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Section 3
Psychotherapy for Infertility Clients

Question 3 | Test | Table of Contents

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In the last section, we discussed two more beliefs about infertility. These included maleness and femaleness as related to passing on a genetic legacy and mourning versus pathological depression.

How does your client cope with loss as a result of infertility?  How do you respond to your client? 

In this section, we will discuss facilitating mourning. This will include the "mourning ritual" technique, mourning and attachment as well as support systems.  As you listen, compare your techniques you are currently using with those presented in this section.

As you are aware, loss is the motif of the couple’s encounter with infertility, and the kinds of losses are both tangible, such as failed medical protocols, miscarriages, still births. . .etc.. and intangible, such as experiencing a trouble-free pregnancy, having a genetically related child, as well as the anticipatory loss of not knowing whether they will ever have children.

Try to keep in mind that although loss is a fundamental aspect of the human condition, not merely a central experience of infertility, we are living in a culture that has difficulty dealing with issues of loss and mourning. Not only couples, but clinicians as well may have difficulty talking about grieving and loss.

By attending to the motif of loss, I try to help the couple identify and address their losses. At times, this may mean probing for the implicit or implied loss. When couples talk about, for example, not qualifying for or experiencing failure in regard to a treatment protocol, questions arise not only regarding loss but the nature of the loss often need to be asked.

♦ 3 Questions about Perceived Losses
This means stepping beyond the "How did that make you feel?" level of clinical inquiry; and asking about the perceived losses, for example:
-- 1. "What were you each hoping for?"
-- 2. "What did the treatment failure, miscarriage, afternoon in the park without children…etc. mean to you?"
-- 3. "How is this loss different from other losses that you’ve encountered?"

I have found that partners’ ability to comfort each other about their losses improves over time. At first, many couples are awkward about expressing sadness in front of and/or receiving comfort from the other. This is especially true when infertility produces the first serious losses the couple has yet encountered.

This can be approached in a variety of ways. For example, each partner might be asked what he or she feels would be most comforting. For some, it may mean exploring beliefs associated with the expression of sadness, for example, assumptions about masculinity and not showing emotion. For others, a ritual may be an appropriate form of mourning

Technique: Mourning Ritual
Because rituals can facilitate the mourning process, I often ask my clients to try a "mourning ritual" to help them grieve the loss of fertility. This involves the couple creating rituals of their own. Most couples need some guidance in order to create a ritual that incorporates elements that address their losses. In suggesting and helping the couple plan a ritual, I try to respect what the partners feel lies within their zone of comfort and to encourage them enough to inspire them to take the risk of trying something unusual.

In my experience, I have found that a couple is more likely to feel that creating a ritual sounds "too hokey" if I haven’t spent enough time in helping the couple to articulate their loss. If treated with importance and seriousness, the rationale for a mourning ritual makes emotional sense. Some couples arrive at inventive ways of mourning together without actually realizing they have created a mourning ritual.

Edward, age 35 and Shelley, age 34 had a "Bed and Chocolate Ritual." When Shelley got her period after an insemination, both of them came home from work and cuddled in bed with chocolate and a video. This ritual helped Edward and Shelley to get through another failed attempt.

I have found that some couples prefer to mark their losses with an in-session ritual, especially if I have understood their sadness and not shied away from their pain. In these instances, I am allowed by the couple to be a respectful mourner who amplifies the seriousness of the ritual.

Other couples prefer to perform their mourning ritual alone, although a discussion about how it will be executed may take place in the session. In these instances, the discussion of the ritual can activate or intensify the process of mourning.  A later section will detail the mourning ritual one couple had developed of planting a pine tree for each miscarriage.

♦ Mourning and Attachment
First, let’s discuss understanding mourning and attachment. Have you found, as I have, that couples struggling with infertility have often assume that a part of their mission in life includes the creation of children, and that their roles and identity would be defined by parenthood? Grief, therefore, is not just about the loss of the imagined child, but the loss of their unifying mission as parents, the loss of a special kind of bond.

As Carol, age 43, put it, "I feel a profound sense of loss that we are not actually, physically, going to be able to make love and make a baby and that we’re not going to have this creature that our blood commingled in, our DNA commingled in. You know, I feel like somehow life cheated me out of something that I really, really wanted."

While this loss was one of many to mourn, the creation of and participation in mourning rituals can help partners to construct different kinds of attachments with each other. These empathetic bonds can have special significance and utility. Although they may not replace the unique union of parenthood, an intimate connection brought about through shared mourning can be vital in helping couples get through the anguish and sorrow of infertility. When this opportunity is missed, the effects on the couple’s relationship may be devastating.

Alice and Carl, both aged 48, had experienced long years of what they called a "nonmarried kind of marriage." They connected their gradual disaffection not only to their infertility, but to the fact that Alice mourned alone, at the time the infertility was diagnosed, after each treatment failure, and at various times throughout the years when feelings related to her losses were triggered.

Each time Alice pulled away from Carl to keep her mourning private, she stepped further and further away from her marriage. Carl was aware of her sadness and suspected that it stemmed from the infertility. However, Carl took Alice’s increasing distance as a signal that she did not want him to comfort her. Because Carl felt responsible for having urged Alice to end medical interventions, he was afraid that if he tried to step across Alice’s invisible wall to comfort her, she might use the occasion as an opportunity to reproach him.

♦ Support Systems
In addition to understanding mourning and attachment, second,  let’s discuss changing support systems. I have found that part of understanding the effects of infertility on couples’ lives is recognizing how relationships with families and friends can be altered. Because infertility makes it impossible for couples to move into the parenting phase of the life cycle, relationships with family members can be painful reminders of their situation.

Although some families or individual family members can be enormously supportive, many are likely to have limited understanding of the couple’s plight. Moreover, spending time with other families who have children can be extremely painful. Furthermore, if one partner finds solace in time spent with family and the other cannot tolerate family gatherings, conflicts may arise.

To address the issues of family and friends, I have worked with couples to find strategies for developing workable relationships during their struggle with infertility.  These vary from couple to couple.  Some may look at the kinds of boundaries that existed before the infertility and even evaluate whether these are still comfortable or whether a recalibration of private versus social life makes more sense now. 

Other couples may want to alert family members to their "temporary crisis."  Have you found, as I have, that relationships with significant family members are often reconfigured as a result of infertility?  Would playing this section be beneficial during a future session?

In this section, we discussed facilitating mourning. This has included the "mourning ritual" technique, mourning and attachment and support systems.

In the next section, we will discuss couple issues in the dawning phase.  This will include the crisis and trauma of infertility, the impact on the couple’s relationship, bringing up infertility, helpful questions and attitudes about parenting.
Reviewed 2023

Peer-Reviewed Journal Article References:
Darwiche, J., Favez, N., Maillard, F., Germond, M., Guex, P., Despland, J.-N., & de Roten, Y. (2013). Couples’ resolution of an infertility diagnosis before undergoing in vitro fertilization. Swiss Journal of Psychology, 72(2), 91–102. 

Flykt, M., Lindblom, J., Punamäki, R.-L., Poikkeus, P., Repokari, L., Unkila-Kallio, L., Vilska, S., Sinkkonen, J., Tiitinen, A., Almqvist, F., & Tulppala, M. (2011). Prenatal expectations in transition to parenthood: Former infertility and family dynamic considerations. Couple and Family Psychology: Research and Practice, 1(S), 31–44.

Jaffe, J. (2017). Reproductive trauma: Psychotherapy for pregnancy loss and infertility clients from a reproductive story perspective. Psychotherapy, 54(4), 380–385. 

Papadakis, J. L., Poquiz, J. L., Buchanan, C. L., Chan, Y.-M., Crerand, C. E., Hansen-Moore, J., Kapa, H. M., Nahata, L., Pratt, K. J., Tishelman, A. C., & Chen, D. (2020). Fertility discussions: Perspectives of adolescents and young adults with differences of sex development. Clinical Practice in Pediatric Psychology. Advance online publication.

Pelham, B. (2019). Life history and the cultural evolution of parenting: Pathogens, mortality, and birth across the globe. Evolutionary Behavioral Sciences. Advance online publication.

Quinn, G., Bleck, J., & Stern, M. (2020). A review of the psychosocial, ethical, and legal considerations for discussing fertility preservation with adolescent and young adult cancer patients. Clinical Practice in Pediatric Psychology, 8(1), 86–96.

QUESTION 3
What are three ways of facilitating mourning? To select and enter your answer go to Test.

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