Prenatal Broken Bonds: Trauma, Dissociation and the Calming Womb Model

Maternal (Klaus, Kennell & Klaus, 1996) bonding during pregnancy is associated with positive infant attachment, whereas unresolved, dissociated trauma, chronic affect dysregulation, and obstetric complications during pregnancy seem to alter the bonding experience often resulting in broken bonds. The Calming Womb Family Therapy Model (CWFTM) is a comprehensive, collaborative, team-based, early intervention approach which is intended for treating mothers and their babies from conception through the first year after birth. This model builds a strong early bond between mother-child from the point of conception, which nurtures secure post birthing infant attachment. Its basis is from Murray Bowen’s family approach that understands families as interconnected systems with potential for intergenerational trauma transmission, and Selma Fraiberg’s psychoeducational and psychodynamic work with mothers, and infants to resolve traumatic transferences to their babies while enhancing the mothers’ infant developmental knowledge. The CWFTM expands Fraiberg’s work back to conception to strengthen the bond between the mother-baby dyad, and treats the baby in utero as a family participant. CWFTM uses Eye movement Desensitization and Reprocessing (EMDR) to process maternal unresolved trauma, transference reactions to the baby, and coordinates services with the pregnant mother’s medical teams, social supports, and involved family members. The ultimate goal of the model is to assess and treat dissociated trauma and grief of the mothers’ past, facilitating strong bonds and attunement between mothers and their babies.

Pregnancy is a great source of enjoyment, hope, and anticipation for most women; it may also bring on anxiety, distress, depression, trauma, and feelings of ambiguity (Talley, 2013). Parenting, maternal bonding, and biological effects on fetal development begin before birthing (Daglar & Nur, 2018; Glover & Capron, 2017). Even though pregnancy is a major phase of life for women and their families, prenatal therapeutic interventions are frequently overlooked. Prenatal early interventions support vulnerable mothers who have preexisting trauma or who may be at high risk for prenatal stress. Reducing mothers’ intense fear of childbirth or Tokophobia while increasing their preparedness for labor predicts increase positive bonding and motherhood (Klabbers et al., 2016; Salmela-Aro et al., 2011). Daglar and Nur (2018) found that as prenatal bonding level increases, so does the level of postpartum attachment. While childhood trauma was not found to be predictive of postpartum depression, both past depression and prenatal depression at 12 weeks after birthing convincingly were (De Venter et al., 2016).

For the purposes of this article the following definitions are applied (Cortizo, 2020, 2019). Womb baby refers to the infant from conception, and the evolving emotional attunement of the mother to her baby in the womb. Bonding is defined as the attunement of the mother toward her womb baby during pregnancy, and attachment as the relationship the child forms with the parents after birthing (Bowlby, 1979; Dubber et al., 2015; Hairston et al., 2019; Klaus et al., 1996). Broken bonds imply detachment of the mother toward her womb baby.

Broken Bonds

High betrayal traumas, such as those caused by caretakers or close ones are associated with reduced maternal and child well-being (Choi & Kangas, 2020). An earlier identification of disruptions in bonding, maternal misperceptions about the self and others while strengthening the use of adaptive emotion regulation strategies may be valuable. The foundation of the field of complex trauma and dissociation, and all of the harm that comes from infant attachment-trauma injuries is this very problem – not caring for pregnant mothers and their womb babies early enough or during conception.

Some of the major bonding obstacles include, but are not limited to;

Recurrent post-traumatic stress disorder (PTSD) leading to depression, PTSD associated to prenatal substance abuse (Delker et al., 2020; Sanjuan et al., 2019), anticipatory anxiety, unplanned or unwanted pregnancy, maternal separations from loved ones, abandonment by partner, family illness, financial deficits or poverty, family deaths, hormonal and acute physiological changes, baby’s gender, domestic violence history and recent occurrences, unresolved spontaneous abortion (SAB) or planned abortion (TAB) trauma or fetal demise, medical trauma, genetic fetal disorder/complications, preexisting mental disorder or concurrent multiple diagnosis, pregnancy rejection, pregnancy denial, fetal idealization, recent immigration, language barrier, cultural (Kruger, 2020), gender and racial oppression, religious restrictions, affect phobia, unresolved grief, recent flashbacks, nightmares, memories of previously dissociated trauma.

Swales et al. (2018) findings suggest that the effects of childhood exposure to traumatic events remained after accounting for more proximal traumatic events in adulthood, and that these early traumatic experiences foretell cortisol levels in at-risk pregnant women and prenatal covarying after adult trauma. They concluded that there could be consequences for the mom–baby dyad from cortisol maternal elevation and that the relationship between adult trauma and prenatal cortisol is moderated by childhood trauma. While discussing each prenatal barrier to bonding is beyond the scope of this article, identifying maternal broken bonds is of utmost significance and value for the purposes of assessment, treatment, and prevention. Treating trauma in the life span earliest stage is the CWFTM optimal goal.

Prenatal Treatment

Prenatal psychotherapy to support distressed mothers is crucial and often overlooked (Weinstein, 2016) or contraindicated (Müldner-Nieckowski et al., 2015). Continuously elevated maternal stress may result in abnormally high and prolonged concentrations of cortisol that could have harmful effects on the developing baby (Verny, 2018). The effects of prenatal opioid and cannabinoid secretion that go with dissociation may be existent, but has not been studied. The field of psychology has become increasingly aware of the effect of the maternal emotional mental state and toxic stress on babies (Buss et al., 2012; Kaplan et al., 2008; Lipton, 2005; Shore, 2016, 2012). Since prenatal dissociated trauma is likely to be activated, this period offers enormous opportunity for intervention and hope for parents, particularly if either or both are survivors of extreme, chronic abuse (Guyon-Harris et al., 2020; Lev-Wiesel et al., 2009; Platt et al., 2009).

Complex trauma enduring pregnant women may lack prenatal medical and emotional social supports as they start to fulfill their mothering role. The goal of targeted dissociation and trauma-informed support services and programs is to decrease the pregnant woman’s toxic stress morbidity, improve her experience of maternity care, and positively impact the outcomes for her and her infant (Delker et al., 2020; Platt et al., 2009). Making sense of the past creates space for prenatal bonding and post birthing attachment.

The CWFTM

The Calming Womb Family Therapy Model (CWFTM) presents an early intervention approach to assessing and treating pregnant mothers, their womb babies, and the family system from conception throughout their prenatal care, and a year after birthing (Cortizo, 2019).

In the next section, the five elements or pillars of this model will be explained.

Pillar 1: In Utero Developmental Guidance

In utero developmental guidance identifies the importance of providing the earliest and most up-to-date prenatal psychoeducation to the mother and her partner. This intermediation is adapted to alleviate the expectant mother and womb baby’s chronic external pressures and emotional dysregulation. Both Fraiberg (1980) and Bowen (1966) reported that the manner in which a mother was nurtured and reared in her own infancy and childhood affects how she parents and interacts with others. Addressing the mother’s doubts, providing in utero developmental psychoeducation, enhancing her womb baby bonding, clarifying the couple’s relational misconceptions, and healing multi-intergenerational dysfunctional patterns is critical at this stage. Even though they did not directly address dissociative phenomena or “prenatal” developmental guidance, Fraiberg (1980) offered a template to assist clinicians understand maternal avoided, projected, or transferred painful aspects of the self, and their unswerving impact on infants. Such material provided an outline for the model’s ten-month prenatal experience-dependent, in utero developmental guidance, that is contingent on and concordant with maternal regulation practices, and highlights the importance of supporting mothers during their prenatal care. Maternal psychotherapy gains and achievements during gestation may be more readily transmitted to subsequent generations.

Traumatic Transference

Negative transference in the therapeutic situation is a defense against hurtful feelings that are being transferred and reexperienced with the treating therapist. This enactment offers the psychotherapist an opportunity to assist the patient acknowledge and work through similar patterns in the patient’s relationships with others. When these are validated and explored, the mother can find new responses to old conflicts (Fraiberg, 1980). Pre- and perinatal transference is a protective defense.

An example of an expectant mother/womb baby negative transfer of feelings is a woman who experienced frequent sexual abuse growing up who later rejects or constantly fears for her infant girl, alternatively, the girl child may continue to trigger trauma memories in the mother who may become dismissive and indifferent toward her child due to the fear of nurturing a girl who may relive and reenact her childhood pain. If the infant is male, the mother may fear it, or have difficulty feeling loving toward him because of her abuse by males.

Projection

Projections or the disowned, dissociated defense against unconscious desires both positive and negative refers to the denial of their existence in herself and attributing these to others, such as the baby, the therapist, or the partner. It is the parental transmission of their own problems and fears unto others, each other or their children. For example, a mother may perceive her womb baby girl to be in danger, because of her traumatic past, and repeatedly react with fear and worry as the child grows up until the child’s sense of safety becomes dependent on the mother’s constant protection (Bowen, 1966). Mothers, who project their own traumatic histories onto female children, can cause all kinds of misattunements.

With a male baby, the mother may perceive the infant as frightening and potentially harmful to her. I have frequently observed mothers having serious problems bonding and attuning to male children because of their own unresolved trauma.

Pillar 2: Multigenerational Family Therapy

Multigenerational Transmission Process refers to family repetition of patterns from one generation to the next (Bowen, 1976). Bowlby (1979) observed and acknowledged how a parent’s own childhood care and mothering experiences become an internalized model of future parenting. Therefore, it is crucial to treat both mother and womb baby from the moment she initiates her gestational care. The perpetuation of dysfunctional and negative patterns from one generation to the next is both treatable and avoidable (Cortizo, 2020).

Pillar 3: Collaborative Pre-Perinatal Trauma Informed Approach

As a pre-perinatal trauma therapist, I work closely with the mother’s OB/GYN team, including the ultrasound technician. This may include periodical meetings and phone conversations. Best clinical outcomes are attained when all the prenatal teams communicate and collaborate from the mother’s first trimester and post birthing.

An overlooked robust medical bonding resource for parents is the ultrasound exam. Even initially ambivalent pregnant mothers often report a closer bonding experience after seeing a physical image of their unborn baby.

Pillar 4: The Mother-Womb Baby Dyad

In the CWFTM, the mother and her womb baby are the focus of the prenatal family psychotherapy. Maternal prenatal care, self-regulation, and emotional wellness are at the core of the CWFTM. Although this article focuses only on the treatment of the mother-baby dyad, the full CWFTM program provides family therapy and addresses the impact of pregnancy on the partner and the baby’s siblings. Family members are welcomed to attend sporadic or ongoing conjoint sessions, but ultimately the mother-womb baby dyad will remain the identified clients (Cortizo, 2020, 2019).

Understanding prenatal stress, developmental trauma, dissociation processes, and their direct impact on the developing fetus can inform psycho-therapeutic treatment decisions, especially when treating pregnant mothers who are severely distressed and dissociative. Fetal neurobiological attachment and stress systems may be altered by maternal stresses in the limbic-hypothalamus-pituitary-adrenal axis and limbic-autonomic nervous system, possibly influencing the development of fetal ‘fixed action patterns’ built from primitive defensive reflex activation (Thomson, 2007).

The pregnant mother’s sense of emotional mastery, “in utero developmental” prenatal knowledge, and physical calmness are crucial to her womb baby bonding. Throughout the pre-perinatal care therapy sessions, the mother will learn and practice multiple state change interventions such as, somatic relaxing exercises, trauma informed mindfulness (Forner, 2019) and grounding practices that enhance her sense of wellness, reduce her emotional distress, and increase her sense of self mastery and prenatal tranquility. Trauma informed treatments such as EMDR therapy which increase internal and external resources are beneficial to both the mother and womb baby during the early parenting periods (Cortizo, 2020, 2019).

Supporting titrated interventions that increase maternal and womb baby’s felt sense of safety and regulated internal environments, is especially beneficial for women with preexisting histories of trauma, unresolved grief, and traumatic stress symptoms (Weinstein, 2016).

The importance of acknowledging the presence of the baby from conception by the mother is at the core of bonding and maternal attunement.

Interrupted prenatal bonding and maternal interactions in early infancy are associated with deficient child outcomes. Thus, the benefits of identifying early risk factors for such disrupted interactions (Khoury et al., 2020). Nyström-Hansen et al. (2019) recent study points to the prospect of third trimester high cortisol concentrations (HCC), being a possible prenatal indicator for upcoming parenting difficulties and deficits in expectant mothers with severe mental illness and histories of adverse childhood experiences. Such finding may expedite timely prenatal interventions geared to support and treat pregnant maternal deficits which may result in adaptive maternal interactions in early infancy. Most recently, Khoury et al. (2020) reported study results that reflect the importance of measuring high levels of HCC on pregnant mothers and depression. According to the findings both HCC and depressive symptoms interacted to predict both maternal withdrawing (high depressive symptoms with HCC) and inappropriate/intrusive interaction (low depressive symptoms with HCC). Both of which are deleterious for infant development.

Pillar 5: Prenatal EMDR-CWFTM Framework

The purpose of the CWFTM application is to assess, treat, and prevent traumatic bonding, maladaptive repetitions, and to increase the pregnant mother’s wellness. The simultaneous and titrated practice of the CWFTM and EMDR therapy support the pregnant women and their womb babies’ attunement and bonding. Dissociation phenomena in response to trauma can interfere with prenatal bonding when the mother is not able to be in touch and feel the shame, grief, fear, or pain caused by an event or multiple past traumatic incidents.

The CWFTM is a comprehensive early trauma intervention approach for the assessment and treatment of pregnant mothers and their womb babies throughout their prenatal care and a year after birthing. It provides in utero developmental psychoeducation, facilitates collateral support and collaboration with the medical services to the mother. Multi-intergenerational maladaptive reenactments, projections, and unwarranted transferences are identified and treated timely, within a comprehensive model that respects and values the client’s family beliefs.

While EMDR therapy strives to resolve and eliminate the originating traumatic effects of the memory, other therapies make every effort to reduce symptoms. Most trauma treatments focus on state changes, while EMDR emphasis is on trait change. Consequently, EMDR is the therapy of choice for the CWFTM. From the initial stages of prenatal care, the EMDR therapy is informed by the CMFTM, both are used concurrently.

I have consistently practiced and seen how deeply prenatal EMDR therapy alleviates symptoms and reprocesses past traumatic memories that are the result of maladaptive past life experiences causing current distress, interfering with the maternal bonding, and affecting the prospect of the infant’s secure attachment. Therefore, EMDR therapy needs to be readily available to the expectant mother as soon as feasible. It is recommended that the treating OBGYN-MD or midwife, are trauma educated and EMDR informed prior to treatment to enhance team collaboration and strengthened outcomes. EMDR therapy medical consent is optional, but recommended. The EMDR therapy standard protocol is informed by the CWFTM gestational recommendations.

Some EMDR-CWFTM recommendations include: titrated psychosocial/attachment/birth history, individualized treatment planning, prenatal trauma and dissociation screening, in utero guidance education, EMDR instruction (phase1); extensive resourcing, symptom stabilization, dissociative processes, and trauma informed mindfulness (Forner, 2019), gestational relaxation practices and preparation (phase 2); all other phases 3–8 are the same as the EMDR standard protocol with particular emphasis to gestational somatic attunement, and maternal bodily regulation and containment (Cortizo, 2020).

There are other techniques that could also be used along with the CWFTM such as hypnosis, and somatic therapies in particular, but there are also narrative techniques and many other ways to resource the mothers and help them work through their own issues. While this paper focuses on the integration of EMDR therapy, and the CWFTM, other therapeutic techniques, such as hypnosis and somatic interventions, may also prove effective, but those were not included in the development of this protocol.

Conclusions

The purpose of the CWFTM application is to early assess maternal trauma and dissociative processes, to provide EMDR adapted interventions, to increase mother-baby dyad bonding, to repair broken bonds, and to increase the pregnant mother’s internal resources. Because women with a history of maltreatment, complex trauma, and dissociative adaptation are at risk to be re-traumatized or overwhelmed by birthing, and to dissociate, it is recommended to universally assess for dissociative coping early on prenatally. The concurrent practice of the CWFTM and EMDR therapy to support pregnant women and their womb babies’ is recommended for optimal attunement and bonding. Such potential for integral resilience, harmony, and healing is associated with reduced psychopathology, improved wellbeing, and multi-intergenerational transmission of health. The CWFTM ultimate objective is to conceive and nurture healthy infants by promoting bonding, providing prenatal developmental education and guidance, and to heal trauma in the earliest life span stages.

Disclosure

Dr. Cortizo developed the Calming Womb Family Therapy Model and receives fees for training therapists in the use of this model and in the treatment of pregnant women.