Abstract:

Introduction and Background. Post-traumatic stress disorder (PTSD) is a major mental ailment in the realm of public health, prevalent in 8% of the Western world’s population and much more when including partial/subclinical PTSD. Studies of standard intervention methods indicate a certain degree of clinical effectuality, but the syndrome still poses a significant public health problem since no method has proven overwhelmingly effective. Postpartum post-traumatic stress disorder (PPPTSD) is a subset of PTSD. Although giving birth is a healthy part of the life cycle, it also risks the lives of mother and fetus. Childbirth trauma serves to describe objective medical events (Czarnocka & Slade, 2000; Fairbrother & Woody, 2007; Soderquist et al., 2009; Tomasis, 2014), for example: the type of birth – vaginal or assisted (vacuum or forceps), or C-section (elective or emergency). Childbirth trauma also encompasses subjective/psychological descriptions that are no less relevant – such as the mother’s feelings of loss of control or guilt; impersonal treatment or negative attitudes exhibited by the hospital staff; unacknowledged fears, questions or requests; insufficient information, privacy or respect; and unsatisfactory postnatal care or treatment (Czarnocka & Slade, 2000). The prevalence of full PPPTSD in the Western world is 1%-6%, whereas the rate of women suffering from partial PPPTSD is 8.3%-32%. There were 184,457 births in 2018 in Israel (Central Bureau of Statistics, 2018b), meaning that every year the number of women at risk of developing full PPPTSD ranged from 1,844 to 11,067 and partial PPPTSD from 15,310 to 59,026. The World Health Organization (WHO) published a position paper in 2012 identifying maternal mental health as a “world health priority,” due to the implications for those suffering from this syndrome in the context of various life cycles (psychological, functioning, family, social and other implications) (Vignato et al., 2017). Neuro-Linguistic Programming (NLP) is a unique intervention method that may be attributed as belonging to the cognitive-behavioral branch of therapy, operating within the overlap between neurological (N) processes, linguistic (L) processes and learned behavior patterns (P), to enable conceptual, cognitive and behavioral changes. Although the method has been in use since the 1970s and abundant testimonies indicate its effectiveness, little research has been done on the subject, particularly its value in treating PTSD. Since NLP activates cognitive and behavioral processes to change automatic responses (thoughts, emotions and behavior), this research studies the effect of an NLP protocol dedicated to treating women who developed PTSD after giving birth. The multifaceted effect includes the entire spectrum of PTSD expressions: “intrusion,” “avoidance,” “arousal” and “negative alterations in cognitions and mood” (as specified in DSM-5). The intervention effect also manifests in aspects of “post-traumatic growth” and “functioning in various life cycles,” e.g., career, parenting/motherhood, health, relationships, society and community.

Research Aims. This research was conducted to examine possibilities of employing an NLP protocol to treat PPPTSD, focusing on the experience and results of the therapy process. To this end, changes in the abovementioned post-traumatic symptoms were tested throughout and following the therapy. The therapy process was likewise evaluated by examining the women’s turning points throughout the treatment, the impact of the process on the various emotional and functioning aspects of the life cycle, and post-traumatic growth. Finally, the research studied how NLP skills and techniques affected the therapy experience and post-traumatic occurrences throughout and following the therapy sessions.

Research Method. The research was conducted in the mixed methods case study approach. Due to its focus on individual therapy, it has the character of a “case study” that deciphers personal actions and processes in diverse contexts, and it enables assessing how those change over time (Yosifon, 2001). The case study integrates qualitative and quantitative research methods in a mixed methodology format. Since each method serves as a prism of the other, they may be defined as being on the “integrative qualitative-quantitative spectrum” (Creswell et al., 2003). The research population included two groups. One group was composed of 15 women, all members of the Maccabi HMO in Israel, up to two years after giving birth and diagnosed with full or partial PPPTSD. These women were treated with a dedicated NLP protocol developed to treat PTSD. The protocol included the Swish patterns – Visual, Auditory and Kinesthetic, the Trauma Process and the Hero’s Journey Process. The second group consisted of the professional research staff: the diagnostic psychiatrist, the psychologist specializing in NLP and the research coordinator. The group of patients filled out three measurement questionnaires before, during and after the series of therapy sessions: one to assess PTSD, one on functioning and one on post-traumatic growth. All the patients also underwent semi-structured in-depth interviews following the therapy. The final four patients who joined the research gave their consent to have all their therapy sessions recorded. The second group, comprising the professional team, underwent semi-structured in-depth interviews regarding each of the patients, and also expressed their own insights, interpretations and overview.

Findings. The findings indicate the effectiveness of the NLP protocol for treating PPPTSD. The quantitative findings indicate improvement in each of the parameters studied. The level of general PTSD decreased, and improvement (decrease) was marked in each of the post-traumatic symptoms, i.e., “intrusion,” “avoidance,” “arousal” and “negative alterations in cognitions and mood.” These changes, as well as those reflecting level of functioning and post-traumatic growth, were all evident between the first, pre-treatment measurement and the third, post-treatment measurement. These findings were also found to comply with the plentiful qualitative information that was received. The qualitative part raised thoughts, opinions, emotions, feelings and interpretations in real time as the women dealt head-on, by means of NLP techniques and skills as detailed in the therapy protocol, with their difficult experience in giving birth and the ensuing PTSD. The patients’ descriptions and statements all indicate improvement and relief in post-traumatic symptoms, functioning and post-traumatic growth. These descriptions also draw attention to the use of the mechanisms of resilience, cognition, imagination, emotion and feeling in the therapy sessions, which places the therapy protocol firmly within the salutogenic orientation that focuses on health factors as opposed to risk factors (Antonovsky, 1998). It is also evident that the protocol under study helped impart a sense of control. Throughout the research stages the subjects increasingly became agents of change who exercised control over their renewed connection with family/societal support factors, in all aspects of attitudes and beliefs about self and world, and experienced restored feelings of capability and self-esteem. Thus the protocol successfully met the post-trauma therapy aims (Calhoun & Tedeschi, 2006; White, 2007), including improvement in responses to post-traumatic reminders, in the trauma memory and narrative, and in transitioning from limiting schemes/beliefs into empowering beliefs that support growth and change.

Conclusions and Recommendations. This is pioneering research in the field of PPPTSD intervention and treatment, particularly with regard to the NLP protocol for treating trauma. This study provides abundant evidence – from various perspectives – on difficult childbirth experiences, their effect on women in different life cycles, and the positive experience afforded by NLP treatment intervention. Evidence also arose concerning the achievement of the therapy goals, its effect on changing perception of the childbirth experience, and resulting changes in perceptions of life cycles, improved functioning and post-traumatic growth. The innovation and contribution of this research lies in a number of areas: (1) The NLP therapy protocol offers a goal-oriented therapy Consequently, it is highly recommended to integrate NLP techniques that target the component of depression as well; (4) The research process necessitated meetings with different personnel in the health system in addition to the sessions with the research population, resulting in unexpected insights concerning the childbirth experience and its many ramifications. One extremely meaningful insight was the understanding that post-traumatic stress following childbirth tends to go “under the radar” of the health system, receiving insufficient diagnostic or therapeutic attention (unlike postpartum depression). It is therefore essential to encourage the Israeli health system to enrich and increase the existing knowledge on this subject, understand its importance and proceed to create a mechanism expressly for identifying and treating PPPTSD.