Case Consultation: Traumatized Pregnant Woman
Carol Forgash
Smithtown, NY
Andrew Leeds
Santa Rosa, CA
Claire A. I. Stramrood
University Medical Center, Groningen, The Netherlands
Amy Robbins
Atlanta, GA
Case consultation is a new regular feature in the Journal of EMDR Practice and Research in which a
therapist requests assistance regarding a challenging case and responses are written by three experts. In
this article, Amy Robbins, a certified eye movement desensitization and reprocessing (EMDR) therapist
from Atlanta, Georgia, briefly describes a challenging case in which a pregnant woman seeks treatment
for trauma suffered in a tornado. The clinician asks if it is advisable to provide EMDR treatment and what
concerns she should be aware of. The first expert, Carol Forgash, provides some general information about
pregnancy and psychotherapy and outlines considerations, concerns, and contraindications for proceeding with EMDR. She recommends that if treatment is chosen, the therapist proceed with a recent trauma
protocol to specifically target the traumatic memories of the recent tornado. The second expert, Andrew
Leeds, comments on the absence of randomized controlled trials (RCTs) or other scientific reports exploring the safety of EMDR treatment of pregnant women. He states that pregnant women with symptoms of
posttraumatic stress should understand that there is a high probability that EMDR will improve maternal
quality of life and that the risks of adverse effects on stability of pregnancy are probably low, but that
these remain unknown. The third expert, Claire Stramrood, explains that the few case studies that evaluated EMDR during pregnancy have found positive effects but pertained to women with posttraumatic
stress disorder (PTSD) following childbirth. She asserts that once obstetricians have been consulted,
women have been informed about possible risks and benefits, and, given their informed consent, they
should be able to choose to commence EMDR therapy during pregnancy.
Keywords: EMDR; posttraumatic stress; acute stress disorder; tornado; pregnancy
Therapist’s Request
I have a client “Judy” referred to me by her primary
therapist for eye movement desensitization and reprocessing (EMDR). She is 7 months pregnant. She
was in a tornado a few months ago in which her entire
house was leveled, and the closet in which she and her
family were hiding was pulled into the tornado and
they “landed” on the street. They were all injured.
Judy has become obsessed, panic filled, frightened . . .
you name it . . . about the weather. She bought hard
hats for everyone in the family. When the weather is
even slightly rainy and thundering, she escalates into a
full-blown panic attack and has everyone hiding, checks
the weather several times a day, and becomes hyperfocused when impending “bad weather” is coming.
Judy heard about EMDR and is desperate to do this
to ease these issues. I explained to her the liability of
doing this with a pregnant woman and she said, “I’m
not worried, what I am doing to my baby (extreme
stress) is far worse than me doing EMDR.” I do have
an informed consent. What are your thoughts? Would
you do EMDR with her?
Journal of EMDR Practice and Research, Volume 7, Number 1, 2013
© 2013 EMDR International Association http://dx.doi.org/10.1891/1933-3196.7.1.45
45
Response From Expert No. 1,
Carol Forgash
I’d like to start by providing some general remarks
about pregnancy and psychotherapy. Pregnancy is defined as a normal healthy state for most women: that
of carrying an embryo from conception to delivery.
Although, until the fourth quarter of the 20th century,
it was often pathologized by the medical profession,
pregnancy is not an illness.
As a therapist who has treated many pregnant
women, I am comfortable considering the use of
EMDR with pregnant clients. However, in the EMDR
community, I have observed that treating pregnant
women is still of concern to many therapists. I base
this statement on the large number and frequency of
questions about using EMDR with pregnant patients
posed to the EMDR Institute LISTSERV.
If therapists are willing to view pregnancy as a
normal situation, it is easier to exercise clear clinical
judgment. This brings up the issue of countertransference. If the therapist has had a difficult pregnancy and
so forth, she may need to seek consultation because her
own state of mind may be influential in her decision to
use EMDR with pregnant clients. Male therapists who
have a spouse or relative who may have had problems
while pregnant might also profit from consultation
about issues that emerge for them. Providing information about EMDR to the obstetrician or midwife
and getting a release from the practitioner can also allay the therapist’s concerns. I would also recommend
that the therapist have a conversation with the physician and ask them for information about any pertinent
issues that might affect the treatment. In addition, the
therapist can let the physician know that they understand the implications of posttraumatic stress disorder
(PTSD) on the health of the client and explain the
need for trauma treatment.
In the case of Judy, where we don’t have much information about her prepregnancy and current health,
I would say the following: Under normal circumstances, if the client is in good health, the pregnancy is
stable, and the therapist has received clearance from
the obstetrician to treat the client with EMDR, I
would trust and respect her decision to have EMDR
treatment. Elevated stress hormones are harmful both
to the pregnant woman and her baby (Poggi-Davis &
Sandman, 2006). It appears that Judy has been severely
stressed since the tornado and has intrusive symptoms of PTSD. She is correct about needing trauma
resolution (Harvey & Ramirez, 2010) because PTSD
can have negative effects on both maternal and fetal
health. When conferring with the physician, let them
46
know that you understand implications of PTSD on
the health of your client and explain the need for trauma treatment.
I would take a careful history, including any health
or past trauma events, including Judy’s fertility and
pregnancy history over her lifetime, her attitudes
toward pregnancy, any symptoms of PTSD, panic
disorder, anxiety, and depression. It would also be important to look for any contraindications to treatment.
These might include an unstable dissociative disorder
or psychosis. Another concern would be a significant
lack of partner/spouse/family support. Her relationship with her physician/midwife is also an important
element to consider. In terms of medical issues, does
she have any conditions which put her at high risk?
Barring these conditions, because there is very little
time left in the pregnancy, I would proceed to develop a
treatment plan that would include educating her about
EMDR, teaching self-soothing and stress-reducing
strategies (if necessary), then setting up a target about
the tornado experiences and processing them.
If Judy wished to continue in treatment after the
delivery because she had a significant prior trauma
history, I would explain that other traumatic events
could be treated later. The focus of current treatment
would be on the tornado and its effects on her.
In addition, because the tornado only occurred a few
months ago, I would work with an EMDR recent incident protocol rather than the standard EMDR protocol.
This client’s continuing experience of distress related
to her experiences in the tornado clearly indicates that
the effects of the original event have continued into the
present day. I would use the Recent Traumatic Episode
Protocol (R-TEP; Shapiro & Laub, 2008). This protocol
is understood to integrate unprocessed parts of an entire traumatic episode: the event, experiences that occur
after the event, and the possible changing meaning of
the original event until the present. R-TEP works with
the disturbing images, the event, multiple targets within
the event, and the theme of the entire episode. It has
the potential to limit associations to only this episode using eye movement desensitization (EMD; Shapiro, 1989),
with repeated returns to the target. The goal would be
to keep the doors to any earlier traumas closed off.
The R-TEP also stresses preparation and containment strategies such as the self-soothing and
stress-reduction exercises mentioned earlier. In the RTEP approach, the client tells the chronological story
of the trauma using bilateral stimulation. The next step
is to scan the event and report points of disturbance
(POD). A target (the image, negative cognition [NC],
positive cognition [PC], validity of cognition [VOC],
subjective units of disturbance [SUD], body sensation)
Journal of EMDR Practice and Research, Volume 7, Number 1, 2013
Forgash et al.
is developed around each POD. For Judy, some possible points of disturbance might be the scene of the
house being leveled, the injuries to her family, or a
rainy day. Each would be processed. Finally, the
theme of the entire episode would be processed. For
this particular pregnant client, this approach would be
very appropriate.
Response From Expert No. 2,
Andrew M. Leeds
The question of the safety of EMDR for pregnant
women has not been explicitly addressed in the scientific literature. Searches of online databases (PubMed,
PsycINFO, and the Francine Shapiro Library) have
turned up no published reports that would indicate
any danger from EMDR treatment. On the contrary,
Stramrood et al. (2012) reported positive clinical outcomes in a case series with three pregnant women
who had developed symptoms of posttraumatic stress
after traumatic experiences in their first pregnancies.
In all three cases, EMDR treatment was provided during a subsequent, second pregnancy in cases referred
for treatment by the attending obstetrician.
As an EMDR trainer, over the course of 20 years,
I have received a small number of isolated personal
reports in which women have complained of unstable
pregnancies following EMDR sessions. These women
believed that treatment with EMDR was a factor in
their subsequent need for bed rest and medical consultation (Leeds, 2009, p. 88). Such reports cannot
be considered scientific evidence of risk, but they
should not be casually dismissed either. The women
who made these reports might have developed unstable pregnancies even if they had not participated in
EMDR treatment sessions. Over the course of many
consultation groups and workshops, I have observed
that the fear of treating pregnant women with EMDR
is fairly widespread. This may be caused by potential
“risk factors” that were identified in standard EMDR
training program manuals from 1991 onward. (Similar
unfounded fears seem to apply to offering EMDR to
those facing legal procedures or for those with identified genuine epileptic seizures.) Thus, consultation
with a woman’s obstetrician might not even be encouraged by a clinician who erroneously believed
EMDR to be too “dangerous” for a pregnant woman.
EMDR treatment for symptoms of posttraumatic
stress is known to be highly effective and efficient
(Bisson & Andrew, 2007). In the absence of scientific
study of the safety of EMDR treatment for pregnant
women, the probable benefits to maternal quality of
life (and reduced stress for the developing fetus) have
Journal of EMDR Practice and Research, Volume 7, Number 1, 2013
Case Consultation: Traumatized Pregnant Woman
to be weighed against an unknown degree of safety.
Until there are RCTs with a sufficiently large sample
of pregnant women, an appropriate discussion would
indicate that the risk to stability of pregnancy is probably low but may not be zero, whereas the potential
and probable benefits for women with posttraumatic
stress symptoms (and their fetuses) are high. Until
there are RCTs to provide further guidance on this
issue, a conservative approach would suggest that
EMDR reprocessing should only be employed with
pregnant women after consultation with or upon referral by the woman’s physician. At present, it would
appear that the same general risks apply to offering
EMDR treatment to pregnant women as to all other
adults. Appropriate screening for risk factors such as
a severe dissociative disorder should take place as
always. In Judy’s case, the information provided in
the summary is insufficient to clearly determine her
readiness for EMDR. In particular, no information is
provided about her early history, whether there is any
history of an anxiety disorder or whether the clinician
has screened for dissociative symptoms. In an actual
EMDR case consultation, such information would be
requested. Once these issues have been clarified and
informed consent has been obtained, EMDR should
be offered to women who are or who may be pregnant when they are suffering from symptoms for
which EMDR is known to be effective.
Judy is eager for EMDR. There are no identified,
defined risks to EMDR treatment of Judy or of pregnant women in general. Absent of any specific risk
factors not disclosed in the case summary, it would
seem a shame to prolong her suffering merely because
she is pregnant. Furthermore, at the time of birth, her
untreated PTSD symptoms might adversely impact
her ability to form a maternal–infant bond (Liotti,
1992; Madrid, Skolek, & Shapiro, 2006), complicating
her subsequent treatment and potentially affecting her
newborn child. In my own clinical practice, assuming
that she met general readiness criteria, the answer is
“yes.” I would offer Judy EMDR treatment. In the absence of a referral by her obstetrician (or a history of
unstable pregnancy), I would first suggest she discuss
her desire for EMDR treatment with her physician,
but whether she had that discussion or not, the benefits of EMDR treatment far outweigh the general risks
of treatment.
Response From Expert No. 3,
Claire A. I. Stramrood
In many cases of psychological problems during
pregnancy, including stress, depression, and anxiety,
47
doctors and therapists are faced by a choice between
two evils: using treatments that are potentially harmful for the fetus or prolonging the state of being mentally unhealthy with possible adverse effects on the
fetus (and pregnant woman) as well.
In my response to this case consultation, I will put
forward several arguments in favor of using EMDR in
pregnancy. However, in this particular case, I would
discuss the risks and benefits for Judy and then leave
the decision up to her.
In international and national practice guidelines,
trauma-focused cognitive behavioral therapy and
EMDR are recommended as the treatments of choice
for trauma victims suffering from PTSD or acute
stress disorder (American Psychiatric Association, 2004;
National Institute for Health and Clinical Excellence
[NICE], 2005). The information provided with this
case is brief but includes features of both conditions.
A proper diagnosis of Judy’s symptoms would be
a required first step. Once it has been established that
her symptoms are such that she may benefit from
EMDR, the question is whether the treatment should
be applied during her pregnancy. In the 2001 EMDR
book, Shapiro recommends caution because possible
hyperarousal and increased stress after the treatment
may negatively affect the mother and fetus (p. 96).
Unfortunately, the risks and benefits of applying EMDR during pregnancy have not been well
researched. Two pilot studies have been published
pertaining to women with PTSD following childbirth.
One study used EMDR in three pregnant women
(Stramrood et al., 2012), and in another study, four
women were studied of which one was pregnant
(Sandstrom, Wilberg, Wikman, Willman, & Hogberg,
2008). Both studies pertained to women suffering
from PTSD following childbirth. In other words, the
preceding delivery was the traumatic event.
The first study was conducted by the research
group that I am part of and took place at a university hospital in the Netherlands. The three women
had been traumatized during previous delivery, and
they had each developed PTSD related to the birth
of their child. They were now pregnant again, showing PTSD symptoms and expressing fear about the
upcoming birth. EMDR resulted in stress reduction,
fewer posttraumatic stress symptoms, and increased
confidence about the upcoming delivery of their
second child. Furthermore, despite complications
during their second deliveries, all three women had
a positive experience of the second birth. With the
aforementioned women, we had either direct referral
or consultation with the obstetrician, and in my opinion, this is a crucial element.
48
In this specific case, Judy’s trauma and stress are
not related to pregnancy or childbirth but to a tornado
that the family was in. Considering the fact that Judy
is already 7 months pregnant, I can see arguments
for postponing the EMDR treatment until after the
baby is born. Stress is known to negatively affect fetal
neurodevelopment (O’Donnel, O’Connor, & Glover,
2009), but in all likelihood, most adverse effects of
Judy’s stress on the fetus have already occurred by
7 months gestation. Another argument would be that
EMDR itself may be stress provoking, with possible
negative consequences to the pregnancy, as mentioned by Shapiro (2001). However, whether or not
treatment has taken place during pregnancy does
become relevant in the postpartum period because
unresolved trauma/PTSD may negatively affect the
mother–baby bond (Parfitt & Ayers, 2009) and impair
secure attachment of the infant (Liotti, 1992).
From Judy’s perspective, I can very well imagine
that experiencing so much daily stress related to the
weather is such a burden that any solution with potentially rapid effects is more than welcome. With
that in mind, EMDR would definitely be an option
because many people experience its positive effects
after only a few sessions.
In conclusion, EMDR during pregnancy has
thus far been researched on small scale, with very
positive effects for women suffering from PTSD following previous childbirth. In such cases, I would
definitely recommend EMDR. Although there is no
research on EMDR treatment during pregnancy for
women whose trauma is not related to a previous
pregnancy and childbirth, the cause of the PTSD is
not important, and this is insufficient reason to dissuade or refuse EMDR during pregnancy. Provided
that referral by or consultation with the obstetrician
has taken place, women have been informed about
possible risks and benefits, and, given their informed
consent, they should be able to make the choice
themselves.
References
American Psychiatric Association. (2004). Practice guidelines
for the treatment of patients with acute stress disorder and
posttraumatic stress disorder. Arlington, VA: Author.
Bisson, J., & Andrew, M. (2007). Psychological treatment
of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, (3), CD003388.
Harvey, L., & Ramirez, A. (2010). Hurricane trauma: The effects of prenatal stress on child development. Retrieved from
http://uwf.edu/argojournal/admin/body/Research_
Paper-Harvey_&_Ramirez_Submission_for_Argo_
Journal.pdf
Journal of EMDR Practice and Research, Volume 7, Number 1, 2013
Forgash et al.
Leeds, A. M. (2009). A guide to the standard EMDR protocols
for clinicians, supervisors, and consultants. New York, NY:
Springer Publishing.
Liotti, G. (1992). Disorganized/disoriented attachment in
the etiology of the dissociative disorders. Dissociation,
5(4), 196–204.
Madrid, A., Skolek, S., & Shapiro, F. (2006). Repairing failures in bonding through EMDR. Clinical Case Studies,
5(4), 271–286.
National Institute for Health and Clinical Excellence. (2005).
Post-traumatic stress disorder: The management of PTSD in
adults and children in primary and secondary care. London,
United Kingdom: Author.
O’Donnell, K., O’Connor, T. G., & Glover, V. (2009). Prenatal stress and neurodevelopment of the child: focus
on the HPA axis and role of the placenta. Developmental
Neuroscience, 31(4), 285–292.
Parfitt, Y. M., & Ayers, S. (2009). The effect of post-natal
symptoms of post-traumatic stress and depression on
the couple’s relationship and parent-baby bond. Journal
of Reproductive and Infant Psychology, 27(2), 127–142.
Poggi-Davis, E., & Sandman, C. A. (2006). Prenatal exposure to stress and stress hormones influences child development. Infants and Young Children, 19(3), 246–259.
Sandstrom, M., Wiberg, B., Wikman, M., Willman, A. K.,
& Hogberg, U. (2008). A pilot study of eye movement
desensitisation and reprocessing treatment (EMDR) for posttraumatic stress after childbirth. Midwifery, 24(1), 62–73.
Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior
Therapy and Experimental Psychiatry, 20, 211-217.
Shapiro, F. (2001). Eye movement desensitization and reprocessing. Basic principles, protocols, and procedures (2nd ed.).
New York, NY: Guilford Press.
Shapiro, E., & Laub, B. (2008). Early EMDR intervention
(EEI): A summary, a theoretical model, and the recent
traumatic episode protocol (R-TEP). Journal of EMDR
Practice and Research, 2(2), 79–96.
Stramrood, C. A. I., van der Velde, J., Doornbos, B., Paarlberg, K. M., Weijmar Schultz, W. C. M., & van Pampus, M. G. (2012). The patient observer: Eye-movement
Journal of EMDR Practice and Research, Volume 7, Number 1, 2013
Case Consultation: Traumatized Pregnant Woman
desensitization and reprocessing for the treatment
of posttraumatic stress following childbirth. Birth, 39
(1), 70–76.
Meet the Experts
Carol Forgash is a licensed clinical social worker in private practice in Smithtown, New York specializing in
complex trauma. She is an EMDR International Association (EMDRIA)-approved consultant and provider
of EMDRIA-approved workshops. She co-edited and
contributed to Healing the Heart of Trauma and Dissociation with EMDR and Ego State Therapy, and has written several articles and book chapters about EMDR.
She is a past president of the EMDR Humanitarian
Assistance Program.
Dr. Andrew M. Leeds, PhD, is a California licensed
psychologist and director of training for Sonoma
Psychotherapy Training Institute in Santa Rosa,
California. He is an EMDRIA- and EMDR Europeapproved consultant and provider of basic training in
EMDR. He authored A Guide to the Standard EMDR
Protocols for Clinicians, Supervisors, and Consultants
(2009) and has written several book chapters and journal articles on EMDR including a research study on
resource development and installation (RDI).
Dr. Claire A. I. Stramrood, MD, is a resident in
obstetrics/gynecology from Utrecht, the Netherlands.
She recently completed a PhD thesis on women with
PTSD following childbirth. She was the main author
of a pilot study on EMDR treatment for PTSD following childbirth that was published in 2012, and has been
involved in establishing an integrated care model for
women with fear of childbirth.
Correspondence regarding this article should be directed
to Carol Forgash, LCSW, BCD, 353 North Country Road,
Smithtown, NY 11787. E-mail: cforgash@optonline.net
49