For peripartum women, their historical experiences of childhood abuse and neglect may have longstanding effects that impact their pregnancy and child-rearing in adulthood in ways which may increase the risks for intergenerational transmission of negative outcomes. Several of these adverse consequences are described elsewhere in this volume. The investigations described in this section focus on resilience-related findings from our translational program of research evaluating maternal and infant outcomes among women exposed to childhood maltreatment (CM).

The Maternal Anxiety during the Childbearing Years (MACY; Muzik, PI) study is a longitudinal investigation from pregnancy through 18 months postpartum. The research oversampled women endorsing CM (N = 214, including n = 145 with CM histories). During the study, women completed surveys and qualitative interviews. Mothers completed questionnaires at delivery, 4, 6, 12, 15, and 18 months postpartum and engaged in free play and structured sessions (at a 6 and 15 months postpartum visit) focused on interactions with their children.

To explore protective factors, our first study (Sexton et al. 2015) examined main and moderating effects of resilience as measured by the Connor-Davidson Resilience Scale (Connor and Davidson 2003) and childhood trauma severity on postpartum depression, PTSD, positive family functioning, and maternal self-confidence. Despite the high rates of CM in this sample, most mothers did not evidence PTSD (79.5% negative for diagnosis) or postpartum MDD (80.4% negative for diagnosis) at 4 months postpartum. Main effects were noted for CM severity and resilience on postpartum PTSD, MDD, and positive family functioning with trauma severity associated with poorer outcomes and resilience associated with better outcomes (i.e., decreased psychiatric risk and improved family support). Mothers endorsing higher levels of resilience were also more likely to report increased sense of parenting mastery.

Specific to moderating effects, the interaction of CM severity and resilience was associated with postpartum PTSD and MDD risk. When stratifying participants into quartiles of highest and lowest CM severity and resilience groups, we found an absence of PTSD in mothers with the lowest levels of CM, irrespective of resilience. However, for mothers with the highest levels of childhood abuse and neglect, the level of resilience was a major protective factor for the presence or absence of PTSD. Specifically, only 8% of those mothers with highest resilience and high CM exposure met PTSD criteria in contrast to 58% of mothers with lowest resilience and high CM. Similarly, among women in the highest resilience group, none met the criteria for MDD, irrespective of CM severity. But for women in the lowest resilience group, the level of resilience made a difference. In this low-resilience group, 25% of women with low levels of CM met diagnostic criteria for postpartum MDD compared to 68% of those with high levels of CM. These results suggest that resilience is critical for all mothers and is associated with improved family well-being, maternal competence, and reduction of PTSD and MDD risk. In addition, particularly for mothers with histories of childhood maltreatment, greater resilience may buffer against some of the common psychiatric outcomes associated with early trauma. This has particular clinical importance. CM histories, discussed elsewhere in this volume, are associated with adverse peripartum outcomes. Yet, resilience-enhancing interventions may offer a pathway to attenuate some deleterious effects associated with childhood trauma.

One facet of resilience, the ability to establish and solicit aid from social support networks, appears particularly protective against postpartum depression in at-risk women. Focusing on mothers with histories of CM, we evaluated the main and moderating effects of CM severity, social support, and income on postpartum depressive symptoms (Muzik et al. 2017). As may be expected, the severity of CM increased the risk of postpartum depression, while annual income and social support were inversely associated with symptoms. We observed a significant support-by-income interaction indicating that high social support mitigated the association between low income and depressive symptoms. Specifically, we found that mothers with high social support and low income reported significantly fewer symptoms than those mothers who also had low income but also experienced low social support. Most importantly, these low-income mothers with high social support were not significantly more symptomatic than high-income maternal peers with high social support. These results highlight the importance of close postpartum interpersonal relationships, particularly for those with limited financial resources.

We further investigated protective factors that may buffer against suicidal ideation (SI) among MACY-enrolled mothers with CM histories during the first 18 months postpartum (Muzik et al. 2016). Longitudinal trajectories indicated that 63% of mothers denied SI at all time points, and most mothers described only transient SI throughout this time frame. Specifically, at 4 months postpartum, resilience, financial resources, and being married or having a cohabitating partner reduced SI risk. At 6 months, the presence of family support was the primary protective factor against thoughts of self-harm. At 12 months, married or cohabitating mothers and those endorsing less trauma-specific shame demonstrated reduced risk of SI. At 15 months, resilience was associated with the presence or absence of SI, but only married/partnered status was predictive of the severity of thoughts. Finally, at 18 months, lower trauma-related shame was the only identified buffer against SI. Together, these results underscore the importance of understanding the interplay and variability of postpartum protective factors. Our findings suggest resilience and associated protective factors are not universal and constant safeguards but may fluctuate in importance depending on temporal changes in mother and infant development and interact with stressors (i.e., returning to work, loss of extended family support after early postpartum, increasing independence of the child, changes in sleeping and eating schedules) that may vary between parenting newborns and toddlers.

Psychological strain and morbidities secondary to myriad adulthood traumas are reviewed elsewhere in this volume and not further considered here. However, fewer investigations of resilience have been conducted and warrant attention.

In a study of peripartum resilience following Hurricane Katrina, Harville et al. (2010) found that older mothers, those in partnerships, and Caucasian women demonstrated increased peripartum resilience, whereas those who sustained a direct injury or illness demonstrated reduced well-being. Surprisingly, experiencing storm-related damage was correlated with report of increased resilience. Some possibilities may explain this finding. It may be the case that loss of property or other resources prompted mothers to engage social support networks and other resources that mitigated strain. Additionally, the immediacy of the stressor within a peripartum context may have increased the propensity of women to utilize active coping skills in response to burden.

In another study of proximal trauma, Hughes and Riches (2003) reviewed pertinent evidence specific to the clinical management of traumatic pregnancy loss. They report that, since the 1970s, close contact between parents and the deceased child has been recommended by care providers based on the belief this practice would assist mourning and reduce negative outcomes. However, in contrast to this philosophy, research found women who did not hold their babies following death were less likely to experience delivery- or miscarriage-related MDD or PTSD. Rather, the facilitation of social support engagement demonstrated improved resistance to psychiatric symptoms. The authors rightly note that for many women who experience pregnancy or child loss, parental autonomy, cultural practices, and personal preferences are paramount. Specifically, it may be the case that mothers elect to hold miscarried or stillborn children for important reasons even if it does increase their risk for psychiatric symptoms. In such cases, it is important to offer grieving parents control during this process. However, current evidence does not appear to justify this practice as a clinician-initiated recommendation for reducing adverse outcomes or facilitating healing. Together, the authors’ findings augment the importance of empirical assessment of routine clinical advice in order to limit potential for harming vulnerable populations.

Within non-trauma populations, studies have primarily examined the role of social support as a mechanism to inhibit the development of postpartum MDD. In a synthesis of the literature, Robertson et al. (2004) concluded that maternal perceptions of available emotional and practical support were associated with reduced probability of developing MDD postpartum. In addition to reducing depression risk, Leahy-Warren et al. (2012) further demonstrated that social support was positively associated with maternal self-efficacy in first-time mothers. The consistency with which interpersonal relationships appear associated with positive outcomes is likely exceptionally relevant for traumatized women although consideration of other potential factors associated with peripartum resistance to mental health concerns remains warranted.

While several factors associated with postpartum resilience have been identified, features associated with postpartum recovery from depressive symptoms exhibited during pregnancy have been more elusive, and longitudinal research remains scant. Gotlib et al. (1991) prospectively assessed 730 women from pregnancy through early postpartum on a number of factors: age, marital duration, stress, severity of depressive symptoms during pregnancy, bonding in the family of origin, coping strategies, and negative attitudes. Regression analyses did not confirm relationships between any of the variables under investigation and recovery from depressive symptoms. Similarly, Andersson et al. (2006) examined maternal age, economic resources, partnership status, alcohol and nicotine use, parity, obesity, and prenatal health difficulties and similarly did not identify factors apart from history of psychiatric disorders prior to pregnancy as predictive of depression and anxiety trajectories from pregnancy to postpartum.

In a separate longitudinal research study with pregnant women (Sexton et al. 2012), we observed 39% of women experiencing significant depressive symptoms at 32 weeks of pregnancy did not exhibit clinically significant symptoms at 12 weeks postpartum. We examined demographic factors, medication and psychotherapy utilization, prenatal exercise behaviors, history of depression, history of negative life events, family and partner support, adequacy of resources, and domestic division of labor as potential predictors of symptom course. Of the factors investigated, prenatal exercise, fewer depressive symptoms in pregnancy, and cohabitation with a partner were related to recovery from depressive symptoms at the postpartum assessment. While this sample was not drawn from a study emphasizing trauma history, a lifetime history of negative event exposure was not associated with reduced likelihood of recovery. Among multiparous mothers, a history of past postpartum depression, but not lifetime depression history, differentiated between those with transient and persisting complaints. Together, results suggest continued research is warranted to further discern factors associated with postpartum mental health recovery in those with prenatal symptoms. The finding that exercise behaviors are associated with improved mental health outcomes may be helpful to investigate further empirically given that most pregnant women experiencing symptoms do not engage in medication or therapy services but may consider other wellness recommendations from care providers.

For many providers, facilitating recovery with traumatized women is simultaneously rewarding and challenging. Trauma survivors often present to care at various stages of healing with characteristics that may influence the therapeutic relationship and content. Not uncommonly, clients may be mistrustful of therapists or others they perceive as authorities, particularly if their trauma involves a perpetrator in a position of power. Likewise, clients may find themselves triggered when clinician characteristics are similar to stimuli present during traumatic events. For instance, rape survivors may be initially anxious about working with male therapists if their perpetrator was a male or otherwise physically or experientially similar. Others may display strong emotions of fear, anger, shame, and disgust. Concurrently, they may note a numbing of positive emotions and incapability to feel warmth and attachment to others. Some may have processed their trauma in such a way that solidifies negative cognitions about being responsible for their own injuries, that others are generally dangerous, and that they are not capable of recovery. During and after pregnancy, these beliefs can extend to perceptions that they are not “up to the challenge” of parenting, that they are harming their fetus or child with their inability to manage stress, or that others will not help when they need support. Oftentimes, survivors articulate difficulties with communicating effectively with tendencies toward aggressive or passive interactions that limit their ability to have their needs met. The use of Socratic questioning and motivational interviewing strategies may be particularly beneficial for “rolling with resistance,” providing affirming support, facilitating understanding, and developing rapport.

It is important to recognize that most of the symptoms that present in the context of depression, PTSD, and affect dysregulation often represent behaviors that were functional at the time the trauma occurred and developed for the purposes of assisting with the prevention of further harm or coping during taxing stressors. For instance, emotional numbing may have originated as a coping strategy to reduce emotional pain when situations could not be physically avoided. However, when these tendencies persist, individuals may find themselves limited in their behavioral and emotional engagement.

Fostering a clinical environment in which survivors feel autonomous, supported, safe, understood, and validated is paramount. For many clients, the therapeutic relationship may be their first disclosure of trauma. Normalizing experiences and matching clients’ pace are key to developing trusting and safe relationships. Some may have decided to disclose to others and perceived disclosures as supportive interactions that bolster well-being. Others may have had a history of disclosure experiences that were harmful. For example, those experiencing sexual trauma in the military frequently describe an initial assault followed by secondary stress when attempting to disclose their attack. They may describe being disbelieved, threatened, or minimized during these occasions. In the context of interpersonal violence, many describe receiving questions from social supports such as “why didn’t you just leave?,” which often appear accusatory. Beyond direct personal experiences, cultural norms influence trauma responding. Rape survivors may conclude that they are to blame for their attack and that it happened to them “for a reason,” beliefs that are often societally reinforced. Clients are often particularly attuned to the verbal and nonverbal signals provided by therapists during disclosure encounters. As such, it is particularly important that we examine our own potential biases and are thoughtful in our responses to difficult clinical content.