they are recollecting something. With implicit memories, this is not the case (Blakeslee, 2008). This means that to the person remembering them, these memories are experienced as a visceral and present reality, happening in the now. The lack of knowledge about implicit memory formation lead to many unfortunate medical decisions, among them the practice of anesthesia-free surgery for infants under one year of age until the mid-1980's (Cunningham Butler, 1987).
As we know, a person's entire system is geared toward learning and development on all levels during the PPN period, but especially during the "early brain growth spurt" which begins in the third trimester (Schore, 2002). This orientation toward learning causes each experience we have to imprint the whole organism deeply. As we integrate these implicit somatic imprints they become explicit – in other words through therapy we make sense of the original experiences instead of being unconsciously affected by them. This basic process is understood and applied by many contemporary forms of somatic therapy.
Another feature that is specific to working with PPN imprints is that the prenate has, from conception onward, an experience of existing in a 'dyadic' system. In other words, she does not exist independently from her mother. This makes the attachment aspect of this work so extraordinarily important, since any traumatic experience the prenate has is always experienced in a relational, attachment context. So, in addition to learning how to work with somatic imprints, the practitioner has to be available to support repair of attachment ruptures that happened when the client was in an extremely sensitive and fragile state. This requires very specific verbal, emotional, energetic, and touch skills. If one imagines the difference in size between a fetus and her mother, and the lack of available defensive responses for the prenate one can understand why all PPN threats are experienced as existential. Adding to this the fact that as we remember them, we perceive them not as a memory but as a current-moment experience, it becomes clear why PPN practitioners need strong skills in supporting clients through deep autonomic nervous system dysregulation – while at the same time being available for attachment repair.
The truth is that challenging early somatic memories stay with us throughout our lives unless they are integrated. They can impede our ability to know what we want, move toward it, and connect fully with our loved ones and our selves until the day we die. What is more, a practitioner who has learned to work with these earliest of experiences has acquired valuable skills to sit with any traumatic experience any client brings to therapy and any implicit memory, whether it was formed preverbally or in adulthood. It is crucial that PPN therapists integrate their own early material in order to be able to support a client adequately.
As discussed above, PPN therapy is applicable to any phase of the lifespan. While some practitioners stay closely within the more "traditional" PPN framework and see clients who are pregnant or have an infant who is exhibiting symptoms of a traumatic birth, others apply it to a wide variety of clientele. Following is a partial list of PPN psychology applications with short descriptions.
- Preconception Support: Couples who may have problems conceiving or who want to prepare consciously for the being they are calling in. This may involve working on their own past, including their own prenatal or birth experiences, earlier pregnancies, or their relationship.
- Prenatal Support: Pregnant couples who are facing emotional or physical challenges or who want to give their growing baby an integrated experience in the womb. This can also involve preparation for the birth process.
- Perinatal Support: Some birthing mothers choose to bring a support person to the birth, whether this is a doula or a PPN practitioner (many PPN practitioners are also trained doulas). Some midwives have a background in PPN psychology. The more support for the baby and for both parents (not just the mother in labor), the better. This also refers to Ray Castellino's (2014) concept of "two layers of support", which suggests that each person at a birth should have two support people available for them.
- Postnatal Support: If the birth was challenging or traumatizing for the mother and/or the baby (in many but not all cases, trauma occurs for both) the mother may seek support. Maybe she is not coping well with her new role, shows signs of postpartum depression or her baby is showing symptoms - such as not sleeping or nursing, having difficulties being soothed, being "colicky", etc.
- Family support: Families may search out a practitioner for at any age of the child. Common reasons are: The parents are feeling overwhelmed and are having their own material come up in a way that makes it challenging for them to be present for each other and their children. Alternatively the children can be showing symptoms of distress (acting out, withdrawal, problems making friends, etc) but no other interventions seem to be effective. Remember that because PPN trauma is so early, it is completely unconscious/implicit yet pervasive. A good illustration of the power of the PPN period is a 1985 study that showed the connection between teenage suicide and birth complications (Salk et al.).
- Couples Support: Couples who find that other forms of therapy are not reaching the layers where their problems reside may seek a PPN therapist. Our unconscious early imprints affect how we act in intimate relationships – how we approach sexuality, attachment, trust, and fidelity. Some practitioners focus on the interactions of each partner's early imprints with the other's.
- Support for Adults: Throughout their adult years, clients may seek out a PPN practitioner because they have a problem that does not seem to respond to any therapeutic intervention. Often these people have a strong desire for deeper connection with themselves and others but are unable to achieve it without knowing why. Practitioners may offer individual or group work for adults.
- Organizational Coaching: Some practitioners apply PPN psychology principles (which emphasize basic safety, connection, cooperation, and differentiation) to organizational coaching, in order to establish a healthy and functional group environment.
- Educational Settings: PPN psychology principles utilized in any educational setting ranging from preschools and professional training institutes to universities have proven to be valuable. One example of this was Santa Barbara Graduate Institute, a university that was founded on and guided by PPN psychology principles.
- Support for the Dying: It has been noted that the themes and difficulties encountered as we came into our human body can show up again as we prepare to leave it. Getting support for this period can allow for a more integrated dying experience.
When Should a Client Seek PPN Therapy?
I usually recommend PPN therapy if there is known early trauma or if the client has been working on an issue for some time without achieving significant changes, despite professional support. The client may also be aware of a certain challenge in her life but has no idea why she has this problem, meaning there are no events she remembers that could have caused it. The same is true for children of all ages: If the parents are not able to soothe them and the children are acting in ways that don't make sense to the parents I recommend PPN therapy to address early experiences, even if there is not known trauma history. Another indicator can be if the parents are feeling disconnected from their children without knowing how to find the connection again.
PPN practitioners come in many variations. They may use art therapy, cognitive-behavioral approaches, somatic therapies, bodywork, movement therapy, energy work, coaching, or other modalities. They may work with groups, couples or individuals; with specific issues like addiction, physical symptoms/illness or attachment disorders. They may be medical doctors, doulas, psychotherapists, teachers, massage therapists, or occupational therapists. What they all have in common is that they share the understanding that if the root of a problem lies in the PPN period, it will not be resolved until the original experience is addressed. They all have experienced that if they support their clients in integrating and consciously embodying their early periods, they become more functional, satisfied and whole beings. And most of these practitioners have experienced this in their personal lives as well.
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Castellino, R. (2014). Two Layers of Support: Creating the Conditions for Healing (DVD). London, GB: Owl Productions.
Cunningham Butler, N. (1987). The ethical issues involved in the practice of surgery on unanesthetized infants. AORN Journal, 46(6): 1136-1144.
Gluckman, P., Hanson, M., Cooper, C., & Thornburg, K. (2008). Effect of In Utero and Early-Life Conditions on Adult Health and Disease. New England Journal of Medicine. 359:61-73. DOI: 10.1056/NEJMra0708473
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