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

Section 20
Isolating Stigma & Shame of Infertility in Taiwan

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Because Taiwanese culture emphasizes blood-related offspring carrying on the family name, people with infertility problems suffer from a high level of stress and distress psychologically and socially (Lin, 2001; Lin and Tsai, 1999). About 10%-12% of couples of reproductive age, or approximately one in six couples suffer from infertility (Leiblum, 1997). Research indicates that women experience considerably greater psychosocial distress, more somatic difficulties, lower self-esteem, higher levels of depression, and greater interpersonal sensitivity related to their infertility than men (Abber et al., 1991; Berg and Wilson, 1991). About a half of women consider infertility as the most upsetting experience in their lives, worse than divorce or the loss of a parent (Mahlstedt et al., 1987).

Counseling has been strongly recommended to help people with infertility problems deal with the psychological distress caused by medical treatment and infertility-related psychosocial problems in Western countries (Boivin, 1997; Covington, 1995). Unfortunately, it is rare in Taiwan to provide counseling services for this population. This case study is presented as a pioneer to illustrate a 10-month individual counseling process and outcome with a Taiwanese women undergoing medical infertility treatment.

Background information
This client, named Sue, was 38-years-old and had experienced infertility for more than 6 years. She sought assisted fertility treatment 2 years ago at a Centre for Reproductive Medicine in a hospital in southern Taiwan. Sue initiated counseling right before her infertility treatment and continued to participate in counseling for 10 months.

She has been depressed and has had occasional suicidal ideation during the past 7 years. She felt hopeless, empty, lost, and desperate with life and demonstrated anxiety, depression, and psychosomatic symptoms such as sweating, nausea, trouble swallowing, sleep disorder, difficulty breathing, irritability, back pain, brooding, excessive worry over physical health, complaints of pain, depressed mood most of the day, markedly diminished interest or pleasure, significant weight gain, hypersomnia, loss of energy, feelings of worthlessness and excessive guilt, diminished ability to think or concentrate and indecision.

Sue was married at the age of 31 and has been in conflict with her husband for the past 7 years. Sue described her husband as cold, selfish and distanced from her. Sue accumulated her anger, grief, sadness, pain, and disappointment internally and demonstrated psychosomatics and symptoms of depression and anxiety.

She quit her job three years ago when she turned 34 and tried to have a biological child. She stayed at home all day, rested and isolated herself from the world. After 3 years of effort, Sue did not conceive. Sue has been in a constant state of depression, anxiety, hopelessness and helplessness. Her health has been getting worse with back pain and psychosomatic symptoms. Sue viewed herself as a failure.

Counseling process
The counselor employed relationship centered counseling (RCC) (Kelly, 1994, 1997), an eclectic counseling style to counsel this client. The RCC represents as a humanistic integration that gives primacy to the humanizing and counseling relationship, conceives of technical expertise as the instrumental extension of relationship, and affirms the necessity for an in-depth synthesis of both for effective counseling. It emphasizes the primacy of relational humanness in the counseling process and provides a core humanistic orientation for integrating a variety of counseling techniques from different counseling approaches.

At the first counseling interview, the client, Sue, was thoroughly assessed by the counselor and was diagnosed with Generalized Anxiety Disorder, Major Depressive Disorder, and Adjustment Disorder according to the DSM (fourth edition) (APA, 1994). The counselor focused on developing a relational/humanistic counseling relationship by actively listening and demonstrating genuineness, congruency, empathy, friendliness, warmth, caring and unconditional positive regard. Sue's motivation for change was highlighted and hopes for success were established. Pre-counseling education was conducted in order to clarify the counselor’s and the client's roles, and the functions, procedures, and norms of counseling.

After thorough discussions with the counselor, Sue set up both short-term and long-term goals for counseling, including helping her get pregnant by improving her physical and mental health; minimizing her psychosomatic symptoms; and relieving her negative emotions, such as anxiety, depression, sadness and grief.

The counselor helped Sue achieve an awareness of her desperation of wanting a biological child, which might be substantially related to her feelings of loss and emptiness in her current life combined with her traumatizing experiences, such as the physical and emotional abuse in her childhood, adolescence and marriage. Sue's psychosomatic symptoms and obsessions regarding reproduction were deeply interwoven with the traumas from her childhood experiences and her marriage.

During the process of exploration, Sue felt much pain in dealing with the traumas from her family of origin, such as the trauma resulting from the conflicts with her harsh father, distanced mother and siblings. She also felt helpless and hopeless in dealing with the constant conflicts with her husband, and the stress from her husband's family. Sue was encouraged to express her pain, grief, loss, loneliness, sadness, helplessness and desperation. The counselor supported Sue's exploration, recognition, and acknowledgement of her negative feelings and emotions through a humanizing and trusting therapeutic relationship.

The counselor integrated a variety of counseling skills to facilitate the development of the therapeutic relationship. Various therapeutic techniques from different counseling approaches were applied to broaden the humanistic counseling relationship. For example, cognitive-behavioral techniques, such as reinforcement, behavioral assessment, concrete goal-setting, behavioral modification, life management, modeling, assertiveness training, muscle relaxation training, and problem-solving skills were employed to help Sue gain positive and functional behaviors. Emotional catharsis, cognitive restructuring, and behavioral modifications were effective for Sue in dealing with her problems.

Meanwhile, Sue was aided in exploring her psychological traumas and dealing with the resultant emotions of grief and loss. Techniques applied to counseling included the analysis of her defense mechanisms, family history, memories of childhood experiences, biographical retrospection, free association and transference (psychodynamics); the use of empty chair, role plays, and self-talk (Gestalt); and discussions on her communication patterns, boundary-setting, family structure, roles and functions in both her family of origin and her current family (family systems).
Psychoeducation was provided by the counselor. Sue learned to do muscle relaxation, deep breathing, and low-impact exercises (such as yoga) to improve her physical and mental health. In addition, Sue was encouraged to consult a nutritionist to change her eating habits and a physical therapist to help heal her back pain and spine problems.

After three months of counseling, Sue underwent her first assisted reproductive treatment (artificial insemination) and failed to conceive. The doctor advised Sue to try another type of assisted reproduction treatment, in-vitro fertilization (IVF). Sue's negotiation with her husband about IVF treatment resulted in a large fight. She was disappointed in her husband because he was unwilling to pay the fee or make an effort. During this period of time, the counselor mainly focused on Sue's loss and grief and gave her time to deal with her emotions. She was encouraged to express her anger, pain, and other feelings concerning herself, her loss, her husband, and her family of origin directly and fully during the process of counseling.

After 4 months of counseling and infertility treatment, Sue actively asked to concentrate on her career development during counseling sessions, with the goal of pursuing a job. Sue was eager at this time to change her life and improve her interpersonal relationships. In order to improve Sue's interpersonal relationships as well as her occupational status, the counselor worked with the client to explore career interests and occupation preferences, and set up career goals and objectives. After thorough discussions, Sue decided to go back to school to prepare for a future career. The counselor focused on enhancing Sue's self-confidence, self-esteem, and self-value, and minimizing her anxiety and fear of failure before Sue took the college entrance examination after a preparation of 2 weeks.

Sue passed the exam and was enrolled in a local college as a freshman. This new situation was viewed as a very stressful and exciting event. Sue worried about being rejected by younger students and falling behind her classmates academically, but in reality, she did very well in her studies and she made a few good friends. These positive experiences had a significant impact on her. Sue described her success at school as the first time she felt goal-directed and satisfied with her life and her performance in the past 7 years.

Sue's lifestyle was very different. She was no longer lying in bed, dreaming of an unborn child and waiting for time to pass. Instead, Sue was busy studying, discussing with classmates in groups, collecting information for her assignments, and making plans for her future. She admitted that she grew through learning and became competent and confident, particularly when her academic performance was at the top of the class. Sue looked much younger, and felt more active and energetic. She went out and had fun with classmates and enjoyed her student career in college.

Sue actively shared her feelings and emotions with her counselor regarding her new life and experiences. Sue's symptoms were substantially reduced, her mood was quite stable, and her lifestyle was much more active. Sue did low-impact exercises regularly, attended social events with friends from time to time, and had energy for studying and other activities.

Sue stated that she still wanted a biological child, and that she would continue working on it by improving her physical and mental health. She was aware that her strong desire to have a baby was related to her hopelessness toward her current life and marriage. At the same time, she made progress in her career development. She gradually transferred her attention from blaming others to depending on herself and being responsible for her own life. She made an independent decision to study for an exam in order to gain a job and a professional license. She demonstrated her courage to face the negative parts of her marriage, and decided to initiate the next stage of her life by working on herself and gaining support from her friends. Sue was actively studying for an exam for an official job. She terminated the counseling when she had been enrolled into the college for three months and felt her life being on track.

Counseling outcome
Sue improved after a 10 month individual counseling intervention. Sue described herself as more positive and more assertive in pursuing her goals, and her life as more meaningful. The counselor’s observations and evaluations supported the client's positive changes, such as being more assertive, life-oriented, present-oriented, goal-oriented, and demonstrating more self-confidence, positive-thinking, functional behaviors, and a positive attitude toward herself and others when compared with her pre-counseling state.

Sue came back for a follow-up three months later. She stated that she was still working on having a biological child and continued to prepare for a job exam. She focused mainly on studying, exercising, relaxation and planning for her future. Sue expressed that her life had changed since her initiation of counseling and her enrollment in college. She studied very well, gained self-confidence and self-control, improved her interpersonal relationships, extended her social support network, and enhanced her satisfaction with life. It seemed she was able to put her past into a new framework with a positive perspective.

This case demonstrated the complexities of infertility interrelated with multiple problems within the Taiwanese cultural context; problems with the family of origin, current marriage and in-laws, career, meaning of life, self-identity, self-confidence, self-esteem and interpersonal relationships. Without support from her husband, her family of origin, her husband's family, and other relatives and friends, Sue depended completely on herself for the past six years, while struggling with infertility and its related problems. It was important for Sue to seek help and gain support from a counselor.

This case study highlighted that infertility is a big stressor for Taiwanese women and it was traditionally viewed as a female problem attached with stigma and shame. With infertility problems, Sue suffered from a great amount of distress and stress. Due to the long-standing cultural mandate toward motherhood, infertility affects women more than men, and women experience considerably greater psychosocial distress, more somatic difficulties, lower self-esteem, higher levels of depression, and greater interpersonal sensitivity related to their infertility (Abbey et al., 1991; Berg and Wilson, 1991; Greil et al., 1988). Women were more active in seeking medical information for infertility treatment and in taking assisted infertility treatments than their spouses (Berg and Wilson 1991). The finding of this case study corresponding to the results of Western studies indicated that women with infertility problems tended to suffer from psychological distress and emotional disturbances toward infertility and its treatment (Greil et al., 1988).
- Lin, Yii-Nii; Counseling a Taiwanese woman with infertility problems: Counseling Psychology QuarterlyJun 2002; Vol. 15; Issue 2.

Personal Reflection Exercise #6
The preceding section contained information about a Taiwanese woman dealing with infertility. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
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.

Crespi, B., & Dinsdale, N. L. (2021). The sexual selection of endometriosis. Evolutionary Behavioral Sciences. Advance online publication.

Ghuman, N. K., Raikar, S., Singh, P., Nebhinani, N., & Kathuria, P. (2021). In it together: A dyadic approach to assessing the health-related quality of life and depression among infertile couples. Families, Systems, & Health.

Online Continuing Education QUESTION 20
Although Sue did not conceive a child, her quality of life improved drastically by the end of treatment.  How did her counseling achieve this? Record the letter of the correct answer the CEU Test.

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