by Caroline Rock
The World Health Organisation estimates that ten to eighteen per cent of couples around the world experience difficulty conceiving a child. Historically, investigations into the psychological aspects of infertility concentrated on psychopathology. In the latter part of twentieth century, in approximately fifty per cent of all cases of infertility, no medical reason could be found and it was assumed that the causes were psychogenic. Many of these findings were based on theoretical speculation or anecdotal evidence and concentrated on the female partner; men as well as male infertility were largely ignored. It was not until years later when diagnostic abilities improved that it became accepted that underlying physiological conditions were most likely to be the main causes of infertility, shared both by men and women. From a psychotherapeutic standpoint the focus then began to shift from psychogenic causes to the actual psychological and psychosocial impact felt by couples or individuals diagnosed with infertility.
According to Nyboe et al. (2008), it is fair to assume that the need for psychosocial counselling for involuntarily childless couples will increase in the coming years. The Women’s Health Council of Ireland (2009) has predicted that the demand for advice and treatment for fertility problems will increase in Ireland over the coming years because of the trend here to delay parenthood to pursue careers and financial security. This implies that professional counsellors are more likely to encounter clients coping with feelings of loss and grief associated with an infertility diagnosis.
This article will look at the most effective ways to deal with a couple or individual presenting with the emotional side effects of fertility problems. By looking at the different interventions in relation to fertility counselling, therapists can become equipped with ways to help and support clients dealing with fertility difficulties.
What is Fertility Counselling?
Fertility Counselling is a specific type of counselling often provided to patients within clinics as part of their overall fertility treatment. However couples or individuals may also choose to attend a counsellor not employed by a clinic.
According to the Human Fertilisation and Embryology Authority (1998) the following tasks of counselling can be distinguished in the context of infertility treatment: information gathering and analysis, implications and decision-making counselling, support counselling and therapeutic counselling.
The overall aim of Fertility Counselling is to provide emotional support and to help a couple or individual deal with the emotional, relationship and stressful challenges that occur when trying to achieve a pregnancy through assisted reproductive technology. With the support of a counsellor couples can look at implications of certain treatments. A fertility counsellor can help them prepare for treatments, and explore the options and implications when making decisions about starting, changing or stopping treatments.
Within sessions clients can learn to deal with the emotional impact of infertility and work on relationship issues that may arise as a result of treatment. Couples can explore ways to cope with unsuccessful treatment cycles or pregnancy losses. They can develop coping strategies for dealing with other people’s pregnancies, births and children. People often need to handle insensitive comments or reactions from families, friends, work colleagues and society in general. Sessions can provide a safe place to express the difficulty and hurt experienced by clients trying to negotiate their way through this journey. Dealing with these issues can help them feel more in control of their day to day interactions with people. For those couples or individuals who have decided on using donor eggs or donor sperm, fertility counselling is a very important support which allows them to discuss and explore all the specific issues, concerns and implications that are related to this type of treatment. Fertility counselling within the clinics is usually only accessed while the patients are undergoing treatment and so they often need outside support before or after attending a clinic.
Before couples have even reached the doors of a fertility clinic they have usually been through years of trying to conceive naturally and have already experienced much loss, sadness and disappointment. Likewise if they have decided to cease medical intervention without having achieved a pregnancy, they are left with these feelings and usually at a more intense level. At any stage of their infertility journey, they may be required to process painful emotions.
According to Gibson (2007) cognitive behavioural counselling, grief counselling and support groups have been viewed as the most utilised techniques in counselling couples with infertility.
Diamond et al. (1999) identified four emotional phases of infertility which represent transitions that a couple may experience
- Dawning – increasing awareness of fertility problems.
- Mobilisation – initiating of medical diagnostic testing, concern and recognition of a problem.
- Immersion – this is the most complicated phase; increased medical testing and treatment with ongoing uncertainty.
- Resolution – this could be ending medical treatment, recognising and mourning the loss of not having a biologically related child or changing focus and looking at other options such as adoption or childlessness.
The counsellor could identify where each of the couples is located on this model and work the therapy around this.
Cognitive Behavioural Therapy: CBT
With years of struggling to conceive a child many couples begin to establish maladaptive thought patterns. Thoughts of self can be distorted with focus on parental identity and nothing else. CBT can attempt to reverse these patterns of thinking by focusing on the cognitions which are maintaining the sadness, guilt, anxiety, grief or depression. The CBT counsellor can help to change the pessimistic outlook in the present and on the future by facilitating the couple to concentrate on the positive idea about themselves and their relationship. “By using cognitive-behavioral treatment, one of the goals of the professional counsellor is to use a series of therapeutic procedures that will result in the modification of the couple’s worldview.” (Smith and Smith, 2004: 59).
Ellis (1977) argued that emotional or psychological disturbances are largely a result of illogical or irrational thinking and that one can rid oneself of most of the emotional or mental unhappiness and disturbance if one learns to maximize the rational and minimize the irrational thinking. This unhelpful thinking is known as cognitive distortion. According to Smith and Smith (2004) some of the most common cognitive distortions in the thinking of infertile couples may be
- ‘All or nothing’ thinking: for example “if I fail to conceive and have a child, I am a total failure.”
- Jumping to conclusions and negative non sequiturs: for example “since all our friends are aware that we cannot have children, they must think we are incompetent”.
- Fortune telling: for instance “everyone at this party will be talking about the fact we don’t have children.”
- ‘Allness’ or ‘neverness’: for example “we will never have children and so we will never be happy again.”
- Labelling and overgeneralisation: such as “because I cannot have children I am not a complete person.”
CBT can help infertile clients to see the difference between this dogmatic ‘musturbatory’ thinking and the type of thinking that denotes the client’s preferences.
Freeman et al. (1990) advocate the use of the cognitive model when dealing with female clients who feel responsible for the fertility problem. In therapy the negative beliefs and the negative patterns of thought, action and affect are challenged and modified leading to changes in emotional responses and ways to better cope with infertility.
Gonzalez (2000) recommends that therapeutic interventions, when dealing with infertile women, should include
1) an awareness and understanding of cultural and ideological messages that drive women’s identities 2) the empowerment and development of inner strength 3) the recognition of self in non reproductive terms 4) strengthening of the marital relationship beyond the immediate cultural expectations of procreation and the nurturing of a spiritual or philosophical life to enhance coping and personal growth.
(Gonzalez, 2000: 629)
According to Whelan (1980) a helpful exercise in reviewing parenting options involves having the couple write down a plan for the next five years. They write it assuming that they will eventually have a child and then write it again assuming they will never have a child. This can be a difficult exercise as some couples may be resistant to the idea of never having a child. However, there is a certain freedom to it and it allows couples to think differently and imagine a life without a child as well as setting realistic limits to their pursuit of parenthood. For couples whose lives have been on hold while trying for a baby this exercise can help them to get on with their lives.
“Externalizing the problem is a counselling technique that helps couples to think of the problem as separate from themselves.” (Long and Young, 2007). It is part of a narrative approach to counselling. The couple work towards decreasing the self or relational importance of the infertility problem. They learn to view fertility in a different way and to attach an alternative meaning to it. It should still be used in the context of empathetic listening and not construed with problem solving. It is helpful to question educational and cultural beliefs surrounding fertility. The couples can then deconstruct long held cultural beliefs which may not be helpful to them and replace them with more positive stories relative to their own lives.
Constructivism is an initial step in working with people who are contending with grief and who wish to embark on a meaning reconstruction process. This is especially applicable to couples who have accepted that they will never have a biological child. It can also be valuable for couples who find themselves stuck in the ‘limbo’ stage of infertility as it can help them to continue to lead more satisfying lives instead of waiting for their fate.
Constructivists believe that realities are created by individuals as they endeavor to make sense of the world (Raskin and Bridges, 2002). Therefore, from this perspective, it is important to understand the personal reality of loss for individuals and couples rather than assume a universal reaction to infertility. Gilles (2003 cited in Bridges, 2005) proposed four main processes utilised to reconstruct meaning in response to loss: sense making, benefit finding, identity change and continuing bonds. Couples who have been diagnosed with infertility have a need to make sense of this loss. This understanding can be fostered by physiological means but also as importantly by psychological meaning which can lead to sense making and meaning reconstruction. The therapist can respond with constructivist orientated questions such as:
What were the prior constructs about parenthood and previously held assumptions of fertility? In what ways have these constructions changed? How is the process of infertility understood? How important or unimportant is it to understand the causes of infertility (e.g. involvement in medical aspects)?
(Gilles, 2003: cited in Bridges, 2005: 11)
Benefit making can help bring to light some possible positives or life lessons associated with infertility. It is not meant to alleviate the distress associated with the loss but to aid in the process of meaning reconstruction. Such questions may include: “Where have they found surprise sources of support? What untapped strengths have they discovered? In what ways have they grown closer as a couple? What personal awareness has been discovered?” (Gilles, 2003: cited in Bridges, 2005: 11).
A diagnosis of infertility marks not only a change in one’s life course but also marks a change in identity. The following questions may be used to help understand both the process of identity change and the changes themselves;
How does the infertility diagnosis affect their view of self? How does the infertility diagnosis impact their view of their relationship? With the loss of the assumption of parenthood, what else has changed in their lives? In what ways has their general outlook on life changed (e.g. world view, philosophy, spirituality)?
(Gilles, 2003: cited in Bridges, 2005: 12)
Work in therapy on ‘continuing bonds’ can focus on the possibility of continuing a bond with the image of the ‘desired for’ or ‘unrealised child’. This could take the form of involvement in the lives of other children for example nieces or nephews. Continuing bonds can also focus on the difficult area of family or friends and how to deal with the unknowingly insensitive questions and sometimes thoughtless remarks. Dealing with personal and social relationships is an important component of meaning reconstruction. The following questions may help in the counselling setting;
Who in their lives is most supportive of the diagnosis of infertility? In what ways have relationships outside their primary one changed in light of infertility? What is the role of children in their lives in light of the infertility diagnosis? What connection, if any, is there with the anticipated and unrealized child?
(Gilles, 2003: cited in Bridges, 2005: 12)
The Person-Centered Approach
The Person-Centered approach is also effective in helping these clients.
Counsellors offering the core conditions of empathy, acceptance and congruence and following the client’s agenda can facilitate an individual, diverse, process. Recognising the intangible loss of a child not yet conceived is a primary purpose of many infertile couples’ grief. Accomplishing this recognition through catharsis as well as cognitive exploration is the function of the discourse of counselling: “Counsellors should be aware of the fact that the feelings associated with clients’ fertility status strike at the very core of their sense of self. Clients may never be completely finished experiencing these feelings” (Daniluk, 1991: 320).
Even if a couple succeed in having a baby, these feelings may linger in some shape or form. However a point of resolution and acceptance can be worked towards in therapy. Grief and loss can be managed. Identities can be reconstructed. Interaction with the outside world can become easier. And eventually the fertility difficulties may provide an opportunity for personal and relationship growth.
In order to address what can be done to alleviate the emotional struggle experienced by couples and individuals who have been diagnosed with infertility, therapists should be aware of therapeutic interventions available to them. It is evident that counselling can have a very positive impact on couples and can help them take stock of their lives which may have become engulfed in efforts to conceive. It is therefore difficult to imagine a couple or individual negotiating their way through this life crisis without professional guidance. It also brings to awareness the deep, emotional conflict associated with fertility problems, an awareness which may influence the choice around when to start a family. Most people factor having children into their life plan from an early age. However, whether or not there is an awareness of the possible obstacles involved, the presumption that it will happen seems to supersede any doubts. When this presumption is challenged the outcome can feel devastating.
For the majority of couples, infertility is likely to be experienced as a chronic stressor. Emotional distress and demanding treatments and experiences accumulate over an extended period of time requiring different coping strategies to successfully adjust, adapt, and maintain emotional and marital equilibrium regardless of the ultimate outcome (Covington and Burns, 2006).The problem of infertility may be permanent or temporary. It may last a couple of years or a lifetime. Most of the time there is no way of knowing and so the emotional pain often sees no end. However, with the support of a trained therapist, couples can be guided to rework their self-images, their identities and their relationship with each other and their extended families. This may help them to accept their current diagnosis and see themselves as having vital roles in their relationship, their family and in society.
Although, as a therapist, being equipped with appropriate counselling interventions is important, our most effective tool is our ability to connect with the clients and form a supportive and trusting therapeutic alliance. Ultimately, infertile couples want their feelings of despair, anxiety, sadness, loss or anger validated. For some it is about realising that these feelings are ‘normal’ for their situation, for others it is about recognising that they are experiencing a ‘life crisis’ and this is why they are feeling intense stress and anxiety and for some it is about being able to sit and cry and express their longing and desire for their own baby. Seeing the pain through their eyes is the first step towards healing. This pain is eloquently described by the words of a woman going through her own infertility journey:
Infertility is pain that is handed out in doses, it’s not all at once, it stays with you and lingers. I realize that I may never have a child of my own, it is a very real outcome that I try not to think about too much, yet the reality of that truth haunts me at times. I have felt pain both physically and emotionally. It doesn’t go away and it can’t be rated on a scale of one to ten, because the pain vibrates out and touches family members, spouses and friends in totally different ways . . . it touches whole lives and has little mercy.
Caroline Rock graduated from PCI with a BSc in Counselling and Psychotherapy. She currently works from her private practice in Ashbourne and in Slane, Co. Meath and is specialising in the area of Fertility Counselling. Caroline also works as part of the counselling team in SIMS IVF Clinic in Clonskeagh, Dublin. She can be contacted at <http://www.livewell.ie> or at 083-4393715.
Bernard, C.A. (2012). Don’t Ignore the Pain of Infertility. <http://cristaleen.blogspot.ie/2012/04/dont-ignore-pain-of-infertility.html>. Accessed on 10 September 2013.
Bridges, S.K. (2005). ‘A Constructivist Approach to infertility: Loss and Meaning Reconstruction’. Contemporary Sexuality, Vol. 39 (12).
Covington, S.N., Burns, L.H. (2006). ‘Infertility Counseling’. A Comprehensive handbook for Clinicians. UK: Cambridge University Press.
Daniluk, J.C. (1991). ‘Strategies for Counselling Infertile Couples’. Journal of Counseling and Development, Vol.69: 317-320.
Diamond, R., Kezur, D., Meyers, M., Scharf, C. N., and Weinshel, M. (1999). Couple Therapy for Infertility. New York: Guilford Press.
Ellis, A. (1977). ‘Rational-emotive therapy: Research data that supports the clinical and personality hypotheses of RET and other modes of cognitive-behaviour therapy’. The Counseling Psychologist, 7, 2-19.
Freeman, A., Pretzer, J., Fleming, B., and Simon, K. (1990). Clinical Applications of Cognitive Therapy. New York: Plenum.
Gibson, D.M. (2007). ‘The Relationship of Infertility and Death: Using the Relational/Cultural Model of Counseling in Making Meaning’. The Humanist Psychologist, 35(3), 275–289.
Glover, L., Gannon, K., Sherr, L., and Abel, P. (1996).’ Distress in sub-fertile men: A longitudinal study’. Journal of Reproductive and Infant Psychology, 14, 23–36.
Gonzalez, L.O. (2000).’ Infertility as a Transformational Process: A Framework for Psychotherapeutic Support of Infertile Women’. Issues in Mental Health Nursing, 21, 619 –633.
Human Fertilisation and Embryology Authority (1998). ‘The HFEA Code of Practice’. <http://www.hfea.gov.uk/code.html>. Accessed on 9th September 2013.
Long, L.L and Young, M. E. (2007). Counseling and Therapy for Couples (2nd edn.). Pacific Grove, CA: Brooks/Cole.
Nyboe Andersen, A., Goossens, V., Ferraretti, A.P., Bhattacharya, S., Felberbaum, R., de Mouzon, J., Nygren, K.G. The European IVF-monitoring Consortium for the European Society of Human Reproduction and Embryology (ESHRE). (2008) ‘Assisted reproductive technology in Europe, 2004’. Results generated from European registers by ESHRE. Human Reproduction, 23:756-771.
Raskin, J. D. and Bridges, S. K. (eds.). (2002) Studies in Meaning: Exploring Constructivist Psychology. New York: Pace University Press.
Smith, J.A., and Smith, A.H. (2004). ‘Treating Faith-Based infertile Couples Using Cognitive-Behavioural Counseling Strategies: A Preliminary investigation’. Counseling and Values, 49, 48-63.
Women’s Health Council. (2009). Call for Infertility Awareness. <http://www.rte.ie/news/2009/0923/fertility.html>. Accessed on 21st August 2011.
Whelan, E.M. (1980) A baby?….Maybe (2nd edn.). New York: Bobbs-Merrill.