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New motherhood can be a time of excitement and joy, but it can also be challenging in a multitude of ways. The journey into motherhood is a period of uncertainty and unpredictability, coupled with the responsibility of looking after a new life. Research shows that approximately 15% of mothers experience persistent anxiety in the first year after giving birth,¹ and a recent UK report also highlighted that suicide is the leading cause of death among women in that first year.² Numerous studies show that early motherhood is recognised as being a particularly vulnerable time.

It’s clearly important that therapy professionals are aware of the range of feelings and experiences encountered during this period. A widespread misconception is that most maternal psychological difficulties manifest as postnatal depression; we now know that mothers also experience other challenges after birth. In comparison to postnatal depression, postnatal anxiety (PNA) is under-recognised, with a recent study revealing that it’s an unfamiliar concept among professionals involved in maternal care.³ This highlights the importance of raising awareness of maternal anxiety, so that women can be well supported by those in the caring professions. Ìý

What is postnatal anxiety?

PNA is anxiety experienced within the first 12 months after the birth of a child. The core characteristics of maternal anxiety are difficult to define and, critically, lived experiences will vary from one mother to the next. Some themes that might come up in the therapeutic dialogue include (but are not limited to):Ìý

• worries about infant welfare, mothering capabilities, parent/infant bonding
• physical ‘fight and flight’ feelings
• distressing thoughts relating to infant harm
• feelings of panic and overwhelm
• feelings of uncertainty
• social and relationship factors relating to becoming and being a mother. Ìý

Importantly, as therapists, we should not hold assumptions or preconceptions of what PNA is. Each mother will have their own unique set of circumstances, including a family history, a personal birth story and a relational, social and cultural context. All of these will have a bearing on their experience of early motherhood and, as therapists, we need to encounter each mother in her uniqueness and seek to understand her. Ìý

There’s a lack of research into therapeutic approaches for PNA. NICE guidelines state that anxiety experienced during the postnatal period should be treated from the perspective of individual disorders, such as generalised anxiety disorder (GAD), panic disorder (PD), obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). Some DSM-5 disorders (for example, GAD) specify that anxiety must have been present for at least six months, and this is problematic for new mothers, given that anxiety may start soon after birth.^4,5 My own research⁴ argues that PNA should be considered as a separate phenomenon, specific to being and becoming a mother.

The impact of PNAÌý

If left unsupported, PNA can have profound implications for a woman’s wellbeing. A study by Dawson et al⁶ revealed that maternal anxiety can have a significant impact on mother/infant bonding. Other studies have highlighted that PNA can negatively impact breastfeeding,⁷ and lead to adverse consequences for a child’s cognitive and social development.⁸ Other outcomes may include relationship difficulties and a withdrawal from social contact.⁴ Clearly, these studies highlight the importance of working towards a better understanding of mothers’ experiences so that they can be supported.

Encouragingly, there’s been growing investment in perinatal mental health services (PMHS) in recent years, and specialist clinics have been established across the UK to support women who experience severe or complex mental health challenges during pregnancy or after birth. What’s notable is that many women will not meet the threshold to access support from PMHS, but will still benefit greatly from therapeutic services. While some will get help via primary care, others will turn to the private sector. Below, I offer some general considerations to therapists who may encounter new mothers experiencing mild to moderate levels of anxiety, drawing on my clinical experience and doctoral research.ÌýÌý

Barriers to support

There may be some barriers to accessing support. Mothers can be wary of beginning therapy due to societal stigma. They may even have fears that their baby will be taken from them if they reveal their struggles to a professional.^9,10,11 Many mothers will have difficulty in finding childcare to enable them to attend appointments^.12,13,14 It’s also important to keep in mind that if childcare is arranged, mothers may be anxious about leaving the baby in someone else’s care. Ìý

Finding time

Given the multiple demands that come with looking after a baby, mothers may find it difficult to commit to regular sessions at set times. Research shows that mothers welcome some degree of flexibility around appointment times.¹² Therapists must be mindful about what they’re prepared to offer and what their working contract will be. In my experience, telephone or online sessions offer a practical means to access therapy and can be easier for a mother to commit to. Other alternatives may include offering home visits or arranging ‘walk and talk’ meetings in a local park, so that mothers can bring their infants with them. What matters is that consistency and reliability are offered.

Establishing a working alliance

Once a time and mode of delivery have been agreed, the establishment of a strong working alliance is key. Mothers can be frightened of revealing how they’re feeling to others, for fear of what they might think of them.⁴ Many mothers hold the belief that they’re the only ones who are struggling and that everyone else is coping. If a mother makes an enquiry seeking therapy, it’s important to keep in mind that it will have taken great courage for her to take this initial step. Numerous studies highlight that the fundamental factor for a good therapeutic outcome is the practitioner/client relationship.¹⁵ Given that experiences of anxiety can result in feeling disconnected from others, this places even more importance on forming a strong therapeutic union. Mothers may initially present in therapy feeling guarded,¹⁶ and a supportive, empathic stance is essential to establish safety and trust. Ìý

Among the many therapeutic approaches available, I’ve highlighted a small sample below. There’s not space in this article to go into every modality and approach. What’s most important is that practitioners work within their own skill set, and use the approach they feel most competent with.Ìý

Existential approach

My own research highlighted the existential dimensions of PNA: being responsible for a new life is an anxious undertaking, and a mother becomes acutely aware of the fragility of human existence. In becoming a mother, a woman steps into the unknown, not knowing how to be a mother or how to look after an infant. An existential stance maintains that ‘…anxiety is a teacher, not an obstacle or something to be removed, explained, rationalised, avoided or solved’.¹⁷ From this perspective, client and therapist will embark together on a journey of exploration to seek to understand new motherhood, and to make sense of anxious feelings within the context in which they arise. To do this, therapists need to be comfortable with uncertainty and resist leaping in with answers and reassurances. Motherhood is an ever-evolving process, asÌýone of my research participants said, ‘It’s like shifting sands… every time you thought you’d got somewhere, it just all changed again’.⁴

Becoming a mother entails learning to tolerate the unknown and unpredictable dimensions of motherhood. Vos¹⁸ writes that being a therapist is sometimes comparable to Socrates’ notion of midwifery: helping the client to give birth to their inner wisdom. This metaphor seems particularly appropriate in maternal counselling, as therapists accompany women in and though their struggles to reach a place of understanding and insight. Mothers may begin to understand how motherhood can be meaningful and fulfilling despite its day-to-day difficulties. Ultimately, every mother will learn to approach mothering in her own way, but this takes time. Existential therapy can assist in exploring the paradoxes, dilemmas and choices encountered along the way. Ìý

Cognitive behavioural approaches

CBT offers a valuable approach in the treatment of PNA, and studies looking at online CBT delivery for mothers have yielded promising results, with an overall reduction in anxious symptoms and psychological distress.^5,19 Anxiety and depression can coincide, and since CBT is also effective for postnatal depression,²⁰ it can be used for mothers who are experiencing low mood in addition to anxious feelings. Ìý

Many women experience intrusive thoughts of accidently or deliberately harming their child, and research highlights that this is a common experience among new parents.²¹ CBT can be effective at helping mothers to understand these distressing experiences,²² and can also assist in exploring themes relating to becoming a mother, such as responsibility, coping strategies and decision making.²³ Bear in mind that carrying out homework tasks between sessions may be a challenge for mothers who are short of time.

Acceptance and commitment therapy (ACT)

ACT has an emphasis on acceptance of thoughts and feelings, rather than trying to change them. This offers rich potential for therapeutic engagement with PNA: difficult feelings in new motherhood can be seen as an appropriate response to being in a new and unfamiliar phase of life. ACT offers a vehicle for understanding thoughts and feelings within the context of becoming a mother. A 2019 study²⁴ noted that ACT was effective at reducing self-stigma – something prevalent in anxious mothers.⁴ Another study observed that ACT was useful for exploring women’s changed identities, and helping them to understand their personal values.^25Ìý

Creative therapies

Arts-based therapies offer a creative means for working with new mothers, and provide a powerful medium to express difficult thoughts and feelings. Working with mothers to create imagery that represents their experiences and moods can aid discussion around some of the dilemmas and contradictions arising in early motherhood.²⁶ Art therapy has also been found to assist mothers in developing understanding of their own and their baby’s needs, as well as improving mother/infant interactions.²⁷ Creative approaches offer a vehicle for expression and hold the potential to discover meaning out of uncertainty. For women who are exhausted from the demands of new motherhood, arts-based therapies can offer an outlet when words can’t be found.²⁶

Planning for ending

Ending therapy with new mothers can be an anxiety-inducing process,⁹ and the conclusion of therapy should be planned in collaboration with the mother. The option of a gradual ending may be desired, in which the final few sessions are spaced at longer intervals.Ìý

Therapists can explore a range of self-care strategies for mothers to use, both alongside therapy and after therapy has concluded. Strategies that have been shown to be effective for mothers include personal journalling,²⁸ progressive muscle relaxation techniques,^29,30 and the use of mindfulness tools, such as those available via phone apps.³¹Ìý

Summary

My purpose in writing this article is to raise awareness of the phenomenon of PNA, and to illuminate some of the practice considerations for working with new mothers. Therapeutic support for PNA is a developing area and research is limited. Bearing in mind the vulnerability intrinsic to this period of a woman’s life, procedures around safe and ethical care are vital, and referral to specialist services should be made if needed.Ìý

Engaging in supportive postnatal counselling can help to explore and normalise feelings of anxiety, reduce feelings of stigma and shame, and increase self-confidence. It’s important to look beyond a ‘mental illness’ perception of PNA, and to seek to understand the embodied, relational and cultural dimensions of the experience. Coming to therapy takes courage and every encounter is an opportunity to explore maternal anxiety with sensitivity and compassion. Each mother is unique, and the therapeutic approach needs to be bespoke to reflect this. What matters most of all is that women’s voices are heard, and that we as therapists are ready to listen, bear witness and support mothers during this important period of their lives.