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Therapy

How to Treat Tokophobia in Therapy

Treating tokophobia requires a customized approach in therapy.

Tokophobia is the fear of pregnancy and/or childbirth. For an introduction, please see this previous post. In it, I suggest that there are nuanced ways that individuals can experience tokophobia. In addition to primary tokophobia (fear without having been pregnant or given birth) and secondary tokophobia (fear occurring after a traumatic pregnancy, loss, or birth experience), I notice the following additional subtypes:

  • Reluctant: A person with tokophobia who wants to get pregnant.
  • Avoidant: A person with tokophobia who avidly does not want to get pregnant. This type involves significant avoidance and compulsions (more OCD-like).
  • Ambivalent: A person with tokophobia who is uncertain about whether to pursue pregnancy.

To date, there does not seem to be enough evidence one way or the other to support the effectiveness of therapy for tokophobia. That is not to say there aren't benefits, but that it has not been studied methodically enough.

That said, it stands to reason that empirically supported techniques that address similar phobias and symptoms would make sense to apply to tokophobia. I would argue that the therapeutic approach used should be informed by the type of tokophobia a person is experiencing. Here are some suggestions for therapeutic modalities, specific techniques, and other considerations that may be useful based on type/qualifier:

For secondary tokophobia

For those with tokophobia resulting from a traumatic pregnancy or birth experience, addressing the trauma and working with a trauma-informed therapist would be ideal. Eye movement desensitization and reprocessing (EMDR) has been shown to be especially effective for addressing symptoms of PTSD. Treating tokophobia from a trauma perspective may be especially relevant if there is a history of sexual abuse.

For reluctant tokophobia

For the person with tokophobia who has decided they want to attempt to get pregnant, they are likely primarily experiencing excessive and uncontrollable worry in response to the process. Cognitive-behavioral therapy (CBT) may be useful as a first therapeutic strategy to address the worry. CBT works to address cognitive distortions, which are unhelpful or inaccurate thoughts that cause distress and negative patterns of behavior. Cognitive distortions can come in the form of catastrophizing (e.g., “I will bleed out and die when giving birth and leave behind my family.”), all-or-nothing thinking (e.g., “I will be in pain the entire pregnancy.”), overgeneralization (e.g., “My friend had multiple miscarriages so I likely will too.”), shoulds (e.g., “I should be naturally drawn to parenthood. What is wrong with me that I’m so scared?”), etc.

A particularly common theme with tokophobia is a perceived inability to cope with bodily changes and pain. Using CBT to create a more realistic sense of one’s ability to cope is important.

By methodically identifying and challenging specific thoughts, they can become more manageable. The idea is not to solve the problem, eliminate doubt, or reach certainty, but to practice challenging distorted thinking in order to have a more balanced and realistic viewpoint. And then, to practice accepting uncertainty (see ACT principles below).

For avoidant, OCD-like tokophobia

This type of tokophobia may respond best to exposure and response prevention (ERP), a type of CBT and the gold standard for addressing OCD symptoms. For a person experiencing this type of tokophobia, chances are there is no amount of thought-challenging or information-gathering that will quiet the insatiable kernel of doubt that insists that pregnancy could or may have occurred. In this case, engaging with the thoughts runs the risk of getting mired in them and perpetuating the fears.

Rather than getting caught in the weeds of addressing specific fears through traditional CBT strategies, there is likely more progress and relief to be found in labeling the thoughts as part of tokophobia/OCD (i.e., not to be taken seriously), leaning into uncertainty, staying present-focused, resisting compulsions and avoidance as aggressively as possible, and charging ahead with meaningful values-driven action (in spite of any obsessive concern about getting pregnant). It takes time, practice, and discomfort, but when done properly, ERP can be life-changing and effective.

For ambivalent tokophobia

The focus of therapy for those unsure about whether to try to get pregnant or not will likely be to explore their concerns and phobic responses in a safe environment with the support and guidance of a therapist. A goal of therapy can be to arrive at a decision one feels good about and that aligns with their goals and values. It shouldn't be a choice based on fear (the decision may even be confidently deciding to hold off on deciding for now!). Some tasks for therapy:

  • Exploring and identifying highest values. This worksheet is an example of a values sorting exercise to help inform the decision. Is family something you’ve always imagined? Is carrying a biological child yourself an essential part of that? Are there competing values (e.g., independence, exploration, creativity) that take priority or conflict with the path of parenthood?
  • Normalizing alternative paths to parenthood or choosing a childfree life. There are many ways to make a family. Biological children through pregnancy are not the only route! Obviously there can be logistical and financial hurdles, but adoption, fostering, using a surrogate, etc. are all excellent options. Similarly, being a parent is not a requirement for a happy or fulfilling life by any means. A person may feel pressured by their family and society at large to have children or have them in a specific way. Taking another course can be experienced as shameful or a failure, though of course it is not. Processing any shame or personal grief that comes up around this decision can be part of therapy.
  • Acknowledging that a person may never feel “ready” or “certain” and there is no “right” answer, but they can make the best decision they can with the knowledge they have at the time. Being pregnant and careening towards childbirth feels inescapable. Once a person’s pregnant, there’s no getting off the ride, which understandably leads to feelings of panic for many. However, by not deciding, a decision is still being made. If you are waiting to feel certain and ready, you may never take the plunge. It’s okay to conclude that you are simply not ready to make a decision just yet. It’s also okay to not be sure and go forward anyway, with an awareness that you can do everything in your power to be supported.
  • Assessing resources. So much of the arguments against having a baby through pregnancy may stem from a belief that “I can’t handle it” or a fear that the tokophobia is insurmountable. Taking stock of the various sources of support a person has or can seek out and secure (psychotherapist, physical therapist, family, friends, books, yoga practice, and other coping strategies, etc.) and mapping out a plan can bolster their sense of their ability to effectively handle a challenging experience. (See section in upcoming post on building a support network).

For all types of tokophobia

Interoceptive exposure for physical and panic symptoms: Physical symptoms (e.g., increased heart rate, shortness of breath, dizziness, nausea, chest pain, sweating, sense of dread) can arise in response to simply thinking about pregnancy/childbirth or being confronted with a trigger. These can be addressed the same way as panic symptoms that arise in other contexts--through gradual exposure to the symptoms to learn that they are tolerable, not a sign of actual danger, and always ultimately pass.

Gradual exposure to the concept of pregnancy and/or childbirth: This process of desensitizing and acclimating to the idea of pregnancy or childbirth can go so slowly. Maybe first by simply saying the word “pregnant” out loud, then related words, building up to looking at images, etc. As with exposure to physical symptoms, the idea is to move away from avoidance of thinking about the topic (because avoidance fuels anxiety in the long-term). The ideal place to be is a neutral, even bored, response to the concept.

Acceptance and Commitment Therapy (ACT) principles: ACT is a psychotherapeutic approach that uses skills such as acceptance, mindfulness, thought defusion, values, and committed action--all with the aim of increasing psychological flexibility. These skills might be especially useful in helping someone with ambivalent tokophobia to do values work or for someone who is pregnant/trying to get pregnant to practice acceptance of discomfort and uncertainty. In general, we know that the war against anxiety is won through tactics like acceptance and curiosity/openness rather than efforts to control or vanquish. The skills of ACT could help promote action in the face of fear.

Mindfulness and somatic approaches: For many, the central fear in tokophobia is of bodily changes, unavoidable discomfort and pain, and feeling trapped. Especially for those considering and attempting to get pregnant, mindfulness can offer ways to cope with those changes and prepare for labor. A diligent mindfulness practice can offer the ability to stay grounded and present, to be observant of whatever sensations arise in each moment.

Tackling tokophobia involves taking reasonable steps to be informed, supported, empowered, and in-control while building skills to embrace uncertainty and to reduce avoidance and compulsions. If pursuing therapeutic support (highly recommended by this biased therapist), take the time to find a good fit for a therapist, and work with the therapist to be clear on what form of tokophobia you have so that you can determine the best therapeutic strategies to address it.

Read on for additional treatment suggestions for tokophobia.

For further reading, please see the reference section below.

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830168/

https://core.ac.uk/download/pdf/25510068.pdf

https://www.glowm.com/pdf/section4_chapter21.pdf

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13138

https://www.cambridge.org/core/journals/the-british-journal-of-psychiat…

https://theconversation.com/tokophobia-what-its-like-to-have-a-phobia-o…

https://www.womenandbirth.org/article/S1871-5192(17)30025-2/abstract

https://www.theatlantic.com/health/archive/2016/06/tokophobia/489206/

https://www.theatlantic.com/notes/2016/07/how-to-overcome-your-fear-of-…

https://www.nct.org.uk/pregnancy/how-you-might-be-feeling/tokophobia-ho…

https://www.birthtraumaassociation.org.uk/

https://www.postpartum.net/learn-more/postpartum-post-traumatic-stress-…

https://theswaddle.com/the-pathological-fear-of-getting-pregnant-is-cal…

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