| The Couple as an Entity: The Power of Treating the Couple as a Whole/Peter L. Sheras and Phyllis Koch-Sheras | |
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Couples and Infertility: Clinical, Intervention and Practice Development Issues/Laurie Kolt |
| Working with Couples around Couples and Work/Jayne Speicher-Bocija |
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COUPLES & INFERTILITY: CLINICAL, INTERVENTION AND PRACTICE DEVELOPMENT ISSUES
Infertility touches the lives of one out of every six couples in the United States alone and the numbers are rising. The experience of infertility is marked by multiple sources of severe emotional pain, making this population excellent candidates for psychotherapy. This article will cover the clinical issues couples face as well as intervention strategies. Since infertility is a relatively new area for clinicians and still remains vastly under served, practice development steps will also be discussed to assist other psychologists in adding this clinical specialty to their practices. Clinical Issues & Symptoms Infertility threatens a people’s life dreams for their future. It is associated with feelings of depression, anxiety, anger, loss and hopelessness. Couples are faced with not knowing when or if they will ever have a child, yet they live in a world full of parents with children. Each month couples submit to costly, time consuming and invasive medical procedures and are filled with hope and anticipation only to be disappointed once again. During a time when they are already feeling separate and different from their family and friends, infertile couples don’t share much of their pain with others. When friends and family innocently ask when they are finally going to start a family, they feel caught off guard about their private struggle and give vague or awkward responses. In addition, injections of fertility drugs can be a source of both physical pain and amplified emotional reactions (Kolt, Slawsby & Domar, 1999). Another marital stressor is a marked change in their experience of sex. Daily temperature readings, injections, ovulation kits, untimely rushes to the doctor’s office and sex upon demand take away most of the enjoyable romantic experience of sex. Their family and friends may not have any idea about the degree of stress they are experiencing. Yet there is a 37% depression rate in women with infertility and in many cases it can be very severe (Domar, Broom, Zuttermeister, Seibel & Friedman, 1992). A couple dealing with infertility looks like any other couple on the outside. Few people in their world understand the depth of their pain. A psychologist who understands infertility dynamics and treatment can serve as a safe harbor for them to cope with their chronic stressful feelings. A useful intervention is to reframe each medical attempt as a step towards their goal and not the final solution. When a couple understands that their reaction may be painful but normal, they can begin to endure the roller coaster emotions more effectively. I like to use the analogy with clients that coping with infertility is like preparing for a marathon and not a sprint. If you put 100% into each cycle and view it as an end-all solution, you will burn yourself out and become emotional exhausted. But if you prepare for a long road ahead, you can pace yourself and weather any failed cycles with the perspective that you are still on course and heading in the right direction. Research points to severe depression and anxiety as contributing factors in some infertility and has been associated with the activation of the body’s “fight or flight” response. Cognitive restructuring and guided visualization have been successfully used to decrease the depression and anxiety in some cases (Domar, 1996). Clinicians can also serve as an advocate in navigating through the medical options to help couples make the right choices as well as know when to acknowledge that it is time to take a break or stop trying altogether. Typical therapeutic issues include:
A healthy pregnancy can occur very soon after receiving a diagnosis that has a clear medical resolution yet many cases go on for months and even years. The following progressive stages of infertility developed by Diamond, Kezur, Meyers, Schraf & Weinshel (1999) are associated with differing types of marital strain. As months go by with no successful pregnancy, more pronounced psychological symptoms occur. The entrance into each new stage marks an additional loss – of their innocence and the escalation of their underlying fear that they may never have a child. The Dawning Phase Shock and disbelief are often the initial reaction to a diagnosis of infertility for most women. Problems can occur because men and women typically approach the problem from different perspectives. Women typically tend to respond to infertility with more anxiety and despair and want to process their emotions verbally. Initially, men tend to minimize the problem and quickly focus on how to “fix” it. This style may reduce their anxiety about seeing their wives in pain. Yet women often react to this by feeling angry and cut off leading to further isolation, depression and marital stress. Interventions during this phase can center on helping both partners develop communication skills so they each feel heard as well as supported. Mobilization Phase After a couple acknowledges that a serious problem exists, they start investigating medical assessment and treatment options. It is essential for psychologists to understand what these options entail so they can help them make effective choices. Interventions can examine the meaning of parenthood, feeling “out of sync” with their peers and reducing both anxiety and depression. Middle & Early Immersion Phase This devastating and exhausting phase is the most stressful as time, disappointments and money spent drags on. It is in this phase that women with infertility can have equivalent levels of depression and anxiety as women who are HIV positive or have cancer (Domar, Zuttermeister, & Friedman, 1993). Communication can seriously break down due to anger and emotional pain. Individual sessions can be a useful approach in processing issues during this phase. By taking a break from their medical infertility treatments some of this tension can be defused. A referral to RESOLVE, a support organization found in most major cities, can help them feel less alone in their struggles and increase their peer support. Late Immerson Phase As tension escalates and finances are drained, couples may need to explore alternate methods to having a child or consider childfree living. Helping them mourn becomes a key role for the psychologist. Less expensive and complex medical procedures give way to more high tech and more expensive ones. Options include exploring assisted reproductive technology (ART). These include various forms of in vitro fertilization, utilizing donor eggs or sperm or using a surrogate mother. New clinical issues develop as a “third party” enters into the equation of having a family. Couples therapy can help them pragmatically as well as emotionally weight the advantages, risks and feeling about each option. For example, if they chose to use donor eggs or sperm, what type of donor do they want to choose? This may depend upon religion, physical characteristics or other variables that are important to them. Should they use an anonymous donor or one that is genetically linked to the family? Issues about costs, success rates of different procedures (and even different doctors) fill their minds with complex options to weigh. This all occurs while they feel a strong, focused urgency to start their family. Clinicians can help them slow down and explore all options with more depth and clarity. Resolution Phase If a couple still has not been successful in starting their family they eventually stop medical treatments, mourn the loss of having a genetically related child and move on to adoption or child free living. If the couple has another child and has been dealing with secondary infertility, the mourning phase is equally important. In the vast majority of cases, it is not possible to move on with life until the future has been reorganized in a person’s mind and given new meaning. To do this entails the preparation of a place in the life story for an altered set of hopes and dreams (Becker, 1990, p. 236). Letting go, forgiving, accepting and saying good bye to what was once a special dream, is important therapeutic work. With this closure underway, the couple is ready to redefine realistic goals for living out their future. Legacy Phase Some couples find themselves estranged from each other and stay wounded by the experience of infertility for many years. There may be lingering resentments, low self-esteem, isolation or chronic depression. Psychotherapy can move couples through a positive experience of resolution, helping them become more closely bonded from the shared experience. Having weathered a strong storm they have gotten to know themselves and each other on deeper levels. While under tremendous stress, they have developed new skills to improve their support for each other and enhance communication. They have learned to take responsibility for their feelings and accepted that the world includes things that they can not ultimately control. Parenting after infertility is often associated with a greater appreciation for the value of children and parenthood than for most couples (Golombok, Cook, Bish & Murray, 1995). Yet some may be overprotective, too child-centered or fear an unpredictable loss of their precious children. Psychological interventions can address these residual issues. Since this population is usually bright and high functioning, parenting classes can also be a helpful adjunct. Infertility and Bioethics Many infertile couples are able to correct anatomical or hormonal problems and conceive their children naturally. Yet for those who can not, complex questions can surround some of the high tech procedures. For example, when using a donor, will they ever share their story with their child? If so, when and how? The choice of how many fertilized eggs to implant is an important issue. Too few and this $12,000 to $17,000 procedure can fail. Yet implanting too many can lead to multiple births. Since most of these parents are older, they need to consider if they have enough time, energy and love to keep up with twins, triplets or more. It is not unusual for to multiples to be born premature and they have an increased incidence of serious health problems. Prior to becoming pregnant the couple needs to consider whether they would choose selective abortion to increase the health of the remaining fetuses. Each couple must take into account economic and religious variables as well as their personalities and life goals. Couples therapy can be a useful forum to ultimately make the kinds of decision that will give them a feeling of wholeness and inner peace in the form of family that they create. Counter transference issues are important to examine before assisting couples in making these choices. Although the media may at times display the fringe examples of infertility, a seasoned psychologists knows that it is rare that an infertile couple wants to build a designer baby. In the years that I have worked with infertile couples I have yet to come across a couple whose goal is to create another Einstein, an Olympic athlete or a child that looks like a model. Their primary goal is to satisfy their desperate search for what most couples take for granted – the opportunity to have a family. Infertility therapy is a valid clinical specialty and I believe that we have a great opportunity to correct any public misconceptions about the intentions and the true experience that infertile couple face. Infertility provides many opportunities to educate the public and give psychology away. Practice Development Issues Various forms of denial may keep people from looking squarely at how to cope with their problems. Some people assume that seeing a therapist implies that they are weak or sick. They may not know that they can overcome their problem until your message reaches out to them. So it is imperative that you find effective ways to let people know what you do and how you can help them. Research over five decades has shown that the public does not how to find appropriate psychotherapy or understand how it can benefit them. (Wood, Jones, & Benjamin, 1986). To address this lack of information about our craft, I developed the following 10-step practice building model with the goal of combining sound practice building skills, with integrity and sensitivity (Kolt, 1996). The model is useful for all specialties although it was originally developed for an infertility clinical practice.
Update Your Knowledge Base With Current Research, Theory and Applications Therapists who choose to specialize in infertility need to be familiar with all of the aspects of the infertility experience. They must understand treatment options, medical terms and common emotional reactions. A thorough review of the literature and research is an important first step. Other avenues to build clinical competence can include supervision, trainings and joining professional organizations. American Society of Reproductive Medicine (ASRM) is a multidisciplinary organization that has information and conferences that focus on the medical, ethical, psychological, and social issues of infertility. Understand Demographics To develop good clinical programs and select targeted ways to reach out to your community, you must know who your client really is and what they want from their perspective. The age of most infertility clientele will range from the mid-thirties to the early forties. They are relatively affluent, bright, articulate, educated, highly functional, dual career couples. They are used to being in control and are caught off guard by this problem that they never envisioned having. They have great motivation to feel better as well as do what ever they can to participate in the success of their attempts to conceive. Design Services for Your Community Begin by designing individual, couples and group programs. The mind/body model is a very useful approach to integrate into your services to reduce emotional and physiological components of stress that can impact upon infertility outcomes. Develop an Eye Catching & Professional Brochure An effective infertility brochure creates rapport with infertile couples before they even meet. This can increase the likelihood that they will understand the value of entering therapy. Be sure that you write in terms that the general public will understand and relate to. This is a completely different writing style than academic or research writing. The content should incorporate information on 1) the prevalence of infertility 2) clinical issues they will identify with and 3) a summary of your program development. Here is an example from my own infertility brochure. “The pain of infertility can enter the deepest part of your being and remain there. Embarking on this unique journey to finally begin your family can include many tests and medical procedures. During the course of your care, you or your partner may experience roller coaster emotions from excitement and anticipation to repeated frustration. Research has shown that depression, isolation, anxiety and feelings of “not being in control” are often seen in people coping with infertility. But psychotherapy can help” (Kolt, 1997). Identify People and Organizations with Whom to Interact Join RESOLVE, the national infertility support organization. If your community does not have one yet, contact their national headquarters and tell them that you are interested in getting one off the ground. Through them, you can receive invaluable local information on infertility-related doctors and resources in your community. RESOLVE also offers generous opportunities to write articles for their local newsletter and present workshops to potential clients. Write an introductory letter and send it out to all the OB/infertility doctors in the yellow pages. Include common psychological symptoms, how a psychologist helps and that you are interested in working collaboratively to provide better patient care. Mention that psychotherapy can create more compliant patients and can also contribute to their fertility success statistics, an issue that holds much interest for them. Infertility clientele are sophisticated consumers and often ask doctors about their success rates with their type of infertility before they choose their doctor. Incorporate Your Information into an Annual Business & Marketing Plan Began by visualizing your ideal infertility practice goals and then pull them down to earth and make them clear, specific, measurable and realistic (Kolt, 1999). Then write down how many clients you want to see doing individual and couples work. What average fee per hour do you want to make? What are the estimated costs you plan to invest in your program and marketing avenues? Become Know as the Community Expert Start by thinking of avenues to maintain regular visibility with referring medical personnel, organizations and potential clients. Develop quarterly mailings to remind them that you work with infertility. Begin to develop local articles and seminars on infertility. Clinicians comfortable with media work may find periodic times that new coverage can be timely, providing massive public exposure at virtually no cost. Look For Timely Opportunities To Give Psychology Away Recognize when infertility issues present themselves in one’s community or in the national media so you can educate the public and provide a competent, realistic and compassionate perspective. Recent national news coverage included an Internet site that sells donor eggs from models and highlighted a couple who wanted to use a surrogate mother to “grow their baby” so she could continue to be on the road pursuing her singing career, portray a superficial and negative image of infertile couples. These types of stories can add to the awkwardness, shame and isolation that some infertile couples already feel. By poignantly sharing real struggles and issues that infertile couples face with your local news media, you can balance the sensational perceptions, as well as reach people that do not know that psychologists can help. Thus, more infertile couples not under psychotherapy can say, “Hey, that psychologist is talking about us… Now I know that we are not alone... Now we know there is help… And now we know where we can get it.” Measuring Your Results A monthly practice summary form (MPS) can provide you with an effective tool to put your practice growth in perspective (Kolt, 1997). Imagine how well you could grow your practice if you could you could assess your income, expenses, referral source data, accomplishments, challenges and solutions on a monthly basis. Using MPS’s is a must for serious practice builders to gain a deeper perspective on the state of their practice. They will help you grow your practice more efficiently and effectively. Enjoy the Journey Get into the heart of what it must feel like for a person coping with infertility, and it will boost your confidence, vision and enjoyment in building your practice. Your referral sources and potential clients will sense that you care, that you are approachable and that you genuinely enjoy being able to help. This alone can increase referrals and build your practice at a faster pace. Even in areas that are filled with psychotherapists, an infertility specialty is a virtually untapped avenue that is ripe for professional growth. Since infertility is still a new field, tremendous opportunities are wide open to develop a successful and rewarding practice within the US and across the globe. Since the original article on my work in infertility practice development was published by Psychotherapy Finances in 1995, I have heard from clinicians from Brussels, Jamaica, the USA, Australia, New Zealand and China who were interested in entering this clinical specialty. The practice building model can work in rural communities, large cities and across cultures. Equally important, you can tailor it to fit your own personality and practice goals. When you decide to enter this field, know that you are among a global connection of cutting edge clinicians that are committed to competence in an important and rising clinical specialty. References Becker, G. (1990). Healing the infertile family: Strengthening your relationship in the search for parenthood. New York: Bantam Books. Diamond, R., Kezur, D., Meyers, M., Schraf, C., & Weinshel, M. (1999). Couple therapy for infertility. New York: Guilford Press. Domar, A.D. (1996). Stress and infertility in women: Is there a relationship? Psychotherapy in Practice. 2 (2) 17-27. Domar, A.D., Zuttermeister, P.C., & Friedman, R. (1993). The psychological impact of infertility: A comparison with patients with other medical conditions. J. Psychosomatic Obstetrics and Gynecology, 14, 45-52. Domar, A.D., Broome, A., Zuttermeister, P.C., Seibel, M., & Friedman, R. (1992). The prevalence and predictability of depression in infertile women. Fertility and Sterility, 58 (6), 1163. Golombok, S., Cook, R. Bish, A., & Murray, C. (1995). Families created by new reproductive technologies: Quality of parenting and social and emotional development of children. Child Development, 66, 285-298. Kolt, L. (1999). How to build a thriving fee-for-service practice: Integrating the healing side with the business side of psychotherapy. San Diego, CA: Academic Press. Kolt, L., Slawsby, E., & Domar, A. (1999). Infertility: Clinical, treatment and practice development issues. In L. VandeCreek & T. Jackson (Eds.), Innovations in clinical practice: A source book. Sarasota, FL: Professional Resource Press. Kolt, L. (1996). How to build a thriving infertility practice. La Jolla, CA: Kolt Consulting. Kolt, L. (1997) 25 essential office forms for an efficient, professional and ethical practice. La Jolla, CA: Kolt Consulting. Wood, W., Jones, M., & Benjamin, L. T. (1986). Surveying psychology’s public image. American Psychologist, 41, 947-953. INFERTILITY TERMS & DEFINITIONS Taken From : Kolt, L., Slawsby, E., & Domar, A. (1999). Infertility: Clinical, treatment and practice development issues. In L. VandeCreek & T. Jackson (Eds.), Innovations in clinical practice: A source book. Sarasota, FL: Professional Resource Press. The basic diagnosis of infertility is usually made after one year of unsuccessfully trying to conceive a child. The four primary contributing factors include 1) couples waiting too long to have children allowing more time for illness, disease or aging to present reproductive problems 2) earlier and more frequent sexual activity by teens that created a sexually transmitted disease 3) drug use or 4) pollution or poor nutrition. People who diagnosis and treat female infertility are usually endocrinologists, OB/GYN’s and midwives. Urologists focus on male infertility factors. Hi tech medical interventions are referred to as Assisted Reproductive Technology (ART). According to a Center For Disease Control 1997 report, the percentage of ART births per woman’s cycle was 19.6% with the woman’s own eggs and about 30% with donor eggs. Donor eggs are used when a woman’s own eggs are too old or are unable to function properly. Infertility can be based on anatomical problems, hormonal problems, endometriosis, past medical problems or surgeries, and even unexplained origins. Several medical procedures have been developed to bypass infertility. Here are some common terms: In Vitro Fertilization (IVF): An egg and a sperm are put together in a laboratory dish. Upon a successful fertilization, the embryo is put into the woman’s uterus. Gamete Intrafallopian Transfer (GIFT): The eggs and sperm are laparoscopically inserted into the fallopian tube. Then any fertilized embryos float into the uterus. Intrauterine Insemination (IUI): Frozen sperm of the husband or a donor are placed in the uterus by catheter, bypassing the cervix and upper vagina. Intracytoplasmic Sperm Insertion (ICSI): A single sperm is injected into an egg with a microscopic pipette. Upon successful fertilization, the resulting embryo is then placed in the uterus. Zygote Intrafallopian Transfer (ZIFT): Eggs are first fertilized in laboratory. Eggs that become fertilized are then placed in the fallopian tubes. Intracytoplasmic Sperm Injection (ICSI): A single sperm is injected into an egg with a microscopic pipette. Upon successful fertilization, the resulting embryo is then placed in the uterus.
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| Laurie Kolt, Ph.D. | ||||||
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