Beyond Protection Mode: Transforming CBT for Pregnancy After Loss - Interview with Specialist Aleks Balazy-Knas
How integrating trauma-informed approaches, nervous system regulation, and compassion transforms therapy for clients navigating pregnancy after previous loss.
Pregnancy after loss isn't simply anxiety with a specific focus—it's a complex intersection of trauma, grief, and the biological drive toward connection, all occurring simultaneously in both mind and body.
In this interview, Aleksandra Balazy-Knas shares her pioneering approach that integrates traditional CBT with trauma-informed care, nervous system regulation, and compassion-focused techniques.
Drawing from her extensive experience supporting hundreds of clients through pregnancy after loss, she offers valuable insights into why standard approaches often miss the mark and how therapists can adapt their practice to truly meet these clients' needs.
Aleksandra explains her concept of the "dual timeline" phenomenon, and provides practical examples of how body-based interventions can create transformative outcomes. Whether you occasionally work with pregnancy after loss clients or are developing a specialised practice, this interview offers essential guidance for more effective, compassionate care.
Q: Many therapists feel uncertain about working with pregnancy after loss clients. What unique challenges do these clients face that standard CBT approaches might miss?
The biggest challenge with pregnancy after loss clients is that standard CBT approaches weren't designed for their unique situation. Their bodies and minds are trying to process trauma whilst simultaneously attempting to bond with a new pregnancy. When we use only traditional CBT, we mistakenly treat protective behaviours as problems to fix.
A client checking for bleeding 15 times a day isn't just thinking irrationally – her body is trying to protect her from experiencing another devastating loss. These clients also experience what I call a "dual timeline" – constantly comparing the current pregnancy to their previous loss. When they reach the gestational week where they previously lost their baby, their body physically remembers this trauma.
You'll notice this dual timeline in session when a client says, "I'm 14 weeks now, and that's when I lost the last baby," whilst physically tensing, breathing shallowly, and struggling to maintain eye contact. These are moments where standard CBT would miss the embodied timeline activation that requires a different therapeutic response – something we explore deeply in supervision.
My journey to this work began with my own frustration using standard CBT techniques with these clients. I vividly remember working with a woman who could rationally challenge her catastrophic thoughts but still couldn't sleep before scans. This gap between cognitive change and embodied experience drove me to explore the approach I now teach in supervision.
Recognising pregnancy loss as trauma, even when it doesn't develop into full PTSD, is essential for effective treatment. Sometimes we need to process these traumatic memories directly as part of the healing journey.
Q: You often mention that pregnancy after loss anxiety isn't just about fear – it's about 'being stuck in protection mode'. Can you explain what this means and why it matters for treatment?
After a pregnancy loss, the nervous system makes a promise: "I will never be caught off-guard again." This creates a state of constant vigilance where the body is always looking for danger. When a client is in protection mode, her normal body sensations can feel threatening, and her ability to feel safe is dramatically reduced.
You'll see protection mode in action when a client tells you, "I need to check for bleeding before every meeting" or "I can't look at baby items without feeling sick." In supervision, we examine how to respond when a client says, "But if I don't check, something bad might happen" – not by challenging this belief, but by honouring its protective function while expanding capacity.
Why does this matter? Because trying to use purely thinking-based approaches to address a physical state won't work. We need to shift from challenging thoughts to building capacity for safety and regulation first. This understanding also removes shame from therapy. Rather than asking clients to stop behaviours that feel necessary for survival, we honour these responses while gradually building new patterns of safety.
In supervision, we specifically address these moments where standard CBT approaches fall short – like when clients continue checking for bleeding despite cognitive restructuring, or when they intellectually understand statistics but their bodies remain on high alert. Together, we develop tailored protocols for these challenging scenarios where standard approaches have stalled.
Q: "How have you adapted CBT specifically for pregnancy after loss? What makes this approach different from standard anxiety treatment?"
In my work with pregnancy after loss clients, I've found that combining traditional CBT with other evidence-based approaches creates the most effective support. First, I've altered the sequence of therapeutic intervention. Standard approaches often begin with challenging unhelpful thoughts before addressing behaviours or feelings. With pregnancy after loss clients, I begin with body-based tools and regulation techniques before working with thoughts. This helps clients feel physically safer first, creating the conditions necessary for cognitive work to be effective.
Second, I use modified thought records for this population. Rather than the standard approach focused on identifying thinking errors, these adapted records include elements of compassion-focused therapy with specific sections for "what my body is trying to protect me from" and "what would feel supportive right now." This honours the protective purpose of anxious thoughts whilst creating space for new possibilities.
Third, I use carefully tailored exposure exercises specific to pregnancy after loss. These include graduated steps for pregnancy-related triggers, such as reading birth announcements, buying small baby items, or sharing pregnancy news. These exposures are always paired with regulation techniques to ensure they build tolerance rather than reinforcing trauma.
Perhaps most importantly, I blend elements from trauma approaches, ACT, and compassion-focused therapy with traditional CBT. For example, instead of challenging catastrophic thoughts about loss, we use techniques that help create a different relationship with these thoughts whilst honouring their protective intent. When needed, we also process traumatic memories of the previous loss to reduce their ongoing impact.
The result is an approach that maintains the structured nature of CBT that clients find reassuring, whilst addressing the deeper physical and emotional patterns that standard methods miss. It works better precisely because it's tailored to the unique reality these clients experience.
Q: You talk about combining CBT with nervous system regulation. Can you walk us through how this works in practice, perhaps with a specific example?
Imagine a client, Sarah, with overwhelming anxiety before ultrasound appointments. In a standard CBT approach, we might identify catastrophic thinking and try to challenge these thoughts. My integrated approach works differently.
We begin by recognising that Sarah's anxiety isn't just about thoughts – it's her body anticipating trauma happening again. In session, I guide her through specific breathing and movement exercises designed to signal safety to her nervous system. As her physical state shifts, we notice these changes, building awareness of what safety feels like in her body.
Only once we've established this calmer state do we introduce thought work. But rather than challenging her thoughts as irrational, we explore them through a lens of protection. We then develop a detailed plan for the scan that includes both cognitive and physical components – specific regulation practices, a personalised playlist, a physical anchor object, and compassionate responses for anxious thoughts.
We also carefully address the clinical environment itself – who should accompany the client, how to effectively communicate her needs to medical staff, and specific strategies for handling triggers, especially if the scan will take place in the same setting where previous trauma occurred. The scan situation is extremely threatening, so we ensure the client stays within her safety zone as much as possible whilst building capacity to handle inevitable triggers.
This creates a remarkable difference in outcomes. Rather than white-knuckling through appointments using willpower, clients develop a genuine capacity for physical regulation that transforms their entire experience of pregnancy.
Q: Could you share a specific example of how this adapted approach has helped a client to actually enjoying their pregnancy?
*Emma (name changed due to the confidentiality) came to me at 11 weeks pregnant after two previous losses. She was checking for bleeding up to 20 times daily, had completely disconnected from her pregnancy, refused to use the word "baby," and was having panic attacks before each appointment.
First, we focused on nervous system regulation to widen her comfort zone with uncertainty. Once we established this foundation, we incorporated modified cognitive work – honouring the protective function of her fears while creating space for new possibilities.
The turning point came around 16 weeks when Emma felt the baby move for the first time and experienced a brief moment of connection. By 24 weeks, the transformation was remarkable. Emma had reduced symptom-checking from 20 times to 3-4 times daily, started using the baby's name, purchased her first baby item, and begun planning a small celebration for reaching viability.
What continually moves me in this work is witnessing these profound moments when a client first allows herself to feel connected to her pregnancy – often with tears and the words "I never thought this would be possible." These transformational moments are why I'm passionate about training other therapists in this approach through supervision.
Q: What are some common misconceptions therapists might have about working with pregnancy after loss clients, and how can they better support these clients?
The major misconception is treating pregnancy after loss anxiety as general anxiety with a specific focus. Another is believing that anxiety naturally resolves as the pregnancy progresses past certain milestones. In reality, anxiety often shifts focus rather than diminishes – from fear of miscarriage to preterm labour concerns to birth trauma worries.
Perhaps most problematic is the belief that the therapeutic goal should be anxiety elimination. Our aim shouldn't be to eliminate protective responses, but to expand capacity for both protection and connection simultaneously.
To better support these clients, therapists should:
Validate protective anxiety as normal and adaptive – it's not pathological but a natural response to trauma
Focus on regulation before cognitive intervention – the body needs to feel safer before the mind can engage
Help clients hold both anxiety and connection simultaneously – rather than trying to eliminate fear
Create safety within uncertainty rather than offering false reassurance
Consider body-based interventions as primary rather than supplementary
Explore actively responding to threat responses rather than automatically trying to relax them – sometimes acknowledging and respecting the protective response is more effective than attempting to eliminate it
Most importantly, therapists need to shift from fixing to witnessing – creating a therapeutic space that can hold the full complexity of the pregnancy after loss experience.
Q: For therapists interested in specialising in this area, what would you say are the most important things to understand about pregnancy after loss that might not be covered in standard CBT training?
Specialising in this area requires developing expertise beyond standard training in several crucial areas.
First, it's essential to understand the physical underpinnings of pregnancy after loss reactions. Standard CBT training typically doesn't cover how trauma alters body awareness – the ability to accurately interpret bodily sensations. For these clients, normal pregnancy sensations can trigger threat responses because the body's interpretation system has been fundamentally altered by loss. Understanding this requires specialised knowledge of trauma physiology that goes beyond typical CBT understandings.
Second, therapists need to develop nuanced expertise in disenfranchised grief. Pregnancy loss creates a unique form of grief not fully recognised by society, where clients often lack the ritual, acknowledgment, and support available for other losses. This grief becomes further complicated in a subsequent pregnancy, creating what I call "concurrent grief" – mourning a previous child whilst attempting to bond with a current pregnancy. Standard bereavement approaches rarely address this complexity.
Third, specialised understanding of attachment theory as it applies to prenatal bonding is crucial. Pregnancy after loss creates a profound attachment dilemma not addressed in standard training: clients intuitively understand that emotional investment increases pain if another loss occurs, creating a protective detachment that conflicts with biological drives toward connection. This requires specialised knowledge of prenatal attachment processes and their intersection with grief.
Fourth, therapists need a good understanding of the medical context, including familiarity with high-risk pregnancy monitoring, common complications, and medical terminology. Without this knowledge, therapists can't effectively partner with medical providers or help clients navigate complex healthcare interactions.
Finally, and perhaps most importantly, therapists must develop a trauma-informed approach to uncertainty. Standard CBT often aims to increase tolerance for uncertainty through cognitive means, but pregnancy after loss requires a fundamentally different approach. These clients have experienced the worst-case scenario, making uncertainty not just cognitively challenging but physically threatening. Working effectively requires specific training in body-based approaches to creating safety within uncertainty – something rarely covered in standard CBT programmes.
For therapists committed to specialisation, I recommend supplementing standard CBT training with specific education in trauma approaches, somatic trauma methods, perinatal loss, and interpersonal neurobiology. This creates the interdisciplinary foundation necessary for truly effective work with this unique population.
Q: How do you see the field of pregnancy after loss therapy evolving?
I see several promising developments. First, the integration of neuroscience and traditional therapy approaches will accelerate, moving us beyond treating thoughts and body responses separately. Second, pregnancy after loss will be recognised as a distinct clinical area requiring dedicated training and expertise.
Third, we'll see a shift toward proactive rather than reactive care models, with loss survivors receiving specialised support from preconception through the postpartum period. Fourth, there will be growing recognition of how cultural, racial, and socioeconomic factors shape pregnancy after loss experiences.
Finally, we'll pay increased attention to the long-term implications for parenting and child development. This understanding will expand our therapeutic focus beyond pregnancy to support healthier family systems long-term.
My supervision provides the missing link between your existing CBT expertise and the specialised knowledge needed for this evolving field. We focus on practical application: identifying protection mode in real client language, sequencing interventions effectively, and adapting standard tools to address unique patterns in this population. Whether you're occasionally working with pregnancy after loss clients or developing a specialty practice, supervision provides the guidance necessary for confident, effective clinical work.
As therapists specialising in this area, we have the opportunity to lead this transformation, developing approaches that better serve our clients whilst advancing the broader fields of trauma treatment and perinatal mental health.
Aleksandra Balazy-Knas is a perinatal CBT specialist with particular expertise in pregnancy after loss. She has developed an integrated approach combining CBT, ACT, CFT, and trauma-informed techniques to help clients navigate the complex emotional landscape of pregnancy following loss.
With extensive training in trauma approaches and nervous system regulation, she divides her time between the NHS and private practice, providing both clinical services and professional supervision for therapists working in perinatal mental health. Her practice encompasses the full spectrum of perinatal concerns, including antenatal and postnatal distress, tokophobia, birth trauma, and perinatal OCD.
Aleksandra is passionate about advancing the field of perinatal mental health through professional training and supervision. Her approach has helped hundred of clients transform their experience of pregnancy after loss from one of constant vigilance to genuine connection and joy.
To inquire about supervision opportunities, email aleks@unscrewingmotherhood.co.uk with "Perinatal Supervision" in the subject line.
You can visit her website here.
Connect with her on instragam @unscrewingmotherhood
And connect with her on substack!
This was really interesting, thank you!