Conception Patients
by Jennifer Hunt, SAMBICA (Senior Accredited Member British Infertility Counselling Association)
People who have become highly stressed will often feel out of control and in a state of chaos which in itself will be frightening so the first task in stress management work with clients is to enable them to understand what stress is (‘therapeutic information giving’) so that they can make better sense of their symptoms rather than fear they are going mad or are seriously ill5. This should include written and verbal information about the ‘Fight or Flight Syndrome’. This is the body’s normal and necessary reaction to danger but, when it is repeatedly triggered by stress, it often has long-term effects that become psychologically and physically harmful which in turn will affect the person’s behaviour5. Where stress is not addressed people may become at risk of serious medical problems including hypertension, coronary disease, irritable bowel syndrome and ulcers as well as significant and disabling mental health problems5, 6 .
The Stress of Infertility and Assisted Conception
The stress experienced by people with fertility problems is well described in the literature on the psychological impact of infertility which recognises the importance of therapeutic interventions. As a result, in the UK, legislation uniquely requires assisted conception treatment centres to offer counselling and support to their patients7. Stress was ranked second to that involving the death of a family member or divorce by couples undergoing treatment8. Infertility counselling became a new field of counselling expertise when a professional body was established in 1988 (The British Infertility Counselling Association (BICA)) and specialist accreditation procedures were recognised in 20079.
The biological interaction of stress and infertility has been found to be a result of stress induced hormones affecting the female reproductory organs and interrupting the ovulatory cycle in some women10, 11, 12. More recent studies have indicated that ovulatory function can be restored when woman learn to use cognitive behavioural strategies to reduce stress13.
However, the majority of research points to stress being a result rather than a cause of infertility. In a review of the literature, it was found that infertility-related stress increased marital conflicts, decreased sexual satisfaction, sexual functioning, life quality evaluation, self-efficacy, intimacy and health14. A more recent systematic review of 25 years of research identified clinical and sub-clinical levels of anxiety and depression in woman who had had a failed IVF treatment cycle, with no recovery amongst >20% of these 6 months later15. A further study found women continued to be affected by treatment failure and involuntary childlessness 20 years later16.
A common theme in explaining the stressful impact of infertility is that it represents a life-crisis and people experience grief reactions similar those in bereavement16, 17, 18. However, the losses of infertility can be harder to resolve because they are less visible than when an actual person has died or is dying19. When a fertility problem is first diagnosed, people often experience considerable shock, they may find it so difficult to believe that they seek second and third opinions, go into denial and be unable to tell anyone about it. As time goes by feelings of anger, sadness guilt and despair may emerge and these can lead to strains in relationships with friends, partners and colleagues. Life is often disrupted by the intensive schedule of an IVF cycle and some people are so affected that it leads to absence from work for short or prolonged periods. When successive treatments fail the losses accumulate and can include loss of hope, self-esteem and self-confidence, sense of woman or man-hood, sexual being, body-image, longed for roles and identity - parent and grandparent20, 21.
Stress increases when the infertile person finds it too difficult to mix with friends and relations who are absorbed in their own child-bearing and family-raising, leading to increased social isolation, hostility and depression22. There is also now evidence that a significant number (26 -36%) of patients drop out of treatment as a result of psychological stress from the procedures they have had to endure and the experience of treatment failing even when they might have succeeded in conceiving if they had persevered23, 24.
Not surprising then that the availability of psychologically therapeutic interventions are valued and promoted in the field of infertility and assisted conception7, 25, 26, 27,. The effectiveness of such therapy in the treatment of mental health disorders has been evidenced in a systematic review of outcomes in evidence-based research (Leichsenning ’07). Cognitive behavioural therapy (CBT) is commonly cited as the most effective form of therapy (Sheldon ’93, Leichsenning ’07) in general and has had good results when applied in the field of infertility to treat anxiety (McNaughton ’02, Tarabusi ’04) and depression (Hynes ’92, Hunt ’97, Terzioglu ’01) as well as other symptoms of stress (McNaughton ’00, Campagne ’06). Many patients recognise that counselling and support can play a part in how they cope with, and survive, the experience of assisted conception with one study reporting that 67% would select the treatment centre on the basis of stress reduction therapy being available (Bankowski ’06).
Cognitive therapy is based on the theory that much of our stress and anxiety arises from maladaptive thinking and the meaning that we attribute to a situation determines our emotional response to it (Course book 4, Beck *, Palmer * ). In the words of Epictetus in the first century AD ‘Men are disturbed, not by things, but the views they take of them’ (Blackburn and Davidson ’90). We evaluate our own worth using a set of inner rules or thoughts and when these are distorted we respond emotionally to the distortion, not the reality. Since what we do and how we behave is influenced by what we think, our behaviour can also become inappropriate and unhelpful if our thinking is unrealistic or self-destructive. (Course book 4, Palmer *, Hunt ‘97). Therefore CBT aims to modify the client’s cognitive structures, first by identifying the distortions, challenging them and then learning to replace them with rational thoughts. The client will then be in a better position to recognise more effective coping strategies (behaviours) for stressful situations and engage in problem-solving that could lead to solutions. Amongst infertile people, those who adopt an optimistic attitude (Litt ’92), who actively seek to resolve their infertility issues (Hynes ’92) and who talk openly about the problem (Beaurepaire ’94) fare better psychologically than those who do not.
Work Context
The Infertility Counselling Service at which I am employed has traditionally used a Person-centred or Integrative approach. Sessions are confidential and the contract between counsellor and client is agreed on the basis of therapeutic need. I first became interested in the use of a stress management approach when I gained a Certificate in Stress Management at the Centre for Stress Management, London. However, the materials I have received and work I have done since registering for the Stress Consultancy Training have deepened my own understanding of stress and its management, providing me with a much wider range of tools and strategies in my work with clients. This work is of particular benefit to patients in the months before they commence treatment so that they can reduce their stress, feel psychologically and physically well in preparation for it. Before a first session I send clients the leaflet Understanding Stress and the following forms provided in Course Book 1: a stress assessment questionnaire, the Holmes and Rahe Scale, Cooper’ Life Stress Inventory and the Subjective Measure of Change. This provides me with a stress profile and enables clients to identify their main sources of stress and what they wish to achieve through our sessions. At present my employers have authorised a contract for each client to receive 5 sessions as a pilot scheme. I would hope to extend this to 8 sessions in the future.
Case Examples
1. Janet was 39 years old, married and had been trying to have a child for 8 years when she first came for counselling. She appeared depressed, with symptoms of low mood, sleep disturbance, reduced appetite, poor concentration and tearfulness. Whilst she had been active in the sense of attending for treatment cycles, it was apparent that her attitude was passive and unquestioning, a matter of submitting herself to whatever she was told to do rather than an active and engaged participant. She had told none of her friends about her infertility and the years of treatment. If people asked her if she had children she pretended she did not want a family and she avoided everyone with children if she possible could. This meant that she had long ceased to socialise with friends or even keep in contact by phone so she was lonely and isolated. The stress profile and early sessions with Janet showed that she had very low self-esteem and self-confidence reinforced by her inner dialogue of negative thoughts (Brendgan ’02) – “I feel like only half a woman”, “I’m a failure”, “my life is meaningless”, “my husband only stays with me because he’s sorry for me”. The sexual relationship with her husband was significantly affected – she tried to avoid it by going to bed at different times than he did, but would not discuss it with him.
Janet found that she gained most from the CBT aspects of her stress management sessions. Initially she found it hard to believe that her unhappiness was to a large extent a result of her cognitions and but she agreed it would be worth trying to do the work. In order to bring her maladaptive thinking into awareness I explained the theory about the influence of thoughts on emotions and behaviour and gave her the leaflet ‘Negative Thoughts’. She agreed to use the Stress Thought Log and Negative/Positive Mood log both of which enabled her to recognise the words and phrases that were inaccurate and she most frequently repeated in her inner dialogue. She begun to automatically notice and change her style of thinking from self-destructive to accurate. The positive impact on her self-esteem was very noticeable.
As her self-confidence rose, Janet agreed to work on some of her behaviour that was contributing to her depression and stress. She took the risk telling just one friend about her infertility and also decided to share her feelings more with her husband. The experience was so helpful that she found herself able to tell other close friends, she began to see these people socially again and to take part in some of the hobbies she had once enjoyed. Further progress was made when she agreed to write a list of all the people she would like to be back in contact with and the activities she had once enjoyed. This formed the basis of her next action plan that would improve the quality of her life and therefore her mood.
Janet is no longer depressed although she is sometimes justifiably sad that she is childless. She has decided against any more treatment but she thinks of this as an achievement, not a failure and herself as a success story of a woman who has survived the trauma and loss of infertility. She knows that she can have a fulfilling life with her husband.
2 Peter and his wife discovered that he had a very low sperm count which was the probable cause of their infertility. They are due to start treatment in 2 months. His stress profile showed that he felt anxious nearly all of the time, had headaches and dizzy spells, raised blood pressure (150/89), he was drinking more than usual but did not smoke, took no exercise and his diet was poor. Peter often felt angry, believed he was on work overload and felt a failure. He had been checked medically and none of his symptoms were somatic. He wanted to feel physically well again, control the anxiety and stop feeling a failure.
Peter responded best to learning relaxation techniques and the work we did on his life-style (Changing your Life-style, Course book 8) and time-management (mindtools.com). He had been frightened by the dizzy spells and, despite the doctor’s reassurances, did think they were due to a heart or brain problem. Learning about the physical and psychological impact of poor breathing proved helpful and he was surprised to find how much more in control he felt after using the Audio tapes on deep breathing and Active Progressive Muscle Relaxation (which he preferred to Passive Progressive Muscle Relaxation and Visualisation). The value of these was reinforced by a reduction in dizzy spells and headaches and a marked lowering of his blood pressure. Once he felt physically better he felt he could handle taking up exercise, joined the gym and got out the bike he had not used for several years. He began to lose weight, had more energy and his self-esteem improved. We discussed how some foods can mimic the stress response (Wilke ’04) and, with the help of his wife, he changed his diet to cut down on fats, refined sugars and caffeine. Again he was surprised to find how less stressed he felt.
Feeling more motivated and in control than before gave him the energy to tackle his work problems. Here the Stress and Personality Type questionnaire (Course Book 3) was useful in helping him recognise that his Type A behaviour was dysfunctional, time-wasting and created hostility (Cooper ’88, Palmer ‘92). The information on negative thinking habits (Course book 4) enabled him to see that his self-defeating thoughts also played a big part in his poor work performance. He found Problem Solving Strategies (Course book 4) and Time Management (Course book 5) were effective. By writing down daily work targets and how long he needed for each task he was able to see that it was all quite manageable so long as he kept to priorities and delegated better. With the help of the Negative /Positive Mood Log and Stress Thought Log (Course Book 4) Peter learned to acknowledge his strengths as well as the things he needed to change in the way he approached his work and relationships with colleagues.
Peter did make good progress in achieving his goals and needs to continue to use the strategies he has learned to keep himself healthy and emotionally well before and after the forth-coming IVF treatment.
Pat was very nervous and tense at her first appointment, looked tired and near to tears. She had undergone several IVF treatments at another centre and decided she would try one more time at our centre. We talked about what she was hoping to achieve in the way of therapy and she said she wanted to be able to cope with the outcome of the treatment if it was unsuccessful and not allow it to break up her marriage. As she only had 6 weeks before starting we agreed any therapeutic interventions would need to have immediate effect. Stress management work would be appropriate to help her feel less anxious and more in control of her feelings and reactions.
Pat scored 177 on the Holmes and Rahe Scale indicating that her stress levels were becoming serious and could lead to health problems. Reasons for her high stress score included the recent death of her father after a long illness, financial problems as a result of the large sums spent on infertility treatment and having stopped work herself because of the stress and distress of failed treatment cycles.
I asked Pat to keep a stress diary for the first week so that we could identify what was causing the most stress (Waines ’07). This revealed a strong tendency to be always trying to please others regardless of how bad she felt herself. Her inner language was full of inaccurate imperatives – ‘I must not be anxious’, ‘I ought to see my mother every day’, ‘I should get another job’ and negative self-constructs and beliefs - ‘I’m not attractive’, ‘my husband is fed up with me’, ‘I will never be happy if this treatment fails’, ‘it will never work for me’. She said she could tick nearly all the items listed in the leaflet Negative Thinking Habits and the outcomes in her Stress Thought Log (Course book 4) showed that she nearly always felt guilty, despairing and useless. Her anxiety could reach a point where she was hyperventilating and felt sick. All of this indicated the need for cognitive and behavioural strategies, relaxation techniques and assertiveness training
Until Pat could feel more in control of the symptoms of anxiety she could not take in information about negative thinking. She found the Passive Progressive Muscular Relaxation Exercise with visualisation (Course book 1) using the audio tape left her feeling much calmer and, because she could do this herself, she felt more in control which reduced the anxiety further. Pat was encouraged to use this twice a day at first and she then added the Autogenic exercise and Learning to Trust you Breath (Course book 6) to reinforce the benefits.
Although Pat needed to do a lot of work to challenge her negative thinking, she was quick to understand the difference it could make and from her daily log she could see how realistic thinking left her free of guilt and able to see herself in a positive light. She agreed to try to think about her own needs as well as others. By writing a list of all the things that were fun, relaxing, helpful and comforting for her she could plan some of these things into each day – actions that changed her attitude to herself and improved her self-esteem. This was borne out by having her hair restyled, buying new clothes and taking pride in her appearance again showing that her sense of femininity and confidence in her relationship with her husband was returning.
The outcome of Pat’s treatment was that she became pregnant and is expecting her baby in December. She needed all her newly acquired stress management strategies to deal with her anxiety that she would miscarry in the first 3 months but is finally enjoying her pregnancy.
Summary
People with fertility problems experience high levels of stress in addition to normal life-stressors and can be at risk of mental health disorders that include depression and anxiety. Stress management counselling is an effective treatment and this should be offered to patients before during and after they undergoing the additional stress of assisted conception treatments.
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