Expectations, Perspectives and Well-being: Cognitive Strategies to Enhance Emotional Health during Pregnancy and Postpartum

by Aga Grabowski, LCSW, Co-founder of Wildflower Center for Emotional Health             

 

Is the crib assembled? Check. Hospital bag packed? Check. Baby’s clothes washed and neatly folded? Check. Pediatrician selected? Check. Car seat purchased? Check. Birthing classes attended? Check. There are so many things moms and dads-to-be do in order to prepare for their baby’s arrival. We are inundated with information about what we need and cannot do without as we move towards parenthood. We tend to eagerly act on it out of desire to do what is best for that little human being we are about to welcome into the world. Indeed, we are parenting long before the baby is born! 

The loving desire to ensure that the baby has all that he or she needs is not the only motive that drives most parents’ efforts to get ready for the baby’s arrival. The need to bring a sense of order and organization and to feel in control at the threshold of one of the most unpredictable, all-consuming, and rapid life changes an adult human being might experience is a powerful engine for the preparatory frenzy that accompanies pregnancy.

This need is understandably bundled with some level of anxiety. It is after all inherently difficult to tolerate uncertainty. As much as human beings seek growth and change, we are also creatures of habit, thriving under circumstances in which we know exactly what is going on, what to expect, what will happen next. As a result, pregnant women in particular are prone to engaging in what are called “control strategies” – attempts to get rid of unpleasant sense of fear and anticipation via planning, information-gathering, resource-seeking. Preparing the nursery, reading books, and attending classes are all means of reducing contact with these negative emotions. This is not inherently a “bad” thing – these preparations allow women and their partners to begin creating a bridge into the postpartum world and make the changes feel less drastic. This being said, too much of a good thing can become problematic. 

Namely, as we exercise our cognitive “muscle” of problem-solving and control, we are NOT exercising the muscle of letting go, of allowing, and of accepting – all key skills that increase emotional well-being of new parents and need to be practiced alongside problem-solving. So much in the early postpartum period is not amenable to our control strategies: we cannot force the childbirth experience to be what we dreamed it would be, we cannot will the baby to eat well, and sleep well, and be born healthy. We cannot make our partners and family members act exactly the way we would like them to, we cannot force worry and fear to dissipate. In the moment when our reality is unfolding differently than we intended it to, it would seem we have no choice but to greet it as it is, with all its flaws and imperfections.  But do we? 

Unfortunately, all too often, we do not. Every human being is intimately acquainted with the experience of struggling with aspects of their reality they did not wish for or that they worked hard to avoid. The mind is skilled at coming up with resistance: “Why me?”, “What is wrong with me for feeling this way?”, “I should try harder”, “This is unfair”, “This is not how this was supposed to be!” During the transition to parenthood, replete as it is with unexpected outcomes we cannot fully control, the ability to accept and tolerate the reality as it is, while of course problem-solving aspects of that reality that are amenable to change, is an important predictor of emotional well-being. 

The formal term for this skillset is “psychological flexibility”, defined by eminent psychologist and researcher Steven C. Hayes as “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.” In other words, psychological flexibility is about willingly adapting to changing circumstances based on what a particular situation requires and what best serves our long-term values. It means holding on to our thoughts and emotions lightly and shifting perspective as needed to effectively face the demands placed on us. 

Anna (name changed to preserve confidentiality) is a former psychotherapy client whose experience exemplifies a psychologically flexible response that combines the skillset of problem-solving and acceptance. During her pregnancy, Anna imagined that she would be able to nurse her baby for at least six months, just like her best friend did. She looked forward to the bond this would forge with her baby. Anna’s baby was born via an emergency cesarean section and from the beginning, she struggled to produce milk; additionally, her baby had many difficulties with nursing. Anna engaged in problem-solving strategies: she met with two lactation consultants, she spoke with her pediatrician, she attempted to pump and feed the baby from a bottle, but in the end she could not produce enough milk and her supply dried up. The baby required formula. Anna was understandably in touch with much sadness and anxiety as she engaged in all these efforts to salvage her ability to nurse. However, she simultaneously refused to give credence to thoughts that would at times show up in her mind and suggest that she was deficient, unfit to care for her baby, a bad mother. 

Instead of spending energy on worry and anxiety about breastfeeding that would take her out of the present moment with her baby, Anna asked herself: “What really matters to me?” and came to realize that while nursing was of great significance to her, the significance stemmed from the desire to be present to and care for her baby, and that there were many ways in which this desire could be fulfilled. This psychologically flexible response to a painful situation did not mean that Anna’s sadness at the loss of her dream immediately vanished, but it helped her handle the pain without making it worse. Equally importantly, Anna remained in touch with the only reality that afforded her a chance at being and feeling alive: the present moment. 

At Wildflower, psychotherapy with pregnant women always entails efforts to increase psychological flexibility. As women prepare their nurseries, we simultaneously encourage them to prepare their minds to respond flexibly and adaptively to changing demands placed upon them. Below are some skills and practices that we strive to add to the coping toolbox of every expectant and new parent.

Mindfulness: Learning to observe our minds at work

Mindfulness refers to the intentional practice of paying attention to the present moment in a nonjudgmental fashion. You do not need to subscribe to Buddhist or other Eastern philosophies to derive the benefit. Nor does this practice require that we become still and sit cross-legged on a pillow. Mindfulness is simply about attentional training: rather than being swayed by whatever thoughts show up in our minds, we learn to observe the mind’s processes in a slightly detached fashion, and then choose what we want to attend to. For example, a pregnant woman might be thinking about her baby’s impending arrival and be plagued by self-doubt and fear: “I can’t do this! What if I won’t be able to handle the sleepless nights? What if I develop postpartum depression?” Being mindful, she practices acknowledging the presence of these thoughts and brings acceptance to the experience of fear without judgment or further rumination. She makes the choice to notice the thoughts as just that – thoughts and not facts – and without needing for them to be gone, she shifts her attention to whatever she chose to be present to at this moment. Perhaps this means that rather than spending the evening lost in worry, she actually enjoys dinner with her partner. 

Through mindfulness practice, we become more accepting of whatever shows up in our minds without simultaneously engaging in a struggle with the mind’s content. Our judgments lose the power to affect our moods and actions although they may still be present. This is extremely helpful especially in the postpartum period when women are more vulnerable to negative self-talk in context of sleep deprivation and hormonal and psychosocial upheaval of this time. 

Holding expectations lightly

Our negative self-evaluations are like a fog that gets in the way of being able to see where we are going. The ability to observe our mind’s processes and not be derailed by the first emotionally-laden judgment or negative thought that shows up enables us to be more flexible in our choice of action in stressful situations. We get to deal with the situation directly, as it is. This is key in the initial postpartum months when our schedules, plans and expectations become easily, unexpectedly and often abruptly derailed.

A classic example: One of my former clients, Emma (name changed to preserve confidentiality), needed to go grocery shopping with her two month old. She hoped she could accomplish that in the morning. After that she wanted to do her laundry and her friend was planning to come over for lunch. At 8 am she started getting herself and the baby dressed. The baby nursed longer than expected and was inconsolable afterwards. Emma was getting frustrated. She needed to go shopping! She tried to get the baby to burp to see if that would help calm her down. It didn’t do much. Finally, the baby fell asleep in Emma’s arms. Every time Emma tried to transfer the baby to the stroller, the baby started crying but would fall asleep right away once Emma rocked her and allowed her to remain in her arms. So there they were, still in pajamas at 10:30am. 

There is such potential for frustrated struggle in this situation! At every turn, Emma’s expectations were disappointed. Emma kept needing to adjust. She noticed the mounting frustration and took a few deep breaths. She recognized the desire to stick to the plan and asked herself: “Given the situation, what is going to be effective?” She chose to accept that the morning was not going to go according to the plan. This in turn allowed her to relax and she problem-solved those aspects of the situation that could be dealt with. She called her friend from the couch and asked her to get a few necessary items from the store on her way over. She also decided she would try to go shopping later in the afternoon. 

Willingness

In order to do what Emma did, we first have to see clearly that the situation requires our flexibility, and we need to work with what we have got rather than what isn’t there. In other words, we need to cultivate willingness to experience whatever the reality is – and let go of rumination about what it should be, what is fair, what we would prefer, what someone else may be experiencing, etc. Importantly, this stance of willingness has nothing to do with resignation or defeat; it is a choice, a conscious, mindful decision to deal with the reality in front of so that we can remain in contact with what really matters. 

Focus on values  

When powerful emotions take over, everything may seem calamitous, black and white and final. We temporarily lose our ability to ascertain relative importance of a given issue. Reflecting on our core values, particularly when we are not feeling distressed, goes a long way towards preserving the ability to ground ourselves when presented with an emotionally challenging situation.

One of my clients shared with me the following experience that illustrates the power of remaining in touch with the bigger picture when the internal storm is raging. Denise (name changed to preserve confidentiality) is seven months pregnant. One day she had to stay at work late. She was utterly exhausted. As she drove home, she imagined how wonderful it would feel to relax in a bathtub, eat dinner prepared by her husband and look in on her peacefully sleeping toddler. She was horrified to discover that her daughter was not yet in pajamas at 9pm, her husband was shouting and the smell of burnt food filled the kitchen. A wave of anger and resentment washed over her and she was ready to yell, “You can never do anything right!” to her husband when she remembered to ask herself: “Does this really matter? What matters?” Warmth replaced anger as she recalled her earlier reflection on the value of spending time with her loved ones. She remembered she wanted her home to feel like an oasis – and while it certainly did not feel this way in this particular moment, she realized she had a choice: to contribute to the chaos already present or to act in service of the value of bringing peace to her home. She chose the latter so she took a few deep breaths, kissed her husband and little girl and proceeded to help her husband with their daughter’s bedtime routine. When that was done, the couple decided to let the kitchen dishes remain unwashed and ate cheese and ham sandwiches while sitting on the living room couch. 

Our values serve as a compass that guides us in difficult circumstances. They connect us with deeper, underlying meaning of everyday situations and interactions. We can never “accomplish” our values – instead, we are either acting in ways that are in service of values, thereby increasing sense of purpose and meaning in our lives or in ways that move us away from that very purpose and meaning. If we find ourselves making an “away” move from values, the mindfulness skills can help us notice that without becoming entangled in judgments and change our behavior so it better reflects the valued direction. 

Psychological flexibility in the perinatal period

Increasing our psychological flexibility during perinatal period is an important component of emotional self-care. To thrive in this tumultuous time, we need to practice responding to stressors like a suspension bridge does: by willingly flexing and swaying under various pressures. This very ability is what makes us more resilient. We can grow this important coping skillset before and during pregnancy by practicing mindfulness, learning to be flexible in our expectations, being willing to wholeheartedly work with unexpected outcomes instead of reacting rigidly and with resistance, and identifying what is truly important and meaningful to us.