EMOTIONAL CHALLENGES OF THE REPRODUCTIVE YEARS: PART I - INFERTILITY & PREGNANCY LOSS
Gina Hassan, Ph.D., Donna Rothert, Ph.D., & Lee Safran, MFT.of Perinatal Psychotherapy Services - A collective of psychotherapists who specialize in issues facing women during the reproductive years.
(These articles appeared in the Alameda County
Psychological Association Newsletter, Fall and Winter
issues of 2006, and in the CAMFT Magazine, The Therapist.)
Daria is a 42 year-old woman who, along with her partner, has been trying to begin a family for the past 18 months. She has had two pregnancy losses and multiple medical interventions in an attempt to increase her chances of conceiving and carrying a healthy baby to term. Daria has a high stress career and she is tired and depleted as a result of the many months of hope and disappointment. She feels angry and isolated because all of her friends have had children without difficulty. She also feels ashamed of and frustrated with her body for failing her. Deeply pained by the multiple losses she has suffered, Daria is becoming increasingly isolated and feels that her friends and family are insensitive to her pain.
This vignette illustrates some of the complex issues that individuals experiencing infertility and pregnancy loss may face. With increasing numbers of professional women delaying childbearing, a factor that significantly raises the risk of both infertility and miscarriage, many of us are seeing women in our practices who are struggling with reproductive crises. The following is a brief overview of relevant issues and treatment options for those experiencing infertility and pregnancy loss.
Infertility, defined as the diminished ability or the inability to conceive and have offspring after a year of regular intercourse without contraception, affects about 10-13% of heterosexual couples. (Medicinenet.com 2006) Infertility is first and foremost a stressful experience, often including physical, social, financial and psychological challenges. An infertility diagnosis can give rise to a profound sense of loss including: the monthly disappointment, miscarriages, the loss of conception being natural and without intervention, the loss of intercourse being spontaneous and romantic as opposed to on demand or technical, and sometimes the loss of the idea or dream of pregnancy.
Women’s individual experiences of infertility vary, yet there are a number of common factors which most women will experience: feeling that one is being left behind, that one is being denied a biological right, that one’s body is failing, that one is failing one’s partner, and that one’s sexual identity has become a merely physical identity - a constellation of sexual/biological organs which are prodded and probed and treated as scientific objects. Additionally, single people and same sex couples may face insensitivity and discrimination in their efforts to conceive. Given the sense of exposure during this process, both to the medical world and well-meaning friends and family inquiring about pregnancy status, many women feel like they are under the microscope.
Grief work may be an important component of working with women experiencing infertility; however, unlike grieving a pregnancy loss, which is a known outcome, infertility grief exists in relation to an uncertain outcome. It is one that involves recurrent hopes and disappointments which over the course of time can lead to anger, shame, vulnerability, feelings of hopelessness, poor self esteem, social isolation, anxiety, and depression. Acknowledging and making a place for women to speak about their anger, sadness, hopelessness and lack of control, are similarly important features of treatment with women seeking counseling for infertility. Stress reduction techniques such as meditation or progressive relaxation can be helpful for managing recurrent and ongoing stress.
Normalizing the tendency to feel envious of others and helping women find ways to address their need to protect themselves from painful situations, for example attending baby showers or children’s birthday parties, while not becoming overly isolated, will be important goals in therapy. Identifying primary triggers and helping each woman to identify and articulate the kind of support she needs is important, as well as helping her figure out how best to communicate her needs in a way that feels acceptable to her, and most likely to achieve the desired results. While individual therapy can address many of these issues, groups can be invaluable in helping women feel less alone and isolated during this struggle.
Couples work can be helpful in supporting healthy communication between partners. Men and women often experience and cope in different ways and it is important to make room for individual differences. Sex and money, challenging issues for many couples, may be particularly stressful for couples who are not only undergoing scrutiny of their sexual and reproductive life, but going into debt to do so. Therapy can also be helpful in supporting the strengths of the couple such that they do not become overly focused on family building, but can continue to make room for enjoying their relationship for what it is.
A significant number of wanted pregnancies end without a baby. Approximately 15-20% of known pregnancies end in miscarriage (before 20 weeks gestation) and about 1% of pregnancies end in stillbirth (a loss at 20 weeks gestation or later). Additionally, couples may decide to terminate a pregnancy after a prenatal diagnosis of serious illness or be advised to undertake a selective reduction of a multiple (twins or higher order) pregnancy for medical or other reasons. Although there are very significant differences in these experiences in terms of length of pregnancy and whether or not there is an element of decision-making, all types of pregnancy loss may lead to strong emotional responses and psychological complications.
As research since the 1980s has shown us, the vast majority of women become significantly attached to their babies prior to birth, and indeed, it is considered a major psychological task of pregnancy to do so. Although responses vary, and typically are more intense following later losses or recurrent losses, any neonatal death may lead to a significant grief response with a wide range of feelings including depression, guilt, anger and confusion.
In addition, aspects associated with many pregnancy losses (blood, shock, labor induction and the resulting labor and delivery of a baby that is known to be dead) may be traumatic and lead to complications such as dissociation and survivor guilt. The lack of bereavement rituals for pregnancy loss and cultural discomfort with emotional reactions to miscarriages, stillbirths and other types of pregnancy loss may contribute to one’s sense that these feelings are unacceptable.
Whether due to this perception that their feelings are intolerable to others, or because part of the early grief process often involves fear and a sense of being overwhelmed, people experiencing perinatal bereavement often minimize or deny their reactions. Unfortunately, this common strategy can lead to greater distress and longer lasting symptoms. Individual treatment may be beneficial to many people following a pregnancy loss, but is specifically indicated for those experiencing the most severe symptoms, especially if suicidal ideation and/or significant dissociation is present.
Group treatment may take place through hospital or other drop-in support groups or ongoing weekly therapy groups comprised of those who have experienced neonatal loss. Participation in such groups can decrease isolation, as well as normalize and validate the range of grief responses. Groups can also provide a safe place to process the individual meaning of the loss and consider future decisions. Couples therapy may be useful for coping with incongruent grief responses, decreased intimacy and feelings about trying to conceive again. All treatment options for those who have experienced pregnancy loss and/or infertility can make an enormous impact for people processing what is often a life-changing experience.
Kohn, I. and Moffit, P.L. A Silent Sorrow Pregnancy Loss: Guidance and Support for You and Your Family, Routledge, New York, 2000
Peoples, D. and Ferguson, H. Experiencing Infertility: An Essential Resource, Norton & Co, New York, 1998
Speckhard, A. Traumatic Death in Pregnancy: The Significance of Meaning and Attachment, Ch.4 in Death and Trauma: The Traumatology of Grieving, Figley, et. al ed.s, Taylor & Francis, Washington, D.C., 1997 Resolve: The National Infertility Association.