The period following childbirth represents a very delicate phase of settling and redefinition of personal and relational identity for new mothers.
As Kristi Sawyer wrote in her blog, ‘matrescence’, the time of ‘mother-becoming’ is a critical transition period involving shifts in hormones and identity, during which we often expect women to be happy and excited for the upcoming arrival.
The experience of childbirth has a positive connotation, but at the same time it contains elements of concern.
Many women, when they are about to give birth, experience a strange mix of feelings: joy — because it is generating a life — but at the same time distress, fear, pain and threat.
When these two groups of emotions coexist, there is a tendency to only show positive emotions, and to feel ashamed of showing the negative emotions and talking about the negative aspects of childbirth, also because of the social and cultural pressure.
The negative aspects related to the experience of childbirth should be recognised by the women, in terms of both remembering, and talking about this aspect of the experience.
Instead, memories are pushed back and ignored, and the mother is unable to translate the traumatic and negative experience into words.
And when these experiences don’t find a way to express themselves in words they can cause emotional difficulties. Generally, the postpartum period is a critical and vulnerable phase, in which the risk of postnatal depression and post-traumatic stress disorder (PTSD) is very high.
It is often thought that only women experiencing complicated childbirth (prematurity, or other health problems in mother and/or the child), can be affected by PTSD. However, this is not always the case: new mothers with normal childbirth, can experience symptoms of PTSD, even in the absence of psychopathological risk factors or complications.
Recent studies in post-partum PTSD have shown that childbirth is a stressful and traumatic event per se, not only due to the physical pain, anxiety, fears, worries and uncertainties associated with childbirth, but also because the negative aspects of childbirth are not mentally processed as a social and personal experience: they are not verbalized, nor verbalizable.
The personal, social, and family beliefs around childbirth, often conveyed by narrative on maternity, lead mothers to openly express only the positive aspects of childbirth — not the negative.
The Expressive Writing paradigm:
As I have said, new mothers may tend to avoid communicating and elaborating on negative effects and thoughts related to childbirth, because of personal, social, and family beliefs, often conveyed by the general shared view on maternity, which could lead them to express only the positive aspects of childbirth.
Doctor James W. Pennebaker, an American social psychologist, clearly defines avoidance as central symptom of PTSD, and underlines how negative or upsetting events that are kept secret or silent are more likely to result in health problems. According to inhibitory theory, the failure to express emotions and traumatic experiences affects physical and psychological health negatively.
People usually try to avoid or inhibit depression symptoms, frightening thoughts and flash backs, sleep problems, and other posttraumatic symptoms induced by stressful and traumatic experiences. The efforts spent to avoid these unexpressed thoughts and feelings may increase psychological distress and psychosomatic symptoms.
Instead, negative thoughts and emotions should be spoken about more openly. Even better is to express negative thoughts and emotions in writing, which demands more integration and structure than spoken language.
Bringing out emotions and thoughts through writing can deactivate avoidance mechanism and enable the elaboration of distress. Expressive writing thus helps emotional regulation and promotes a new stronger sense of efficacy and mastery.
The expressive writing is a form of writing therapy developed primarily by Doctor Pennebaker in the late 1980s. The seminal expressive writing study instructed participants in the experimental group to write about a ‘past trauma’, expressing their very deepest thoughts and feelings surrounding it. In contrast, control participants were asked to write as objectively and factually as possible about neutral topics (e.g. a particular room or their plans for the day), without revealing their emotions or opinions.
People in the experimental group, as compared with controls, were shown to have reductions in negative effects of stress and made significantly fewer visits to a physician in the following months, demonstrating the value of expressive writing. Furthermore, other studies have shown that expressive writing may have the potential to actually provide a ‘boost’ to the immune system, perhaps explaining the reduction in physician visits.
The importance of avoidance symptoms in PTSD following childbirth has been supported by various studies, showing for example that negative subjective childbirth experiences lead to avoidance symptoms and psychological maladjustment, and even to a clear PTSD diagnosis in the first year following childbirth.
How did I know about Expressive Writing?
Many variations of the expressive writing procedure have been implemented, all similarly showing that it benefits a significant proportion of those who participate.
I would like to talk about a particular research study that one of my psychology teachers, Professor Paola Di Blasio, presented during her teaching for my Masters Degree in Developmental Psychology in Milan.
The study investigated whether an expressive writing intervention decreases depression and posttraumatic stress symptoms after childbirth.
113 women were recruited when pregnant with their first child and then randomized to either expressive writing or to neutral writing. For the expressive writing, they were asked to write about ‘their deepest thoughts and feelings experienced during labour and childbirth’, while for neutral writing, they were asked to write about ‘what you have done and what has happened in the days of and after childbirth’. Women were assessed in the first few days after child birth, and again after 3 months.
The study showed that, after 3 months, PTSD and depressive symptoms were lower in women who had performed the expressive writing task compared with those who had not.
Interestingly, the writing intervention reduced PTSD symptoms in all mothers, even those with minimal initial symptoms.
This was the first study to indicate that expressive writing can be a helpful, low-cost, early universal intervention to prevent postpartum distress for women.
Moreover, this evidence is consistent with the experience of women described in our previous blog on the ‘Maternal Journal’, a group-based intervention also aimed at using journaling as a path to prevention of, or recovery from, mental distress in the perinatal period.
All together, these activities point to the powerful effects of writing about the emotions of childbirth as a tool to promote mental wellbeing, either as private experience or as part of a group, based on women’s preferences.
The message is always the same: do not avoid negative emotions and thoughts, instead, share them with yourself and others.