Existential Issues in Experiences of Infertility

by Lindsay Mitchell

Involuntary childlessness affects one in six couples at some point during their lives and it is a unique journey for each individual who experiences it. This article will touch on some reactions to this experience, selected to illustrate some concerns of the existential approach to therapy.

Van Deurzen (1996) states that existential therapy is ‘concerned with the understanding of people’s position in the world and with the clarification of what it means to be alive’. It is based on the ideas explored by European philosophers of the nineteenth and twentieth centuries such as Keirkegaard, Nietzsche, Heidegger, Husserl, Jaspers and Sartre. Existential therapy uses a phenomenological approach which avoids ‘models that categorise or label people’ (Van Deurzen 1996) but rather allows for a description of the way that person is in the world, continually evolving and making sense of their existence.

One of the assumptions underlying the existential approach is that by confronting and coming to terms with the ‘givens’ in life, including uncertainty and their personal mortality, people can affirm their freedom and live more authentically, defined by Van Deurzen (1996) as being true to oneself. Not living authentically can lead to existential anxiety and guilt for an unlived life. The existential approach is diverse (Cooper 2005) and does not have ‘techniques’ but the therapeutic method may include striving to bracket the therapist’s assumptions and biases that would distort understanding of the meaning of the client’s life and situation. The purpose of existential therapy is to help people ‘come to terms with the transformative process of life’. Yalom (1980) states that the method of existential psychotherapy is one of deep personal reflection which is often catalysed by a ‘boundary’ experience, for example, the collapse of some fundamental meaning-providing schema.

In the context of meaning-providing schemas, involuntary childlessness can be an existential blow that has repercussions in many areas of the individual’s life. The impact of this experience will be explored in the context of Yalom’s four ‘ultimate concerns of life’: death, freedom, isolation and meaninglessness, which, though looked at separately, are all interconnected.

Death

“Infertility is a death experience… This was a part of my journey…. When you find you cannot achieve a pregnancy and eventually find out you can’t father a child, these children (of your hopes) die. You mourn their passing, even though they were never born.  My personal feeling at my diagnosis was guilt and shame”. (Brown 1998)

Yalom (1980) proposes that fear of death is the primal source of anxiety and that humans find different ways of achieving symbolic immortality including creative, theological and biological modes. When the sense of ‘generations inevitably succeeding one another’ (Raphael-Leff 1991) disappears, the individual confronts their own mortality and the two basic defences against the terror of death, identified by Yalom, are challenged. Firstly, the belief in one’s specialness: a client quoted by Goldenberg (1997) states, “… but this isn’t special. This is deficient!” Secondly, the belief in an ultimate rescuer is challenged and Cudmore (1997) notes that thoughts of punishment from God are common. ‘Even the most rational infertile person finds it hard to shake off the feeling that s/he is not being ‘allowed’ to have a baby, as a punishment for past unexpiated transgression or because it is inexplicably forbidden.  A frightening shadowy side of wanting to conceive is a continued vicious cycle of anxiety that the more it is wanted, the more it will be withheld’  (Raphael-Leff 1991).

Confrontation with one’s own mortality is also evoked in small domestic details.   What will happen to the family ‘heirlooms’?  It can be painful to look through photo albums where there are no photos of the next generation. For me, it is Munch’s image of ‘The Scream’ which comes closest to describing this visceral confrontation with my finite life, its absurdity and meaninglessness, and the lack of an ultimate rescuer. This experience of confrontation with nothingness is something I share with many other beings. Paradoxically, when I experience this abyss – as far as I can go for a brief time – I experience a shift in myself, an urge to want to engage with life, and my energy to find meaning in my own existence comes back. It is akin to Yalom’s (1980) description of one possible result of the confrontation with death being an ability to ‘trivialise the trivia in life’ and stop doing the things one does not wish to do.   The present moment, the here-and-now, becomes informed with vitality, because we realise we do not have forever.

Freedom

The ‘given’ of infertility means the individual must cope with and sometimes make challenging choices around how to ‘be-in-the-world’, about social, medical, financial, career, ethical and other aspects of their lives.   Of course, having a baby also affects many levels of existence (Arnold-Baker and Donaghy 2005).  The diagnosis of infertility can be a slowly unfolding situation which may or may not result in the arrival of the longed-for child and seeking help can confirm reality – the infertility cannot be denied and it may not be solvable.

I still feel I have an infertility problem. I don’t feel it is fixed by the birth of a child or even achieving a pregnancy. Because this problem still exists, there are still limits on my choices that would not be there if I was fertile. For example, the choice to try for a second child is in some respects harder than trying for the first (Brown 1998:172).

Ongoing developments in medical technologies offer hope but also bring lengthy periods of often intrusive and sometimes physically painful treatments, disruptive to life and ‘years of waiting, wishing and wanting sometimes extending into menopause’ (Raphael-Leff 1991). Given that the statistics for success (defined as ‘take-home-baby’) of ART (assisted reproductive technology) cycles average 15-25%, the chronic ambiguity and uncertainty about outcome can be the most disruptive of all the implications of embarking on high-tech treatments. Indeed, uncertainty of outcome accompanies this entire process – not only, will I become a mother or father but also: what will this next test reveal, will I produce enough eggs, will they fertilise … and so on. Once embarked upon, it can seem as though no part of this journey is under the person’s control.

The hope held out by medical treatment may even be withheld from the couple, reinforcing their feelings of lack of choice and failure:

This obstacle on our uphill struggle took us by surprise. Matt and I simply couldn’t choose a program. We had to be accepted into one – pass their test for which we couldn’t study or prepare the right answers. All we could do was apply and wait for their judgment. Again we felt out of control and physically inadequate (Harkness 1992:195).

Existential Isolation

Goldenberg (1997) states that ‘how to ‘be-in-the-world’’ is often the most difficult area for the involuntarily childless and that ‘they can feel a strong sense of isolation and alienation from family, friends and what they perceive as mainstream society’. Childless people can find their pain and isolation paradoxically highlighted at times of others’ joy and coming together, such as births, christenings, family gatherings and holidays.

Now that I’m a parent I have met dozens of people who empathize with me. It seems everyone knows what it’s like to be up all night with a crying baby.  All I need to do is reach out and there are friends and family saying, ‘We’ve been there ourselves, you’ll make it through.’ That is the difference between now and then.  I faced my infertility on my own. It was, and still is, the most isolating, lonely, frustrating experience I have ever had (Harkness 1992:327).

As well as the individual losing the opportunity to navigate a significant stage in adult development, couples can feel that they never make the transition from being a couple to being a family, and the long struggle with infertility can have damaging and/or strengthening effects on their relationship. Whether the couple part or stay together, their experience together seems to create a poignant awareness of the other.

You cannot imagine the bonds in a childless marriage. Bonds of guilt from the partner to blame, and bonds of compassion from the other.  So while the relationship may have its joy and light in other areas, on the issue of childlessness, there is a bond of shared sadness (Brown 1998:180).

In the view of Raphael-Leff (1991), ‘Each person in the couple may be privately protecting a small flame, fearful of allowing their partner’s ‘sense of loss, anger, grief and disappointment from flooding in and extinguishing it – thus even hope can increase the insularity and isolation’. Goldenberg (1997) believes that the experience of infertility ‘can be felt as a separation from the core and rhythm of life, sometimes to the point where the infertile can doubt the reality of their own existence’.

Meaninglessness

The person can find themselves painfully confronting the meaning of their own existence:

At this particular point in time, it is difficult for me to view my life as truly meaningful without children.  My belief – whether I like it or not – is that being a parent defines a person as a human being more clearly than does any other role in life.   I see this as true for both women and men. Consequently, no matter how I struggle, I see myself as an undefined, unfulfilled, insignificant person….While it is not unbearably painful to attend baby showers or to spend time with young families, doing so heightens the sense of my own life’s relative meaninglessness  (Harkness 1992: 353).

There may be a fear that failure to conceive will render the person’s whole life as meaningless, that they will in a sense be invisible and worthless. Goldenberg (1997) states that their ‘struggle is often to find new reasons and new ways to live’.

Therapy

With its focus on disclosing and understanding what it means to be alive for the client, existential psychotherapy ‘is likely to provoke a confrontation with myriad values, beliefs, assumptions and judgments that the client has maintained without properly acknowledging or reflecting upon their existence and their impact’ (Spinelli 1997). In therapy, an opportunity exists to reflect upon the value and meaning the person attaches to being a biological parent and the assumptions and beliefs they hold about not being a biological parent. Perhaps this reflection will reveal that some of these beliefs and values are fixed, or ‘sedimented’, to the extent that they may be limiting the contemplation of new ways of being-in-the-world.  The concept of un-knowing outlined by Spinelli expresses ‘the attempt to treat the seemingly familiar …as novel, unfixed in meaning, accessible to previously unexamined possibilities’.  Through increasing awareness of our freedom to choose our responses to life’s givens, we can also experience the anxiety which this responsibility and freedom provokes, given the uncertainty of outcome.

The therapist becomes both the representative focus point towards which the client expresses his or her way of being and the ‘exception to the rule’ whose way of being with the client provides the client with the possibility of experiencing and allowing novel ways of being (Spinelli 1997). Spinelli also states that ‘existential-phenomenological theory assumes that all reflections upon our lived experience reveal that existence is relationally-derived’. Whether this is something you agree with or not, the therapeutic relationship can provide a useful focus on ‘being-with-others’, the chance to examine a core issue of isolation for those experiencing infertility, possibly manifested through secrecy, shame and shutting out others, as well as feeling excluded.

There are many valuable approaches to therapeutic work with those experiencing infertility, such as cognitive behavioural therapy (Hunt and Monach 1999), bodywork, gestalt therapy, biofeedback, relaxation techniques, visualization, ritual and hypnotherapy. Group work can also be very helpful and there is a reasonable body of literature on using some of these approaches in this field.   Increasingly, people complement medical treatment with self-help activities and support groups (National Infertility Support and Information Group), including online groups and helplines, and these can reduce feelings of isolation and lack of control.

Infertility has been characterised as quintessentially an experience of loss – for example, loss of physical experiences such as pregnancy and the sensuality of small children; of social experiences and family relationships associated with parenting; the loss of the hoped-for future and roles with one’s partner; and spiritual loss, possibly a sense of abandonment by god. It is also a loss which is not characterised by memories. The ‘diagnosis’ may not be certain and the loss may not be absolute for many years – technology, fertility-enhancing techniques and the possibility of a ‘miracle’ can offer hope for a long time for lots of people, making it hard to know when to decide to move on. Yalom (1980) has some interesting insights into the difficulty of making decisions – ‘to decide one thing always means to relinquish something else … decisions are very expensive, they cost you everything else’.    Loss can also be a key element in depression and there is evidence that those experiencing infertility are vulnerable to depression, possibly at twice the expected rate (Domar 1993).

This brief look at the experience of infertility through some existential dimensions has, of necessity, been limited. Issues of embodiment and time, for example, which are relevant to both topics, are worth exploring and the interesting area of therapy for fertility enhancement, revealing body-mind connections, has a small number of research publications. Although rooted in philosophy, an existential dimension in therapy is not a detached, intellectual endeavour, but rather, it can give us a language to help us understand our individual experiences, emotions, beliefs and responses in the context of wider universal human concerns.

Lindsay Mitchell is a psychotherapist in practice in Limerick and is a pre-accredited associate of IAHIP.   She can be contacted at cordiner@eircom.net

References

Arnold-Baker, Claire and Donaghy, Miriam (2005) Procreation. In Emmy van Deurzen and Claire Arnold-Baker (eds) Existential perspectives on human issues: a handbook for therapeutic practice.  Basingstoke: Palgrave Macmillan.

Brown, L. (1998) Why me ? The real-life guide to infertility.    East Roseville: Simon & Schuster, Australia.

Cooper, Mick (2005) Therapeutic background.  In Emmy van Deurzen and Claire Arnold-Baker (eds) Existential perspectives on human issues: a handbook for therapeutic practice.  Basingstoke: Palgrave Macmillan.

Corey, G. (1996) Theory and practice of counseling and psychotherapy. Pacific Grove: Brooks/Cole.

Cudmore, L. (1997) The loss of the fantasy baby,  Journal of Fertility Counselling 4 (2) : 16-18.

Domar, A. D. et al. (1993) The psychological impact of infertility : a comparison with patients with other medical conditions,   J. Psychosom. Obstet. Gynaecol. 14 Suppl.: 45-52.

Goldenberg, H. (1997) Who am I, if I am not a mother?  In Simon du Plock (ed.) Case studies in existential psychotherapy and counseling. Chichester: Wiley.

Harkness, C. (1992) The infertility book: a comprehensive medical and emotional guide.  Second edition.  Berkeley: Celestial Arts Publishing.

Hunt, J. and Monach, J. (1999) Cognitive behavioural therapy: a valuable approach to infertility counselling, Journal of Fertility Counselling 6 (1) :18-21.

National Infertility Support and Information Group  

Raphael-Leff, J. (1991) Psychological processes of childbearing. London: Chapman & Hall.

Spinelli, E. (1997) Tales of un-knowing : therapeutic encounters from an existential perspective.  London: Duckworth.

Van Deurzen Smith, E. (1996) Existential therapy.  In Windy Dryden (ed ) Handbook of individual therapy. London: Wiley.

Yalom, I. D. (1980) Existential psychotherapy.  New York: Basic Books.