Can Counselling help Pre-Menstrual Disorders (PMS, PMDD and PME)?
(Nb. If you have already done some background reading about PMDs, please skip to the sub-heading ‘How can counselling help?’)
Pre-menstrual disorders (PMDs) bring distress to multitudes of reproductive-age women. Up to 80% of women suffer from PMS, but around 5% suffer from Premenstrual Dysphoric Disorder (PMDD), a severe form of PMS listed in the Diagnostic and Statistical Manual of Psychiatric disorders (DSM) and validated in 2019 by the World Health Organisation as a “medical condition”. Women suffering from PMDs report up to 300 different physical, psychological and behavioural changes during the lead up to their periods. However, those women who suffer from PMDD may struggle to work, hold down healthy relationships, and cope even with simple tasks during this time of the month. PMS and particularly PMDD therefore have a huge impact on women’s lives; yet awareness of and research into these conditions (perhaps affected by negative stereotypes and/or stigma) has been relatively low.
The most common form of treatment offered to women suffering with moderate to severe PMS or PMDD whose symptoms are not sufficiently improved by lifestyle changes (e.g. diet, supplements, exercise and stress reduction) are anti-depressants or hormonal treatments, such as the contraceptive pill. However, in many cases symptoms do not markedly improve and women are left feeling hopeless, helpless, depressed and trapped in a cycle in which they feel out of control and powerless. In such cases many will turn to surgical options: a bilateral oophorectomy (removal of the ovaries) and sometimes a hysterectomy (removal of the uterus), to induce a ‘surgical menopause’. Counselling is not always considered because PMDs are thought by many to be solely physical conditions. However, in up to 40% of cases, patients who initially self-identify as having PMS or PMDD also have underlying mood or anxiety disorders, which therefore often re-classifies their ‘disorder’ as a ‘Pre-Menstrual Exacerbation of an underlying condition’ (PME). In such cases, counselling can be invaluable – as not only can it help these underlying issues, but in so doing it can also alleviate the exacerbation of these issues at hormonal times of the month.
Because the majority of women are unhappy with the idea of taking long-term medication, psychological interventions are arguably the best first option for treatment of moderate to severe premenstrual symptoms. In fact a 2002 NICE funded randomised control trial (RCT) comparing the effectiveness of antidepressants with a specialised eight session, fortnightly counselling package for women with PMDD, showed the counselling to be as effective as antidepressants in reducing symptoms after six months, and more effective after one year. In fact in contrast the symptoms of those receiving anti-depressants were shown to worsen after the one year follow-up (1).
How can counselling help?
Managing PMDs
The specialised counselling package referred to above used a combination of Cognitive Behavioural Therapy (CBT) and Narrative Therapy, and focussed on several aspects of PMDs that counselling can alleviate, which are believed to have an impact on premenstrual distress. Broadly speaking these elements were:
– Examining the story or ‘narrative’ that women tell themselves about their PMDD and how this affects their experience of it.
– Looking at the relationship between PMDD and stress: examining and modifying specific stress triggers.
– Examining the link between assertiveness and PMDD e.g. setting boundaries and learning to say no.
– Redressing the balance between work/chores and enjoyable activities: examining blocks to doing this, and looking at attitudes towards rest and self-care.
– Identifying and reframing vicious cycles of thoughts, feelings and behaviour.
Relationship and family difficulties were also considered throughout the counselling eg. the ability to state needs and share responsibilities fairly; looking at how partners react to and view/label PMDD, and how this affects the sufferer; and the levels of support available for women in all their relationships. Anger management was also touched upon where relevant, to help women manage difficulties with emotional expression in their relationships.
One important factor which tends to worsen PMDD symptoms is “splitting”, or the tendency to view experiences in black and white terms rather than shades of grey. For example, women might use terms such as “out of control / in control”; “I’m myself / I’m not myself”; or “I’m a good person / bad person” to describe their states at different times of the month. In other words this splitting can reflect a confused sense of self, such that the person views themselves and their identity in a rigid way. These might for instance fit in with idealised views of women – reinforced by families, partners or society e.g. ‘superwoman/in control/multi-tasking/efficient’ and ‘loving/caring/always there for others/good listener’. Whilst these are nice traits to have, they are not all that a woman is; and the pre-menstrual phase can be a time in which the buried, unwanted parts of us can rise up, which are currently viewed negatively e.g. ‘selfish, messy, lazy’.
PMD sufferers commonly live with a ‘toxic inner critic’ which manifests as a constant judgmental voice either directed towards the self, or as an ‘outer critic’ directed towards others. This voice can often display perfectionist tendencies, such that nothing the sufferer says or does is ever good enough – creating a constant effort and striving without ever reaching fulfilment or peace. This in itself is a stressor, exacerbating hormonal sensitivities, but which can be addressed through compassionate, mindful awareness and cognitive reframing or ‘thought-stopping’. Sufferers might see undesirable or unwanted aspects of themselves in a negative light, but these aspects can actually be reframed as indicators of unmet needs e.g. the need for time alone, away from responsibilities and to not have to be there, always available and loving towards everyone. Such beliefs have an inevitable emotional counterpart eg fear, anger or self-hate. Similarly, within relationships there might be a splitting tendency towards self-blame or projection of blame onto partners during this time of the month, rather than seeing the nuances or complex relational dynamics playing out. ‘Cognitive reframing’, used in CBT, helps women to see stressors in a different way – incorporating more subtleties and shades of grey into their perceptions of themselves and others, thus potentially leading to decreased emotional activation and a more realistic (as opposed to ‘all or nothing’) sense of identity.
The ‘new wave’ of CBT also provides potential support in the alleviation of premenstrual distress. For instance Dialectical Behaviour Therapy (DBT) can help with emotional regulation, distress tolerance, interpersonal skills and mindfulness. Similarly, Acceptance and Commitment Therapy (ACT) can help sufferers change what they can (e.g. through diet, exercise, stress reduction, cognitive reframing), whilst mindfully accepting what they can’t change (e.g. decreased energy, increased emotional vulnerability). This is very important, as research shows that non-judgmental acceptance of hormonal changes is the most effective coping strategy for reducing distress during the premenstrual phase (2).
Healing PMDs
Research shows a high correlation between trauma and PMDs. This could mean that women who suffered early traumas such as abuse or neglect have an increased sensitivity towards negative experiences, and/or have not developed strong emotional regulation skills and therefore struggle to cope with the effects of hormonal changes in the body. In addition, unresolved emotions (e.g. rage, misery, disempowerment, helplessness, grief) from unprocessed traumatic events may remain within the body and manifest each month during hormonal times.
In ‘Waking the Tiger’ (3) trauma expert Peter Levine writes that “(If undischarged) energy (relating) to a traumatic event is not processed, these responses can remain in the body and begin to incorporate mental and psychological characteristics into their dynamics” (p143). Levine claims that these trauma symptoms can manifest as physical ailments, which can result from dissociation within and from the body. He states that PMS (in common with gastrointestinal symptoms e.g. irritable bowel syndrome and recurring back problems) can be the result of a “disconnection between organs in the pelvic region and the rest of the body” (p141). If so, one explanation of PMDs could be: a manifestation of unprocessed emotions which are repressed (dissociated) during calmer times of the month but which fight for attention and re-integration during hormonal times. Thus connecting back to themselves, their body and experiences and grieving / releasing old emotions still held in the body could arguably alleviate PMD symptoms in sufferers. The intensity of emotional charge during the premenstrual phase can sometimes facilitate that process if these emotions aren’t blocked – leading to a purification of sorts, before the relative calm of menstruation.
Spiritual speaker and writer Eckhart Tolle alludes to this phenomenon in ‘The Power of Now’ (4), writing that women are often “taken over by the pain-body” at this time of the month with “an extremely powerful energetic charge that can easily pull you into unconscious identification with it” (p120). Tolle claims that it isn’t just the individual woman’s pain manifesting at this time of the month, but also her share of the ‘collective female pain-body’. The individual pain (from one’s own hurts and traumas) and collective pain (e.g. from male subjugation of the female, exploitation, rape, childbirth and child loss over thousands of years) “restricts the free flow of energy through the body, of which menstruation is a physical expression” (p120). He suggests that women can choose to either identify with the emotional and physical pain, or take the opportunity to consciously transmute it into the wisdom of enlightenment. He writes:
“The pain-body awakens particularly at the time preceding the menstrual flow … If you are able to stay alert and present at that time and watch whatever you feel within, rather than be taken over by it, it affords an opportunity for the most powerful spiritual practice, and a rapid transmutation of all past pain becomes possible” (p32). The support of a counsellor can be beneficial in guiding this process, particularly where past abuse or trauma is present.
In Conclusion
Seeing PMDs through a medical, ‘disease model’ lens, where sufferers are passive and powerless over their bodies and must be fixed by drugs or surgery, is just one perspective. Another lens is that this ‘condition’ has a message for us about what is out of balance in our lives and/or what needs healing. For example, PMDs might force us to rest and relinquish some responsibilities, or allow us to express feelings that are suppressed the rest of the month. They might also be leading us to confront our relationship to ourselves and others. Christiane Northrup states that the body is wise and sends messages all the time regarding what is and isn’t right for us. She says it is worth asking the question “Why did my body choose this particular condition? How does it serve me on my path?” (5).
In relation to PMS, women can potentially ‘use’ this condition to move from a position of disempowerment into empowerment, by taking ownership of this process and by growing in awareness. In this way it is possible to gain some control over the PMDs which historically have controlled us. This may involve changing our language or narratives e.g. the story of the ‘PMD Monster’ becomes the story of our body’s ‘wake up call’ to look at underlying issues or unresolved traumas which need our attention. Consequently our wake up call might lead us to peer through a socio-cultural lens, which shows the female body to be relatively disempowered within a culture that does not value and respect men and women’s bodies equally, and in which women are asked to suppress the natural rhythms of their monthly cycle in order to fit in to societal expectations and the economy.
Counselling is about change, but also about acceptance of what we can’t change. We can’t necessarily do anything about our hormonal sensitivities, but we can change our relationship to those sensitivities and what they bring up in our lives and bodies. We can change our attitudes to PMDs and consequently to ourselves: in this way potentially changing the unwanted and feared ‘disorder’ into a companion and guide.
References
(1) Ussher, J.M., Hunter, M. S. and Cariss, M. (2002). A Woman-Centred Psychological Intervention for Premenstrual Symptoms, Drawing on Cognitive-Behavioural and Narrative Therapy. Clinical Psychology and Psychotherapy 9, 319–331. Available at https://www.researchgate.net/publication/224054006_A_woman-centred_psychological_intervention_for_premenstrual_symptoms_drawing_on_cognitive-behavioural_and_narrative_therapy.
(2) Read, J. R., Perz, J. And Ussher, J. M. (2014). Ways of Coping with Premenstrual Change: Development and Validation of a Premenstrual Coping Measure. BMC Women’s Health 14, 9000. Available at https://doi.org/10.1186/1472-6874-14-1.
(3) Levine, P. A. (1997) Waking the Tiger: Healing Trauma. California: North Atlantic Books.
(4) Tolle, E (2004) The Power of Now: a Guide to Spiritual Enlightenment. Vancouver: Namaste Pub.
(5) Northrup, C. (2020) Women’s Bodies, Women’s Wisdom: Creating Physical and Emotional Health and Healing. New York: Bantam Books.