Anyone knows what "anxiety management " entails for Tokophobia etc

[elizaregina]

I am about to start the process of requesting ELC and meeting consulant next week. I am wondering about this process of anxiety managment etc.

I wonder because if someone has had a normal labour like me, and still couldnt cope, doesnt want to do it again.....how can they calm my fears, about round two - when absoluty no one could guarantee that this time it wouldnt be even worse with all sorts of things happening.

I cant see any coping stragegies at all working for me, as every min of labour I will be thinking is this when X Y Or Z happens.

ie - if someone hasnt had vag labour - i can see how they may try and push counselling but if somone knows what its all about - had a so called " text book" birth etc....
what on earth will they try and do?

many thanks

I don't know Eliza.. how pregnant are you? I thought I was in the same boat as you at one point (although my first birth wasn't textbook, it had some minor complications that I blew up out of all proportion) but I suppose the key thing is your diagnosis here.

I thought I had secondary tokophobia. I worried as you, that because I had "been there, done that", my fear was patently "real" and that no amount of talking could shift it.

I understand that some people do, and maybe you are one of them, but it turns out I didn't. I had untreated PND and perinatal OCD that I thought was linked to the birth but have since realised really were not. At all. So my extreme panic and anxiety about birth which had me DESPERATE for a cs actually dissipated substantially once I realised that really my thoughts had a stranglehold over me yet did not even reflect my experience of birth or my thoughts about how birth could be. I was just in a tailspin. My anxiety was real but it was not actually provoked by childbirth per se, childbirth had become the focus for all my anxieties about EVERYTHING. Once I realised this (triggered mainly by the fact it looked like I WOULD get a cs and that it didn't actually release my fears at all), it suddenly became apparent that my fear, though huge, wasn't CAUSED by anything external to me. I was just afraid of a lot of things because I had a mental health condition causing me to seek risk in everything potentially adverse.

Basically, I had a history of a very chaotic, frightening childhood that meant that life experiences can provoke a massive flight-or-fight response in me which manifests as this panic/terror/obsession. Once I realised that, it actually really reduced how seriously I took the thoughts (but not entirely, I'm not going to pretend I had a Eureka moment... I have to work hard at this all the time to keep training my brain in new ways of thinking and responding).

Hypnobirthing has done a lot for me but I haven't delivered yet and still have another few weeks to go. I am not fear-free, I am still obsessive, but things are more manageable (in the main).

Sorry, posted too soon. I suppose what I am saying is, depending on how long you have, you may gain something by going to counselling and you have nothing to lose. If it turns out that you have tokophobia that doesn't respond to talking treatment, then you will get your cs... but you owe it to yourself to work out if it is actually birth or if there are other issues that you can deal with, because otherwise the fear may just move to something else after the birth and cause PND.

By the way, I would have SWORN blind I didn't have PND. Honestly. I thought how I felt after birth was normal... now I look back and am amazed!

I don't know the answer to your question, sorry, but would be interested to find out. I had a planned CS for my 1st after a diagnosis of primary tokophobia - the psychiatrist said (and everyone else agreed!) that given my levels of anxiety and the fact I was pregnant, counselling wasn't worth trying.

I did ask what it might have involved, and was told - a mix of talking about my fears to a counsellor, 'aversion therapy', where I would be exposed in a controlled way to increasing levels of 'birth' engagement - images of birth etc (which is weird, because seeing images of birth in a book when I was very young was part of the whole problem) - general techniques to manage anxiety, such as breathing, visualisation, self hypnosis if appropriate.

Now - I'm not a sceptic about this stuff, having had depression and counselling over the years which was very helpful for me. But I do know it's not a magic wand, and can be a long and winding road, so I get very frustrated when people pop up on threads and blithely advise people to 'get therapy' as if CBT or similar came with a guarantee on the tin. It's also asking a lot of any therapy to get you to a given point, which is where you need to be to give birth. Say someone has a phobia of spiders - it might take a lot of work to get them to the point where they could stay in the same room as a spider, and that would be a huge advance for them - but they still wouldn't be able to pick it up and give it a kiss!

Which was largely the issue for me and counselling/therapy. They couldn't see it getting me 'far enough' in time. I think too because it involved longstanding issues to do with sexual abuse as a child, it was a fairly complicated mess to unpick, IYSWIM.

One interesting thing about anxiety management is that it tends to assume that your anxiety is the problem, not the thing you are worried about. Sounds obvious, doesn't it - but to me, there's a world of difference between fear of birth and a fear of, say, buttons. Or worms. Buttons and worms are really not going to harm me. It's easy to see how that fear is irrational. But birth CAN be a risky, dangerous, damaging and painful process. I'm not saying that's ALL it is! Or trying to deny anyone's positive defintion of it! but I do see where you are coming from, I think, in terms of the things you fear still being possible.

Interestingly, in the letter my psychiatrist wrote to the consultant MW (the MW let me read it, otherwise I wouldn't have seen it), the psychiatrist mentioned the 'uncertain' outcome of birth as one of the reasons that counselling wouldn't be successful for me, and that ELCS was a preferable procedure. What I was told this meant was that if a VB went badly for me or my baby, then they were very concerned about the consequences for my mental health - essentially the strategy of 'try and calm yourself down and give VB a go' wasn't a sensible one.

It will be interesting to hear from people who have been through counselling for secondary tokophobia, esp if, like you, they had a 'normal' VB first time round.

PS ironically, I have used meditation techniques and breathing to manage general anxiety (successfully) for years, and it was really useful staying calm during my ELCS. However, I could not and still can't imagine using them to get me anywhere near a VB. Interesting that it can be so successful for me in one way and not in another.

Thanks Fruity Bread,

Your psychiatrist sounds very reasonable to me, its the uncertain outcome.... this is what I cant get my head round, if they send me for counselling.....whats the point no one can guarantee me a safe birth!

and also I am afraid of spiders, i like your point about fear of other stuff not actually hurting us but of course birth can or will.

Interview - yes get your point, but giving birth gave me more pain than I could manage or could manage again...so its not issues around it - or it could be along with the pain i felt and un certainty.

The more I see about this, the more I get the feeling that tokophobia as a fear just isn't understood and that there is an assumption that the fear is the same for everyone, rather than being very specific to each individual.

I have to say I find the idea of looking at images of birth to normalise them and make them seem less scary as pretty laughable. Mainly as its never bothered me and I don't have a problem with that. And lets face it, theres a world of difference between a straightforward VB and a operative VB. I'd doubt they'd be showing you the worse case outcomes going "its not that bad now is it?". I have to say, to a certain extent I find the approach disingenuous, slightly patronising and in certain cases more likely to cause even more distress than actually be of benefit.

I think its worth pointing out that the NICE guidelines on the subject are interesting in themselves. They say counselling should be offered, but they then go on to say they actually have no idea whatsoever what types of treatment would be successful and there was a desperate need for research on the subject to discover what actually does help.

What it means in effect is there is no type of counselling or treatment recommended in this country for tokaphobia. So anxiety counselling in one area could be wildly different in nature and quality from the next. (Not to mention that I've seen one Swedish study on the subject that actually showed the type of counselling they were trialling was actually shown to have no benefit to those women who had a fear of childbirth).

That said I do think that they need to try and offer the counselling as an option. As everyone is different and what might not work for one person, may well be ok for someone else and be great for them. But my key point here though is to offer, not force. Precisely because we don't have any idea whats going to help as there is no research out there currently that says "we understand the problem and this is a solution".

Personally the idea of being forced to go through counselling I find somewhat distressing in itself as I do find that its not listening to whats bothering me most and why I find the idea of a VB unacceptable in the first place. Not being listened to and my fears taken seriously are also a substantial part of my fear in themselves. Its about a trust and faith in being in control of the situation as much as I can and being treating as an individual rather than just another person in a factory conveyor belt. I don't believe counselling would rid me of what bothers me ultimately, and might actually make me more anxious in the long run as a result.

In that respect I agree with fruity about there being upside down thinking about anxiety and childbirth. The fact that birth is uncontrollable and unpredictable is more the problem for me, rather than the anxiety in itself. The anxiety just stems from that.

And even if I could manage my anxiety during the birth, would that necessarily leave me ok after the birth? Its not just about managing the fear during birth, but also about how you reflect on it afterwards. I do think that some people get through the experience, only for them to be hit with various feelings after the fact. Thats just as much of an issue. To just try and manage anxiety during the event seems to be missing a massive point in my mind.

I think this mystery and lack of knowledge of what treatments for tokaphobia might actually be, how the process works, the availability of them or whether they are compulsory is creating just another anxiety along the road. Not to mention the outrageous decision by some hospitals to completely ignore NICE guidelines in their infinite wisdom.

The sooner we have a better understanding of the subject and a range of options developed the better, but I do that ultimately involves getting rid of one size fits all policies and a culture of targets across the board. Its all very well monitoring CS rates etc to make sure they aren't being overused but if you aren't also monitoring rates of things like secondary tokaphobia too, its utter bullshit.

I know I was told by a leading psych that CBT can be difficult in pregnancy because of that uncertainty factor, because the fears aren't indisputable so I understand this.

I think that they will most likely grant your request for CS on MH grounds BUT you do have to jump through these hoops... and remember that there are many phobias that have a rational component e.g. fear of dying or loved ones dying, health phobias where there is a family history of a certain disease that may be genetic (say breast cancer etc).

I suppose what I am struck by is:

1. you have said you don't see the point as no one can guarantee you a safe birth
2. you really don't want to go to counselling to look at this.

In terms of 1) no one can guarantee anyone a safe birth ever to anyone. Many people aren't that concerned by this as we know but for those of us who have clinical level response to this fact of life there are a variety of ways in which we choose to deal with it... so I have 2 friends who had PTSD after birth and one chose ELCS and the other chose a home birth and both were the right choices for them, but they were both helped by counselling to get to the point of deciding the best course of action.

In terms of 2), I'm just wondering if there's anything about the idea of counselling for this that is uncomfortable or difficult for you or if you have bad experiences of counselling in the past or known people who have? Sometimes people can have "resistance" to the idea of therapy and it can occur for different people for different reasons and it may not apply to you, but my view would be that if you go and there is nothing to be gained from it, you can stop at any stage but it might be a useful thing to try?

There are definitely people whose issues won't be overcome within pregnancy or even ever who have these phobias. However, there are people who will. It sort of depends on what underpins it I suppose. My concern would be that if what they call "intolerance of uncertainty" underpins the phobia that it will transfer without treatment e.g. it could be that you get the CS and that's fine but then you start to fear e.g. your baby dying or someone molesting them or any one of another myriad of things that no one can guarantee you won't happen.

I say this as someone who started just where you are and have had CBT and Mindfulness therapy twice weekly as well as private hypnobirthing sessions since week 28 of this pregnancy and am just about holding myself afloat... and I don't yet know how I will be when I get closer to birth. It may yet be I should have stuck to an ELCS plan and all of this is nonsense, I'm just throwing thoughts out there that were helpful to me when others presented them when I was in your shoes? Hope that makes sense.

HmmmThinkingAboutIt, my experience of counselling was that the counsellor was VERY pro-CS from day one but through exploration I discovered that was not right for me. I don't think any good counsellor will force you into any one particular method of addressing it, they should just help you explore and investigate your own thinking about it so that you know definitively that the decision YOU make is one you have thought through and have confidence in your own decision.

Their job shouldn't be to sway you towards a vb or cs either way...

The pictures/images thing is exposure and response prevention and is an OCD treatment, so I guess if it does nothing for you, you can rule out or minimise the possibility of OCD being a root cause of the fear?

My understanding is that for tokophobia, just getting the CS seems to "resolve" the fear which would not be the case for OCD so it's just a way of exploring that. I could be wrong..

Interview

I think my fear is of being put through counselling by people who dont care about me but want to push me towards a vb coz of numbers. reading alot of stories on here i just have no trust in the health proffs.

i get your point and why it all worked for you - but i have been thru labour, i came relativly unscathed but i was in too much pain. i couldnt cope with it nor the other things, the worry going thru it.

I have had experinced two sudden close losses a while ago and am ok with all that.

Hmmthinking, thanks for the excellent points - very very useful!

All my friends had awful births I was the only one who had it OK! I just dont think i am going to be so lukcy next time...

I think this is part of my point though InterviewMad. That everyone is different, but ultimately with clear information about what counselling might involve and whats its aims were being "out there" would reduce anxiety about yet another thing rather than adding to it, which I happen to feel is now part of the process. And that does involve people not feeling pressured to go through counselling if they don't feel its going to be right for them, if that information was freely available. (Equally, it also means people being able to access it because they know its available and think they would benefit from it, rather than suffering in silence and then ending up with problems in the future.)

Atm I feel its difficult to achieve that, given the inconsistency and the resistance of certain Trusts in even recognising the mere existence of Tokophobia. That culture is unhelpful for everyone - whether they end up with a ELCS, a homebirth or anything else.

A do feel there is an underlying suspicion of counselling being created by that and there is a lack of faith in the way they will be treated and whether counselling is just a way of trying to change minds and persuade people into something they aren't comfortable with ultimately.

For example just yesterday there was a lady asking about why, when she had requested an ELCS she was still being referred to a VBAC clinic and then I felt that the OP was implying exactly the same with this thread (please correct me if I am wrong about this though!).

There needs to be mountains of effort and work done to redress this lack of trust tbh.

x cross with you eliza.

I am more than happy to go to the " counselling" appt with consultant, but I am very very wary.

I am afraid of being spoken "at" my fears not being taken serioulsy, and just having to go on the roundabout of rubbish until i get my ELC.

Ie a consultant will baffle me with medical terms, stats etc....that I wont be able to reply too but wont agree with and still want an ELC.

I may get lucky and feel listened too, but when consultants do have to keep CS quotas down, and think about budgets, i dont see how they will be able to give me a balanced view.

Really unless you go private how can you get a true view.

Eliza, you are most definitely not alone in feeling like this. Its a very sorry and sad state of affairs.

not sure what x cross means!

thanks for all points though, feel as though i need to go in very armed.
i am really hoping for a happy stressfree pregancy this time, and dont want it turned into nightmare ironically by health proffs.

i m more than happy to go for counselling but as said before i have been thru labour, if it went as well, it was too much and if its worse its far too much,

You are right about info. Obstetric consultant doesn't have skills to assess you or counsel you objectively but I was seen by Perinatal MH consultant at NHS Mother and Baby Unit and he actually took my concerns and medical nature of my mental health presentation very seriously, was primarily interested in gathering info to make a diagnosis vs what to do re birth. CBT and Mindfulness were both private and more inclined to spin it as less medical/more to do with past/more briefly treatable.. Felt no pressure from anyone or directiveness.. Even specialist mh midwife would have supported cs. I just decided not for me.

I meant crossed posted. (you posted at same time previously and said some of the stuff I thought you implied.)

Its awful how people feel this is a battle they have to go into armed before they even begin rather than feeling they can have an honest, open and supported discussion about the subject.

Good luck. Hope it goes well :)

Hmm' you make a very good point about mistrust of counselling - I think proper support and counselling could make a world of difference in various ways (as I said, I've had a fair bit of counselling for depression, and thank goodness) -

But it's clear birth phobias are not widely understood, attitudes towards them vary hugely, and if women see counselling as a disguised attempt to force them into an unwanted VB, then it's just not going to work.

The NICE guidelines do imply that a maternal request CS is something to be 'counselled away', to some degree. Woman asks for CS - is offered counselling - if after counselling she STILL wants one, she should have one.... Structurally it seems more like a hoop you have to jumo through to get a CS. And I know HCPs don't have to pay attention to NICE guidelines anyway.

FWIW, the psychiatric support I had when I was pregnant, once the CS had been agreed (around 20 something weeks) was very good - it just consisted of making sure I had someone I could talk to if I got very anxious, and talking about my triggers (the ones I knew about, anyway) meant they could advise staff and try and organise my care accordingly. I also got a very courteous follow-up appt to check for PND, which I didn't get, but it was nice of them to ask! So perinatal mental health support doesn't have to be just about trying to persuade women to have VBs....

Fruity, I'm very glad you lurk on these boards. Your experience is a really positive story of how it should be treated and I think its something thats needed. Its good to hear that there are good stories out there.

If only you were the norm, rather than it unfortunately seeming to be a complete lottery.

I hope Fruity my experience will be more like yours i will try and go in with an open attitude and hope for the best.

I think it is probably dependent on where perinatal mental health teams are more established, with things like Mother and Baby Units than anything. I have a birth care plan and will have a CPN come to check on me after birth, DH has unit's number and is to ring as soon as I have baby to trigger the move to postnatal services, if I appear to have any symptom exacerbation they will assess within 24 hours. And I have no prior mood disorder or anything like that...

I honestly don't see the counselling as a means to prevent VB's but as a means to establish they are necessary. They're not for every woman though they might be for many. I thought it would be for me but I really do believe that counselling revealed I had different needs. I think agreeing to counselling is a sign of your commitment to your own decision, if it is a true right decision for you counselling will only confirm that not change your mind. And all counselling should be patient-centred with no agenda, NHS counsellors shouldn't have any vested interest either way. It would be wrong if it were being provided by people with a vested interest in what happens with you obstetrically.

I have just read the blurb about this consultant, she runs a bereavment clinic as well as one for mothers who found the birth traumatic no matter what the outcome....so that sounds more hopeful in that it might be more balanced.....

we shall see! I have noticed though even some people who seem to be midwives come on and still push VB even when the op is in great distress and has lots of history or medical background to make vb even more stupid or scary!!

I had to go to see the consultant mw before my first ELCS was signed off. It ISN'T counselling. The NHS simply doesn't have the money or time to do this. It's just an appointment do they can cover themselves that you're making an informed decision if you're requesting CS. Dead straightforward, no argument, just lots of facts about the realities of section etc.