Tag Archives: Couples

How to help domestic violence clients during shelter-in-place situations

By Federico Carmona April 13, 2020

It’s heartbreaking to read the variety of articles circulating about vulnerable people trapped at home with their abusers because of shelter-in-place mandates during the COVID-19 pandemic.

Unfortunately, experience reminds us of a concerning reality that is typical of these uncertain times: Adverse labor market conditions are positively related to domestic violence. Research conducted after the Great Depression of the 1930s, the farm crisis of the 1980s, and the Great Recession of 2008 found that economic crises have significant negative effects on the quality of intimate relationships and parenting in working families. Marital conflict, abuse (particularly violent controlling behavior), and a decline in parenting quality are among the harmful effects in families of a macroeconomic downturn.

In my role as a trauma therapist, I have seen dozens of domestic violence clients during clinical intakes and in counseling. I have also read a multitude of articles on the subject about studies and reports from different parts of the world. Shelter-in-place mandates aren’t a good thing for women and children who are the targets of abuse. The anticipatory anxiety and uncertainty of these times can cause negative emotions to churn, leading to behaviors that increase the already-concerning number of domestic violence and child abuse cases. There is no “how-to” manual to deal with the current situation, of course, but the safety of this vulnerable population demands us to do our best.

How can the counseling community help domestic violence clients who are trapped at home with their abusers? I offer a few suggestions:

Reach out between appointments/sessions. One of the critical signs of abuse is the isolation of victims of domestic violence from their networks of love and support. An occasional check-in from us can empower these clients to tell us more about their situations and perhaps even dissuade their abusers from further violence as we keep checking in.

Listen, just listen. People experiencing domestic violence need an empathic ear — someone who will allow them to vent their repressed emotions and feelings without judgment. We are not to offer advice, only listen and empathize. It’s just time to build trust.

Validate clients’ feelings, emotions and beliefs even when they don’t make sense. The best way to build trust with clients experiencing domestic violence is by being present with them. We’re present with them through our vicarious empathy, active listening and compassionate validation. Our empathy is vicarious because it takes an emotional toll to connect with someone’s anguish and suffering. Active listening requires us to be disciplined enough to fully concentrate on what the client is saying rather than on the answer that we might have in mind to their situation. Clients experiencing domestic violence require validation — compassionate validation — because many times, their decisions (or lack of them), circumstances and beliefs don’t make sense to us.

Introduce them to mindfulness exercises. Clients experiencing domestic violence live in a world of fear and anxiety because of the cycle of abuse. At first, they’re worried because of their confusion and inability to make sense of and control the incipient abuse. In time, as the abuse increases, worry turns into anxiety and fear.

Mindfulness can help these clients become aware of their emotions, thoughts and bodies to take control of them and find much-needed relaxation. Meditation exercises shouldn’t necessarily be long. There are plenty of sites online with short, simple exercises, from breathing to stretching, that can help clients gain the bodily and emotional awareness they need to function.

Remind clients of their strengths and qualities. One of the benefits of practicing active listening is the ability to notice in clients’ stories what they have forgotten about themselves: their own power, qualities and strengths. By doing this, we help clients not only to survive their circumstances but also to move toward a better future as survivors of domestic violence who deserve lives of meaning and purpose.

Help clients to start a project. Because of shelter-in-place mandates, more perpetrators of abuse are at home all of the time. This increases the emotional state of “walking on eggshells” for domestic violence clients. We can help distract these clients from that state by brainstorming with them or suggesting a project to them. It could be an individual project based on their abilities, strengths and qualities that we noticed in their stories, or it could be a project that involves their children.

Assist clients in making a safety plan. Making a safety plan is incredibly useful. It doesn’t need to be complicated or lengthy. The simplest way of doing this is by helping these clients become aware of their circumstances (call the problem what it is — domestic violence). The rest of the plan might involve:

  • Trying to avoid conflicts and arguments during the mandated confinement
  • Involving their children in most of their home activities
  • Reaching out to relatives and trusted friends (when possible)
  • Being prepared to leave at any moment (i.e., having money, documents, car keys, children’s backpacks filled with some clothes and snacks ready to go)
  • Calling 911 when they feel that they or their children are in danger (even in a shelter-in-place situation, law enforcement will issue an emergency protective order to separate victims from their abusers)

Involve others. We can help our clients experiencing domestic violence to think about the resources they possess to deal with their situation. One of these resources could be men who are part of the couple’s life in some way (e.g., clergy, friends, relatives, co-workers, classmates, teachers, bosses).

When families and friends get involved, perpetrators of abuse can sometimes be dissuaded from causing harm to their partners and children. The presence of fathers, brothers, neighbors and friends prompts accountability. Some of these individuals might be willing to offer their support and speak up against the ongoing abuse. Victims of domestic violence can only break their silence and become survivors if they feel supported. We need to be cautious, however, and see each client in their particular context, giving consideration to whether this type of intervention could put them in more danger than they already are.

Help clients build a network of support. Isolation is one of the most critical signs of abuse. It creates a hated dependency on the abuser. Imposed isolation robs victims of domestic violence of their personhood. It suppresses their voice and identity piece by piece as family members and friends are pushed away. Connections are the simplest way to beat domestic violence. It is critical that victims of domestic violence get reconnected with relationships they trust. It is also crucial to get these clients connected with other survivors of domestic violence (via online groups) so they can claim their victory and begin the journey of healing from the trauma caused by the abuse.

Inspire clients to pursue self-sufficiency. Studies show that when women’s wages are relative to those of men in dual-income couples, there is a significant reduction in domestic violence. To be self-sufficient is to have bargaining power. It’s to have the ability to exert influence in the relationship. There are public resources designated to help survivors of domestic violence pursue further training and education with the purpose of becoming self-sufficient. Check with social services agencies about these resources.

These recommendations aren’t intended to override the urgency of calling 911 when someone is facing a clear and present danger at home. Let law enforcement personnel figure out how they will bring individuals and families to safety during shelter-in-place situations. Emergency protective orders are being issued even with the courts closed.

 

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Federico Carmona is a trauma therapist for victims of domestic and sexual violence at Peace Over Violence in Los Angeles. He is also an ordained elder in the United Methodist Church. The experience of domestic abuse in his ministry and his own family motivated him to seek specialization in clinical counseling, specifically in trauma, to assist survivors of domestic and sexual abuse and violence to reclaim their identity, peace, and lives with dignity and purpose. Contact him at federico@peaceoverviolence.org.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Recovering from the trauma of infidelity

By Lindsey Phillips April 1, 2020

Most people agree that a sexual affair counts as infidelity, but what about sending a flirty text? What if your partner takes out several loans and acquires a large debt without your knowledge? Does engaging in virtual sex with someone other than your partner, connecting with an ex on social media or maintaining an online dating profile even though you are already in a relationship count as betrayal? The answer depends on how the people in the relationship define infidelity.

A recent study commissioned by Deseret News found conflicting answers when 1,000 people were polled about what constitutes “cheating.” The majority of respondents (71%-76%) said that physical sexual contact with someone outside of the relationship would always meet the threshold for cheating. However, a slimmer majority thought that maintaining an online dating profile (63%) or sending flirtatious messages to someone else (51%) should always be considered cheating. The lines on whether following an ex on social media constituted a betrayal were even more ambiguous: 16% said it was always cheating, 45% thought it was sometimes cheating, and 39% answered that it never was.

As this poll illustrates, how one defines infidelity is subjective. Thus, Talal Alsaleem, a leading expert in the field of infidelity counseling and author of Infidelity: The Best Worst Thing That Could Happen to Your Marriage: The Complete Guide on How to Heal From Affairs, stresses the importance of clearly defining infidelity in session. “A lot of therapists make the mistake of not putting enough attention into defining infidelity,” Alsaleem says. “From the first session, if we don’t agree on what to call it, we cannot go any further” because correctly identifying the problem guides which counseling interventions will be used.

If counselors set the stage poorly from the beginning, they risk alienating one or both parties, he adds. For instance, referring to infidelity as “inappropriate behavior” risks minimizing the betrayal. On the other hand, clients and counselors could exaggerate an issue if they refer to something being infidelity when it really wasn’t.

Alsaleem, a licensed marriage and family therapist in private practice at Happily Ever After Counseling & Coaching in Roseville, California, points out that when defining infidelity, research often relies on heteronormative values, which excludes any relationship that does not fit the “traditional” model (read: a heterosexual, married couple). To account for the various types of relationships that exist and people’s microcultures and macrocultures, Alsaleem developed a flexible definition of infidelity that can work for all of his clients, including those who are LGBTQ+ or polyamorous.

“All relationships should have a contract — whether verbal or written — that stipulates the number of the partners in the relationship … the emotional and sexual needs that are expected to be fulfilled in this relationship, and to what extent those needs are exclusive to the partners in the relationship,” Alsaleem explains. “So, infidelity is a breach of contract of exclusivity that you have with the partner(s) … and it’s outsourcing those needs to others outside the relationship without the consent of the partner(s).”

Although having a relationship contract is helpful, it is much less so if the partners maintain implicit expectations of each other that aren’t covered in the contract or if they allow the contract to become static, says Alsaleem, founder of the Infidelity Counseling Center. “It’s very crucial for people not only to have a clear contract in the beginning but also to continue to have those discussions [about their relationship expectations] on a regular basis,” he says.

Alsaleem believes his definition of infidelity not only works for clients of various backgrounds but also provides counselors with a buffer from their own biases about what infidelity is. When it comes to infidelity counseling, “therapists tend to confuse therapeutic neutrality with thinking that they don’t have a role to play,” he says. He asserts that his definition allows therapists to remain neutral without minimizing accountability.

Cyber-infidelity

Technology has provided new frontiers in infidelity because it offers higher accessibility, greater anonymity and opportunities for cyber-infidelity, says Alsaleem, who presented on this topic at the 2020 conference of the International Association of Marriage and Family Counselors (IAMFC), a division of the American Counseling Association. In fact, technological advancements such as virtual reality pornography and teledildonics — technology that allows people to experience physical tactile sensations virtually — are adding new layers of complexity to infidelity and relationships.

People can use technology to escape real-world problems and reinvent themselves, Alsaleem notes. One of his clients suffered from erectile dysfunction. Because of the shame and stigma associated with his condition, he turned to virtual sex as a way to accommodate for the deficit rather than dealing with the issue with his wife.

“Because [technology] is a new frontier, it’s an unchartered territory. Not too many people can agree on what’s appropriate or what’s inappropriate online infidelity behavior because we don’t have a reference point for it,” Alsaleem says. “That ambiguity makes it easier for people to cross those lines because in their minds, they’re not doing anything bad.”

Alsaleem worked with another couple who were in a happy relationship, but their sexual intimacy had decreased because of common life stressors such as work and parenting. Rather than talk to his wife about it, the husband started watching pornography, which evolved into virtual sex. When the wife discovered this, she felt betrayed, but the husband didn’t think his actions constituted an affair because it wasn’t happening in the real world. He considered virtual sex to be an acceptable alternative to “real cheating.”

Situations such as this one further emphasize the need to clearly define infidelity and establish a relationship contract, says Alsaleem, who points out that the good thing about his definition of infidelity is that it applies to both real world and virtual world affairs. Using his definition, counselors could work with a couple to help a partner realize that virtual sex is a form of infidelity by asking, “Was there an agreement between you and your partner that all your sexual needs would be fulfilled by them only?” If the partner acknowledges that this agreement was in place, then the counselor could ask, “Is what you did derivative of sexual needs? If so, did you outsource this need to someone else?” This form of questioning would help the partner realize that he or she did in fact breach the contract of exclusivity.

Transcending relationship dissatisfaction

Relationship dissatisfaction is a common cause of infidelity, but it is far from the only cause. Alsaleem recommends that counselors consider three categories when working with infidelity.

The first is dyadic factors, which are any relationship issues that lead to the couple not having their sexual or emotional needs met by each other.

The second category is individual factors — each partner’s personal history and overall mental health. Counselors should ask about clients’ family history and previous mental health issues, not just their relationship history, Alsaleem advises. He points out that some mental health issues, such as bipolar disorder and narcissistic, antisocial and borderline personality disorders, may increase the likelihood of infidelity.

People who experienced sexual trauma at an early age are also more likely to engage in infidelity as adults because the trauma may have affected their attachment, sexual identity and the type of relationships they have in adulthood, Alsaleem adds.

The third category is sociocultural factors, including a person’s job, culture, family, friends, lifestyle, environmental stressors, etc. Survey data taken from Ashley Madison, a website that helps married people have affairs, reveal that certain careers and occupations are more correlated with infidelity. These careers typically involve frequent travel; expose people to trauma; feature long, stressful hours; or offer unhealthy work environments (among the examples provided were military personnel, first responders, nurses, police officers and people in sales). This finding illustrates how one’s sociocultural factors can facilitate infidelity behavior, Alsaleem notes.

Treating the trauma

Sometimes clients who experience a partner’s infidelity meet the criteria for posttraumatic stress disorder (PTSD), says Gabrielle Usatynski, a licensed professional counselor (LPC) and founder of Power Couples Counseling in Boulder and Louisville, Colorado. In fact, because the emotional response to infidelity (e.g., ruminating thoughts, sleep problems, erratic behaviors and moods, health problems, depression) can mirror responses to other traumatic events, some therapists have started using the term post-infidelity stress disorder to describe this parallel.

“If you pull up the DSM-5 and look up the PTSD criteria and change the word traumatic event to infidelity, it’s almost going to be picture perfect in terms of the symptom criteria,” Alsaleem points out. “There will be triggers, flashbacks, hypervigilance, avoidance behavior, and manifestations related to the knowledge about the affair and everything related to the affair.”

The fallout from infidelity can also spill over into other roles that people occupy, such as being a parent or a professional. This can lead to guilt and shame if they are not performing well in another area because they are preoccupied with the trauma of the betrayal, he says.

Despite having worked for a while with couples in crisis, Alsaleem found that none of the counseling tools he had acquired over the years adequately dealt with infidelity. If counselors use a generic trauma-informed approach with infidelity, they may have a strategy to handle the sensitivity of the issue, but they won’t have a clear understanding of the obstacles and the steps needed to overcome them, he says.

Alsaleem started jotting down observations of his clients dealing with infidelity and discovered several struggles that these clients shared regardless of the type of relationships they had, the length of their relationships, or their cultural or religious backgrounds. These shared struggles included defining infidelity, handling the emotional impact of infidelity, and navigating the significance of the affair narrative. Alsaleem’s observations led him to develop systematic affair recovery therapy (SART), which provides counselors with a treatment method for helping couples process and heal from the trauma of sexual and emotional infidelity.

SART describes seven milestones clients go through as they heal from infidelity:

  • Setting the stage for healing
  • Getting the story
  • Acknowledging the impact
  • Choosing a path
  • Creating a plan of action
  • Implementation and healing pains
  • Sustainability

“Your role [as a counselor] is to help them process what happened, to make sense of it, so this trauma does not define the rest of their lives, whether as a dyad who are rebuilding the relationship or as individuals who have decided to separate and move on to other relationships,” Alsaleem says.

He warns that the process isn’t easy because clients often come in with knee-jerk reactions about what they want to do. Counselors must help clients resist making impulsive decisions and instead encourage them to make up their minds after completing the proper steps and understanding why they are making their decision, Alsaleem says.

With affair recovery, Jennifer Meyer, an LPC in private practice in Fort Collins, Colorado, finds it helpful to have couples write down their feelings and emotions, which can be intense. From the beginning, she asks couples to share a journal and write their feelings back and forth to each other.

After the couple has had time to identify and process the cause of the infidelity, Meyer asks the partner who has been unfaithful to write an apology letter and to read it to the injured partner in session. In this letter, the offending party conveys that they understand the pain they have caused and feel remorse for their actions. Even if the couple decides not to stay together, the letter helps repair the damage caused by the infidelity, and the partners can move forward (and, eventually, into new relationships) without carrying the pain and trauma with them, Meyer says.

Navigating the affair narrative

Some therapists avoid having clients share details about the infidelity because they fear it will create more harm or retraumatize clients, Alsaleem says. He argues that narrating the affair is a painful yet crucial part of recovery that can help facilitate healing if done with the right level of disclosure.

Alsaleem dedicates an entire day in his SART training program to teaching counselors how to help clients share their affair stories without retraumatizing both parties (by sharing too much or too little information) and without minimizing or exaggerating what happened. With infidelity counseling, “every mistake counts,” he says. “When people are coming in after the discovery of infidelity, whether it’s recent or from the past, they are very fragile, so that’s when you need to be strategic and adaptive and plan each intervention and how to respond to the outcome of the intervention.”

Meyer, a member of both ACA and IAMFC, often finds that clients want to ask the offending partner multiple detailed questions about the intricacies of the affair. Meyer is aware that the answers to these questions have the potential to create even more hurt and trauma for her clients, so she is honest with couples about this possibility and guides them through the process.

Alsaleem provides a brief example of how counselors can determine the appropriate level of disclosure when clients share their affair stories (but he advises clinicians to seek further training before trying this approach). He first asks the offending partner to be proactively transparent when sharing the affair story. They shouldn’t hide anything, he says, and they should go out of their way to show the injured partner(s) the unpleasant truths that led to the affair. This is done not to traumatize, he emphasizes, but to show the offending partner’s capacity to be open and honest.

Alsaleem also tells injured clients that they can ask anything they want about the affair. But before they ask, he helps them determine whether the question will help them understand what type of affair it was or why the affair happened. If so, then it is a fair question, he says.

For example, a client dealing with a partner’s sexual infidelity may want to ask, “What specific sexual activities did you engage in?” If the partner who was unfaithful is dealing with a sexual addiction (an individual issue), then the specific sexual activity is not important to understanding the motivation or what went wrong in the relationship, Alsaleem says. However, if the infidelity occurred because of a compatibility issue (a dyadic issue), then that would be a fair question because the betrayed would discover in what ways they are no longer fulfilling their partner’s sexual needs, he explains. 

“The need behind the question [can be] healthy and appropriate, but sometimes [clients are] not asking the right question because they don’t know how to address that need,” Alsaleem adds. He advises counselors to ask clients what they are trying to learn about the story with their questions and help them figure out if these questions are the best way to obtain that information while avoiding further traumatization.   

Affairs can evoke intense emotions in session, especially when discussing the affair story. To ensure that emotions don’t escalate to an unproductive level, Meyer uses a preframe such as “You seem calm at the moment, but this is difficult, and I want to ensure you can both talk without being interrupted. If things get out of hand, I’m going to ask for a timeout. You can both ask for a timeout as well.”

Meyer also uses her own body language — such as scooting up in her chair or standing up — if clients start yelling uncontrollably, or she physically separates them for a few minutes by having them take turns going to the restroom or getting a glass of water. These subtle changes help clients calm down and not get stuck in fighting, she explains.

Creating an imbalance to facilitate healing

Usatynski, an ACA member who specializes in couples therapy, approaches infidelity counseling differently from couples therapy where betrayal is not the presenting issue. In ordinary couples therapy, she strives to keep therapy as balanced as possible, focusing equally on the complaints of both partners and the unresolved issues that each brings to the relationship. But when infidelity is involved, she intentionally creates an imbalance of power and initially allows the injured party to have all of the power. The offending party, on the other hand, does not get to bring any of their complaints about their partner or their relationship to the table until they have successfully addressed the injured partner’s distress. This treatment works only if the offending party expresses true regret for the harm they have caused their partner and expresses a genuine desire to rebuild the relationship, Usatynski adds.

Usatynski’s approach comes from a psychobiological approach to couple therapy (PACT), which is a fusion of attachment theory, developmental neuroscience and arousal regulation developed by Stan Tatkin. When betrayal is the presenting issue, this method requires that clients move through three phases as they process and attempt to repair their relationship.

The first phase addresses the trauma the injured client has experienced by allowing them to express all of their emotions about the betrayal. “It’s when people feel like they have to hold back [emotions] or they can’t get angry or there’s nobody there to listen to them that actually creates trauma or at least makes it worse,” Usatynski says.

The partner who was betrayed can also ask any question they want about the affair during this phase, and the offending partner has to answer honestly. Many therapists who work with betrayal are concerned about the injured partner being traumatized by finding out the truth, Usatynski says. She admits this is a valid concern, so therapists should support the injured partner throughout the process. However, she advises that therapists not shy away from the truth coming out because, as she explains, the only way to repair the relationship or build something new is with total transparency.

If clients are hesitant to ask about the affair, therapists need to explore this hesitation with them. The injured partner may say that they don’t want to know what happened out of an inability to deal with feelings of loss and the practical implications of the relationship ending, Usatynski adds.

During this initial phase, the offending partner has no power to negotiate. They must simply sit and endure the rage and inquiry of the person whom they betrayed, Usatynski explains.

The second phase of PACT involves the offending partner providing the betrayed with whatever support is needed to correct the injury to the attachment bond between them, Usatynski says. This phase could involve declarations of commitment, appreciation or praise, as well as loving actions on the part of the offending partner. However, only the injured partner can decide what behaviors are reparative, she explains. The goal of this phase is resolution.

During the third phase, the injured partner lets the offending partner out of the “doghouse” and, together, the couple decide the new rules and new relationship contract they will have going forward, Usatynski says.

According to PACT, the dysregulation of one’s nervous system (such as during states of hyperarousal or hypoarousal) may lead to discord between the couple, Usatynski says. Thus, counselors should not only track clients for signs of dysregulation but also teach couples how to track each other’s nervous systems.

When Usatynski notices a client showing signs of dysregulation (e.g., changes in skin color, posture or vocal tone), she will ask the other partner if they recognize the change. For example, she might say, “Did you see how your partner’s skin color just changed when he or she said that? What do you think is going on with him or her right now?”

The goal is interactive regulation — the couple learning the specific strategies that soothe, regulate and excite each other, Usatynski notes. “These tracking skills are particularly important in the aftermath of betrayal because … [they help the offending partner] develop a greater awareness of how their behavior affects their partner. These skills also boost sensitivity and empathy,” she explains.

A silver lining?

Alsaleem compares infidelity to a heart attack for the relationship. “It’s a critical wake-up call,” he explains. “It forces [clients] to really lay all the cards on the table and make an informed decision.” Do they commit to fixing all of the deficits and work toward having a better, stronger relationship, or do they end their relationship and find new, healthier relationships?

Alsaleem says several of his clients began therapy devastated by the trauma of infidelity, but by the end, they admitted they were almost glad it had happened because it ultimately led them to having the relationship they always wanted with their partner. For some people, infidelity is the catalyst that ultimately allows them to get unstuck, he explains.

When clients decide to repair their relationship, Meyer helps them develop a new, explicitly stated contract regarding the rules in their relationship moving forward. She asks them to write down their agreement about these new relationship rules (including how quickly they would inform their partner that they experienced a compromising situation and what constitutes infidelity going forward) and ways they could be vulnerable to future affairs.

“As counselors, we can’t assume every couple wants or needs strict monogamy,” Meyer adds. So, this new agreement can take many forms depending on the relationship. For example, partners in a committed relationship may agree that being involved with another person sexually is OK as long as they discuss it first with their partner or keep everything in the open.

Of course, clients in infidelity counseling may also decide to end their relationship. Even so, by showing up to counseling, clients have taken the first step toward ensuring that infidelity does not define the rest of their lives, Alsaleem notes.

“Infidelity is an awful event, but it doesn’t have to be devastating. It actually has a silver lining. Infidelity — as awful as it is to experience, as awful as it is to happen — can actually be a good thing to help people change their lives,” Alsaleem says. “If treated appropriately, it can actually enrich people’s lives and make them more resilient and make them better in the long run.”

 

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Related reading: An online companion article to this feature, “Helping clients rebuild after separation or divorce,” provides strategies for helping clients to process their grief and start over.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Helping clients rebuild after separation or divorce

By Lindsey Phillips March 25, 2020

Jennifer Meyer, a licensed professional counselor (LPC) in private practice in Fort Collins, Colorado, had a client who, after 30-plus years of marriage, discovered that her husband had been embezzling money from their joint business. This infidelity, along with his recent verbal abuse, prompted the woman to get a divorce. The client was hurt, shattered, ashamed, lost and confused about her future, Meyer says. For the previous 30 years, she had shared friends, children, family and a business all with the same partner. How would she be able to start all over again now?

Clients such as this one often find that they have to rebuild their lives because, in some ways, divorce is the “death” of a relationship. Meyer tries to help clients accept that divorce is a big loss — one often accompanied by feelings of betrayal and trauma. To overcome this loss, she works with clients on processing their emotions (which often include anger, shame and blame), communicating their needs, establishing healthy boundaries with their ex-partner and rebuilding their lives.

The stages of divorce

Meyer, a member of the American Counseling Association and the International Association of Marriage and Family Counselors (an ACA division), specializes in divorce coaching and recovery. She has noticed that her clients often exhibit signs of grief, such as feeling unmotivated and having trouble sleeping. In fact, going through a divorce can be similar to going through grief, but it can be further complicated by layers of legal issues, financial strain, individual mental health challenges, the experience of parental alienation, the challenges of co-parenting, and the realities of dividing assets, Meyer says.

Meyer gives clients a handout of the seven stages of divorce, created by Jamie Williamson, a family mediator certified by the Florida Supreme Court. Williamson draws on the well-known “stages” of grief, but her model ends with rebuilding — a stage when a person’s acceptance deepens, they let go of the past and they find a way forward.

Meyer, who presents on the emotional journey of divorce at an ongoing national women’s workshop in northern Colorado, adapted Williamson’s model to illustrate the complexities of grieving a divorce, which she likens to climbing Mount Everest — a climb they didn’t sign up for. In this metaphor, she pairs six stages of divorce with sample thoughts of what clients may be feeling:

  • Denial: “This climb is a complete waste of time. I should be home trying to save my marriage”
  • Anger: “This divorce is expensive. Why is this happening to me? I didn’t plan for this.”
  • Bargaining: “I would do anything to turn back and make things right with my spouse. What if I don’t make it? Will my kids be OK?”
  • Depression: “I’ve lost my spouse and some mutual friends. I can’t sleep. I feel so lonely.”
  • Acceptance: “I no longer idealize my past. This process taught me how strong I am.”
  • Rebuilding: “I’m excited to close this chapter and begin creating a happy future.”

In between these stages, she says, clients are growing and learning. They start to learn who their true friends are, and they learn more about themselves, their boundaries and their expectations.

Meyer’s metaphor also highlights that the stages of divorce are not sequential. For example, someone might move from being angry at the financial cost of divorcing to wondering if they should get back together with their ex out of a fear that their kids won’t be OK to being angry again that this experience is happening to them.

Processing emotions

Meyer uses emotionally focused therapies to help clients turn inward to process their feelings about the separation or divorce. One of Meyer’s clients was frustrated because she felt her ex-spouse was never emotionally available. So, Meyer had the client close her eyes and picture the ex’s face. Then, she asked the client, “What would you say to your ex from an angry perspective? What would you say to your ex from a hurt perspective? And what do you imagine your ex would say back to you?”

This role-play exercise helps clients not only process their feelings and find a way to move forward from their hurt and anger, but also recognize their own part in the marital problems, Meyer explains. She cautions counselors not to focus on the self-responsibility part too early but says that as clients move through the stages of divorce, counselors can gently encourage them to look at what part might have been theirs.

Meyer has also noticed that women often want to take all of the responsibility for a relationship ending, so she tries to help them realize that both partners played a role. To do this, she might say, “There’s 100 percent blame out there. What percentage of that would you claim, and what percentage is your ex-partner’s?”

Owning their responsibility can also be empowering for clients, Meyer adds. They often feel like everything was done to them, so realizing the role they played and how they would handle that differently in the future helps them move forward, she explains.

Meyer also has clients write goodbye letters to their exes (or any family members or friends they have lost in the divorce). In the letters, they name all the things they will miss (e.g., “I will miss your hugs,” “I will miss your excitement to go to concerts”) and the things they won’t miss (e.g., “Goodbye to your smelly socks on the floor all the time,” “Goodbye to the fact that you never prioritized me”). This exercise allows clients to express their hurt, anger and sadness and helps them let go of the relationship, she says.

Developing healthy communication and boundaries

Some of Meyer’s clients also have a difficult time knowing how to act around the other partner after deciding to divorce. They may feel guilty for setting boundaries on someone who used to be their partner, but Meyer reminds them that the relationship has changed. “The communication that you wanted and needed while you were married or together is … very different, so you’re going to need to each have boundaries around your communication,” Meyer says.

Meyer helps clients figure out the source of their distress with their ex-partner and guides them in establishing better boundaries. For instance, if a client was upset because their ex-partner kept showing up to their child’s soccer games and hounding them about renegotiating a part of the divorce, Meyer would help the client communicate new boundaries by coming up with phrases such as “Let’s talk about this in mediation” or “If you call me names or raise your voice, I’m going to end this conversation.”

Gabrielle Usatynski, an LPC and the founder of Power Couples Counseling (a private practice with offices in Boulder and Louisville, Colorado), also focuses on the way the couple communicate and behave around each other. “One of the points [of divorce counseling] is to help them develop the capacities they need in order to engage in fruitful conversations that do not get scary and dangerous,” Usatynski explains. To do this, she teaches couples about the value of treating each other with fairness, justice and sensitivity, even in the midst of divorce. She also helps couples learn to negotiate and bargain with each other so they can create win-win solutions for divorce and co-parenting.

A psychobiological approach to couple therapy (PACT), developed by Stan Tatkin, acknowledges that there is a difference between what people say they do and what they actually do, Usatynski says. People’s narratives are subject to inaccuracies that can throw the therapist off track in terms of understanding what is really happening with the couple, she explains.

A couple’s attitudes and problems, as well as their ability to engage with one another, are largely driven by the state of their autonomic nervous systems, Usatynski continues. “Therapists should facilitate these nervous system states in session and intervene while the couple is in those particular states,” she says. “The goal is to collect and bring to bear as much raw, unedited information [as possible] from the body, brainstem and limbic brain.”

For this reason, Usatynski uses a technique called staging, which targets the body and deep brain structures. Couples act out problematic moments in their relationship in front of the therapist. Because people have different perspectives, finding out exactly what happened is not Usatynski’s goal. Instead, she wants to find situations that created distress for the couple and see for herself the mistakes the couple made in their interaction.

So, if a couple going through a divorce had a heated exchanged when the father dropped the children off at the mother’s house, Usatynski would ask for them to act out that exchange in her office. When the father says, “Your music is way too loud. The kids don’t need to hear the music that loud,” the mother responds, “Stop yelling at me in front of the kids, and don’t tell me what to do.”

Usatynski notices this is a point of distress for the couple, so when they finish acting out the scenario, she discusses this misstep with them. For example, to help the father understand that he came across as demanding and made his wife look bad in front of the kids, Usatynski might ask him, “Did you say, ‘Please turn down the radio?’”

After discussing each of the missteps, Usatynski has the clients re-enact the scenario. This time, however, they have to come up with ways of relating to one another that are nonthreatening, fair and sensitive. “When we allow our clients to stumble along, the solutions they find on their own are going to be way more powerful, creative and effective than anything we could offer them,” Usatynski says. “The process of discovering their own solutions also gives them a greater sense of empowerment and competency that they really can do this on their own.” That is ultimately the goal of counseling, she adds. Only when a couple is really struggling to come up with viable solutions on their own will Usatynski provide suggestions.

Acting out the scenario in the brain state they were in at the time of conflict and then learning a better way to handle the situation helps clients react differently the next time they find themselves in a heated exchange, Usatynski notes.

Starting over

After clients have gone through the emotional journey of divorce, they need to start rebuilding their lives and hoping for a better future. To help clients start this process, Meyer returns to the letter writing exercise, but this time she has them write a “hello” letter to their new life and the aspects they will enjoy most. For example, clients could write, “Hello to traveling by myself without someone who gets impatient,” “Hello to being able to decorate my bedroom the way I want to,” “Hello to time with friends again” or “Hello to the stronger, more confident me.”

One of Meyer’s clients brought in items that represented her divorce, including the goodbye letter she had written in a previous session. She then went outside with Meyer and burned it all. This act symbolized her letting go of that relationship and taking a step forward.

Meyer has also had clients go outside and use nature as a metaphor for their progress and healing. For example, one client said that an old tree that had been chopped down represented her at the beginning of her divorce, but by the end of it, she identified with a stronger, healthier tree.

Divorce is a devastating event that no one wants to experience. In fact, according to the Social Readjustment Rating Scale developed in 1967 by psychiatrists Thomas Holmes and Richard Rahe, divorce is the second most stressful life event for adults (behind only the death of a spouse). But clients can rebuild their lives and have a hopeful future.

“When you work on [what happened in the relationship] and you figure out what your part was and what was going on with the partner that you didn’t think was healthy, you can really find the good part of you and salvage the rest of this to the point where you’re in better spot than you ever were,” Meyer asserts.

Meyer watched her client who divorced after 30-plus years of marriage undergo an incredible transformation throughout their sessions. The client realized how often she had done what was asked of her (by her ex-spouse, her kids and her employers) without considering her own needs. She began to slow down, set boundaries and say “no.” She realized what she deserved in a relationship, and she learned how to select and be a better partner in the future.

By processing her emotions about the divorce and betrayal and letting go of the blame, shame and anger that had become such a heavy burden for her, the client began to feel younger in her body and make healthier life choices. And with Meyer’s guidance, she realized she didn’t have to be afraid to start over.

 

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For more on this topic, look for an in-depth feature article on helping clients cope with divorce or infidelity in the April issue of Counseling Today.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Understanding stillbirth

By Samantha Rouse December 5, 2019

What if there was a trauma that affected 25% of our adult female clients? Wouldn’t we want to know about it? This isn’t just a hypothetical for counselors, yet chances are that we as clinicians are ill-prepared to effectively identify and treat our clients who fall into this population.

In the United States, 1 in 4 women experiences some form of infant or pregnancy loss. Included in this statistic are the more than 26,000 women who experience a stillbirth each year. A stillbirth occurs late term after an otherwise healthy baby could have survived outside of the womb. Stillbirth often is defined as the death of a baby after 26 weeks’ gestation.

Long before my decision to get my education and become a professional counselor, I became one of those 26,000 mothers. It was only natural that the area of stillbirth would become an area of interest for my own research during my doctoral studies. It was my experience in my job, however, that led me to see the gaping hole in our field of professionals who are competent and knowledgeable enough to provide help. Each time a new referral came in that had reported any kind of pregnancy loss, she was immediately referred to me. This was because most people hold one of two positions: 1) The person who has experienced what the client is experiencing is the best person to help the client, or 2) I cannot help someone with something that I have never experienced myself.

This flawed referral process creates an issue with our profession being able to provide quality care to clients who have experienced stillbirth. Referral of these clients solely to those counselors who have experienced stillbirth themselves can be harmful to both the client and the counselor. The counselor may become overwhelmed at the number of clients with this specific need so close to her own traumatic experience, potentially resulting in burnout for the clinician. An equally disturbing result of this referral process is that other counselors are denied the opportunity to treat and learn from this population. This keeps the number of competent counselors lower than is needed.

Understanding the trauma

The death of a child is an unexplainable pain. Author Jay Neugeboren famously wrote, “A wife who loses a husband is called a widow. A husband who loses a wife is called a widower. A child who loses his parents is called an orphan. There is no word for a parent who loses a child. That’s how awful the loss is.” It feels unnatural for parents to outlive their children, regardless of the child’s age when he or she dies. However, stillbirth presents unique characteristics that make this scenario even more complicated for bereaved parents.

The experience of stillbirth has a high level of ambiguity. The death of a baby leaves so much unknown, and mothers often find themselves wondering why their baby died, what their baby would have looked like had he or she grown up, what the child’s voice would have sounded like, and how their family would have been different had the child lived. This ambiguity often leads to the death having a lack of meaning, in that the mother is often searching for the purpose of the child’s life. Mothers might repeatedly ask themselves questions such as “Why me?” or “Why did God give me a baby just to have it die?”

Stillbirth does not involve only grief; it also involves a trauma or multiple traumas. Most people think that stillbirth occurs when the parents are told at delivery that their baby was born dead. This is not the case with modern medicine. Typically, the parents are alerted to the death of their baby before the delivery, and the mother then has her labor induced. The news of hearing that their baby is dead begins the first trauma.

The trauma continues during labor and delivery, which is now the antithesis of the joyful experience the mother had anticipated over the course of her pregnancy. Sorrow and silence replace what were once expected to be feelings of elation and the sounds of a new baby crying. After the painful experience of the labor and delivery, the mother is given the option of seeing her baby. Depending on how long it has been since the baby died, the appearance of the baby might be affected. Some mothers choose to see the baby and will hold, rock and take pictures of their child.

After delivery, the mother is moved into a room that is often located within the labor and delivery area. The trip from the delivery room to her recovery room exposes the mother to sights and sounds such as banners proclaiming “It’s a boy!” and other families’ loved ones cheerfully gathering in the hallways to see their own bundles of joy. The grieving mother’s room is empty and silent. Her door remains shut in an attempt to drown out the sound of crying newborns from other rooms.

After a couple of days of hospital care, the mother is sent home and must tend to her recovering body. In the days that follow, she will develop the same physical response to childbirth that a mother with a living child would. Mothers who have experienced stillbirth are often encouraged to bind their breasts to “dry up” their milk.

Within a day of delivery, the mother must make decisions about the autopsy and burial options for her baby. The mother must wrestle with the decision to keep the casket open or closed during the funeral or burial service. This decision is often based on the appearance of the infant at birth (because the skin of a baby who is stillborn is frequently affected). A tiny casket is often presented and seems out of place in the environment of the funeral home.

If the mother or father is employed, their time off goes by quickly before they must return to what is expected to be their “normal” life. In many cases, paid time off or bereavement leave is not provided to these parents because the stillborn child was never considered a living person. The parents do not receive a birth or death certificate for their child for the same reason. For a birth certificate to be given, the baby must have shown signs of life after delivery, even if it was only for one breath or heartbeat. In most states, a stillborn baby cannot be claimed as a dependent for tax purposes. (Tip: Some states offer a “stillbirth certificate”; this may be a resource for clients if appropriate for their treatment.)

Best practices for screening

In many practices, the intake process includes a generic demographic question for reporting family size. This might include a fill-in-the-blank option for the client’s number of children or number of living children. (Tip: Replace “number of children” with “number of pregnancies, number of live births, and number of living children.” This ensures that all areas — miscarriage, stillbirth or the later death of a child — are covered.)

Screening for stillbirth through the demographic paperwork is the first step. This initial paperwork offers a small glimpse into the client’s full story. Reviewing the paperwork prior to the initial clinical interview will alert the clinician to the need to discuss the client’s experience of stillbirth (if the client discloses it in the paperwork).

The clinical interview can be difficult for both the counselor and the client when it comes to discussing a stillbirth. Because of social expectations and the ambiguity of their loss, women are less likely to report a stillbirth than they are other experiences. It is much easier for a person to put a number on the intake paper regarding number of pregnancies and number of living children than it is to openly bring up a stillbirth during the clinical interview. For this reason, direct questioning on the part of the counselor is vital.

Counselors may initially find it uncomfortable to directly ask clients about any type of pregnancy loss. It is important for counselors to practice using the correct terminology and language appropriate for a stillbirth. Additionally, they should get comfortable with other terms that the mother might use, such as died, death, dead baby, dead child, etc. It may be beneficial for counselors to practice using these terms out loud with a trusted person to become more comfortable saying them. When counselors are comfortable discussing stillbirth and other pregnancy loss, clients are likely to recognize this and move to a higher level of openness about their own experiences sooner rather than later. This allows for the therapeutic relationship to develop at a faster pace, leading to more rapid treatment results and a higher client retention rate.

For many clients, the disclosure of a stillbirth might happen later on or might never happen, due in large part to societal views of stillbirth (e.g., they do not “count,” they never existed, mothers must “move on”). This will hamper the overall depth of the therapeutic relationship and can also prevent appropriate treatment of the trauma.

Need-to-know factors

As counselors, it is our responsibility to ensure that we are knowledgeable about the variety of issues that our clients face. With such a high prevalence of stillbirths, it is important that we truly understand this experience to provide competent treatment. There are several key points of which counselors need to be aware.

>>  Social supports: Not surprisingly, the presence of strong social supports has shown to be an important factor in a person’s recovery following a stillbirth. These supports can include a spouse or significant other, family members, friends, and involvement in a church or religious community. A person’s support system often diminishes following a stillbirth because of the “hushed” nature of the experience.

>>  Use of clients’ language: Mothers of stillborn babies will often give their babies a name. If the client uses the baby’s name in session, the counselor needs to refer to the stillborn child by name and not as “the baby.” The mother may be hesitant to speak the baby’s name, again due to the hushed nature of stillbirth. It can benefit the therapeutic relationship for the counselor to ask, “What would you like for me to call the baby?” This also avoids the question, “Did you name the baby?” which could imply that the mother should feel ashamed if she did not name the child.

>>  Suicidality: Mothers who have experienced a stillbirth often report feeling like “I want to go to sleep and not wake up” or “I don’t want to live anymore.” It is important to understand the difference between these thoughts and active suicidal ideation. This is especially important because these mothers often experience postpartum depression along with the grief and trauma from the stillbirth.

>>  Postpartum depression: Mothers who deliver stillborn babies are not exempt from postpartum depression. This can lead to the complex issue of depression tied with grief, trauma and, sometimes, psychosis. Many people, including clinicians, make the mistake of assuming that these mothers are dealing with “only” grief, “only” postpartum depression, etc.

>>  Trauma: Stillbirth is often thought of as producing grief or depression. Approaching it only from this lens, rather than also understanding the trauma associated with the experience, can cause treatment to be ineffective. This limited approach can also prevent the client from feeling fully understood, leading to a poor therapeutic relationship.

>> Comfort terms: The experience of stillbirth is often silenced and met with a “move on” expectation in society. In part for that reason, it is important for counselors to recognize and avoid using common comfort terms. These include:

  “At least you know you can get pregnant.”

  “This was part of a plan.”

  “Thank goodness you have your other children.”

  “It wasn’t meant to be.”

  “There might have been something wrong with it.”

>>  Long-term presence: The mother’s close relationships may become strained or even dissolve in the aftermath of the stillbirth experience. Divorce rates have also been found to be influenced by the experience of stillbirth. If not dealt with, the trauma associated with stillbirth can manifest as a personality disorder or a substance use disorder.

Treatment considerations

The complex nature of the stillbirth experience often leaves counselors feeling lost regarding the potential direction for treatment. Many interventions used in treating grief are applicable with these clients, and other interventions typically used to treat depression and anxiety can also be used.

For example, let’s say that a counselor has a new client beginning services six months after her first child was stillborn. She was referred by her primary care doctor when she made an appointment with the doctor to obtain medication. She is married with no living children, comes from a large family, and attends a nondenominational church regularly. The client reports that she had to quit her job because she was unable to focus and would cry throughout the day. The client discloses that she had a stillborn daughter named Sarah. A funeral and burial were held, but the client says she is unable to “move on.”

The client’s faith and large family can serve as protective factors because they provide her with a large support system. At the same time, they can also be risk factors by triggering the client and reminding her of her loss. One option is to explore with the client whether she has any frustrations with her support system or any negative beliefs and thoughts about herself when around her support system. The client might reply that she wants to avoid being around babies and small children at family gatherings and church services. The counselor shouldn’t then turn the focus to helping the client find ways to cope with being around babies and children because this might send a message of “get over it” to the client. Instead, the counselor could explore the client’s feelings of unjustness and hurt, both providing validation and normalizing how she feels. The counselor would then allow the client to decide on the small steps she wants to take.

A significant amount of ambiguity accompanies the experience of stillbirth. Some clients are comforted by finding meaning in their loss, while others are not. The counselor can explore this with the client and should be aware that the client’s feelings may change back and forth as time passes. If the client cannot attribute any meaning to her loss or does not find comfort in the meaning, the counselor should validate her feelings of unfairness, hurt and anger and empower her to create her own meaning. For example, how can the client use this meaningless loss for good in the future?

It is often helpful to encourage the use of rituals with clients. This particular client named her baby and also had a funeral and burial for her. The counselor could explore ways the client might use other rituals as a means of keeping her daughter a part of her life. For example, she could hang pictures of her daughter in her home, keep a photo of her daughter in her car, visit the cemetery regularly, have an object such as a candle or decoration that represents the daughter during holidays, and so on.

The counselor could also introduce the client to online resources and supports. This may provide a sense of normalization to the client and counteract her feelings of being isolated in her pain. It may also provide a network that can offer creative ideas for rituals.

There are many ways to approach counseling with these clients, but there are also things to avoid. For instance, counselors should avoid bringing in their own beliefs and expectations for these clients (just as with any clients). These mothers should not feel rushed or be made to feel guilty for not getting “better” sooner. Counselors should avoid using the common comfort terms listed earlier. Counselors must also keep in mind that the therapeutic relationship is more important than any particular technique, and they should allow these clients to be actively engaged in deciding what their sessions are like.

Every mother’s experience of stillbirth is different. The mother’s family, religious beliefs and culture all influence her response to the stillbirth. Additionally, her experience is influenced by the protocol of the medical facilities where she delivered and the attitudes of the health care providers involved. Counselors should address all of these factors in session to ensure that mothers are being treated appropriately for their individual experiences. Our society tends to “hush” these mothers and their experiences because stillbirth is so uncomfortable to address. However, these mothers need to be heard, understood and validated as being mothers, even if they have no other living children. After all, born still is still born.

 

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Samantha Rouse is a licensed professional clinical counselor working for Hosparus Health in central Kentucky. She is a fourth-year doctoral student at Lindsey Wilson College doing research on motherhood and stillbirth. Contact her at samantha.rouse@lindsey.edu.

 

Letters to the editor:  ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

In my work as an outpatient mental health counselor, I have encountered numerous clients over the years with stories about reproductive loss. Not only were these stories fraught with sadness and grief, but some of the individuals were still experiencing acute grief even several years later.

As I branched out into my role as a researcher during my doctoral study, these stories stayed with me. So, I began a line of inquiry on reproductive loss that started with infertility and the accompanying grief. Since then, my research on infertility and miscarriage grief has resulted in numerous professional conference presentations and guest lectures. The purpose of this article is to share information that I have learned about those with infertility and to provide methods for best practice in counseling with these clients.

Infertility is generally defined as a condition of the reproductive system that inhibits or prevents conception after at least one year of unprotected sexual intercourse. To account for the natural decline of fertility with age, the time frame is reduced to six months for women 35 and older. According to the Centers for Disease Control and Prevention (CDC), about 12% of women between the ages of 15 and 44 have “difficulty getting pregnant or carrying a pregnancy to term.” Infertility can affect both men and women, despite a common misconception that infertility is a woman’s condition. Infertility in men may be caused by testicular or ejaculatory dysfunction, hormonal disorders, or genetic disorders. In women, infertility may be caused by disrupted functioning of the ovaries (such as with polycystic ovary syndrome, a condition that prevents consistent ovulation), blocked fallopian tubes, or any uterine abnormalities (such as the presence of fibroids).

Infertility can be categorized into one of two subtypes. Primary infertility refers to when a woman has never birthed a child and thus has no biological children. Secondary infertility refers to when a woman experiences the inability to birth a child following the birth of at least one other child. Both forms of infertility produce a cyclical pattern of strong emotion that is often referred to as a “roller coaster.”

Medical interventions

A number of available interventions may be used to increase the chances of becoming pregnant. The best course of treatment will be different for each couple and may depend on considerations such as whether the infertility is male factor or female factor, the cost and availability of insurance coverage, and cultural customs or beliefs. Some couples decide that pursuing any kind of medical treatment is not the right course of action for them. For others, medical treatment may include any of the following interventions.

  • Medication may be prescribed to stimulate ovulation or follicle growth in the ovaries, increase the number of mature eggs produced by the ovaries, prevent premature ovulation, or prepare the uterus for an embryo transfer.
  • Surgery may be necessary, perhaps to clear out blocked fallopian tubes or to remove uterine fibroids.
  • Intrauterine insemination (IUI), also known as artificial insemination, is a procedure in which sperm are inserted directly into the woman’s uterus. The woman may or may not be taking medications to stimulate ovulation before the procedure.
  • Assisted reproductive technology (ART) refers to fertility treatments in which eggs and embryos are handled outside of the body. This excludes procedures in which only sperm are handled (e.g., IUI). The most common and effective ART procedure is in vitro fertilization (IVF).

Undergoing IVF treatment requires a strong physical, emotional and financial commitment. Generally, medications are prescribed to stimulate egg production and may include a series of self-administered injections. Eggs are removed from the ovary using a hollow needle, and the male partner is asked to produce a sperm sample (or a sperm donor may be used). The eggs and sperm are combined in a laboratory, and once fertilization has been confirmed, the fertilized eggs are considered embryos. About three to five days after fertilization, the embryos are placed into the woman’s uterus via a catheter in hopes of implantation. The CDC reports that women under the age of 35 have a 31% chance of conceiving and birthing a child with the use of ART; the chances are closer to 3% for women ages 43 and over.

The IVF process can be a highly emotional time for the woman and the couple, marked by moments of excitement, hope, disappointment or uncertainty. The IVF cycle may be canceled if certain problems develop along the way, such as having too few or no eggs to retrieve, the eggs failing to fertilize, or the embryos not developing normally. Any of these situations may produce a sense of loss for the woman or the couple. After the embryo transfer, it is generally recommended to wait 10-14 days before testing for pregnancy. In some circumstances, a chemical pregnancy takes place. This is when implantation happens that results in an initial positive result, but then the pregnancy does not progress. In other words, a very early miscarriage occurs.

This section on medical interventions is important to include because these interventions are part of the infertility experience and may affect the emotional or mental health of the client. This is true even for women and couples who choose to not pursue treatment; at the end of the day, a decision was made and they must cope with the implications of that choice. Professional clinical counselors who are knowledgeable about the available medical interventions will have better context for recognizing the myriad decisions that these clients face and the potential losses that may occur throughout the process.

The invisibility factor

Take a moment to think about the grief that occurred for you after the death of a loved one. The relationship you had with your loved one was probably clearly defined, and you have memories of that person to look back on. The loss is easily identified and articulated, not only by you but by others who were aware of the death. You most likely had many people express sympathy and give you their condolences, perhaps verbally or by sending flowers. You may have taken time off work for bereavement and attended a ritual such as a visitation ceremony, wake or funeral that helped to facilitate your grief. Your loss was likely recognized, acknowledged, validated and supported in a multitude of ways.

Now think about the losses associated with infertility. One of the major losses is that of the imagined or expected family. Women with primary infertility, who do not have biological children, face the loss of the entire life stage of parenting. This may include pregnancy, passing on family or holiday traditions, and passing on the genetic legacy or surname, plus the eventual loss of other life stages such as grandparenthood. Counselors should recognize that meaning is often attached to these losses which further compounds the pain. For example, not being able to experience pregnancy means that the woman is also excluded from cultural pregnancy milestones such as going to the first ultrasound visit, thinking of fun and exciting ways to announce the news to family and friends, participating in a baby shower, and throwing a gender reveal party. With infertility, the loss comes from an absence of something that has never been rather than the absence of something that used to be.

The stigmatization surrounding infertility contributes to an atmosphere of silence and invisibility. Infertility and its accompanying losses are not as outwardly visible and may not be well known or understood by others unless the woman discloses them herself. Many women who experience infertility feel a sense of failure or self-blame toward their bodies, and some may withdraw socially, isolate, or struggle with their identity and sense of self. The stigma surrounding infertility can make it difficult for women to reach out for support. As a result, they find themselves navigating the experience alone.

When a woman does talk openly about her infertility, other people may not respond in ways that are validating or compassionate, which may make the situation worse than if she hadn’t disclosed at all. For example, comments such as, “Just relax,” and, “Give it time,” minimize the woman’s pain and invalidate her grief. Asking, “Have you tried (fill in the blank)?” or “Have you considered adoption?” implies that the woman is not trying hard enough to find a solution or that what she has tried already is inadequate. Most of the women with infertility I have encountered over the years acknowledge that people generally mean well and offer such comments in an attempt to provide hope or to decrease their own feelings of discomfort when talking about infertility.

Facilitating the grieving process

Professional counselors have a responsibility to provide compassionate and competent mental health treatment. Each infertility journey is unique, and counseling interventions should be tailored to fit the individual needs of every client. Taking clients’ cultural, religious or spiritual backgrounds into consideration, several interventions may be used to effectively assist these clients through their grief.

  • Counselors, first and foremost, can be present and listen. Typically, this is what is missing when family members, friends, co-workers, doctors or strangers offer comments that end up being hurtful or invalidating to the person or couple experiencing infertility. We do not have to have the answers — even as counselors. Just be there.
  • Counselors can assist clients in articulating what they need from others around them. This may also incorporate methods for helping clients increase their assertiveness or self-confidence.
  • Counselors can help clients redefine their life expectations and conceptualizations of womanhood, family and mothering. This may also include processing how clients perceive lost embryos, chemical pregnancies or miscarriages to fit within the family unit.
  • Counselors can help clients manage the roller coaster of emotions and ongoing stress as they are trying to conceive, rather than focusing on finding closure. Closure usually implies resolution, which may not be possible with the prolonged nature of infertility and the treatment process.
  • Counselors can assist clients in developing their own rituals while trying to conceive, undergoing fertility treatment, or after making the decision to stop treatment. For example, a woman once told me that she threw a party after she and her husband decided to stop IVF treatments. The party signified taking control over their decision to remain child-free and served as a celebration of the effort it had taken to come that far. 
  • Counselors can explore appropriate methods of client self-care, including engaging in hobbies, participating in creative or social activities, and even taking breaks (as needed) from trying to conceive or pursuing medical treatment.
  • Counselors can connect clients with appropriate resources. It may be necessary to provide clients referrals to group counseling if they wish to connect with others who have similar stories, or to couples counseling if they are struggling in their relationships. In addition, location or cost can be barriers to clients obtaining the services that would work best for them, so counselors who are knowledgeable about online resources can provide these options. Collaborating with other health care professionals with whom the client is working can also provide more comprehensive treatment.

This is not, of course, an exhaustive list. Grief is a personal experience. Which methods are the best fit for your client should be explored in a therapeutic setting that considers both individual and cultural contexts.

What do counselors need to remember?

Imagine that you are working in a private practice when you meet a new client experiencing infertility. You are a master’s-level clinician and are fully licensed in your state. You have taken one class in your graduate program on grief and loss but have no further specialization or experience with infertility. The client has heard numerous comments, questions and suggestions throughout the years regarding her infertility. She is unsure of how counseling might help, but she feels the need to seek support.

This scenario, while general, is a realistic picture of a possible situation that any clinician could experience. As such, I will provide thoughts on what every counselor should keep in mind when it comes to the areas of infertility grief. I am not attempting to reinvent the wheel when it comes to essential counseling tools; rather, I am striving to provide context for effectively using these tools with clients affected by infertility.

>> Convey empathy and understanding. If I could share only one thing I have learned in my work with women affected by infertility, it would be that so many of them feel and believe that you cannot possibly understand what infertility is truly like unless you have been through it yourself. Many women have asserted to me that they just need someone willing to sit with them through the anguish. Counselors who are attempting to provide encouragement and hope may instead end up inadvertently dismissing their clients’ pain or minimizing their grief. It is also possible that counselors end up avoiding a deeper exploration of the experience completely because they do not know what to say. Do not underestimate your basic counseling skills when working with these clients. Acknowledge, reflect and empathize.

One way that counselors can suggest understanding is through the careful use of language. For instance, matching the client’s chosen language of “baby” or “child” is more appropriate (and accepting) than using the more medically correct terms of “embryo” or “fetus.” Language can also offer a reframe from a label of “an infertile woman” to “a woman affected by infertility.” This choice of words depersonalizes the condition and acknowledges that her identity is separate from the condition.

>> Become familiar with client issues related to infertility. Clients who talk about their infertility journey will use a variety of terms and acronyms. For example, you may have clients talk about the time they were “TTC,” which stands for trying to conceive. They may also mention medications, medical procedures or basic biological functions with the assumption that the counselor is generally informed on these topics. Although asking clarifying questions of clients can help paint a clearer picture of their experience, it is not the client’s job to educate the counselor. Take the initiative early in the working relationship with a new client to learn about infertility in areas in which you are deficient. That way, you will be able to understand the client’s journey and experience in greater context.

>> Validate the loss. The invisibility of infertility may cause some women to wonder whether their losses are real or valid. For example, I met a woman during my research who had elected to try IVF after three years of actively trying to conceive, and she gave birth to a healthy baby after just one round. Still, she felt a sense of loss over the fact that her memories of the conception did not entail a moment of passion and love, but rather recollections of shame and fear. She referred to her husband having to masturbate in isolation to provide the needed sperm sample and her experience of lying on a cold table waiting for the doctor to transfer the embryo. She did not feel that she could verbalize this sense of loss to others, however, because it might make her sound ungrateful. A counselor could validate the loss of the ideal conception story and help her articulate feeling both sad for that loss and grateful for her baby at the same time.

The invisibility of infertility also means that some women may not have the vocabulary to identify and articulate their losses. Women with primary infertility endure the losses of pregnancy, delivery, parenthood and eventual grandparenthood but may not be able to understand for themselves that they are mourning the loss of an anticipated and desired life stage. Counselors can assist clients with developing language for their losses if they are struggling to verbalize their grief.

>> Get comfortable. Discussions about infertility may overlap with other taboo topics such as sex, masturbation, miscarriage and abortion. Many of the women I have met who have been affected by infertility have had miscarriages along the way. This brings about an additional — but connected — situation of grief and loss. Talking about miscarriage can be difficult to do without also bringing up abortion, given overlapping language (e.g., spontaneous abortion) and medical procedures (e.g., dilation and curettage). These topics can be slippery territory for personal bias, but counselors should regulate their own reactions and practice reflection to maintain appropriate neutrality and support. Engaging in self-care can be particularly important when counseling those affected by infertility.

Challenging infertility stigma

More and more, childbearing is being viewed as a choice rather than a societal or marital expectation, yet not having children is still considered to be somewhat taboo. Women are socialized from a young age to prepare for eventual motherhood through childhood play that often fosters a nurturing and caretaking role. Other cultural narratives suggest that women have an ability and responsibility to control their fertility. This contributes to self-blame and shame when they are unable to conceive. Infertility is infrequently discussed publicly and thus carries a sort of social stigmatization. Counselors can contribute to destigmatizing infertility by normalizing conversations about infertility, challenges to conception, fertility treatments, and miscarriage.

Stories related to infertility gained widespread media attention throughout 2018. That March, a fertility clinic in Ohio experienced a technical malfunction that caused the destruction of more than 4,000 eggs and embryos, a loss that most certainly had potentially devastating implications for the affected families. Then, in August, a rare visual of the emotional and physical struggle of trying to conceive was captured in a photograph that went viral of a newborn baby surrounded by the 1,616 IVF needles that it took to conceive her. In the months that followed, actress Gabrielle Union opened up about her emotional fertility journey that included numerous miscarriages and surrogacy, and former first lady Michelle Obama revealed her story that included miscarriage and IVF to conceive her two daughters.

These stories bring visibility to infertility and normalize conversations about the challenges that can come with attempting to get pregnant. Counselors can contribute to destigmatization by engaging in discussions and posing curious but sensitive questions about how resources and support can be bolstered for affected women and couples.

Conclusion

Each infertility story is unique, and no one-size-fits-all solution exists when it comes to helping women and couples work through their infertility grief. Whereas an obvious loss from the death of a loved one usually includes rituals and social support, the invisibility of infertility makes it difficult to identify the losses, often leaving women affected by these losses to deal with them in silence and isolation. Counselors can help clients find the vocabulary to articulate the losses they are grieving, give voice to what they need from the people around them, and create ways to process their grief in a warm, nonjudgmental atmosphere.

 

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Tristan McBain is a licensed professional counselor and licensed marriage and family therapist. She is a recent graduate from the Counselor Education and Counseling Psychology Department at Western Michigan University in Kalamazoo. Contact her at tristanmcbain@gmail.com.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Letters to the editor: ct@counseling.org

 

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Related reading on this topic, from the Counseling Today archives: “Empty crib, broken heart

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.