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Infertility: Interventions for Shame, Mourning, and Feelings of Inferiority
Infertility continuing education MFT CEUs

Section 8
Psychotherapy from a Reproductive Story Perspective

CEU Question 8 | CEU Test | Table of Contents
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

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On the last track, we discussed couple issues in early and middle immersion phase.  This included the roller coaster of hope and despair, loss of innocence, miscarriages and secrecy and protection.

On this track, we will discuss a therapeutic approach to early and middle immersion.  This will include separate sessions, using metaphors, tracking losses and the "mourning a miscarriage" technique.

With the diagnosis of infertility and the increased involvement with the medical system, couples tend to experience heightened stress and anxiety and subsequently are most likely to come into therapy.  Couples often fail to realize how profoundly their distress is affecting the marital relationship until the situation feels dire.  The shifting extremes of hope and despair have a cumulative emotional effect on each partner and put great stress on the couple’s relationship.  Couples eventually may become concerned that the marriage will no longer be able to tolerate the tribulations.

Sid, age 34, and Alicia, age 32, had been arguing for months before they came to see me.  Sid stated, "Had we not been so focused on getting pregnant, we probably would have noticed the toll on our relationship much sooner."  Alicia stated, "We started to question whether we could stay together, if we ever got to be parents.  Then we knew we had let things go on for much too long."

In view of the powerful effects of infertility, I chose to delay any assessments of functioning or personality with Sid and Alicia.  By the second or third session, Sid and Alicia were calmer and less distressed, and then I could assess them more accurately.

3 Approaches to Early & Middle Immersion

#1 Separate Sessions
First, let’s discuss separate sessions.  I found that holding separate sessions with the couple is especially helpful during the immersion phase, in order to validate each partner’s experience.  In the validation process, I can gently probe for problematic beliefs and conflicting feelings that may be contributing to my client’s pain. 

Embedded in the sadness, there may be feelings of grief, anxiety, and anger.  Feelings of defect, whether about the self or the partner, a sense of being less womanly, less manly, or less sexy, and fantasies of ending the relationship or having a baby with another person are common.  Often, these ideas are so overwhelming that the partners may not feel they can discuss these feelings with the other.

I have found that one issue that frequently arises in separate sessions with men is that they feel as though they are not entitled to an equal voice in decision-making about infertility treatments.  They feel they can support their partner’s ending treatment, but that they cannot ask her to continue with treatment because her body is the site of most procedures.  As an offshoot of this thinking, men also may feel that they cannot discuss their feelings of helplessness with their partners. 

In order to bring his voice into the couple sessions, I first try to normalize the man’s feelings by stating that such feelings are common in these situations, and then open up the possibility regarding him discussing his sense of powerlessness with his partner.  The idea is not so much for the man to gain equal voice as it is for him to acknowledge his feelings.

'Future Questions' Intervention
One intervention that I use, when partners are reluctant to discuss significant thoughts and feelings with each other, is to use "future questions."  I explore by asking future questions regarding the longer-term implications of talking or not talking to one another.  Asking these questions can create an atmosphere that allows couples to speak openly about their deepest, sometimes painful thoughts and feelings with each other.

#2 Using Metaphors
Second, let’s discuss using metaphors.  In exploring meaning and belief systems, clients’ metaphors about themselves and the infertility will often be revealed.  Working with metaphors can be especially helpful for couples undergoing this ordeal because metaphors help them describe their experience.  After revealing current constraining metaphors by which couples define themselves or their infertility, I can then ask my clients to create a related but alternative metaphor, thus reframing the material in a positive light.

Here is how I used metaphors with Sid and Alicia

When Sid was diagnosed as being infertile, his wife, Alicia wanted to have a child using donor inseminations.  In an individual session, I asked Alicia, "How included or excluded will Sid feel about having a child with donor sperm?"  Alicia replied, "Sid feels excluded from everything.  He uses this imagery that he’s a lone wolf on the tundra." 

In a separate session with Sid, he talked to me about this lone wolf metaphor.  I asked if he might be able to change the metaphor of the lone wolf to a more inclusive one.  In a later session, Sid stated, "I want to be more active, more like a guardian protector role, so I thought about being an English sheepdog whose role is to guard the sheep."  Would the use of metaphors be beneficial to a client you are current treating?

#3 Tracking Losses
Third, in addition to separate sessions and using metaphors, let’s discuss tracking the couples’ experiences of loss.  Because immersion is the most physically demanding phase, many of the couples’ losses are quite tangible, such as failed treatment attempts and miscarriages. 

Three Questions for Tracking Losses
At each session, I try to keep track of how the couple is experiencing and dealing with these losses by posing questions, such as the following: 
-- A. "Which one of you experienced the treatment failure, miscarriage…etc. as a greater loss?" 
-- B. "Which one of you is more inclined to speak about it with the other?" 
-- C. "What might be the consequences of not discussing this particular treatment failure, miscarriage…etc.?"

Technique: Mourning a Miscarriage
I often suggest that couples use a technique that I call "mourning a miscarriage."  Like the "mourning ritual" technique from track 3, "mourning a miscarriage" involves the couple creating rituals of their own.  However, where the mourning ritual deals with the general loss of infertility, mourning a miscarriage is more specific.  Sid and Alicia had suffered three miscarriages during their infertility treatments, and asked me if I had any suggestions about how they might commemorate their loss.  I suggested that the ritual involve special items like baby clothes or a memorial object of some sort. 

Four Questions for Preparing for a Mourning Ritual
To help Sid and Alicia prepare for their ritual I asked a few questions like:
-- A. "What do each of you need to say?" 
-- B. "What kind of preparation do you need to do?" 
-- C. "Who do you wish to include?" 
-- D. "Does this selected site work for both of you, and does it have a special meaning related to the mourning?"

Sid and Alicia chose to plant three pine trees in their yard to commemorate their three miscarriages.

On this track, we have discussed a therapeutic approach to early and middle immersion.  This has included separate sessions, using metaphors, tracking losses and the "mourning a miscarriage" technique.

On the next track, we will discuss late immersion phase, the donor decision.  This will include genetic loss, egg donation as an "affair," sperm donation as "rape" and feeling like an impostor.

Peer-Reviewed Journal Article References:
Darwiche, J., Favez, N., Maillard, F., Germond, M., Guex, P., Despland, J.-N., & de Roten, Y. (2013). Couples’ resolution of an infertility diagnosis before undergoing in vitro fertilization. Swiss Journal of Psychology, 72(2), 91–102. 

Galst, J. P. (2018). The elusive connection between stress and infertility: A research review with clinical implications. Journal of Psychotherapy Integration, 28(1), 1–13.

Jaffe, J. (2017). Reproductive trauma: Psychotherapy for pregnancy loss and infertility clients from a reproductive story perspective. Psychotherapy, 54(4), 380–385. 

Online Continuing Education QUESTION 8
What are five therapeutic approaches to early and middle immersion? To select and enter your answer go to CEU Test.

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