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

Section 16
Why Isolation & Guilt Affect Women More

CEU Question 16 | CEU Answer Booklet | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Psychological Impact of Infertility
A myriad of feelings, thoughts, and beliefs that couples and individuals experience contribute to the "crisis of infertility" (Cook, 1987; Leader, Taylor, & Daniluk, 1984; Menning, 1980). This crisis involves an interaction among physical conditions related to infertility, possible medical interventions to diagnose and treat infertility, social constructions about parenthood or nonparenthood, reactions of others, and individual psychological traits (Cook, 1987). In dealing with all of these factors, the couple or individual may find that they lack the resources (e.g., medical, social, or psychological resources) to provide support for themselves and their partners (Leader et al., 1984). Although both individuals in a couple may experience this "crisis," research has indicated that women are more negatively affected by infertility (Abbey et al., 1991; Daniluk, 1997; Raval, Slade, Buck, & Lieberman, 1987; Ulbrich et al, 1990; Wright, Allard, Lecours, & Sabourin, 1989). Three factors that provide a better understanding of the psychological impact of infertility for women include the social construction of infertility, emotional responses to medical diagnosis and treatment, and gender differences in emotional responses to infertility. Ethnicity may also be another factor that could provide a better understanding of the psychological impact of infertility for women. However, empirical research in this area lacks adequate minority samples to support any significant findings. Most of this research is based on Caucasian, middle-class heterosexual couples.

The Social Construction of Infertility
With a shift in research identifying stress as the pathological reason for infertility to experiencing infertility as a precursor to stress, recent research has focused on the social construction and interpersonal effects of infertility (Bresnick &Taymor, 1979; Eunpu, 1995; Frank, 1984). The social construction in American society, and many other cultures, is that men and women are meant to become parents, and women are especially socialized to become mothers (Atwood & Dobkin, 1992; Cook, 1987; Edelmann & Connolly, 1996; Matthews & Matthews, 1986; Reed, 1987) Evidence suggests that after the first year of marriage, pressure for married couples to have children increases and peaks during the third and fourth years (Porter & Christopher, 1984). Becoming a parent will often confirm feelings of self-worth and sexual identity when people have been socialized to that role (Shepherd, 1992). In many cases, it may also confirm the meaning and purposes of both the couple's marriage and existence as a couple (Matthews & Matthews, 1986).

In essence, the social construction of the roles of father and mother have become a part of the identities of men and women in our society (Matthews & Matthews, 1986). However, infertility can spoil one's sense of self-identity. Research with voluntarily childless couples suggests that these couples are viewed as unhappily married, psychologically maladjusted, career oriented, selfish, unhappy, and emotionally immature (Blake, 1979; Lampman & Dowling-Guyer, 1995; Miall, 1986; Peterson, 1983; Veevers, 1980). It is not surprising that individuals who are involuntarily childless may have difficulty resolving their own past perceptions of childless couples and thus may be unable to incorporate a positive identity of themselves as child free.

Emotional Consequences of Diagnosis and Treatment
Any discussion of the psychological consequences of infertility must include consideration of the consequences of diagnosis and treatment. The guarantee of medically treating infertility is that there are no guarantees. Recent research indicates that success rates of infertility treatment decrease with each successive 1-month cycle of treatment (Meyers et al., 1995). The cycle of treatment generally consists of a protocol of fertility medications that help to stop a woman's natural menstrual cycle and substitute an artificially produced menstrual cycle while also hyperstimulating the ovaries for egg production. It is not surprising that many of our clients undergoing infertility treatments describe their experiences as an emotional roller-coaster ride. During each cycle of treatment, their hopes for a successful pregnancy escalate. The onset of menstruation creates an immediate sense of failure and frequently depression. These reactions may be attributed only partially to hormonal changes related to drug therapy regimes (Robinson & Stewart, 1995).

Additional psychological factors related to diagnosis and treatment include stress based on the financial costs of treatment, marital conflicts, social pressures, and the invasiveness of medical procedures (Trantham, 1996). This stress is also prevalent among couples who are making decisions to use donor eggs or donor sperm in their infertility treatment plan. Using donors and surrogates involves issues of confidentiality, informing the conceived child of the procedure, strained relationships among family members, and deliberating moral dilemmas (Robinson & Stewart, 1995; Schwartz, 1987). There is also the time involved in waiting to determine if the treatment has been successful and the emotional "letdown" when it has not been successful (Robinson & Stewart, 1995).

The diagnosis of infertility may stimulate feelings of loss such as loss of a life goal, loss of a pregnancy experience, loss of fertility, loss of the potential for bearing children, loss of personal identity, loss of sexual identity, loss of a sense of personal control, loss of health, loss of confidence, and loss of close relationships with a male partner, friends, or family (Leader et al., 1984; Mahlstedt, 1985; Matthews & Matthews, 1986). The feelings associated with these losses may include sadness, frustration, inferiority, loneliness, fear, surprise, moodiness, disorganization, distractibility, fatigue, helplessness, poor self-esteem, shame, betrayal, powerlessness, hostility, and unpredictability (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Daniluk, 1997; Fleming & Burry, 1987; Menning, 1980; Porter & Christopher, 1984). It is not surprising that these feelings are the same as those experienced in reaction to the process of death and dying — shock/denial, anger, guilt, anxiety, grief, and depression (Bernstein, Brill, Levin, & Seibel, 1992; Kikendall, 1994; Kubler-Ross, 1969).

Gender Differences in Emotional Responses to Infertility
Many factors affect the reactions and adjustment of the couple who is experiencing infertility, and it is not surprising that significant gender differences in coping have been found (Abbey et al., 1991; Brand, 1989; Bresnick & Taymor, 1979; Danjluk, 1997; Edelmann & Connolly, 1996; Jones & Hunter, 1996; Keystone & Kafflco, 1992; McEwan, Costello, & Taylor, 1987; Raval et al., 1987; Reed, 1987). Specifically, women have reported experiencing more marital difficulties, including sexual difficulties (Abbey et al., 1991; Daniluk, 1997; Raval et al., 1987; Wright et al., 1989). They also describe their emotional reactions as being more like a grief reaction (Jones & Hunter, 1996). Men report experiencing many of the feelings, thoughts, and beliefs that women have reported (Daniluk, 1997); however, the frequency of their reports and the intensity and duration of these feelings may be more variable for men (Berg & Wilson, 1991; Daniluk, 1997; Edelmann & Connolly, 1996; Jones & Hunter, 1996; Keystone & Kaffko, 1992). This may be because women have greater physical and emotional involvement with infertility than do men; women carry most of the burden, in terms of medical evaluation, and carry physical reminders (e.g., menstrual period) of infertility that men do not experience (Williams et al, 1992).

In a study by Abbey et al. (1991), married women also reported that they believed they had experienced more disruptions and stress in their personal, social, and sex lives compared with their husbands who reported they had experienced more home-life stress. In an attempt to gain control of their experiences, women also attributed more responsibility for the infertility to themselves (Abbey et al., 1991; Daniluk, 1997). At the same time, their husbands held them responsible for the infertility (Abbey et al., 1991). Therefore, women's feelings of guilt about the infertility were confirmed. It is interesting that both husband and wife's attribution of blame to the woman was unrelated to the actual source of the infertility, and sometimes the diagnosis was actually related to male rather than female factors.

When confronted with issues of loss, women tend to share their feelings with their partner or others as a means of coping (Keystone & Kaffko, 1992). However, the male partner may find it stressful to talk about infertility with anyone and, as a consequence, may withdraw (Williams et al., 1992). Men may listen to their partners and react internally but not share their feelings with their partners. Therefore, female partners may believe they are being pushed away, contributing to a sense of isolation. Such feelings of isolation may be more significant for women than for men, as a consequence of gender differences in relational processes.

Treating Infertile Women Using the Relational Model of Development
The psychological impact of infertility clearly creates challenges to adjustment for infertile couples, and especially for infertile women. The precepts of this model thus provide a basis for structuring helping relationships with infertile women. The model provides a context for conceptualizing women's experience of infertility, predicting difficulties in adjustment, and structuring appropriate interventions with individuals, groups, and couples to enhance the process of adjustment. 

Using the Relational Model to Conceptualize Infertility Issues for Women
The experience of infertility has been shown to create feelings of loss, isolation, and self-blame among women (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Daniluk, 1997; Fleming & Burry, 1987; Menning, 1980; Porter & Christopher, 1984). The Relational Model suggests that these feelings contribute to a sense of separation or disconnection from others. When women's experiences about infertility are not heard or responded to by other people, then they detach themselves from others [Jordan, 1999). The infertile woman thus experiences a need to connect with others as an integral part of the process of coping. Failure to establish connections with others can increase feelings of loss, isolation, and self-blame, which potentially lead to a deeper depression for women. This depression can inhibit the infertile woman's action or assertiveness and enforces the loss of sense of control that she is feeling in her infertility experience. Unfortunately, depression in women that is associated with infertility is reinforced by society due to the social construction of fertility discussed earlier. Feelings of inadequacy as an infertile woman are, therefore, reaffirmed by society and not disaffirmed through her relationships with others, especially as it relates to a partner who may withdraw in response to infertility. These feelings of inadequacy and worthlessness disempower the infertile woman and immobilize her in her experience. Therefore, she may begin to believe that she should feel or deserves to feel these feelings.

Structuring appropriate interventions
As described earlier, the Relational Model provides an effective paradigm for structuring helping interventions with women. Each of the approaches arising from the model may be required, individually and in combination, to meet the varied needs of infertile women. These will include attention to empathy and mutuality in the counselor-client relationship, as well as issues specific to mutuality and empathy in individual treatment, group interventions, and couples counseling.

Empathy and mutuality
The counselor-client relationship is vitally important in helping the infertile woman find a connection she is desperately seeking in her infertility experience. The counselor needs to immediately ameliorate any power differential that the woman may perceive in treatment. This is done by demonstrating mutual respect and openness, first through using active listening to making the client aware that the relationship between counselor and client is one designed to help her and provide her with a sense of psychological well-being. The counselor's ability to share experiences regarding infertility [e.g., knowledge of medical technology and improvements, former treatment experiences with infertile individuals and couples) and an openness to learning and being emotionally affected by this client's experience is part of the mutuality, or mutual empathy process, of the Relational Model. The experience of mutuality in treatment is important for infertile women. Women may be experiencing isolation and feelings of selfblame because of a lack of connection with others. This may be partially due to the social stigma of infertility. When infertile women experience the counselor's willingness to risk sharing the experiences of infertile women, the experience can validate women's feelings and thoughts about infertility. When the women's feelings and thoughts associated with their infertility experience are validated, they regain their sense of worthiness and control. Hence, women will be empowered to explore themselves further in their experience of infertility. In essence, infertile women lose their sense of isolation within the infertility experience as they grow in relationships that are hallmarked by an open system of feeling and learning with their counselor.

Individual treatment
The goal in individual treatment, from a relational context, is to provide an opportunity to acknowledge the client's experience as well as the counselor's experience and for the client to develop a new integration of self-other experience (Jordan, 1991). This process begins by working on the elaboration and development of empathy as a means of interacting within the counseling relationship (Jordan, 1991). With the infertile woman, the ingrained feeling of "deserving" to feel guilty, inadequate, or shameful may inhibit her ability to feel empathic with others, let alone herself. First, the counselor is to model empathy and acknowledge her feelings in an effort to normalize them. When she begins to feel "heard" and understood by the counselor, she can begin to explore more of herself in an effort for self-understanding and self-validation.

Second, the counselor needs to help the infertile woman understand that her coping through the use of relationships is not understood or adhered to by society. When this lack of understanding is coupled with the social stigma of being childless in society, then infertile women experience more conflict about their role in society and how to cope effectively with their role. Therefore, efforts are made in relational counseling to deconstruct "fertility" and what that means to infertile women. There is also a focus on recognizing the tensions that arise in women when society ridicules their efforts at incorporating emotional reactions and interpersonal sensitivity into their experiences (Jordan, 1991). Sometimes this focus in treatment takes the shape of reviewing relationships in the client's life that represent these incongruencies. Through this review, mutual empathy and empathic response are used. Feelings, thoughts, and beliefs that the infertile woman may think she cannot verbalize are allowed and recognized. In other words, disowned aspects of the self are recognized. The counselor's job is to objectify these aspects of self and make affective connections with them (Jordan, 1991). In this process, the infertile woman begins to gain a new image of herself, others, and herself in relationships with others.
- Gibson, Donna M., Myers, Jane E.; Gender and Infertility: A Relational Approach to Counseling Women: Journal of Counseling & Development: Fall 2000; Vol. 78, Issue 4

Personal Reflection Exercise #2
The preceding section contained information about implementing the Relational Model of Development. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
What are three factors that were discussed that help in understanding the psychological impact of an infertility diagnosis in women? Record the letter of the correct answer the CEU Answer Booklet.

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