Copyright (c) Donald Robertson, 2010. All rights reserved.
This article is just a draft containing some personal observations about the potential for applying evidence-based cognitive-behavioural techniques to childbirth. This approach has been used for stressful situations such as coping with surgery or chronic illness, and public speaking anxiety, exam nerves, military training, etc. It provides a flexible framework based on a large volume of research on stress and coping, which should be well-suited to the problems of childbirth. However, the first point I would make is that some of the terminology used below would normally be adapted, e.g., when applied to sportsmen terms like “mental toughness” have been used to replace “coping with stress”, etc., and that flexibility in the way things are presented is of fundamental and explicit importance to the approach under consideration.
Stress Inoculation Training (SIT) is a form of cognitive-behavioural therapy (CBT) that developed in the 1970s, as the direct result of an ongoing programme of research by Donald Meichenbaum and others. Meichenbaum , whose work in this area is highly-regarded, was particularly interested in the way people use self-talk (internal dialogue) to manage their own behaviour and emotions. One of his first major insights was the simple, but extremely important, observation that internal dialogue can be studied experimentally by asking people to “talk aloud” while they perform some challenging or stressful task. He realised that self-talk could be more easily modified this way, particularly when people are given the chance to “model” other people, or sometimes a therapist, who can demonstrate more helpful (adaptive) forms of self-talk during the same tasks. (For therapists: SIT is a form of CBT which places more emphasis on coping skills training compared to Beck or Ellis' emphasis on cognitive restructuring.)
Meichenbaum and other researchers became particularly interested in tasks that were demanding because they involved tolerating stress, anxiety, or pain. As a result, Meichenbaum developed a general-purpose, flexible framework for training people in self-instruction and a variety of other coping strategies, called Stress Inoculation Training (SIT). The term “inoculation” refers to the basic treatment rationale, which is that individuals might become “inoculated” or (partially) “immunised” against stress by rehearsing the use of individually-tailored coping skills while confronting a range of different stressful situations, difficult enough to present a challenge but not threatening enough to be overwhelming. The emphasis in Stress Inoculation Training is upon flexibility and adapting the approach to the individual needs and preferences of the client and the demands of their particular situation. This flexible approach in which a “cafeteria” or “menu” of possible coping skills are offered from which the client may choose is based on the overall finding from basic research on stress and coping, which shows that the effectiveness of different ways of coping varies considerably depending on the individual, their circumstances, and the stage of the problem being faced.
Despite the diverse range of problems and client groups that it's been used with, I'm not aware of Stress Inoculation Training having been specifically applied to the problem of coping with stress and pain in relation to childbirth. However, childbirth undoubtedly provides a perfect example of the kind of situation the model is designed for. In this short article, I can only provide a brief outline of what SIT for childbirth might look like. The first point to make is very simply that most existing natural childbirth methods involve a prescriptive approach to training in coping skills. SIT evolved as a broader and more flexible framework for delivering the same skills and strategies. That kind of flexibility is particularly relevant to the specific problems of childbirth, which surely vary considerably. SIT is also designed to increase the sense of empowerment of the individual, by giving them more choice over their coping strategies, because “coping flexibility” and an increased sense of personal control over the situation is known to reduce anxiety. It's worth mentioning that the most common coping strategies used in existing natural childbirth methods are also especially common in typical SIT approaches, i.e., relaxation techniques, mental imagery, breathing exercises, etc. Whereas existing methods tend to favour “positive thinking” (affirmations), however, Meichenbaum and others have questioned the effectiveness of this approach, based on specific research findings, and greater support has been found for modification of underlying beliefs or the use of “self-instructions” of the kind discussed below.
The overall structure of SIT consists of three stages or phases of training, which occur in the following sequence,
1. Education & Conceptualisation of the Problem
This has been found particularly important in previous approaches to natural childbirth. Adapted for childbirth, this stage of SIT would require the woman to keep a written record of any distress experienced between sessions, e.g., worrying about the birth, etc. This would normally consist in writing down the time/date and a brief description of the situation, then the specific thoughts and images (cognition), feelings (bodily sensations or emotions), and actions (things said or done). This is done to raise awareness of typical trigger situations or events and typical patterns of response, including thoughts, actions, and feelings. Spotting patterns makes it easier to anticipate when they will next occur and break the chain of responses at an early stage, to prevent distress escalating. It also allows common themes to be identified in the spontaneous thoughts or images experienced during periods of distress. This approach may help with anticipatory anxiety, etc., but because childbirth obviously isn’t a weekly occurrence in the life of the individual woman an alternative approach might be preferable, which focuses more on assessment of anticipated problems. This might involve mentally rehearsing different stages or aspects of the experience of labour, while reporting thoughts, actions, feelings, sensations, etc., that might need to be addressed.
“Conceptualisation” of a problem basically means identifying what's going on, why the problem is a problem, and how it works. Grantly Dick-Read's “Fear-Tension-Pain” cycle, which suggests that fear of childbirth causes muscular tension which increases pain and creates more fear, in a circular manner, is an example of a very simple conceptualisation model. Modern cognitive-behavioural conceptualisations of stress, anxiety, or pain, could also be applied to childbirth, with some modification. Coping skills, especially self-instructions, are tailored to counter the specific patterns of difficulty identified, based on the conceptualisation of the problem adopted.
2. Coping Skills Training
As in existing natural childbirth methods, coping skills are taught and rehearsed, sometimes in a group or workshop, before being applied to real situations. However, in more general terms, research on stress currently distinguishes between four broad categories of coping, which include,
- Planning and practical problem-solving
- Focusing on managing emotions directly through distraction, suppression, venting, etc.
- Seeking support from others, such as family, friends, community, or experts
- Trying to re-evaluate the situation more constructively, find meaning in it, or adopt an alternative perspective on things
Emotion-focused coping, which tries to directly quell distress, such as distraction or “positive thinking”, is sometimes problematic, except as a short-term solution, if it prevents changes to patterns of behaviour or underlying beliefs. Different types of coping should be considered. Moreover, the client is normally given examples of typical strategies that other people have reported to be helpful in coping with similar situations. The specific techniques used are selected on an individual basis and then tailored or adapted to suit the specific needs of the current situation. For example, with childbirth, one or more of the following coping strategies might be rehearsed,
- Relaxation, which can involve muscular tension-release methods, breathing, mental imagery, or meditation, etc.
- Imagery, there are reasons to believe that “coping imagery”, where people picture becoming distressed or experiencing setbacks, and recovering from them, is more effective than more idealistic “mastery imagery”, which involves picturing being perfectly calm, etc., and free from problems
- Self-talk, there are reasons to believe that coping statements and other forms of self-instruction are more reliable than “positive thinking”, etc.
- Problem-solving, in which problems of all kinds can be identified, prioritised, and systematically addressed at a practical level, by brainstorming alternative solutions, weighing-up consequences, developing action plans, etc.
- Assertiveness, communication, and other social skills, e.g., some women may need to improve communication with their partner or family or to be more assertive with medical practitioners responsible for planning or delivering care
A common theme in Stress Inoculation Training is that the incorporation of verbal self-instructions has been found to improve the benefits of most other coping strategies, and to make learning them easier. Different forms of SIT, for different types of problem, normally help clients to distinguish between four main phases of the coping response: preparation, confrontation, coping with setbacks, and subsequent reflection or reinforcement. Basic research on stress tends to show that people benefit from different ways of coping at different stages in their encounter with stressful situations. Childbirth provides a very clear example of a potentially stressful or “challenging” situation, one that imposes certain demands, and which involves different chronological stages of coping.
- Preparation for childbirth lasts a long time, compared to most other stressful situations. You've got roughly nine months to think about how you're going to cope. During that period, anticipation (prospective coping) of childbirth may involve worry and other problems that need to be coped with, as well as the demands of preparing for the birth itself. At this stage, replacing worry with constructive preparation and problem-solving, is perhaps the main challenge. Example self-instructions: “What is it you have to do? Develop a plan. Focus on the steps you need to take. Replace worry with problem-solving. There are lots of ways to cope.”
- Confrontation of the stressful situation, i.e., actually going into labour, constitutes a different stage of coping, and imposes different demands from the “preparation” stage of pregnancy. I would say that existing approaches to natural childbirth focus disproportionately on this phase, to the relative neglect of the others stages of coping. Coping skills like relaxation, distraction, support from others, and the use of coping statements and self-instructions (or affirmations) can be used. Examples: “I can do this. This is what I've been preparing for. I'm in control. One step at a time. Relax and breathe normally. Use what you've learned. Tension is just my cue to use relax how I was taught.”
- Critical moments, are the particularly difficult or challenging incidents, potential setbacks, which might make you want to “give up”, or feel overwhelmed. In childbirth, these obviously correspond to specific challenges such as painful contractions, or the introduction of unexpected medical interventions, etc. Failure to prepare for difficulty tends to leave people vulnerable to “relapse” or in this case, to feeling overwhelmed, “giving up”, and seeking pharmaceutical pain relief as an alternative to more natural methods, etc. Coping strategies and self-instructions usually need to be adapted for these critical moments, something which doesn't seem to be well addressed in existing natural childbirth methods. For example, in some cases distraction may become more suitable (adaptive) than relaxation techniques, self-talk should focus on motivation and emphasise the temporary nature of certain feelings of pain or discomfort, etc. Examples: “When pain comes just pause and do what you've been practising. It's just my cue to cope and use my techniques. It's temporary, just need to cope for a few moments. Don't try to eliminate pain, just cope better with it. I've got lots of other skills and strategies, I can switch to another one if I need to try something else.”
- Reflection and reinforcement, usually refers to what happens afterwards, once the baby has been born and the major challenges of childbirth are over. Coping strategies are typically replaced with evaluation and interpretation of events. During this period, it is common for people who have set high standards for coping to engage in prolonged rumination or self-criticism if things didn't “go as they planned”, and this is perhaps relevant also to childbirth. Reflection (retrospective coping) should normally focus on deliberate self-praise, and other forms of self-reward, for efforts made, rather than outcomes achieved, and deliberate focus on positive aspects of the experience and constructive learning. Examples: “You did it! You can be proud of yourself. Not everything was under your control but you did your best. Focus on the positive parts. What have I learned? What do I need to remember and take from this experience?”
3. Application & Maintenance
Once coping skills and self-statements have been chosen and adapted to the needs of the client and the different stages of childbirth, as described above, they normally need to be practised. Research on SIT and similar methods has consistently shown that coping skills are more effective when repeatedly “applied” to progressively more difficult situations. This stage is largely omitted from existing natural childbirth methods, however – something that basically flies in the face of research evidence and clinical wisdom from other branches of stress research and psychological therapy. One reason for this is that there perhaps doesn't seem to be much opportunity for pregnant women to practice the coping skills designed for the period of labour itself. However, if you don't practice skills they become rusty and you tend to forget them. They also don't become very well-learned to begin with unless applied somehow to challenging situations. There are probably several easy solutions to this, though.
- The skills learned should be presented as capable of being applied to a wide range of other issues, i.e., daily hassles, problems sleeping, anticipatory worry, etc.
- Opportunities to apply coping skills to a wide range of other situations should be seized upon
- The experience of childbirth should be mentally rehearsed, ideally on regular basis, with rehearsal of coping skills
- Mental rehearsal is known to generally be more effective if it involves evoking mild-moderate amounts of anxiety, which coping skills can then be used to manage
In other words, rehearsal of coping strategies normally takes place on a daily basis in other forms of stress inoculation, and involves progressively more “challenging” tasks or situations, which put coping skills to the test and allow them to grow stronger. In the same way that “inoculation” with a vaccine can strengthen the body’s immune system response, the notion is that practice at facing mildly painful or anxiety-provoking events provides a way to strengthen psychological resilience to stress by improving coping skills and self-confidence.