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

Section 19
Breaking the Silence: Group Therapy for Infertility

CEU Question 19 | CEU Test | Table of Contents
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

Infertility is a silent subject in much of our society. Childbearing, reproduction, and the promotion of family heritage are surrounded by profound and complex feelings. Parenthood is a societal standard desired by most people. The Bible reflects society's emphasis on parenthood: "Give me sons or I shall die" (Gen. 30:6 Today's English Version) aptly expresses the importance of children to our existence. When, not how, to conceive is, the issue for most couples.

For approximately 17% of couples, the basic expectation of having children is not possible (Cooper-Hilbert & Hilbert, 1993). The experience of infertility or reproductive failure pervades the couple's life, necessitating a redefinition of personal identities and goals. (McDaniel, Hepworth, & Doherty, 1992). Infertility forces couples to re-examine the expectations they have had for their lives as individuals, as a couple, and as members of extended families and society in general (Eunpu, 1995).

The issue of infertility lies in the grey area between adaptation to illness and health promotion. As reproductive technologies advance, the medical endpoint for infertile couples becomes ambiguous and, for some, ceases to exist. Couples may spend a major part of their lives trying to conceive at great personal expense and that of their relationships. With the multitude of tests and procedures, they adapt every facet of their lives to the quest for a child, while being expected to lead healthy and happy lives. Infertility challenges the mind, body, and soul, compromising self-esteem and hopes and dreams for the future. One woman described her experience with infertility:

            A blow to my self-esteem, a violation of my privacy, an
            assault on my sexuality, a final exam on my ability to cope,
            an affront to my sense of justice, a painful reminder that
            nothing can be taken for granted. My infertility is a break
            in the continuity of life. It is above all, a wound to my
            body, to my psyche, to my soul. (Mahlstedt, 1985)

Support groups can provide the caring milieu needed to help couples deal with infertility (Watson, 1988; Yalom, 1985). The stress of fertility testing, the physical and emotional pain, and the frequent routine therapies create a tense environment. Couples must be aware of their feelings and needs to ensure well being while facing the overwhelming demands that infertility puts on a relationship. In a support group, partners can pursue harmony as a couple in a caring atmosphere that enables them to find meaning in their experience and existence and can find help to regain self-control and self-determination in their lives.

Literature Review
Infertility is a man's, woman's, or couple's inability to create a child. Most health professionals define it as the inability to achieve a pregnancy after one year of regular sexual relations or to carry a pregnancy to term or live birth (Corson, 1995).

Most infertility research focuses on physiological boundaries and is based on a medical-model approach to treatment (Bresnick, 1981; Cook, 1987; Daniluk, 1988; Mahlstedt, 1985; Menning, 1982). Interest in the impact of infertility on couples' lives has grown along with an expanding body of literature about the psychosocial and emotional aspects of infertility.

Fifty to sixty percent of infertility problems can be successfully treated with appropriate medical intervention (Corson, 1995; Leader, Taylor, & Daniluk, 1984). Many couples, however, cut themselves off from necessary outside support at this critical time.

Infertility is often the first marital crisis faced by couples. Effective communication or conflict resolution skills may not yet be adequately developed in the relationship to help deal with the many consequences of infertility. Partners may perceive themselves as damaged or as a failure (Matthews & Matthews, 1986) and may experience anger, disappointment, and self-doubt (Berger, 1980; Menning, 1980). Sadness, hopelessness, depression, guilt, and helplessness are some of the principle feelings expressed by infertile couples (Baram et al., 1988; Freeman, Boxer, Rickels, Tureck, & Mastroianni, 1985). Other losses or concerns include health, prestige, self-confidence, security, fantasy of a hoped-for event, and the loss of something or someone of great symbolic value (Mahlstedt, 1985). Infertility sabotages a couple's ability to control the one aspect of marriage taken for granted—the ability to have children (Matthews & Matthews, 1986). Childless couples have an increased divorce rate and a doubled suicide rate compared to the general population (Mai, Mundy, & Rump, 1972). The occurrence of extramarital affairs, alcohol abuse, and eating disorders is also higher among childless couples (Burns, 1987).

The literature emphasizes the infertile couple's need for support and counseling. However, while support groups do exist for infertility, they do not focus on couples' needs or on health promotion (Cook, 1987; Mahlstedt, 1985; Menning, 1982, Seibel & Taymor, 1982). Menning (1980) was one of the first researchers who attempted to identify and support the collective psychological experience of infertile couples by establishing a support group (Brown, 1994). Positing that the experience of infertility was similar to that of dealing with death, Menning adopted Kubler-Ross's 1969 model of grief. She promoted the notion of comprehensive management, providing medical expertise and psychosocial support services together and treating the couple as a unit. Until Menning's model, infertile couples had few treatment options and infertility was a short-lived journey. Today we need a more encompassing theoretical framework that adapts to the changing needs of infertile couples.

The experiential process of support groups for infertile couples is not well understood. Most studies have been limited to anecdotal notes based on clinical practice. The focus has been on women, using approaches from medicine and social work, as well as marital and family therapy. Many questions remain about the effectiveness of group therapy: What techniques and strategies are used? How is health promoted? Recent evidence suggests that psychosocial distress and lack of social support may contribute to functional abnormalities resulting in decreased fertility (Barneu & Tal, 1991). Indeed, the hypothesis that infertility causes stress (Mendola, Tennan, Affleck, McCann & Fitzgerald, 1990) is now challenged by the theory that stress causes infertility. It is possible that infertility may partly be caused by a holistic imbalance yet to be understood.

Given such findings, healthcare professionals must begin to implement an approach that emphasizes a balance between mind, body, and soul. Promoting health requires exploring alternative therapies that complement existing medical approaches. To date, research in this area is non-existent.

Watson's theory of human caring in nursing (1988) and Yalom's principles of group psychotherapy (1985) were used in an integrated framework for this project. Watson's theory provides a health pro-motion perspective that focuses on harmony between the mind, body, and soul through "curative" factors. Yalom's "curative" or therapeutic factors provided the principles to guide the development of the support group. Watson's curative factors and Yalom's curative factors are analogous and provided an effective blended theoretical approach.

Watson defines health as the process of unity and harmony and views life as a gift to be cherished. Her theory is value-laden in experiences and responses to personal meanings of human conditions. It includes a deep respect for the wonder and mysteries of life and the power of humans to change and helps individuals achieve self-knowledge, self-control, and self-healing, regardless of the presenting health-illness condition. This value-laden system is blended with the interventions or caring processes that encompass the carative factors.

Yalom's theory and principles of group psychotherapy suggest that the process leading to therapeutic change is very complex. The basic premise of change lies in the fact that human experience can be therapeutic to our lives. These experiences or curative factors are interdependent.

Theoretical Foundations for Therapy
Watson's and Yalom's theories provided the theoretical foundation necessary for developing and managing the support group for infertile couples. Watson's method of discovering and pursuing hidden meanings in life complements Yalom's therapeutic processes, which emphasize experience and reflection on that experience. Combining these two theories provides congruent interventions that function to promote an experiential, caring, and curative group process. Acquiring these skills is critical to the health and well being of couples facing infertility.
The goal of the therapy was to promote health among the couples by helping them work through stress and feelings of loss and by helping them redefine self-image and relationships to enable them to accept their infertility. Rather than focusing on ways to increase the chance of pregnancy, the support group focused on enhancing health and well being through forging a mind-body-soul connection.

Given the personal nature of the information disclosed, limiting the group to five couples would promote group cohesion, the development of trust, and interpersonal learning. Couples were recruited from the office of one infertility specialist. Three couples and two women from various walks of life came together in a fascinating mix that was prepared to share a wealth of experience.

Seven group sessions of 1.5 hours each were completed. The sessions were considered sufficient to enable exploration of the couple's needs and to facilitate appropriate interaction and cohesiveness within a period of time to which group members could commit (Yalom, 1985). The many techniques and strategies presented throughout the sessions included guided imagery, meditation, relaxation, doing something special for the partner or themselves (nurturance), time pies, journaling, cognitive therapy, problem-solving, assertiveness training, communication skills, and bibliotherapy. These techniques were all adjuncts to holistic healing or ways that we use our minds to change behaviors to promote health (Domar & Dreher, 1996; Watson, 1988; Yalom, 1985).

Comments in the group and written evaluations indicated that the support group was a success. The sessions allowed couples to achieve inner harmony and interpersonal learning by exploring their needs and the alternatives available to them. Partners were challenged to speak freely from within. They were encouraged to explore their experience of infertility and the feelings associated with it and to learn ways to transcend the negative experience and heal as a couple, which enhanced the caring/healing relationship. Couples were encouraged to develop and use their own resources for problem solving and to exercise choice, thus controlling the outcome of their experience of infertility.
- Dayus, Deborah, Rajacich, Dale, Carty Laurie; Promoting Health among Infertile Couples through Support Groups: Guidance & Counseling; Summer01; Vol. 16; Issue 4

Personal Reflection Exercise #5
The preceding section contained information about using group therapy with infertility clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Casu, G., Zaia, V., Fernandes Martins, M. d. C., Parente Barbosa, C., & Gremigni, P. (2019). A dyadic mediation study on social support, coping, and stress among couples starting fertility treatment. Journal of Family Psychology, 33(3), 315–326. 

Chazan, L., & Kushnir, T. (2019). Losses and gains of psychosocial resources: Effects on stress among women undergoing infertility treatments and participating in social network systems. Psychiatric Quarterly, 90(4), 717–732.

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.

Online Continuing Education QUESTION 19
How many couples do the authors recommend limiting the sessions to for group infertility counseling? Record the letter of the correct answer the CEU Test.

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