As providers specializing in postpartum support, we all will encounter clients who are looking for support for an upcoming delivery after experiencing symptoms of PMAD. As providers it is our role to support our clients in planning and preparing for the possibility of a second experience with a PMAD. Our role is a unique one. We become an advocate, a detective and a soft place to land for many of our clients who become pregnant after a previously difficult postpartum experience.

Preparing for PMAD means exploring the client’s previous history. If this is a new client coming to therapy because she is pregnant and looking for help so she doesn’t struggle like she did ‘before’ then you know that you need to explore her history to develop a comprehensive support and resource system. If she is a client who you have had before you may be able to draw upon your previous experience with the client to offer support.

With a new client, gathering history may be lengthy, but can also be an opportunity to align and develop a therapeutic relationship. If you are informed that your client had a previous PMAD, starting with how she was diagnosed is a good place to begin. Who diagnosed her? Why did they diagnose her? And what treatment, if any, was provided? If a provider or therapist was seeing her, why is she not seeking support from that provider again? It will be important to understand how she felt supported or not supported if this is the case. This will be a benefit for ongoing treatment as it will be helpful to have a sneak peek into what intervention style may benefit or be a roadblock for you as a team.

If a client self diagnosed, but never had therapy or support, find out how she diagnosed herself. A self-diagnosed client may have benefited from services, but did not have the resources to obtain them. She also may have had symptoms but did not recognize them as significantly impairing, or the opposite- they were significantly impairing but she felt uncomfortable accessing or asking for help. This is a good place to ask about symptoms. “How did you know something wasn’t right?” Often this will lead you to the second step in finding out what acuity of symptoms were. If we know what symptoms previously were experienced, it gives providers a good idea to prepare at that level and above. It is important for providers to support their clients in understanding the possibility for PMADS to reoccur, and to educate clients about what to look for and how to draw on resources and support recovery.

If your client has previously been diagnosed and saw a provider previously, clarify the symptoms and how they were addressed. What treatments were provided? Did the client find the treatments successful? This will take you in one of two directions. If the client found some treatments successful, draw upon those. Empower her to begin to practice these skills if possible. Encouraging her to draw strength in her ability can offer reassurance and confidence in herself as well as in the process of self-care. One example of this may be a client that mentions that breathing deeply helped her to be mindful and relax in moments of stress or anxiety. Encouraging her to practice this skill with you in session as well as at home, gives a tool that was previously useful and easily incorporated into daily life before baby comes and during the postpartum period as well.

If she states that nothing worked, this is where detective work comes in handy. Joining with her by asking what was tried, and if there were any things that helped her symptoms decrease- treatment or otherwise? In both cases, finding out how long it took for symptoms to subside or reduce will be something to take note of. Taking a baseline as well as where she feels she is today. Just because her ‘baby’ is 2 don’t assume that her symptoms have disappeared. I have had clients who state that they have felt better since their baby got older, but that they still don’t feel 100% and now being pregnant is making them scared that they wont ever feel better again. In fact, you may experience clients coming to counseling for PMADs for the first time because of just that. They are fearful that this time will be worse and they will never feel ‘the same again’.

Once you have gathered your initial history of symptoms and treatments, it is time to gather an understanding of supports and risk factors. Every client comes to therapy with a different history, experience and story. It is important with PMADs that you don’t make any assumptions. A client that presents well may have limited supports and a minimal network of friends or family. Just as likely, a client who is presenting severe symptoms with hopelessness and feelings of isolation may have an extensive support network that is unaware of how to help.

To gather resources and supports identify:

Family members. Immediate and extended. I say this because family members may not be easily accessible, however may be willing to at the drop of a hat fly, drive or visit as needed to support the client in need. Just as important is asking about how supportive the spouse or partner was in the previous experience.
Friends. What is her social network. Circle of friends, groups engaged in, etc.
Providers in her corner. Exploring what her experience with her OB/Midwife/MD in her previous experience and currently will be important in developing a healthy supportive team for your client to draw upon when she needs it. If she had medication management previously, it will be important for you to connect or support her in reaching out to ask if she will be able to utilize that provider in the future if she needs, etc.
Skills. What skills does your client already have in her ‘toolbox’ and what can you support her in developing proactively- mindfulness, self care, grounding, breathing skills, etc.

Once you have gathered resources, you can begin to explore risk factors, if you haven’t already taken note of some. Risk factors include any obstruction to health, treatment access, etc. that can play a factor in recovery or magnification of symptoms. Identifying resources that they have and then building on them as you simultaneously identify risk factors and develop a plan to plug them into resources as appropriate or plan to minimize the impact. Common risk factors to consider:

Socially: What is your client already plugged into? What could she be connected with? Friends, YMCA, Activities/Mom support groups/etc.
Previous Diagnosis of PMAD as well as Mental Health Diagnosis: Encourage ongoing engagement with medical providers, voicing concerns with medications, etc. Identifying previous symptoms and Diagnosis. A diagnosis of Postpartum Psychosis previously or a diagnosis of Bipolar may mean that you have a more comprehensive plan and preplanning may have more contact with providers before delivery.
Previous traumatic birth experience: Clients who have had a previous traumatic birth experience may feel a variety of emotions related to being pregnant and the upcoming delivery. Anxiety, worry, PTS symptoms all may be playing a role in the anticipation of delivery.
Hormone Sensitivity: Understanding a clients sensitivity related to hormones- PMS, PMDD, etc. and symptoms that are experienced during these times can be an important part of education for clients and may play a role in the perinatal time.
Support of Family:How involved was partner/spouse, what family support was offered to a single parent household
Age(s) of other child(ren). Caring for one child vs. more + an infant can play a role in stress, sleep, and finances.
Financial: Finances impact a significant part of our lives and the lives of our clients. Clients struggling financially may struggle to attend sessions, pay for daily expenses, housing, insurance, and access to childcare, etc.

As a therapist in the area of PMADs its important to have a wide plethora of resources to pass on to your clients. Having contact points for community resources will be beneficial in your treatment planning for clients coming to therapy for subsequent deliveries after PMADs. It is important that clients find their therapist as a resource to feel better but also as a ‘director’ to connect them to resources and contact points. These resources you should be familiar in your community with would be in each of the areas above in Risk Factors .

Resources to be familiar with:
Financial. Know what resources would benefit clients. Low-income assistance programs, local rec centers, even a contact at the state level for clients needing to navigate the WIC system.
Transportation. Is your client elgible for Meidcaid transportation services? Remebering to refer to places that are easy to access and dont require a car.
Social. Be sure to have community resources that are free are low cost- play groups, free days at museums,mother groups, library story times, free membership fee days at the YMCA, etc. Having resources for moms who are in the later stages of recovery can support in feeling ‘plugged in’ and can support social connections with other parents.
Prescriber/Mental Health Providers/OB/Midwifes. Have a list of contacts to connect/consult or refer is a powerful resource for providers. Often times having a contact for medication provider can make it less confusing for clients to have a direct contact with and can be beneficial for providers when we have questions or need support with a possible referral. Just as important is finding and having resources for intensive outpatient services in your area and contacts at the hospital if you have a referral for inpatient services.

Working with an expecting mama who is concerned about a ‘repeat’ of her previous PMAD experience can be rewarding for both you and your client. Recognizing and appreciating her commitment to ‘feeling better’ and taking care of herself is the first step to pre-planning for her next experience. Taking into account the information she shares and creating a safe nurturing environment is the key to pre-planning for a PMAD. If a client doesn’t feel safe or heard, we wont be able to do our work.

We, as providers know that every pregnancy is different and so is every delivery and parenting experience! Clients may be coming to us feeling scared and concerned that it will be a repeat of their last experience. Supporting your client in planning for what they can plan for, educating them and offering them power in their choices and knowing that you will be available to support them if things they didn’t plan for do happen.

Teresa M. Eltrich-Auvil MS, NCC, LMHC is a provider specializing in PMAD as well as other women’s issues, including miscarriage and infertility. Teresa has been committed to advocacy and promoting awareness and education surrounding the perinatal period since 2006. Her practice Picket Fence Therapy & Consulting is out of Puyallup, Wa in the South Puget Sound. www.picketfencetherapy.com

About Teresa M Eltrich-Auvil

Teresa M Eltrich-Auvil MS, NCC, LMHC Teresa is a perinatal mental health specialist, the WA state Climb Out of the Darkness Lead and has specialized training in infant mental health, infant loss, and equine assisted psychotherapy.