Maternal Mental Health: Working With Clients Experiencing Reproductive Trauma

Many of us initially think of infertility, miscarriage, or postpartum depression when considering reproductive trauma, though the term encompasses a diverse range of experiences that can have a profound and painful impact on physical and mental health and well-being. The ripple effects permeate other facets of life—a person’s identity, finances, family dynamics, relationships, and the ability to work or socialize, among others.

The Maternal Mental Health Leadership Alliance (MMHLA) reports that 75% of those with maternal mental health conditions do not receive the treatment they need, raising the risk of conditions such as anxiety, depression, and post-traumatic stress disorder (PTSD) for themselves and their families as well.

“Reproductive trauma exists across a wide spectrum,” says MJ Harford, NCC, LPC, owner of a private practice and founder of Resilient Returns in Arlington, Virginia. It can also stem from a loss of reproductive function; unexpected or unwanted outcomes in fertility preservation; complications with surrogacy or adoption; stillbirth; birth (perinatal) or pregnancy trauma; fetal abnormalities; and other causes, Harford says.

As she counsels individuals and families navigating these heartrending situations, she stresses that “it is extremely important for me to allow them to label their own experience. Some very comfortably use words like ‘trauma,’ while others prefer their own language.” Her clients span the continuum of these experiences.

“Some folks are coming at the beginning of their family-building process with a learned complication or early loss (“a child does not make a family; your family is as you define it,” she emphasizes). Others have wanted a child for years and are exploring treatment decision-making; some clients are on the other side of birth, contending with a traumatic pregnancy complication or postpartum experience; and others still are navigating the future of being child-free,” Harford says.

In session, clients may present with persistent sadness, anger, resentment, shame, apathy, depression, or anxiety. Thoughts may become obsessions or fixations, Harford says, along with social changes such as withdrawal and isolation; reduced energy levels; lack of motivation; disconnection from a sense of purpose or direction; and other feelings of distress.

Naturally, grief and loss are prevalent. “Loss of their previously known self, loss of a dream, loss of an expected future, loss of a child, loss across so many core domains of life,” Harford says, adding that “this grief is often ambiguous and disenfranchised: It lacks structure, it’s often silent and secret, and it’s part of a greater uncertainty (‘Will treatment ever work for me?’ ‘Will I have a healthy baby?’ ‘Will I ever have a child?’).”

There are many proven evidence-based methods and trainings for this work.

Specifically regarding perinatal clients, “Utilizing approaches like The Postpartum Stress Center’s Art of Holding Perinatal Women in Distress training [an NBCC Approved Continuing Education Provider] in addition to models like acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), and dialectical behavior therapy (DBT) can create a better-fit approach,” Harford says. “We want to utilize an evidence-based, integrative approach that incorporates both bottom-up and top-down models to facilitate a client’s safety and stabilization, organization, and integration.”

She shared her thoughts on how a bottom-up approach to care can be beneficial.

“You have clients who are often confronting a fundamental breach of relationship with their own bodies; the body becomes unreliable, unknown, and uncontrollable. In the therapy context, this type of betrayal requires us to facilitate safety, integration, and engagement with the body to engage in safe, effective counseling. Applying approaches like polyvagal theory . . . as well as sensorimotor approaches and EMDR can all be incredibly helpful.” Harford also appreciates the benefits of mindfulness in stress reduction and self-compassion.

As an ACT practitioner, she also begins by helping clients identify their values as part of a top-down model.

“They are another core anchor for the treatment process. With values in mind, we branch into the ACT process to support meaning-making and taking action. This helps a client do everything from identify, set, and maintain their healthy boundaries (inner and outer); engage in effective self-care and recovery; and advocate for themselves in all contexts, even to themselves.” 

Meaning-making is intended to convey that although these experiences are a part of the client, they do not define the person. “Evidence-based top-down approaches that support narrative and storytelling work and advocacy, or tap into altruism, are key components of recovery and post-traumatic growth.”

There are crucial factors counselors should consider when doing this work, Harford says.

“This area, reproduction, is already fraught with taboo, opinions, biases, and barriers to care. There can be so much shame—the shame of infertility, fetal abnormalities, pregnancy loss, and still birth: ‘Why can’t my body “work” like it's supposed to?’ or ‘Why couldn’t my body protect this baby?’ People are sold ideas and products around their fundamental control over fertility, which perpetuates the belief that if you just did the right things, this would not happen. We want to help our clients find a balance of positive influence over outcomes—a healthy level of agency, which builds resiliency, vs. the unhelpful and untrue belief that we have pure and total control over our ability to have a baby.”

Understanding your own reproductive story is essential, she says. Ask yourself “What beliefs and history surrounding reproductive health, family building, pregnancy, and parenting am I bringing into the room?”

Education is key. “You need at the very least a baseline knowledge of reproduction, reproductive health treatment, and the perinatal period. If you don’t know, don’t pretend to know! It’s OK and can be trust-building to acknowledge your gaps, ask questions, and circle back to the client when you have more information.”

Lastly, “Get consultation and be in the community,” Harford says. “This is hard but incredibly meaningful work. To show up regulated and whole with our clients, we have to be in connection ourselves. We also don’t always know what we don’t know, and having another set of trained, thoughtful ears on our cases is immensely helpful (not to mention ethical).” 

Family members and friends often don’t know how to support someone experiencing this trauma. Harford suggests “the Four A’s.”

• Acknowledge the reality. The reproductive trauma has happened/is happening. When we attempt to pretend everything is “normal” (avoid discussion at all costs, don’t inquire) or express only hope and positivity (“You’ll get your baby at the end of this! Everything will work out, and this will be but a distant memory”), we do not protect the individual, we isolate them, and often, even unintentionally shame them (“Your pain is too big, too awkward, too sad for me to deal with, so let me wrap it up in these other things instead.”). 

• Avoid “at leasts” and “shoulds.” “At least you know you can get pregnant!” “At least now you’ll never have to worry about paying for daycare,” “You should really try this supplement,” “You should really see this doctor,” and similar comments. 

• Ask, don’t assume. Let the person you love, you work with, you know, be in the lead. This means asking things like “I’d like to check in with you about what’s been going on; would that be OK with you?” before sending a detailed follow-up. Or check in with “Is it OK for me to share a doctor who helped me when I was struggling with [a similar experience]?” before you share a referral.
• Accept. Their process might be different than what you would do—different feelings, choices, boundaries, you name it. It can be so hard to see someone we love struggling, but sometimes our anxiety about their pain can lead us into some pretty unhelpful actions.

For counselors and their clients, she also recommends the following resources:

• Return to Zero (RTZ Hope), a national nonprofit support organization
• Janet Jaffee, PhD’s work on reproductive trauma (books, textbooks, trainings)
• The work of Sharon Covington
• American Society for Reproductive Medicine’s (ASRM) Mental Health Professionals Group
• Center for Reproductive Psychology
• Postpartum Support International (PSI)
• The Postpartum Stress Center
• CarryMe Health, a network for supporting families facing fetal abnormalities, pregnancy loss, and still birth 

In closing, Harford emphasizes that small, intentional details in session can have powerful, lasting effects.

“I feel so passionate about the little things being the big things with our clients, like using their stillborn child’s name; maintaining open, calm body language during a client’s sharing of loss or emotional expression; and not shying away from talking about the taboo elements of reproductive trauma like sex and envy. Their experience isn’t one we’re scared of or put off by; they aren’t someone we are afraid of; and they are not ‘other-than.’ It is amazing to engage in what I know to be small acts of validation and to see their profound impact,” she says. “It gives me so much hope throughout the treatment process that simply by connecting with who and what is in front of us, we can make lasting change for our clients.”

MJ Harford owns a private practice in the Washington, D.C., metro area and provides individual counseling services to people navigating the perinatal period and chronic illness. Harford has advanced training in perinatal mental health, trauma-informed treatment, polyvagal theory, and acceptance and commitment therapy. In addition to her counseling work, she launched Resilient Returns, a parental leave support platform that empowers both parents and businesses with compassionate, structured, and measurable support to navigate the critical back-to-work transition.

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.