Some Issues Relevant to Brief Psychotherapy for Married Couples Diagnosed with Infertility Stress Syndrome
Brief psychotherapy can be helpful for couples who are experiencing stress and relationship difficulties in response to diagnosis or treatment of infertility. A therapeutic intervention 10 to 20 weeks in length can be helpful whether or not the medical infertility diagnosis indicates a temporary repairable problem, a permanent condition, or a problem of unknown cause and unknown duration.
Selection of patients
Infertile couples seeking treatment represent a population which typically develop a neurotic level of illness in response to stress (Abbey, Andrews, & Halman, 1991). Guidelines which elaborate on Sifneos' criteria for selection of patients are offered by Nielsen and Barth (1991) and can be appropriately applied to this population. A very brief explication of these criteria is as follows:
- Can the patient circumscribe his or her chief complaint or assign top priority to one out of several difficulties?
- Did the patient have at least one meaningful relationship with another person during his or her childhood?
- Can the patient interact flexibly with the evaluator, that is, experience and freely express feelings during the interview?
- Does the patient give evidence of psychological sophistication?
- Does the patient show adequate motivation for change and not just for symptom relief? (p. 49).
Etiology and course of infertility stress. For most couples the course of medical infertility diagnosis and treatment can take from one to three or more years. Research has shown that the first and third-plus years are the most stressful with couples reporting significant levels of marital dysfunction by the third year (Berg & Wilson, 1991).During that time one or both partners may develop Infertility Stress Syndrome, a stress response to infertility which has many of the characteristics of Post Traumatic Stress Disorder (Millard, 1993).
When infertility treatment is unsuccessful, couples who choose to pursue adoption typically find an infant to adopt within one to two years. Making the transition into adoption can be painful, for it often requires an acknowledgement of the failure of infertility treatment and the likelihood of permanent infertility.
One recent study which included 84 adoptive parents (who had adopted within the last five years) showed that 30% of these parents reported current infertility related stress responses (related to a preadoption stress event) which exceeded trauma norms for rape and family trauma. For 10% of these adoptive parents, the elapsed time since the stress event was almost three years—2.9 years (Millard, 1993).
At various stages in the infertility experience, such as diagnosis, treatment, deciding to terminate treatment, or deciding to pursue adoption, couples can benefit from brief psychotherapy to help them adjust to the stresses and requirements of each stage. Some couples might benefit from brief assistance at every stage; others may only need help at one particular point and not another.
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Assessment of Infertility Stress Syndrome
Brief assessment measures such as The Impact of Events Scale (Horowitz, 1979), can be used to track levels of response to infertility across time, and can indicate whether or not the level of stress is significant. Norms for other stressful events such as rape, family trauma and loss of significant other are available for comparative purposes (Figley, 1985).
A brief measure to assess the level of painful and uncomfortable feelings in response to commonly encountered reproduction-related stimuli can also provide an indication of the level of disturbance of cognitive schemas related to reproduction. The measure, the Reproductive Schema Vulnerability Scale (Millard, 1993) can be used in conjunction with the IES to provide a brief assessment of infertility-related cognitive and emotional distress.
In describing the stress responses they experienced during the acute phase of ISS, 133 subjects had mean scores on the IES which were significantly above the norm for rape and family trauma. Over one fourth of couples (26.6%) in the recovery phase scored above these norms (Walling-Millard, 1993). Clearly, this is a population in distress, one which would likely benefit from brief psychotherapy.
Evaluation of the level of distress can be utilized in forming the treatment plan. Horowitz (1991) states,
When the stress event is ongoing, aims may center on fairly direct support. When the event's external aspects are over, but the person swings between paralyzing denial and intolerable attacks of ideas and feelings, then the immediate aim is to reduce the amplitude of these swings. Similarly, if the patient is frozen in a state of inhibited cognitive-emotional processing, then the therapist must both induce further thought and help package these responses into tolerable doses (p.173).
Unlike treatment situations in which the stress event is past, such as the recent death of a parent, the course of infertility treatment and the transition (for a number of infertile couples) into the adoption process represents a potential source of cumulative losses and ongoing stress events. Brief psychotherapy with this population requires appropriate support as well as a clear focus on developing more functional ways to contain and process individual and interpersonal conflicts engendered by the infertility experience.
Gender dynamics of infertility stress. A review of the infertility literature found that studies of infertile couples report significant distress in those undergoing medical treatment experience, with women more distressed by the infertility experience than men (Millard, 1993).
One study found that emotional distress due to infertility problems was greater for women regardless of whether the husband or wife was infertile (Stanton, Tennen, Affleck & Mendola, 1991). In addition to significant gender differences in response to infertility stress, one study found more highly divergent gender differences in the severity of stress responses during the acute phase of Infertility Stress Syndrome and less divergent (but still significant) gender differences during the recovery phase of ISS. The data showed that the lower the stress level, the lower were the gender differences in stress responses (Millard, 1993).
Clinical work with couples under stress has revealed that the coping styles of men and women vary significantly. The originators of Constructivist Self Development Theory, a theory and treatment model which focuses on trauma survivors, emphasize that helping couples understand and tolerate each other's divergent styles can attenuate an exacerbation of stress-induced conflict (McCann & Pearlman, 1990).
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Goals and Relevant Dynamics of Brief Psychotherapy for Infertile Couples
Horowitz (1991) has defined the goal of short-term psychotherapy as one in which the therapist works to help the patient at least regain his or her present level of personality functioning (p.167). He adds that larger goals are also possible--for example, to rework the predisposing conflicts that might have combined with the stressful event to lead to symptom formation (p. 167).
In the context of infertile couple's therapy such a goal can be expanded to include the larger interpersonal context of the marital relationship. The work would include the construction of a modified working model of each partner's view of his or her self, as well as the view of the couple, with a gradual incorporation of the realities of the infertility experience. Therapeutic work involves modifying schemas such as role relationship models so that the person's inner expectations of self as related to another will accord with new realities (Horowitz, 1991, p. 169).
The type of infertility diagnosis (or the lack of clear diagnosis) can influence each partner's response to such efforts. Some individuals, even after years of medical treatment, will resist making decisions (such as moving on to adoption) which they feel will indicate a loss of hope for a successful pregnancy (and the loss of the image of the self as fertile and normal).
Each spouse carries an image of the couple which has its own relationship to realistic and idealized models. A goal in brief psychotherapy with infertile couples would be to carefully facilitate discourse with (and about) the couple, in order to acknowledge that the image (or cognitive schema) of the couple is being modified as well as the image of each partner.
Interpretations which identify pathogenic beliefs related to each partner and the marital relationship can be offered when appropriate. Further interpretations can be made which associate the couple's current stress experience with previous experiences of marital stress, including the view each spouse has of his or her parent's behavior under stress. These observations can then be integrated with discussion of the way in which the partners experience the therapist's containment of their stress responses and their image as an infertile couple.
Issues of loss and shame. There is often a feeling of shame in response to the failure to progress normally through the developmental phase of reproduction and parenthood. When an experience such as an infertility diagnosis enters into the self/couple image, there is a disruption of the sense of having the typical reproductive choices, and a loss of the experience of being like other people. For some partners shame and guilt may arise, either for the part the individual played in bringing this loss upon the self and the couple, or for one's role in bringing the stigma of infertility into the public image of the self and the couple.
Morrison (1989) states: These constructs [of the ego ideal and the ideal self] play a central role in the evolution of shame as affective experience. Reflecting experiences of failure, inferiority, and defect, shame must be viewed as the consequence of failure to attain the ideals that one forms for oneself and hence failure to fulfill the mandates of the intrapsychic structures that contain these ideals (that is, superego, ego ideal, and ideal self) (p.38). Since it may present in a less pernicious and intractable form than in severe narcissistic (primitive) states, the shame experience need not be a signal of archaic psychopathology (p. 47).
For the infertile couple, then, shame can manifest as Morrison describes: ...in response to public exposure...but shame may also be a response of the viewing, experiencing self alone to internal need and failure. Here, the subjective quest for selfobject attunement and responsiveness, and the response of shame to repeated selfobject absence or failure, complicates the matter of shame as an internal or external (relational) response (p.194).
Once an infertile couple enters into the quest for a successful pregnancy, or at a later time seeks out a baby to adopt, issues (and fantasies) beyond the individual or couple begin to emerge. The couple begins to think of themselves as incipient parents with emerging private fantasies and accompanying open discussions of the expected baby. Each monthly cycle and attempted pregnancy, each infertility treatment -- and its promise of success -- can elicit more fantasies.
Each partner constructs an internalized object of the expected baby as this process continues. Infertility researchers have speculated that women's greater incidence and severity of infertility distress derives in part from the fact that they are more involved and more identified with reproductive processes (Toedter, Lasker, & Alhadeff, 1988, Walling-Millard, 1993).
Each loss of an expected pregnancy or an actual pregnancy often results in a sense that the baby held in fantasy has been lost, either temporarily, or permanently. Feelings of shame may reemerge at this point in relation to the sense of failure.
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Grief issues in infertility
The brief psychotherapy models presented by Horowitz, (1991) and Nielsen & Barth, (1991) lend themselves to the process of working through grief. Such issues abound in infertility, and with each additional stress and loss, frustration and anger are more likely to be displaced. This dynamic can disrupt the couple's relationship even further. If the loss involved an actual pregnancy or a particular adoption opportunity, the earlier fantasy baby, (merged with the actual baby being expected) will then be experienced as lost. This loss must be mourned if the couple is to make a healthy transition to a subsequent opportunity. One goal of brief psychotherapy with infertile couples would be to provide an interpretation of this process, and an acknowledgment of the origins and construction of the fantasy baby as a normal preparation for parenthood. The process would involve a gradual acceptance of the loss of the particular pregnancy or adoption opportunity, while acknowledging the resilience of the fantasy baby when it reemerges at the onset of contemplating the next opportunity. Attention to individual differences is important at this stage, because either spouse may take a defensive position vis a vis the sought-after baby and may resist participating in fantasies or discussions about the baby.
One study showed that infertile women are significantly more vulnerable than men to stimuli related to reproduction (such as the sight of a pregnant woman) and are more likely, as a result, to have painful intrusive thoughts related to infertility (Millard, 1993). This suggests that, for a number of reasons, including the identification of women with their mothers, and the traditional centrality of mothers as primary caretakers of infants, women who have decided they are ready to become mothers may not be as motivated or as able as men to defend against powerful fantasies of the mother/infant experience they desire.
Differences in the level of desire each spouse feels for the baby may emerge as grounds for conflict. If the woman's desire is strong and the man's position is increasingly defensive and self-protective, the woman may interpret this difference as abandonment, a default in partnership, or a retreat from the goal of parenthood per se. At this point, one goal of psychotherapy would be to restore (as much as possible) the sense of mutual holding previously experienced by the couple (Scharff & Scharff, 1991).
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Disruptions of the sexual relationship
The combination of stress-induced interpersonal conflict and medical interventions into the sexual relationship of the infertile couple can result in a loss of motivation or ability to enjoy the sexual relationship. Sex on demand to satisfy infertility treatment schedules often results in impotence on the part of the husband. After weeks of mood-altering oral medications or daily self-injection of hormones to stimulate ovulation, the wife may see her husband's inability to function as betrayal or sabotage.
Another goal of brief psychotherapy with infertile couples, then, is to help them cope with the vicissitudes of treatment in the context of their sexual relationship. As an adjunct to couples therapy, an infertility support group, such as those offered by Resolve, (a non profit infertility support and referral organization), can help couples see the disruption of their sexual relationship as normal in the context of treatment, and can also help them appreciate the temporary nature of the disruption.
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Transference and countertransference
Attention to transference and countertransference issues, in addition to projective identification dynamics, is important for work with couples managing the various crises of infertility and adoption. For a brief discussion of these issues, the reader is referred to Infertility Stress Syndrome: Trauma Exacerbated by Gender Differences (Millard, 1993). For a thorough discussion of psychodynamic psychotherapy with couples the reader is referred to Object Relations Couples Therapy (Scharff & Scharff, 1991).
Brief psychodynamic psychotherapy for infertile couples can equip patients with improved awareness and coping mechanisms which can serve them at various phases of infertility treatment. It can also provide the couple with an experience of the usefulness of couples therapy, making it easier to return for further help if and when it is needed. Such assistance can attenuate stress throughout the course of the couple's relationship, and can serve to reduce stress-related medical problems.
Many general practice clinicians (medical or psychiatric) are unaware of the severe stresses associated with reproductive loss, infertility and adoption. Hopefully, the increase in research and the use of more commonly understood assessment measures (such as the Impact of Events Scale) may encourage service providers to acknowledge the utility of brief psychotherapy for infertile couples.
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Abbey, A., Andrews, F.M., & Halman, L.J. (1991). Gender's role in responses to infertility. Psychology of Women Quarterly, 15, 295-315.
Berg, B.J., & Wilson, J.F. (1991). Psychological functioning across stages of treatment for infertility. Journal of Behavioral Medicine, 14, 11-26.
Figley, C.R. (Ed.). (1985). Trauma and its wake: The study and treatment of post traumatic stress disorder. New York: Brunner/Mazel.
Horowitz, M.J. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209-218.
Horowitz, M.J. (1991). Short term dynamic therapy of stress response syndromes. In P. Crits-Kristoph & J. Barber (Eds.), Handbook of short term dynamic psychotherapy (p. 166-198). New York: Basic Books.
McCann, L., & Pearlman, L. (1990). Psychological trauma and the adult survivor: Theory, therapy and transformation. New York: Brunner/Mazel.
Millard, M. (1993). Infertility stress syndrome: Trauma exacerbated by gender differences (a study of preadoptive and adoptive parents). Unpublished doctoral dissertation, The Professional School of Psychology, San Francisco, California.
Morrison, A.P. (1989). Shame: The underside of narcissism. Hillsdale, N.J.: The Analytic Press.
Nielsen, G. & Barth, K. (1991). Short-term anxiety-provoking psychotherapy. In P. Crits-Kristoph & J. Barber (Eds.), Handbook of short term dynamic psychotherapy (p.45-79). New York:Basic Books.
Scharff, D., & Scharff, J. (1991). Object relations couple therapy. Northvale, NJ: Jason Aronson, Inc.
Stanton, A.L., Tennen, H., Affleck, G., & Mendola, R. (1991). Cognitive appraisal and adjustment to infertility. Women & Health, 17, 1-15.
Toedter, L.J., Lasker, J.N., & Alhadeff, J.M. (1988). The Perinatal Grief Scale: Development and initial validation. American Journal of Orthopsychiatry, 58, 435-499.
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