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!

Wednesday, July 20, 2011

Infertility, perfectionism, and the loss of the "dream baby"

The other day, a client and I were discussing the struggle of giving up the "dream baby"--that is, the idealized vision we all seem to carry around of how perfect and amazing our offspring would be. They might have their mother's eyes, or their father's smile. They are of course adorable, brilliant, and lovable beyond belief. We are sure that if we could just have one, our other problems would seem to diminish in significance, and we would be, finally, happy.

With infertility, not only must we often experience a delay in achieving a pregnancy, but we may also be forced to give up on this vision altogether, even before the baby has been conceived. Whether it is feelings about having to use medicine or ART to conceive, the involvement of third parties, such as gestational carriers, or the loss of a genetic connection to a child by building a family with donor gametes or adoption--it all starts to be a deviation from the "dream".

There are often a lot of feelings of loss associated with giving up the idealized version of your "dream baby", and I think this is one of the factors that makes infertility so difficult to experience. Except here's the thing--no matter how your family was formed, you were never, ever going to get that "dream baby" anyway. Nobody does. Perhaps those blessed with fertility and easy pregnancies can forestall this loss until after the baby is born. But even they will at some point have to acknowledge that their child isn't perfect, can be difficult, and like all of us, has flaws and areas of challenge. One of my favorite psychoanalysts, D.W. Winnicott, wrote that in fact, parents naturally have periods of being very frustrated with and hating their child, because of the demands the child places on them. He thought this was in fact an important part of the developmental process because it allows the baby and the parents to psychologically separate, which is very important for the child's emotional growth.

It is interesting to me why we seem to hold on to our visions of the perfect "dream baby", because we don't have the same expectations of adults. I don't know any perfect adults, and I bet you don't either. So why we would expect a baby, who is just trying to figure out this crazy world, to fulfill our visions of perfection, is curious. Maybe if we didn't have this vision, we wouldn't have the motivation to keep trying to create our families.

In any case, I think that realizing that the "dream baby" is just that--a dream--makes it easier for those of us who have experienced infertility to make decisions about treatment and family building decisions going forward. If your dream baby doesn't exist anyway, maybe it might matter less to you if your child was conceived in an IVF lab, or if you aren't genetically related to him or her. Giving up on the dream baby opens us up to love and accept whomever we are fortunate enough to parent, with all of their own uniqueness, talents, and difficulties.

If you are struggling with this issue, I recommend you make a list of all of the characteristics of your "dream baby". By seeing them in writing, you may be able to better understand your own expectations. It also may help you realize what you hope to gain by becoming a parent, and that there are many paths to that goal.

Although giving up on our impossible fantasies can be painful, it does allow us to engage with our realities, which, especially when it comes to children, can still be quite amazing, no matter how they come to our family.

Friday, July 1, 2011

Infertility and health insurance: the infertility therapist gets cranky

To be perfectly honest, nothing can get me quite as irritated quite as quickly as the subject of health insurance. This in many ways is ironic and possibly unfair. After all, health insurance payments constitute a large portion of my income. Also, I am fortunate to have access to quality medical insurance for myself and my children. To top it off, I spent my entire infertility career living in Illinois, one of the few states to have some form of state-mandated infertility coverage. So really, I know I should have little about which to complain.

And yet, I found myself flooded with those old familiar feelings yesterday, as the less-educated insurance company managed care employee, who had never met my client, demanded during a phone call to know why I had seen Mr. X for more then twenty sessions, and when I was planning on discharging him already. The answer, "Whenever I damn well feel like it!", though running through my head, would not have helped Mr. X get reimbursement for the treatment he needed and wanted. So instead, I played the game, repeating the phrases that insurance companies need to hear, in order to secure continued coverage. I was made even crankier by the realization that since the passage of the Mental Health Parity Act, which went into effect last summer, the insurance company really could not legally limit Mr. X's sessions. But by requiring superfluous clinical reviews, they could put another hurdle between him and his insurance benefits. If I had not followed through with their request, they could have denied his claims--even though this would not have been his fault.

Further, these types if policies have a psychological impact on clients' views of themselves. Although they may feel quite distressed or that therapy is very helpful to them, if an insurance company questions its validity, authorizes only a limited number of sessions, or denies coverage, they often feel their own experiences are invalidated. After all, the "experts" have deemed that their problems are not serious, or that treatment isn't medically necessary. This often causes a serious disruption in the treatment. Now, in addition to working on the original issues that caused them to seek therapy, we must also deal with the feelings of invalidation stirred up by the insurance company. All this while insurance companies are recording record profits--for instance, the local Blue Cross/Blue Shield organization in Illinois just posted a $1.1 billion profit for 2010 (more information here).

When it comes to medical coverage for infertility, the problems are even more severe, for the infertile have much less protection under the law than those with mental health issues. In many states, there is little or no coverage for infertility. There seem to be two main arguments for doing so. The first is that infertility treatment is very expensive and will prohibitively increase insurance premiums and health care costs. However, research suggests otherwise. A 2006 survey demonstrated that when employers did offer infertility coverage, 91 percent of them experience no increase in costs (full study available here).

The second, and to me the more troubling reason, that infertility treatment often isn't covered is that it is not considered a "medical condition". On the face of it, this seems absurd--infertility is generally caused by medical problems and issues, which prevent a person's body from functioning as it should. However, the perception is that infertility is not life-threatening--if you can't have children, it won't kill you. Of course, medical insurance generally covers treatment for a whole host of other ailments that aren't life-threatening, but nonetheless reduce the quality of life from a medical perspective (male impotence being perhaps the most famous example). Mental illness has been perceived similarly, and thus has been covered at much lower and restrictive rates. It took years of active advocacy by the mental health community to begin to change this perception and to garner support for the idea that it should be treated as any other type of medical illness. I suspect that the same type of advocacy will be required of the infertility community.

While lack of insurance coverage for infertility is problematic from a financial and practical perspective, it also troubling from a psychological one. As I have discussed in other blog posts, people with infertility have a tendency to blame themselves for their infertility and to feel a great deal of shame around it. When the insurance company confirms this by refusing coverage or payment, it then provides them with "confirmation" that their beliefs about themselves are true. In my opinion, half of the battle in dealing with infertility is trying to take the self-blame out of the equation, and instead conceptualize it as more of a medical issue. Further, feelings of shame and self-blame often make it more difficult for those struggling with infertility to successfully weave their way through the bureaucratic maze of paperwork and phone calls required to get the insurance coverage to which they are entitled.

I understand that health insurance is a business, and that insurance companies need to make money. It's clear that they are usually very successful in this respect. But it seems to me that to use societal prejudices to deny coverage to those who need to treat a medical condition, such as infertility, is going a little too far in the name of profits. Further, making it purposefully difficult for their policy holders to access their benefits by putting up red tape and road blocks crosses an ethical line as well. Hence all the crankiness.

I've been dealing with health insurance companies in my personal and professional life for the last eleven years, and I have learned a few strategies of coping with the situation. First and foremost, you have to look at any communication between you and your insurance company as a possibly adversarial one. This doesn't mean you should start off by shouting at or fighting with insurance company employees. However, you should recognize that the insurance company's interests and your own personal interests often conflict. Therefore, I suggest you do the following:

1. Always write down the name of the person with whom you are dealing, as well as the date and time of the call. This way, if someone tells you something later that contradicts the information you received, you can refer them back to this prior conversation. Most phone calls are recorded, and you can even ask them to pull the recording for the call.

2. Never assume that the first answer you are given is the correct one. Particularly in complicated situations, such as infertility, the call center employees are often struggling to find the information you request, and they don't always have expertise in the area. If you get an answer you don't like or doesn't make sense, make a record of it, and then call back and ask the same question of someone else.

3. Insist on speaking to a supervisor should any problem arise. Often, you will meet resistance at this request--the employee will tell you that the supervisor can't tell you anything different or do anything else to resolve your problem. I always tell them that I am willing to risk that possibility, and to get the supervisor anyway. Once you are successful in reaching a supervisor, get that person's name and direct line if possible, and call them every time you have a question or issue until the problem is resolved.

4. Educate yourself and know your policy. If you read your plan document, you can refer to it during conversations with the insurance company employees, and many times show them they are wrong. Also, it pays to know your legal rights in your state, in terms of coverage, appeals rules, and how to make complaints against your insurance company if necessary.

5. Don't give up. If you think you are right, then you need to keep fighting. The insurance company may not be particularly welcoming of this, but if you appeal their decision, many times it is overturned. It's hard to keep going when it so irritating and discouraging--but use your anger and crankiness to provide you with the energy you need to get the coverage to which you are entitled.