This blog addresses various emotional aspects of experiencing infertility. It is written by a clinical psychologist who specializes in infertility counseling. Thank you for reading, and best of luck with your journey!

Thursday, December 30, 2010

Stupid $%^! my doctor says--clinical insensitivity and infertility treatment

A few weeks ago I had to go to a doctor for a minor gynecological procedure. I had never met the doctor performing the procedure before, and so I had to briefly go over my infertility history with him. I was rather surprised when he told me, in a jovial, joking manner, that I was obviously "really, really, fertility challenged"--and fact, he mentioned had another term for women like me, but he couldn't use it in polite company! He thought this was hilarious. He then proceeded to comment upon and mock my c-section scar ("Of course you had a c-section--you just can't do anything the easy way, can you?") He also found fault with the fact that both of my children have their birthday in the same month, although since my older daughter is adopted, I hardly see how I could be held responsible for that. It's not as if I received a call from India, 9 years ago, with someone saying, "Hi, you don't know us, but we are young and in love. Do you think we should have unprotected sex or not?"

In any event, what was perhaps most shocking to me about this one-sided conversation is that this doctor, in the course of his work, deals with women struggling with infertility all the time. I would have expected a bit more sensitivity and tact. This doctor seemed to have absolutely no awareness that my medical condition wasn't merely fodder for his jokes--he just seemed thoroughly amused with himself. In addition, he and I didn't have a prior relationship in which he could sense that "joking" around with me about this was okay. A decade or so after this all started for me, my feelings about my infertility are much less intense and raw than they were, but he had no way of knowing that. I could only imagine that if I ran into this doctor several years ago I would have left his office devastated instead of as I did, merely annoyed.

After my appointment, I started thinking about all the examples of clinical insensitivity that I've heard about in my practice lately. I wish I could say that insensitive comments from medical professionals, like the ones I received, were a rarity, but in fact, they are not an unusual occurrence. One common type of insensitivity I've heard from several clients about different RE's is that when the client does not respond as hoped to a given medication or protocol, they are told they are "stubborn" or "misbehaving". Most women find these comments upsetting because they imply that somehow, the women have conscious control over how their bodies are responding to treatment, tapping into deep-seated feelings that they are somehow to blame for their infertility. Rationally, we all know that isn't true--if it were in any way possible to control how our bodies respond to infertility treatment, we would have already done so and had success. But hearing this idea from a doctor, even in an attempt at humor, gives it a little more weight.

A client of mine has graciously allowed me to share another example of clinical insensitivity. She had seen another psychotherapist for different clinical issues, and asked for feedback regarding them during the termination session. Instead of providing her with any, the therapist told her that she needed to work on her feelings of sadness and anxiety because they could be causing her recurrent miscarriages, rather than any underlying medical condition. (Just to be clear--there is no clinical study that shows that negative feelings, such as sadness and anxiety,are a definitive cause of miscarriages.) To her credit, my client fought back, asking the therapist if she believed that her negative feelings caused her miscarriage due to chromosomal abnormalities. And how did the therapist explain her first miscarriage, which occurred when she was elated about her first pregnancy? The therapist refused to back down or let my client off the hook, insisting that her feelings of sadness and anxiety "couldn't have helped" the situation. Again, the implication that my client was somehow to blame for her miscarriages was unavoidable. Needless to say, the treatment did not end well.

In preparing to write this post, I have struggled to come up with a cohesive explanation of why these situations might occur. But to be honest, I'm a little bit stumped. In the case of my doctor, I had such limited contact with him that I could not get any sense of his psychological motivations for acting in this way--except for the idea that perhaps, he was also someone who could be referred to by a term that could not be used in polite company. In situations where RE's tell patients they are "stubborn" or "misbehaving", I imagine it may be some of their own feelings of powerlessness and frustration coming through. Presumably, they really want to help their patients, and when they can't, it probably makes them feel powerless and bad about themselves too. So they might try to deflect these feelings by "jokingly" implying that it's the patient's fault, and not their own.

As for my client's experience with her former therapist, I again find myself hard-pressed to rationally explain that therapist's behavior. Perhaps she is uneducated about infertility and recurrent pregnancy loss, or perhaps she was angry at my client for terminating the sessions. Not knowing her, or more of the surrounding context, it is impossible to say.

As a clinician myself, I'm sure I've unknowingly said many stupid and insensitive things, although I like to think that I am trained to watch for people's nonverbal responses to what I say. If I see the eyes widen, or a lip quiver, it is my usual practice to inquire about these responses. But more importantly, I would hope that when I do inevitably put my foot in my mouth, that someone would tell me that what I said was painful, stupid, and/or inappropriate. I think most clinicians, whether they are in the medical or psychological field, feel the same way. That is why I very much admire my client for her responses to her former therapist--even though in that case, they didn't produce the desired response.

If you find yourself feeling hurt or upset by a doctor or nurse's comments about your infertility, I would urge you to discuss this with him or her. Most often, the clinician in question is going to be very understanding and apologetic. If during the course of that discussion, they are unable to acknowledge how their comments could have been viewed as hurtful or insensitive, then I think that may be a cause for concern. If the same type of comments happen repeatedly, you may need to think about making a change. It has been argued that individuals experiencing infertility often have a heightened sensitivity to comments by others. Even so, if a doctor or healthcare professional feels the need to habitually make upsetting comments to you, you can be pretty sure that it's not you--it's them.

Monday, December 20, 2010

Infertility and the holidays: Misery loves company?

Although it differs from person to person, I think it's safe to say that experiencing infertility generally does not make the holiday season easier. This year, I've read many excellent blog entries and articles that discuss this issue and offer suggestions for how to handle the holiday blues, so I won't reinvent the wheel here.

I do, however, want to add the following perspective from my vantage point as a psychologist--the holidays aren't just hard for those struggling with infertility. In fact, they seem to be hard for almost everyone! Do you know how my colleagues in my office suite and I refer to the month of January? We call it, somewhat affectionately, "money time", because in first week of January, the phone literally starts ringing off the hook with new clients requesting appointments. It seems that all that togetherness, gift buying, and socially-imposed merriment is just the thing that pushes so many of us right over the edge and into a therapist's office.

Now, I am the only one in my office suite who specializes in infertility, and yet all the therapists, with their various areas of expertise, are equally busy in January. It seems that the pressures of the holiday season affects people with all different kinds of issues and from all walks of life. So although feelings of infertility may be making you miserable at the holidays, you will definitely not be alone in your suffering. It may seem like a perverse comfort, but chances are good that if your infertility wasn't upsetting you this holiday season, there would be something else that would.

I can think of at least two culprits for all this unhappiness. The first is the societal, and often familial expectation that we should be happy during the holidays. The story we are told from a very young age is that if you can somehow just inculcate the right holiday spirit, you will be able to transcend the difficulties in your life, at least for a short period of time. Although this does sometimes happen in real life, I don't believe it is actually the norm that so many holiday-themed movies would suggest. When people find that no matter how hard they try to have the right holiday spirit or frame of mind, they still can't feel better about problems that they have, they feel a sense of failure. (This is the same emotional principle that causes so many people diagnosed with infertility to become distressed--despite all their best efforts, they still have not yet achieved their desired results.) The feelings of failure, combined with the upset about whatever they were trying to transcend in the first place, can often cause people to become sad, depressed, and anxious.

Another reason why the holidays can be especially upsetting has to do with the anniversary reactions they provoke. As with any trauma or loss, people often experience increased feelings of grief or sadness at the same time of year when the loss originally occurred. I am always amazed by this phenomena, both in my practice and in my own life. The subtle cues of weather, smells, and plants for a given time of year, along with the overt cues of time-specific activities, can unconsciously remind us of unhappier times and cause us to feel upset. This often occurs even when we aren't consciously thinking of the original trauma, loss, or upsetting event. For example, I had my first miscarriage in early October many years ago. Although after some years, I stopped consciously thinking about it on the anniversary date, on that day I would inevitably find myself, seemingly inexplicably, cranky and miserable. At the end of the day, I would finally figure out why I was so upset. Now I've come to anticipate this anniversary reaction, which has lessened its emotional impact.

Anniversary reactions are particularly strong during the holidays because there are so many cues as to the time of year, everywhere you look. There is no way you can miss all the holiday lights, Christmas carols, parties, and family gatherings. So if you had a bad time of it with the holidays last year, that alone can make you feel upset all over again this year.

I really hope your holidays are wonderful, and filled with happiness and love. But if they don't quite live up to that expectation, because of infertility or for other reasons, know that you won't be alone. Perhaps, when we stop pressuring ourselves to feel a certain way, we can be more in the moment with how we actually feel, good or bad. Often, sitting with our feelings for a while helps us to understand ourselves and our situation better and to figure out what our next steps are. Although it may be rooted in unhappiness at times, the clarity that can be gained may be the real gift of the holiday season.

Thursday, December 16, 2010

Shame, infertility, and why we shouldn't feel that way anymore

Well, it's been quite a week around here in my practice. I don't know if it is the stress of the holidays, the subzero temperatures, or perhaps the near lack of sunlight, but I've been hearing a lot this week about shame.

Shame is a common emotion that occurs when someone is undergoing infertility treatment. Each time I hear a person talk about feeling ashamed of their infertility, this argument presents itself--they feel ashamed that there bodies aren't functioning "normally", and thus they can't easily reproduce and fulfill their alleged biological imperative. In this way of thinking, for women, the ability to become pregnant and produce healthy babies is their most defining feature.

Thus, I hear client after client tell me how ashamed they are of their bodies because of their infertility. The real shame in all of this, from my perspective, is that I’m hearing this from wonderful, heroic people who are doing an amazing job with their infertility treatment. They are doing everything right—working hard to maximize every possible variable they can control.

Here's the other thing I've noticed--the shame doesn't stop at infertility. Even in the fertile world, women struggle with feelings of shame about their reproductive abilities. I recently met a woman who had five children, but felt horrible about herself in comparison to her sister, who had nine children. My acquaintance, although she got pregnant easily, had difficult, high-risk pregnancies and deliveries. She felt ashamed of her body—why couldn’t she do things as well as her sister, who had easy pregnancies and deliveries? Another woman I know feels terribly ashamed of her body because she used an epidural in the delivery of her child, rather than delivering naturally, like her mother did. A friend confided that she felt ashamed that she couldn’t successfully breastfeed her baby, who had severe food allergies.

In all of the above situations, everyone was doing their absolute best, and nobody could do anything else that would change the medical outcome of their situation for the better. So why did feelings of shame have to come into the picture?

I think our society has a lot to do with women’s feelings of shame about their bodies when it comes to reproduction. I've realized that the emphasis on reproduction, although it does have biological elements, is largely a societal construction--and probably, at this point, an archaic one. In an agrarian, monarchy-based society, producing heirs, and children/laborers, is important for the survival of the society.

But things are different now. Given the change in women’s roles in the workplace, not to mention our global overpopulation problems, defining women by their reproductive capacities, on a practical level, isn't such a smart idea anymore. And yet, so many women are still buying into the idea that their reproductive capacities are central to feeling “normal”, or to their self-worth.

The thing about feeling shame about things over which you have no control is that ultimately, it’s a big waste of energy and effort. The shame doesn’t magically improve the situation or provide you with more control. It just makes you feel lousy and therefore less able to function at your highest level. Shame about infertility doesn’t help you, and it doesn’t really help society either.

However, I do have a solution. The great thing about societal constructions is that they are just that—arbitrary constructions—and not actual reality. Therefore, they can, and do change over time. As individuals struggling with infertility, we can simply decide not to buy into the societal values about our bodies when it comes to reproduction. Instead, we can work on not blaming ourselves for things over which we have no control.

So please, please, do me a favor. If you find yourself starting to feel shame, take a moment and think about why. Did you just purposefully run over your grandmother’s pet weasel? Have you recently financially defrauded starving orphans? If so, go right ahead—be ashamed of yourself with my compliments. However, if you are feeling ashamed about your body, your infertility, or anything else over which you have no control—could you please try to stop? Because trust me, you don’t deserve it! And if you hear a friend start down the shame path, could you remind her to stop too? Not only will you be feeling better about yourself, but you’ll also be improving society. And in that, there is no shame at all!

Thursday, December 9, 2010

Resilience is the real fertility

So many times, I am asked by clients, "How will I get through and survive (insert tragedy/setback/loss here)? My answer to them, although perhaps not comforting, is always the same--that you will get through and survive the bad things that happen to you because. well, you really don't have any other choice.

Although that sounds a bit grim, I am constantly amazed by what human beings are capable of doing when they don't have the choice to do otherwise. It seems that if we have the option to escape something painful or difficult, we are usually sorely tempted to take it, even if it may not be the best thing for us in the long run. But it is when we don't have any choice in the matter, that is where the real bravery, strength and creativity become apparent. This is how I define resilience--the ability to keep functioning despite losses and challenges. I feel hopeful that our resilience as a species will be the thing that ultimately keeps the human race from destroying itself. For example, when we actually have no other option, we might finally be motivated to do something about global warming or whatever else threatens our survival.

In my work with clients struggling with infertility, I've seen that despite feeling otherwise, most people are more resilient than they may believe. When confronted with setbacks, disappointments, or losses, most people initially feel that they can’t function successfully. But as the situation evolves, they see that they are able to confront issues they never thought they could, or to give up habits that that never imagined they could. Witnessing these transformations is one of the great things about my work.

It is my belief that when it comes to creating your family, resilience is even more important than physical fertility. You can treat or work around infertility --but without resilience, you often can't make anything happen. Functioning ovaries, happy sperm, and a willing uterus are all nice to have, and make the process easier. But the ability to persevere and keep trying even when the situation is difficult is the one key ingredient necessary for success. When I think about my own situation this way, it makes me feel better. I can take comfort in the fact that although I had significant physical challenges, my resilience was intact, and helped me to take the numerous steps on the long and rocky road to having my own family.

One thing that makes people doubt their own resilience is that the process of being resilient usually isn't pretty. There are a lot of tears and bad feelings involved, along with struggles, mistakes, interpersonal conflicts, and the like. Like so much in life, it's a messy, non-linear road, and you may only realize where you have ended up once you are already there.

If during the course of your infertility journey, you come to a point where feel overwhelmed and like you can't go on, than then you should take comfort in the fact that these feelings are extremely common in this situation. It may sound like an odd thing to say, but if you still have treatment options, then even though the options may be difficult, you are still in a privileged situation. Even more difficult than going forward is the realization that you've come to the end of the road and that you have no more options with which to struggle. So if there is still a battle to fight, take heart. And remember that you are probably more resilient than you believe--and that your resilience will help you do what is necessary to create your own family.

Thursday, December 2, 2010

Managing your infertility treatment--understanding your relationship with your nurse

We often think of our reproductive endocrinologist as our primary treatment provider for infertility treatment. In fact we usually have much more frequent contact, and thus a more involved relationship, with the nurses responsible for the day-to-day monitoring of our care. I have always been impressed with how much responsibility and decision-making power that nurses working at infertility clinics often have. They can decide which of our questions and aspects of our clinical condition are brought to the RE's attention, and they often manage routine aspects of infertility treatment themselves. Thus, it pays to have a good relationship with your nurse--in which he or she is working with you to make sure you are getting the best medical supervision possible.

With a personal infertility career spanning the better part of a decade and a half-dozen clinics, and in hearing the stories of my clients, I have found the vast majority of nurses to be professional, competent, and kind. Many infertility nurses are truly exceptional--medically savvy, organized, and interpersonally sensitive--all traits that I believe can enhance your chances of treatment success. Occasionally, however, I have encountered some less than stellar nursing staff, and in these situations, I have witnessed the potential for negative outcomes.

To understand your relationship with your nurse, I think it is necessary to think a bit about the emotional situation involved in your nurse's job. First, she (or he, but I'm using she here because I've never actually come across a male infertility nurse, which in itself is interesting...) usually has a lot of patients to manage, all at different stages of treatment and with widely varying medical situations. She has to be on top of all the different steps each patient needs to take (imagine managing your own treatment plus 50-60 others at the same time!), as well as to be the liaison between the patient and the doctors. I think it's safe to say it's probably a fairly high stress job. In addition, the nurses, even more than the doctors, are privy to the emotional responses of patients to treatment failures and setbacks. Naturally, your nurse will have her own corresponding emotional reactions to patients' feelings (please see my blog entry on countertransference for a more thorough explanation of this phenomena). She must herself find a way to manage these emotional reactions--ideally remaining emotionally involved enough to be empathic, but with enough psychological boundaries that she does not become overwhelmed by her own feelings, so she is still able to be helpful. As you can imagine, managing these emotions isn't an easy task, and she is at constant risk of developing compassion fatigue, in which she becomes "burnt out", and may want to emotionally distance herself from her work. Add in to all this that infertility nurses are often of child-bearing age themselves, and there is a whole other set of feelings for them to manage. Perhaps they might worry that they too will struggle with infertility. Alternately, if they able to build their families easily, they may feel guilt that many of the couples with whom they work struggle and suffer so much in this area.

Warning signs

As you can see, being an infertility nurse involves juggling a great deal of emotions along with the ever-changing and fast-paced nature of the work. Despite the difficulty involved, I think that most nurses do a good job of remaining emotionally involved but still maintaining good boundaries. However, when things start going awry with a nurse, in my experience it is usually because she is struggling with this task. For example, I have sometimes observed that nurses can take an "us vs. them" attitude towards patients. This can come across as the nurse appearing impatient and irritated with patients when they have valid questions or concerns. It may seem that the nurse in question has a condescending attitude towards patients, in which she treats them as if they know nothing about the medicine involved, and that only she or the doctor are the experts. Because she is not listening to patients fully, or valuing the importance of what they say, she is at risk for missing important clinical information crucial to creating treatment success. And because she has reduced the level of patient trust and goodwill, she may not be getting this information in the first place.

At the crux of this "us vs. them" attitude, in my opinion, is that the nurse feels a strong need to disidentify with the patients with whom she works. In order to not feel overwhelmed by her own feelings regarding their situation, she must feel that they are entirely different from her, and is thus unable to emotionally understand their situation. In my field, we call this an "empathic break".

Although this situation is not common, it does occur, and it can really wreak havoc on an infertility treatment. In my own treatment, I once (and only once) had to fire a nurse off my case because repeatedly, she would not listen to me and refused to take my concerns seriously (which turned out, after speaking to other staff, to be entirely justified.) As I was rather far along on my own journey, I knew that this was not going to work for me--and that there were many other fantastic nurses with whom I could work-so I took the step of speaking to the clinic manager and requesting that we no longer work together. But I couldn't help but think that if I were new to the situation, and didn't know that things could be different, she could have really messed things up for me.

So my advice is, if you continually and repeatedly get the feeling that your nurse is not listening to you, is irritated with your worries, and is repeatedly unempathic to your feelings, you may need to consider talking to her or someone else about this situation. Of course, everyone, even nurses, can have a bad day, or even a bad week or month--but if it is never good, and talking about it doesn't improve the situation, you may need to consider making a switch.

Fortunately, as I mentioned earlier, this type of situation is not the norm. Most likely, you are already working with a good nurse. How can you make your relationship with her the best if can be? In my opinion, the most important facet of your relationship with your nurse is building good will between the two of you. If she can feel that you are a nice person, and someone with whom she can identify, she will be more positively emotionally involved in your case. She will want to help you succeed even more. She will be more likely to take your case to the doctor and think proactively about problems or issues which could occur. You will feel like she likes you, and you will be more open and forthcoming with her, which means she will have all of the necessary information to help the doctor make the best treatment plan. In my opinion, having a good treatment relationship with your nurse can be one of the major ingredients to treatment success.

Acknowledge her situation

As in any working relationship, if you can understand the needs and the situation of the other person, you will be better able to build good will and thus work collaboratively. For instance, if you can show your nurse that you are aware of how busy she is, and of the intellectual and emotional challenges of her job, she will be much more receptive to your needs. If most of the time, you only sound the alarm bell when it's necessary, you will be forgiven the occasional freak out or minor neurotic episode (all of which are inevitable in infertility treatment). Perhaps more importantly, though, you will build good will.

Be visible--but in a good way!

As a patient, one has to walk a fine line between being patient and trusting that the nurse or doctor will address your issues on their own, and being assertive and calling their attention to your concerns. If you simply trust that your nurse will take care of everything, you may be at risk for things being overlooked. If you are too aggressive or always making a big deal out everything, you are at risk for being seen as a "problem" patient. The key strategy here is to educate yourself about your own treatment plan and situation, and to bring up concerns as you have them--but in a polite and respectful way. Don't yell, and give the staff time to call you back or respond to your e-mail. If they don't respond, then you may have to be persistent--but again, in a calm and respectful manner. Remember, there's always time to yell at somebody about something later--but you can't take it back once it's done!

Apologize if necessary

Remember when I said that everyone is entitled to bad day or week every once in a while? This also applies to infertility patients. Given all of the hormones and emotional high stakes involved, it's not unexpected that you might not be at the top of your game, or at your most charming, during some contacts with your nurse. If you feel there are some situations you could have handled better, it might help to talk to her about it. In most cases, you will be greeted with an understanding and appreciative reception. Again, this will help rebuild the good will between the two of you--an ingredient helpful for treatment success.

Show your appreciation

Just as in our own lives, nurses appreciate being thanked for their hard work and efforts, especially if she has gone out of her way for you. If you feel she has done something truly exceptional, in addition to letting her know personally with a thank you card, kind e-mail, or occasional baked good, you could also let her office manager or supervising doctor know how much you appreciate her work and skills. These small gestures can help your nurse recognize the positive impact she is having on people's lives, and that can really get her through the difficult aspects of her day.

In sum, creating good will between you and your infertility nurse may help your treatment be successful, but even if it doesn't, it will at least make your treatment more pleasant. It may also provide you with another person who can understand your situation and offer emotional support.