Eenie Meanie Miney Moe, Catch a Therapy by the Toe
Therapy approaches for fertility, postpartum, pregnancy loss, and perinatal mental health.
bethsiller.com
A Story That Could Be Any Mother’s, this blog is a work of fiction. Names, characters, businesses, places, events, and incidents are either the product of the author's imagination or used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.
A plain-language guide to therapeutic approaches for fertility, postpartum, pregnancy loss, and perinatal mental health.
Finding a therapist that is the best fit for you can feel like a home renovation. There are so many options to choose from, decisions to make and questions to ask: "Do I want virtual, in-person or hybrid?" "Is individual therapy what I'm needing right now or would couples therapy be more useful?" "Would group therapy be too overwhelming?"
There are more therapy approaches than doorknob styles or paint shades. Okay, maybe not that many, but it can feel that way when doing your research. Some therapists have specific modalities while others may use a more integrative or eclectic approach and borrow skills and techniques from multiple theories. Either way, if you're not vibing with the style or approach your therapist uses, it may not be as effective as something that truly resonates with you.
Perinatal mental health is the house with "good bones" that you are hoping to flip. But where do you (the home owner) and your therapist (HGTV host) begin the show? With so many doors, walls, windows and levels within the home, how can you possibly know the next best step?
Just like you can learn the difference between mid century modern and boho aesthetics, you can learn about the various therapies out there and which one might just feel like home.
Grief is so deeply embedded in fertility, pregnancy, postpartum, parenthood and relationships. The arrival of one thing can sometimes mean the departure of another. Loss can present itself in more forms than a shapeshifter. We may find ourselves carrying feelings and beliefs without knowing how they got there because the grief hasn't surfaced yet.
Grief work can live in each of the therapies we'll address, just as it would a house. It may live in the basement, the attic or even the crawl space. When you think of grief, do you view it as mold that may be discovered during inspection that needs to be removed? Is it an old piece of furniture that might not function as it's intended to, but makes the room feel complete?
In your hand is a key. By using it to try and open the different doors in the house, you can find out which locks it opens, what other keys you need on your key chain. So which lock do you want to try the key on first?
CBT Cognitive Behavioral Therapy
CBT is one of the most researched and widely used therapeutic approaches in the world. There are many resources available, such as workbooks, videos, and books that use this framework. CBT has strong evidence specifically for perinatal mental health. The core idea is simple, which is why CBT and variations of CBT are used with children as young as 3 years old, all the way up to older adults. The introduction to CBT begins with a triangle that has arrows going clockwise. The three points on the triangle represent our thoughts, feelings, and behaviors and how they are connected. When we change our unhelpful patterns or thoughts it can change our feelings and therefore lead us to choose a more helpful alternative behavior. One area creates change in the others, and this triangle can apply universally to many different situations.
In the perinatal context, CBT helps you identify any unhelpful thought patterns that could be intensifying your current symptoms. The catastrophizing about another failed cycle (anticipatory anxiety a.k.a. “future tripping”). The all-or-nothing thinking about what makes you a competent parent. The self-blame and labeling that arrives after a loss. The mindreading (assuming what people are thinking without any evidence) that the other mothers are judging you and think you look like a mess. CBT does not tell you to think positively. It teaches you to think accurately. Your thoughts and feelings can be valid; however, validity doesn’t equal accuracy.
You have already seen CBT in action in this blog. The “checking the facts for evidence” process in the postpartum rage post, the Heaven's Reward Fallacy work in the previous post, the cognitive distortions framework, those are all part of the CBT family. It’s the therapy equivalent of zooming out so you can see the full picture with more clarity. CBT invites balance to any skewed thoughts or beliefs that might be holding you back in different areas of your life.
A 2022 meta-analysis published in the Journal of Affective Disorders reviewed 79 randomized controlled trials and found that CBT was effective for perinatal maternal depression and anxiety in both the short and long term. A separate systematic review found CBT to be one of the most effective non-pharmacological treatments for perinatal depression. CBT has also been studied specifically for pregnancy loss, with evidence supporting its use for grief, depression, and anxiety following miscarriage and perinatal bereavement.
CPT Cognitive Processing Therapy
CPT was originally developed for PTSD and it is particularly well suited for experiences that live at the intersection of trauma and meaning-making. If you have been through a traumatic birth, a pregnancy loss, a medical experience that felt violating, repeated IVF failures that shook your fundamental beliefs about the world, CPT may be a good fit for your treatment. CPT allows the healing to take place, using a “Top Down” approach, meaning you work on the thoughts about the trauma, rather than reliving the event(s) through talking about it in detail. This approach can begin at any stage in recovery. This makes it different from some of the other trauma-focused modalities where there may be certain requirements prior to treatment which makes CPT more accessible for those who want to start trauma work right away.
CPT works with what are called stuck points: the beliefs about yourself, others, and the world that the trauma has distorted and rewired. “Things like this happened because God doesn’t think I’m good enough to be a mother.” “My body betrayed me and I will never be able to trust it again.” “If I let myself grieve fully I will not be able to function and they’ll hospitalize me.” CPT helps you examine those stuck points, understand where they came from, and develop more accurate and less damaging ways of understanding what happened.
It is structured and relatively short-term, typically twelve sessions, which makes it realistic to those with even the most jam-packed schedules. Remember, CPT does not require you to retell the story of the trauma in graphic detail. I mention this again because the fear of revisiting the hardest and most painful events of your life can be a deterrent for working on your trauma. Those who have been through prolonged or repeated difficult experiences may feel like they are beyond help and that is just not true. CPT is evidence-based and highly effective.
Research published in ScienceDirect found initial support for CPT as an effective treatment for childbirth-related PTSD, with one case study showing a significant reduction in PTSD symptoms over a 14-session course. A 2023 study in The Cognitive Behaviour Therapist outlined clinical considerations for applying cognitive therapy to PTSD following birth trauma and baby loss, noting the importance of addressing distorted meanings and updating trauma memories. CPT was originally developed by Dr. Patricia Resick and is considered a gold-standard evidence-based treatment for PTSD.
ACT Acceptance and Commitment Therapy
ACT is the therapy for the person who has been told to be positive, practice gratitude, and take some deep breaths. On the inside, this person is visualizing throat-punching everyone while screaming into a pillow in their closet, all while feeling like a terrible person for feeling this way. ACT does not ask you to think differently about your pain. It asks you to change your relationship with it and lean into your pain rather than using avoidance and denial to cope.
The core of ACT is psychological flexibility: the ability to be present with difficult thoughts and feelings without letting them “drive the bus.” In fertility and loss work specifically, ACT helps with the particular anguish and despair of outcomes you cannot control. You cannot make an embryo implant successfully. You cannot undo a loss. You cannot make your body do what you need it to do by wanting it hard enough, praying, or following a certain protocol. ACT will not bull shit you. Instead, it asks: given that this is the reality, what do you want your life to be about? What matters most to you? What actions are consistent with your values even in the middle of this?
It also works meaningfully with the grief that doesn’t quite have a name. The loss of the family you imagined riding your bikes to Coffee Bean on San Vicente. The loss of the timeline you planned around (being married at 26 and pregnant by 28 with your first of 3). The loss of the version of yourself who did not have to go through this. ACT makes room for all of it without requiring you to fix it first.
A systematic review published in Current Psychology found ACT outcomes in the context of infertility to be positive, with evidence supporting its use for reducing distress and improving psychological flexibility in individuals navigating fertility treatment. Research from the Seleni Institute notes that ACT and mindfulness-based interventions show positive results in perinatal populations and have been increasingly studied for both fertility and postpartum applications.
IFS Internal Family Systems
We are all a part of a system. In fact, we exist within a surmountable list of systems, between our work, family, social life, etc. Internal Family Systems is the system that lives within each of us. A big part of IFS is Parts Work (see what I did there?) If you have ever said to yourself, “I know I should feel grateful but part of me is still so angry.”, you already understand the basic premise. IFS operates from the idea that the mind is naturally composed of multiple parts, each with its own perspective and protective role (job), and that healing happens when those parts are understood and integrated by the core part (The Self),rather than suppressed or shamed parts (wounded exiles).
In perinatal mental health, IFS is particularly powerful for the internal conflict that does not resolve through logic. The part that loves your baby completely and the part that mourns the life you had before. The part that feels so lucky for the one embryo that worked and the part that is devastated by the ones that didn't. The part that is doing everything right as a mother and the part that is running on empty and quietly furious. IFS says all of those parts are valid. None of them needs to be eliminated. They need to be heard and spoken with.
It is also deeply useful for the inner critic (unhelpful negative thoughts), that voice that shows up in postpartum and says you are failing at parenthood, you are not doing enough or you’re doing too much, you should be feeling blissful and not so irritable. IFS asks: where did that part come from? How old is that part? Where does that part live? What is it trying to protect you from? What job did it wrongfully assign itself? What does it need to know in order to feel heard and trust the Self part to take over?
IFS was developed by Dr. Richard Schwartz and has been applied across trauma, anxiety, depression, and relational issues. While large randomized controlled trials specifically in perinatal populations are still limited, IFS is widely used by perinatal mental health specialists and is listed as a modality by providers in the Postpartum Support International directory. Research on IFS in trauma treatment shows promising results for reducing symptoms and increasing self-compassion.
DBT Dialectical Behavior Therapy
DBT is the therapy built on the premise that two things can be true at the same time. That is its entire philosophical foundation and it is also, coincidentally, the most accurate description of the emotional experience of fertility, loss, and new parenthood that I know of.
You can be devastated by a loss and grateful for what you have. You can love your baby completely and find postpartum to be brutally hard. You can be doing everything right as a parent and still feel like you are drowning. DBT calls this dialectical thinking and it teaches specific skills for holding those contradictions without being destroyed by them.
DBT has four skill areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. In the perinatal context, all four are relevant. Mindfulness for the anxiety that pulls you out of the present moment. Distress tolerance for the moments that feel impossible and unbearable. Emotion regulation for the postpartum rage, grief and daily overwhelm. Interpersonal effectiveness for the relationships that have changed drastically since you’ve entered this new chapter of life.
DBT was originally developed by Dr. Marsha Linehan. The University of North Carolina Center for Women's Mood Disorders specifically applies DBT to perinatal populations including pregnant and postpartum individuals and those who have experienced pregnancy loss. Research supports DBT's effectiveness for individuals with trauma histories, intense emotional experiences, and multiple concurrent stressors, all of which describe the perinatal experience for many people.
Somatic Therapy Body-Based Approaches
Somatic therapy starts from the premise that trauma and grief do not only live in the mind, they exist in both the mind and body. This theory is also referred to as a “bottom up” therapy approach. The tightness in the chest when you open a pregnancy app or see a pregnant woman in Whole Foods. The shortness of breath when someone asks if you are planning to have more kids. The way your shoulders are permanently somewhere near your ears during a two week wait as if you’re wearing a tightened corset while walking down a dark alley, hearing footsteps behind you from a hooded figure. The body keeps the score even when the mind has done all the cognitive work it knows how to do. What the mind knows logically isn’t real, the body experiences it as fact. This kind of trauma in the body can also time travel and doesn’t understand time.
Somatic approaches vary widely. Somatic experiencing, developed by Dr. Peter Levine, works with the nervous system's incomplete responses to overwhelming events. Sensorimotor psychotherapy integrates body awareness into trauma processing. Breathwork, movement, and grounding practices are often incorporated into sessions. The common thread is that healing is not only a cognitive process and the body's wisdom is part of the clinical conversation.
For people who have been through medical trauma, birth trauma, repeated procedures, or a body experience that felt violating or out of control, somatic work can reach places that talk therapy alone cannot access. Your body was there for all of it. It deserves to have a say and a seat in the healing space.
Research on somatic approaches to trauma is growing. Somatic experiencing is listed among the treatments used by perinatal specialists in the Postpartum Support International directory. Studies on body-based trauma therapies show effectiveness for PTSD symptom reduction and nervous system regulation. The Seleni Institute notes that integrative, patient-centered approaches drawing from multiple frameworks, including somatic methods, produce the strongest outcomes for fertility-related distress.
Narrative Therapy Rewriting the Story
Narrative therapy is based on the idea that the stories we tell about our experiences shape how we understand ourselves and our lives. It believes that those stories can be examined, challenged, and rewritten in ways that give us more autonomy, freedom, and empowerment.
In regards to fertility and loss, narrative therapy is particularly useful for the identity shifts that happen when something you expected to be a straightforward part of your story turns out to be a completely different book altogether. You may have envisioned yourself as “The Little Mermaid,” “Cinderella,” or “Sleeping Beauty” as a little girl, naively believe that “first comes love, then comes marriage, then comes the baby in the baby carriage. Instead, your story became “The Baker and the Baker’s Wife,” “Thumbelina,” or “Up.” The woman who was going to have children by thirty-four and did not. The person whose body did not cooperate with the plan (male or female). The mother whose postpartum experience looked nothing like the story she had expected. Narrative therapy helps separate the person from the problem. You are not your failed cycles, lab results or diagnosis. You are not the worst thing imaginable that happened to you while trying to become a parent.
It also connects naturally to matrescence, the transformation of becoming a mother. Who were you before? Who are you now? What parts of the old story do you want to carry into the new one? What parts do you want to release or rewrite? Narrative therapy creates space to answer those questions intentionally while providing some distance to make it possible to look at.
Narrative therapy was developed by Michael White and David Epston. The Seleni Institute identifies narrative therapy as one of the approaches used by reproductive mental health professionals to help individuals heal and find meaning after fertility loss. Research supports narrative approaches for grief processing, identity reconstruction following trauma, and the kind of ambiguous loss that characterizes many perinatal experiences.
The Integrative Approach: More Than One Key For Whatever Locks Show Up
Most skilled perinatal therapists do not practice only one modality. They borrow from multiple frameworks depending on what you need and when you need it. The grief in the basement might need one approach. The cognitive distortions in the attic might need another. The body holding years of medical trauma might need something entirely different from the part of you that is trying to figure out what your values are in the middle of all of this.
What matters most isn’t that your therapist practices the “right” modality. It is that your therapist understands the specifics of your therapy journey and what can be the most beneficial to your healing. Perinatal mental health may live in the city, while fertility grief is residing in the suburbs. The person sitting across from you, whether it’s in the room or on the screen, they need to know those neirborhoods from the inside, clinically if not personally, and ideally both.
The key in your hand may not open every lock, but now you know more about what is behind each door and that’s an important place to start.
Other Therapy Approaches to consider that are worth the mention would be Compassion-Focused Therapy, Strength-Based Therapy, and Expressive Arts Therapy.
Sources
Sockol, L. E. (2022). Effectiveness of cognitive behavioral therapy for perinatal maternal depression, anxiety and stress: A systematic review and meta-analysis of randomized controlled trials. Journal of Affective Disorders, 300, 272-284.
Kerr, A., et al. (2023). Cognitive therapy for PTSD following birth trauma and baby loss: clinical considerations. The Cognitive Behaviour Therapist, 16, e23.
Daley, A., et al. (2023). Effectiveness of cognitive behavioural therapy-based interventions for maternal perinatal depression: a systematic review and meta-analysis. BMC Psychiatry.
Cook, N., et al. (2024). A case study applying cognitive processing therapy to childbirth-related PTSD: treatment considerations for the postpartum period. ScienceDirect.
Barbosa, C., Santos, S., & Pedro, J. (2024). Mapping acceptance and commitment therapy outcomes in the context of infertility: a systematic review. Current Psychology, 43, 14634-14644.
Schwartz, R. C., & Sweezy, M. (2020). Internal family systems therapy (2nd ed.). Guilford Press.
Levine, P. A. (1997). Waking the tiger: Healing trauma. North Atlantic Books.
Seleni Institute. (2026). Therapeutic strategies for infertility: CBT, ACT, and mindfulness-based care. https://seleni.org
University of North Carolina Center for Women's Mood Disorders. (2024). Perinatal behavioral health and psychotherapy program. https://www.med.unc.edu/psych/wmd
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. W.W. Norton.
If you are located in Florida, California, or Tennessee and are looking for individual support, I would love to work with you. Learn more about therapy services at bethsiller.com.
Not in one of those states? Beth offers virtual workshops and professional trainings available nationwide. Find out more at bethsiller.com.
This post is for informational purposes only and does not constitute therapy or medical advice. Beth P. Siller, LMFT is a licensed therapist, not a physician. Please consult a qualified medical or mental health professional for personalized support.
