UM meta tafe) ey Ve ty LINDA D. APPLEGARTH > rapid scientific and medical advances in the and the growth of tw clinies around the world have led to a greater ed reproductive technologt eerstanding and appreciation of the psychoseicial *rnvand emotional needs of individuals who suffer infertility. As the available technology has > along with the vicissitudes of fertility treatment, s have turned to mental heals professionals for ~ ‘ndleating with the many stresses inherent in diag- + procedures and treatment, and for assistance in level- ton making relative to treatment protocols and ative parenting options. + chapter facuses on three general areas bal, historical perspective of inferuiity counsel : anda brict consideration of some key psychological sss that are also commonly a pratt of the: infertility e. The literature review is intended to provide baste educational and theoretical constructs on gvand used a directive (and metaphorical) style hase! vn hypnotic paradigms. These paradigms were fur- hher elaborated in Haley’ pragmatic, problem solving proach, and in Minuchin’ ‘structural’ approach to amily treatment that emphasized resolution of specific snedlinte problems by “altering the transactional pro- sess that reveals and maintains” the problem. the term strategie refers to the therapist's task of developing a strategy, or a plan, to interpret the cliei’s nsnevessful attempted solution at eliminating or ame- iorating his or her own distress. A primary task is to mouvate cents to implement the therapist's strategic intervention/solution, The jruspose of this counseling Ppmach is 10 resolve the original complaint 10 the iont’s satisfaction{(St] Change is therefore effected principally through treating a presenting problem or specific symptom. The treatment is implicitly systemic snd interpersortal Rosenbaum[52] reported that strategic therapy is not 2 particular orientation or therapy: rather, it ean refer ‘ony therapy in which the counselor willingly assunves esponsibility for influencing people and takes an active 135 role in planning a strategy for promoting change. Ile adds, however, that strategic psychotherapy dies Inve major distinguishing characteristics that are patticu- larly relevant, Some of these characteristics are: & Siraegiv work with a epistemology ® Strategic therapy focuses on problems and their therapists systemic solutions: % Sirategic: therapists tend to see client problems as maintained by their attempted solutions; Strategic therapy requires only a small change: Strategic therapists use whatever clivatshring iwhelp teu ake a satistactory Tif Strategic therapy is brief therapy. Solution-focused therapy is an important variation, of strategic therapy[42] that emphasizes building on exceptions to the presenting problem and making tan- sitions rapidly to the identification aud development of solutions intrinsic to the client or problem, As ‘opposed to considering the question “What maintains the problems?” often asked in the strategic therapy mode, the solution-fucused counselarasks, “Haw do we ennstruce solutions?" Walter and Peller[53] pointed out that the presuppositions within this question are that: there are solutions; here 1s more than one solution; # solutions are constructible ‘wel (herapist aud client) can do dhe construction; ® we ‘construct’ or ‘invent’ solutions rather than dis- cover them; ® this process or these processes can be articulated and modeled There are essentially three steps to constructing sol tions in this treatment approach[53] (1) Define what the client wants rather than what he or she does not want; (2) Look for what is working and do more ot it; and (3) IF what the client is doing is not working, have hin or her do something different Solution-focused brief therapy is seen as a total model, described specifically by such practitioners as Olfanlon, Berg and Miller, Ouick, and Walter aud Peller 1 is not 2 collection af techniques or an elabora- tion of a technique; rather, it reflects fundamental ideas about change, interaction, and reaching goals 15 A strategic solution-focused approach to working with infertility patients may involve the use of ‘coping questions.’ Quick{51] stated that coping questions ask how the client goes on in the face ofa difficult, painful situation. An example of a coping question might be: “Givew what this past year of Failed infertility trea ment has been like for you, how have you managed136 lw get through it?” Clients may answer by describiny simple behaviors or saying, “T just do it.” Thus, even if the coping behavior did not seem to be the result of an active choice, the therapist may geuily puint out that the client did have a Choice and that he or she chose a cop ing alternative[51] Identifying coping behaviors and encouraging and amplifying healthy ones (while not ing behaviors that are less useful or healthy) are impor tant tools in solutionefocused therapy. This approach is intended to help patients continue the healthy cop- ing and increase their tolerance for distress. This treat ment process can be extremely helpful to infertility patients, particularly when the therapist is also able to interrupt unsuccesstul coping solutions by redirect- ing Clients’ efforts into more productive and satisfying behaviors In Germany. for example, Holzle et al.[54] developed a solution focused counseling program for infertile cot- ples with a focus on increasing the ability of clients to cope with involuntary chilllesness as a transitory life crieis, with the goal of improvement of life sat- isfaction, independent of pregnancy. Holzle and her ulleagues concluded that, based on patient reports significant reduction af psycholugisal and somatic com- plaints could be reached within a framework of about seven sessions. They noted, however, that this treatment approach should not be used wilh people who demon, strate serious mental health disorders, and stresved the importance of a differeruial dingnusis at the time of intake. Grisis intervention The term crisis futervention originated in relation 0 people with stable personalities and a history of ade- quate coping resiurves, whe are facing important but Ursusitory difficulties.[55] Although infertility pationts fall into this general categary, it fs also common (at, it, most cases, the difficult infertility experience is seldom transitory, Heweven, infertile individuals often experi cence ‘crises within the crisis” particularly when they are confronted by an unexpected event such as failed fertil- ization, premature ovarian failure, a pregnancy loss, or the sudden recommenclatinn to ond treatment. Alilough the precise goals of crisis intervention depend on the specific nature of the crisis, crisix- oriented weatments do share a number of general goals [56] These include: 1 relieving the chent’s symptoms; § restoring the clieat wo his or her previous level of functioning: '® identilying the factors that precipitated the crisis LINDA D. APPLEGARTH identifying and applying, remedial measures: = helpyiny the client connect the current stresses wi past life experiences; 1 helping the client develop adaptive coping skills the- tsa be used in future situations. According to Rapoport [56] minimum goals of all types of crisis intervention, wh the last two are considered optional or feasible only i certain situations, Understanding and developing cop ing behaviors appear to he a key campanant af cris intervention, Lazarus and Folkuian{$7] suggested tha: first fone poals ave the coping is a process and that is situation-specifi. Infertility patiewls are known to use & combiniatio of coping mechanisms, but in certain circumstanees they often fail to do so because of a number of factors The infertility problem may scem too overwhelming © too unfamiliar; the person may use maladaptive cop ing methods; coping may be limited by physical « ‘mental illness; or support from frientls or Tamily tha: would otherwise enable & person to cope 1s unavail able. All too often, infertile patienls revert aver tine te one or two (adaptive oF maklaptive) coping strategies instead of expanding their coping repertoire in response to increased stressors. When coping fails, one may observe what Caplaul58: described as four phases of crisis: 1, Arousal and etlorts at problem sulving behavior increase; 2. With Increased arousal or tension, impairment ensues with associated disorganiza- functional Lion and distress. Arousal reaches a point at whic coping is hindered: The person is 190 anxious or 100 angry or unable (0 sleep properly and 3. Fmergeney resources, bath internal and exter nal, are mobilized and novel methods af coping tried 4, Continuing failure to resolve the problem leads ty progressive deterioration, exhaustion, and. decompensation, Peychotherapeutic intervention can be made at any point during these four phases. Bancroft and Graham{55] noted that there is much scope tor skill and experience: in practicing crisis intervention. Tt requires empathy and sensitivity; therapists also often rely on the skillful use of common sense rather than highly specialized techniques. Although it has been difficult ton ness of crisis intervention because of the range of approaches for which the term 1s applied, this should not deter the counselor from using an approweh Unt ich a convhesion abit the effectiveINDIVIDUAL COUNSELING AND PSYCHOTHERAPY s based on caring, common sense, and practical sug- zestions [55] Infertility patients appear to respond well » crisis intervention and often benclt from having the spportunity to mobilize their coping skills and support Grief Counseling Because bonds of attachment often develop before child is conceived or delivered, it is. important to acknowledge that the breaking of these bonds cither hrough loss or disruption can create intense emotional sain, In the face of these reproductive losses, many fertility patients need to grieve or mourn. Here, grief nd mourning are detined as the intellectual and emo- ional processes that gradually lessen the psychological ond to the last loved one, enabling the bereaved to accept the loss and move forward.{59] Grief counseling for individuals unable to conceive ‘akesa different form from that of individuals who have vperienced a pregnancy lass or perinatal death. For oth groups, it is imperative that the reality of the loss se acknowledged: The loss ota child, real or tantasized, sa brutal shock and feels like an assault on self-worth the meaning of one’ life. The counselors role is to encourage patients to accept the loss. Second, bereaved infertility patients must also be aclped to experience the pain of grief. This crucial aspect of grief consists of expressing in words the rntense feelings that accompany the loss.[59] Leon{8] clded that, in working with the bereaved, it is also nec~ =sssary to challenge directly the therapist's own discome ‘ont with and pathologizing of grief. Third, the counselor can be helpful in assisting indi iduals who have experienced a perinatal death to com- cmemorate the loss. Often, 1 + pene need ssintiance » finding an acceptable way to honorand remember the baby’s death. This can be particularly important when here is a significant burden of guilt in relation to the death (59) Fourth, the therapist may also play an important ‘ole in helping bereaved persons let go of the loss. The bereaved ultimately must withdraw their emotional rigestment in the Toss in order 10 go forward with fe. LLactly, tho therapist may also be called on to assist bereaved individuals to move on, Crenshaw59| pointed one that this ean he very difficult because it inalves relinquishing the hopes, dreams, plans, and aspirations that revolved around the lost dream child, At times, the vesistance to moving on may result from anger that lie has dealt the hereaved a cruel blow. Similarly, some srievers tend to identify themselves as tragic figures, 137 gaining gratification from the solicitations of family and friends. As result of these secondary gains, they have difficulty becoming active participants in life and letting g0y not only of the lost layed one, but alsa af the rae of the bereaved. In sum, srief counseling can be a very meaningful intervention for patients who experience reproductive lus. Often, te feedings of pain caw be extreaely heavy to bear and must be shared, in part, by the therapist and managed supportively. In this way, the counseling intervention provides a secure base and a normalizing experience: for the bereaved CLINICAL ISSUES ‘Transference and Countertransference Although transference and countertransference are intrinsic parts of every paticnt-therapist relationship, it is crucial for infertility counselors to be mindful of pow. erful and compelling countertransference issues when working with patients experiencing infertility and preg. nancy loss. ‘working in this field to have had some form of personal experience with infertility and its associated losses. This position can have positive and negative, cttects. Countertransference, broadly defined as the dhetapist's total response to a patient, bath canscious and uncon- scious, can be useful in understanding the experi ence of the patient.|601 The infertility crisis can be laden with profound feelings for both counselors and clients about gender identity, sellimape, and wishes for nurturance. The feelings that arise within ther pists vary ercatly depending on how they have resolved theit own issues about infertility and pregnancy loss. Unless there is some form of resolution about this aspect of the therapist's life, it will be profoundly ditticult to explore childbearing problems and deci sions with patients while maintaining a'ncutral’ stance, fore come Subtle and not-so-subtle conflicts can the nto play in clinicians’ relationships with clients. AS a therapist personal insues (e-., feelings about becoming a parent, guilt, ambivalence, and anger) car interfere will: yrticats’ efforts at working through their conflicts and con- corns about infertility and loss, In some the uggles with painful, unresolved infertile patient may not only be impacted by the psy- chotherapis: coumiertransference but also by coun- teriransference issues that come from the medical treatment team. There is often an unconscious connec- tion between doctors and patients, nurses and patients, as well as berween atlininistrative stall and patients.138 Kentenich and culleagucs|61] noted that doctors and therapists have characteristics und personality styles that inay influence their reactions 10 patients. For physicians especially, there is a tendency to be proae- five with patients un an ongoing basis so thal there Is rho time tor grief or disappointment. The “unconscious unity (hetween doctor and patient) delends them from emotivns as, for example, they both want to quickly forget’ failires (a0 pregnancy, miscarrinye).” Ken tenich and his colleawues, thus, argue that it is this tunity that explains why psychological considerations snient of infertility are often not permitted in the trea for, at minimum, avuided.161) ‘gell-dizclosure by psychotherapists is another impor. tant countertransference issue in infertility counseling ‘The question often arises regarding lw much to self diselose, iat all, and (0 which patients. Thin issue ust be carclully considered because revealing, personal pain can potentially be nranipalative and self-indulgent rather than serving to further » patient's growth. Leibowit7[h2) believed that the key to self-revelation to a patient is based on a sense of how open i therapist and patient have been with one another and how much tmist and connection have been established in the thera~ peuticalliance. In any case, selfdisclosurt hy therapists must be used in a thoughtful, purposeful way s0 as to benefit or assist a client (aot the therapist) even though Hherapist’s personal experience wath infertility ms, in some eases, inrease his or her ability twempathize with lients’ pain and anger. Self-disclosure can also be a way to model effective behaviors and to close the perceived distance between therapist and client, thereby facile tating greater tnust are openness,[63] In other cases, however therapist's own jnterilty issties may be 24o~ jected onto the clients infertility experience, potentially tntevfeving with the client’ coping, sbilities and efforts to resolue this diffiewlt and painful experience. From a broader perspective, Rosen and Rosen[f) discussed the cltects of infertility patients’ complex psychological dilesnmas on de emotional lives af mental health pro- fessionals, They address, with the wssistance of expe: nnenced colleagues in the field, how psychotherapists’ reactions may “limit or help psychotherapy” with this nique population. Lastly, the psychotherapists pregnancy is a real and obvious event for both clinician and patiewt.{65] ‘Although it can allow for very important therapeutic effects to uecur, it unquestionably allows for critical transference and countertransference issues. A treat- ‘ment crisis can ensue that can potentially lead le Tuarail- jation on the part of the infertile patient, For even the mont experienced therapist, this may be an important time [ur her to obtain supervision UNDA ©, APPIFGARTH THERAPEUTIC INTERVENTIONS. We are told that although theoretical diferences in treatment apprnaches definitely exist, it is unclear as to the extent to which these differences are purely applied jn practice. Experienced climcians are likely to use interventions thal are similar in wtility and intent, if not form, but tht also reflect their own unique personali- ties and experience, as well as situational demands [42 Energetic efforts to distinguish approaches from one another also tisk unfairly dichotomizing and limit ing them. Tor example, the highly interpersonal anc implicit nature of straiegic therapy ts often ignored in favor of its technical companents, Similarly, most pss chodynauie approaches now consider interper factors in psychotherapy to be as important as intrapsy chic ones, Because it appears that infestility patients primarily seek out short-term or brief counseling or psychother apy, Its important to outline some essential character istics and common principles. 1 is also useful to point ‘ou a commun value system that snost brief psychother pies shares{42—44,66] These Include Technical features & maintenance of a clear, specific treatment focus © conscious and conscientious use of time limited goals with clearly defined outcomes ‘6 emphasis on intervening in the present 8 vapid sscossment and integration of assessment within treatment we frequent review of progress and discarding of inef- fective interventions Thigh level of therapist- patient activity pragmatic and flexible use of techniques Shared values = emphasison pragmatism, parsimony, and least intru sive treatment versus cure j recognition that human change is inevitable » inphasig on cllent strengths and resources and the legitimacy of presenting complaints fe recognition that most change occurs outside of therapy we commitment that # patient's outside life is more important than therapy fe a stance that therapy is not always helpful a belief thot therapy is ot timeless. J eon{67] noted that of twenty cases of women pre senting with emotional prublems following preynancy loss, six women left eatment during the consulta~ tion or soon alter therapy began. Of the six, five were ‘also dealing with fulertility before or after their Iss|S VIDUAL COUNSELING AND PSYCHOTHERAPY emarkably, bowever, those five who left treat- ‘arly were the only infertile women in his total =, Other clinicians appear to have had similar noes with infes tility patients. For this reason, it Jally important ro emphasize the sige « of the first session, because it may be the only ‘Ser[42] pointed nt that it is helpful if the clini nsiders each session asa whole in and of itself. To «< cllectively, he described at least six first-session al can serve multiple purposes: forma positive working relurimship. Spend a few moments constructively getting acquainted: + Da seme therapy education, + Ask how you cot be helpful + Uso active listening, empathy, and language thatdemonstrates respect foreach client’ paint ol view. + Find # one-seutence summary to repeat to clients that reflects your urulerstanding of their problem. + Find at least one thing to like or respect about each patient or his or her coping and call atten thon to it, + Create an expectation of improvement 2 Find a treatment focus + Ack whut biought the patient to treatment now rather than earlier or later + Ask what improved since the appointment wis made that patients would like to continue improving + Determine at the beginning what would be tan- sibly different for clients at the end of success ful treatment. + Define problems in specific terms conducive to change + Determine the meaning or significance of a problem to a patient. + If mukiple problems are identified, focus first on the most important 10 the cleat sotiate criteria for a successful outcome + Put solutions in positive, specific, achiev able terms, using client language to facilitate change. + Make goals/solutions achievable, and phice goals within the patient’ control 1. Distinguish clients fromm nonclients, Not every per son who presents in therapy i w candidate for change: * Clients are characterized by the acknowleds- ment of a problem and a willingness to work onit. 139 + Nonelients may acknowledge « problem exists but do not see themselves as part of the solution, Identify patient nvvivariemal levels, and tailor inter. ventions accordingly. 6. Do something that makes a difference immedtarely + Tisten actively and empatheticaly. + Help patients understand that most of their reactions to infertility are normal and pre- dictable. + Discuss the process of achieving desired solu- tions * Conceptualize or reframe problesty in ways that suggest solutions. ‘The focus of treatment in individual counseling with infertility patients can be collaboratively developed with them and is closely related to the ideas of assess- ment and diagnosis. It is therefore important to have sound diagnostic skills while working within an infer- tility patients perception of the problem. A helpful diag~ nostic framework describing personality structures ani] reactions to infertility is presented in Table 8.1. Along with understanding the psychological components of infertility, itis also imperative to ayseas the presence of ‘personality disorders, substance abuse or dependency, sexwl sluise, domestic violence, sociopathy, and other significant mental health disordersiproblems, as well as the patient's cultural expertence and milieu. It is clear that individual counseling with ifs til- ppalients requires special expertise and an under- standing of and appreciation for the many psychos cial and medical components relative to this condi: tion. A commentary by Hart{68] also supports this notion Appendix | delineates qualification guidelines for mental health professionals working in reproduc- tive medicine and stresses the need for a solid know! exec of family-building options, such asalaption, third party reproduction, and childlessness. In addition, an understanding of the potential sociocultural, rehgious, and ethical implications af these choices is critical. Tn sum, the treatment modalities dixcussed in this ehapter can be extremely useful when counseling iner~ tile patients. Most psychotherapists use a combination of interventions to meet cliewis’ needs in the most effec tive and cthicient was. These approaches, however, are only as effective as the therapist who makes use of them. Kottler[43] pointed out a number of common characteristics or qualities uf successful psychothera. peutic outcomes, including 2 counselurs personality skillful thinking processes, good communication skills, ‘and the ability io establish an intimate and trusting relationship.140 LINDA D. APPLEGARTII TABLE 8. |. Personality types and infertility(69] Personality structure Obsessive: orrlealy, systems, perfectionist, inflexible Narcissistic: selt-involved, angry, independent, perfectionist orderline: demanding, impulsive, unstable Dependent: long-suffering, depressed, submissive Avoidant: remote, unsociable, uninvolved Paranoid: wary. suspicious, blaming, hypersensitive Reaction to intertlity Infertility is seen ac punichment for letting things get out of control Infertity is seen as at atlack on autonomy and perfection of self Infertity fs seen ao threat of abandonment Infertility is seen as expected punishment far worthiessniess Infertility and its pracedures are seen as a dangerous invasion of wrivacy Infertility is 0en as annihilating assault coming from everywhere outside of self FUTURE IMPLICATIONS here is a clear future for mental health professionals treating infertile individuals, At the same time, one of the goals of this chapter has been to emphasize the importance of having a sound knowledge of the psy- chosocial experience of infertility and an appreciation ble, the high financial andl exnitional costs involved, and the range of parenting alternatives from which patients might ultimately choose. It is only with this solid back- ground that a psychotherapist can best apply his or medical interventions av: of the numerous her theoretical and clinical expertise to assist individu als struggling with losses and concerns associated with infertility: From a global standpoint, however, the need for a clear understanding of cultural traditions, needs, and experiences will significantly impact how the men- tal health professional practices his or her craft. Clinical interventions thus must be tailored not any to the psy= chological needs of the infertile patient but also to his or her social and cultural needs. In light of the complexities of all forms of reproduc tive loss, it appears thal professional trsvsinng primers and postgraduate courses may, in the future, choose to incorporate or develop specific curricula that address the psychosocial components of infertility. The rapid growth of the assisted reproductive technologies aul the psychological and ethical implications inherent in them require that formal clinical programs be estab- lished to provide training in this increasingly important arena. Credentialing in infertility counseling, dhrough specific country or international professional organiza tions, may also help establish appropriate qualifications and expertise in the field. Subspecialties can be devel- oped that focus on reproductive: healthy ay well as ot perinatal issues including not only pregnancy loss but also pregnancy and parenting after infertility as well as the long-term impact of assisted reproduction on ehil- tlre sl feiies, SUMMARY ® Historically, infertility and reproductive loss were often considered hy menial health professionals as having a dynamic, paychogenic basis. Recently, there has heen a significant shift to supporting infertile individuals and minimizing the destructive emotional components of this medical condition, This shift has occurred among clinicians and researchers on an international level. The five drevretical treatment approaches. pre- sented may be useful in working with individuals struggling with infertility. These include psychody- namie psychotherapy, cognitive-behavioral therapy, strategic andl solution-focused psychotherapy, crisis intervention, and grief counseling. * Clinical issues of countertransference and the role of the therapist who works with this spe- cial population need to be understood, especially because many therapists working in the field have had personal experience with infertility. Many infertile individuals request and/or require only brief psychotherapeutic intervention, + Allinfertility counselors can apply several speci tasks when meeting a new client for the first time. These tasks can serve several important purposes and include: ~ forming « positive working relationship ~ finding a treatment focus ~ negotiating criteria for a successful outcome ~ distinguishing clients from nonelients ~ identifying patient motivational levels and tai- loring interventions accordingly ~ doing something that makesa difference imme- ent approach is only as effective as the therapist who employs it. Individual counseling and psychotherapy with infertility patients is an area that deserves our specialNDIVIDUAL COUNSELING AND PSYCHOTHERAPY tention, The psychosocial needs of those who strug- ‘10 build families are compelling and require clini- +l expertise and a clear understanding of the under- nz emotional issues involved. REFERENCES Mack S, Tucker J. Fevilty Counselling, London: Balliere ‘Tindall, WB Saunders & Company, 1986; 101. © Menning BE. RESOLVE: A support group for infertile ou ples. Ar J Nurs 1976; 76.7589 Menning BE,Counseling infertile couples. 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