Tag Archives: women

Far away, so close: Negotiating relationships during COVID-19

By Laurie Meyers January 26, 2021

COVID-19 has taken away many of our in-person interactions. Office chitchat by the coffee maker. Happy hour with friends. Holiday celebrations. Friends, co-workers, extended family — since the pandemic began, many of us have seen them only virtually. In many ways, it’s like we’re all stuck on our own desert island — closed off from the outside world yet sometimes desperately wishing to vote our “fellow inhabitants” off.

The people we live with. We love them. We’ve treasured the extra time with them. But sometimes we just want them all to go away.

The never-ending togetherness; the uneven distribution of household responsibilities; the challenges of balancing work, child care and virtual schooling; and the career sacrifices that many people (women primarily) have had to make are all creating new stress and tension, while also exacerbating pre-existing conflicts in couples and families. In other words, couples and family counselors are very much in demand.

Seeking moments of solitude and respite

“Time and space are just different this year,” says licensed professional counselor (LPC) Christina Thaier. “We no longer divide our roles and tasks into different spaces, and that means all of who we are has to exist within less space. This is tough for kids and adults alike.”

Work, school, family, intimacy, socializing and relaxing are all wedged into the home.

Esther Benoit, an LPC with a private practice in Newport News, Virginia, points out that many parents are really struggling with roles they never expected to play — such as teacher and tutor when their children encounter difficulties with virtual schooling — while still trying to work from home. Other clients are working outside the home but spending substantial time on the phone providing “tech support” to their adolescent children who are at home alone, Benoit says.

Thaier notes that clients are floundering to find a way to balance everything in the absence of real-life connection to their communities and support networks. “It’s limiting. We miss a lot, and if we live with others, we are taking this on without any real break from our family or roommates,” says Thaier, a couples counselor who is the founder and director of Terrace House, a group practice located in St. Louis. “It’s a strange feeling to feel lonely and cut off from our usual life and, at the same time, never feel we get a break from others.”

“We [also] miss the versions of ourselves that exist in our usual spaces — our co-worker self, our happy-hour self, the version of us that shows up at the gym or the part of us that sings in the car after dropping the kids off at school — and the natural breaks and alone time that were previously built into our day,” she continues.

Thaier, an American Counseling Association member, helps clients envision alternative ways to be their different selves. “Maybe I can access the part of me that comes alive during time with friends by moving our time together to the park with masks,” she suggests. “Or I can plan a 10-minute Zoom call with my favorite co-worker at a time we would usually stop by one another’s desks.”

Thaier and her clients also seek simple ways to re-create those moments of solitude with activities such as taking a walk in the middle of the day, running errands, completing a solitary trip to the store to pick up groceries, or taking a bath or shower. “We’ve also talked about meditation apps and making the most of the early morning or late evening time when most of the house is sleeping,” she says.

Megan Dooley Hussman, a provisional licensed professional counselor and clinical supervisor at Terrace House, says many clients have found not just alone time but also a way to stay centered by engaging in daily rituals such as meditating, walking or even making and drinking tea mindfully.

Some clients also seek quasi-solitude by establishing family reading or movie-watching times, Thaier notes, adding that “quiet is almost alone.”

But with the multiple roles that parents are playing, stolen moments of solitude often aren’t enough, Thaier asserts. She helps parents map out the logistics of making sure that each partner gets their own break at some point during the week. That often involves one parent — or a family member within the household bubble — “hanging” with the kids while the other parent gets some time to themselves, she says. Thaier describes it as a “big win” for parents when everyone else leaves the house — even if only for an hour.

Sharing the struggle

The pandemic has been overwhelming for everyone — in unique but also universal (or at least common) ways. For parents and couples, the biggest contributor to distress and conflict is often unequal distribution of the “mental load,” says LPC June Williams, whose specialties include couples counseling. The mental load, she explains, is everything that needs to be done to keep the household moving. And much of it seems never-ending.

As Williams, a private practitioner in Cedar Park, Texas, points out, everyone is eating all the time when the kids are at home due to virtual schooling. Meals need to be planned and scheduled because family members aren’t necessarily eating at the same time. The dishes seem to self-replicate, requiring multiple dishwasher runs per day. It isn’t uncommon for one parent to manage this process — in addition to keeping the children engaged in online schooling and attempting to perform their “regular” job duties from home. In such cases, the parent spends the day constantly switching focus from their work laptop to their children’s screens. One of Williams’ clients is working and managing the family’s three children while their partner is in another room with the door shut.

When the distribution of household responsibility is not equal, it is often because much of the mental load is invisible, Williams says. She helps make it visible to her couples clients.

Williams will sit with the couple and task the partner carrying the uneven load to walk her through their day. Williams asks the other partner to listen without interrupting. Often, the partner who has been contributing less is shocked to learn the full mental load that their loved one has been carrying, Williams says.

It isn’t always possible to achieve a 50-50 split, Williams says, but she helps couples distribute the load more equitably. They discuss all of the tasks that make up the mental load and talk about how to handle them as a team. Williams asks the partner with the lesser load to think about what areas they would be willing to take over. She then asks the other partner to decide where they are willing to relinquish control. “What’s something you are willing to give away, knowing that it’s not going to be done your way?” she asks. If the partner offloads dish duty, they have to accept that the dishwasher may not be loaded “correctly,” Williams counsels.

Williams also has couples take responsibility for different areas of the house. Once that’s done, each partner’s domain is sacrosanct. “No micromanaging,” she says. “If the trash is your partner’s deal, you don’t say anything — it’s in their lap.”

ACA member Paul Peluso agrees that cooperation and flexibility are essential for navigating home life during the pandemic. He recommends that couples come up with a practical, workable schedule that allows each partner some time off. Unlike Williams, he recommends that couples switch off tasks such as bathing the children, taking out the trash and cooking. This cooperative effort creates a sense of fairness that allows a partner who has had a particularly bad or busy day to ask the other partner to take over a task that the tired partner feels too tapped out to do. The understanding is that the same grace will be extended to the other partner when needed, says Peluso, a professor of counselor education at Florida Atlantic University and a former president of the International Association of Marriage and Family Counselors, a division of ACA.

Peluso also recommends that couples cut themselves and each other some slack, especially during the pandemic. For instance, perhaps the routine has been to fold and put away clothes immediately after they come out of the dryer. “Give yourself a break and let it be in the basket for a few days, and use that time to watch a show together or to talk,” Peluso urges.

Sometimes, an unevenly distributed responsibility cannot be transferred from one partner to another, Williams says. The couple with one partner working and managing school for three kids is doing it out of necessity because the partner with the closed door is constantly in meetings.

In cases such as these, Williams typically encourages couples to explore possible outside resources that can be brought in: “Can we talk to family [about providing help]? Do we have a COVID-safe nanny? A COVID pod so that two days a week the kids are going to another parent’s house?”

Sharing the load becomes more difficult when one partner is working outside the home and the other works virtually or has put their career on hold. This scenario can easily lead to resentment, Benoit says. To the partner who stays home, it can seem as though the partner who works externally has experienced a return to business as (almost) normal, she explains. Meanwhile, the “inside” partner feels like their life has been completely upended because they are either trying to work from home while also providing child care or may even have felt it necessary to leave their job, Benoit says. Resentment builds because the partner at home feels trapped.

Benoit finds it helpful to externalize these conflicts for couples, emphasizing that it is the situation that is the problem, not the person who is working outside the home. Adopting this perspective, it becomes something that the couple can address as a team. The goal is to avoid recrimination and accusations, Benoit says, and to ask instead, “How do we get through this together?”

Although the essential circumstance cannot be changed, the level of resentment can be lowered dramatically, Benoit says, by something as simple as the partner working outside the home acknowledging that the other partner has the tougher end of the deal and asking, “What can I do to help?”

Benoit also emphasizes self-compassion. “I tell a lot of clients that what we’re aiming to do is get through,” she says. “We’re not aiming to thrive, but to survive.”

Couples also must learn that they are not responsible for each other’s moods, Williams says. A felt need to “fix” everything is often present in the partner who feels “overloaded,” she says.

“I work with that person who is trying to fix and [I] help them get more comfortable with everyone’s discomfort,” Williams says. This is doubly beneficial because the person who is underfunctioning may be hanging back as a result of receiving the message from their partner (directly or indirectly) that they never do anything right. Williams wants to help the partner carrying the lighter load to take on more of the burden not because they are being nagged but because it is important to the family.

Williams also asks the “overburdened” spouse about the feelings they are living with. Do they feel the need to fix, rescue, save and control? Do they feel anxious and resentful? If the client acknowledges these patterns, Williams asks whether they like feeling that way.

The usual response? “No, I am mad all the time and tired.”

Possessing a sense of responsibility does not mean that the client is responsible for everyone in the world, Williams counsels.

She gives clients a scenario: Your husband comes in and is in a terrible mood. He sighs heavily and drops his bag. As his wife with an overdeveloped sense of responsibility, you may flutter about and try to step in and take over. The end result? You haven’t fixed anything. He’s still irritated, and now you are too, Williams says.

She tells clients that they can still be compassionate, check in with their partner and ask how their day was. But if the partner responds that their day was terrible, clients need to ask themselves whether they have the emotional energy to carry that burden with their partner, Williams advises. If not, “It’s OK to say, ‘Here’s a soda water,’ give them a hug and move on,” she says.

When clients feel that tension in the pit of their stomach that is pushing them to step in, Williams urges them to do something calming in another room, such as belly breathing, stretching or taking a quick shower. These strategies also have the advantage of physically separating the person from the partner and their bad mood.

“Offer them compassion and allow yourself to remain separate,” Williams advises.

The price women pay

Williams doesn’t generally like to make assessments along gender lines, but she says the consequences of the pandemic are clearly delineated. Women are typically the ones expected to put their careers on pause — to be the caregivers and nurturers, to be more in tune with the children and to meet the family’s needs — even if they are the family’s highest wage earner, Williams asserts. She references a pithy and pitch-perfect quote from sociologist Jessica Calarco: “Other countries have safety nets. America has women.”

Thaier agrees. “Women already tend to take on more of the emotional, social and household roles, and that has not changed despite those tasks further multiplying,” she says. “In my practice, we talk a lot about our humanness, and that no one human can do all the things. We work on asking for help, prioritizing and eliminating what we can, establishing boundaries, and making time for ourselves.”

Women have absorbed a tremendous number of losses but haven’t had time to properly acknowledge those losses, Thaier says. “It’s hard to grieve within the experience of trauma,” she continues. “If we use the definition of trauma as too much, too fast, all of 2020 has been that. The quick reorganization of our lives has required [clients] — especially women — to move into crisis management mode. In crisis management, we do, we don’t get to be. In that way, therapy itself invites a chance for being, even if, after the hour, we revert back to survival mode a good portion of the time. We begin to carve out moments, which build on each other, for something different.”

“In some ways, because everything is different, there are opportunities for everything to be different, and that means families can brainstorm and strategize together on how to take care of the home and one another,” Thaier says. “It’s not easy, and there are lots of challenges. But I see a lot of great conversations happening, and with that, a lot of change too.”

In therapy, clients get to recenter themselves and their experiences, Thaier says. “They can voice resentments, frustrations, fears and anxieties, and their fear that feeling this way makes them a bad mother, partner, employee or friend.”

Thaier encourages clients to question these assumptions and where they came from, and then begin to redefine what is important to them about the roles they play. “For example, if we are redefining being ‘good’ at a relationship from an old definition of trying to not let anyone down to a new definition of being present and authentic with the people we love, we can begin to think about what this might look like,” she explains. “We can notice when the old definition is guiding our behavior and patterns, and we can start to practice new ways of relating.”

Reimagining clients’ relationships and roles often involves rejecting parts of the past by breaking patterns driven by cultural assumptions. But the past can also inform the future. Thaier uses narrative therapy to help clients grieve their losses and find ways to preserve elements of what was lost. “I think a lot about telling the stories of the people and experiences we have loved and that have significantly influenced our lives,” she says. “For a woman who has made the sacrifice of a current work role that is a significant part of her identity, we explore that.

“How did the job bring you alive? What did it make possible? What were the best parts of your day? Where did you imagine this would take you next? How did this role fit into an imagined and cherished future?”

“We can actually strengthen that story even as we grieve the space it has left in the present,” Thaier says. “And we can begin to narrate how the client can access her relationship to her work — or [what] she found possible there — and bring that into the present. In other words, the people and experiences we love become a part of us, and we can continue to take them with us into our futures. Our relationship with them gets to continue, if we want it to.”

An existential pause

The pandemic-induced global slowdown has provided people an opportunity (even if unrequested) to examine their lives and reevaluate their priorities, Peluso says. A number of people are asking themselves if they want to get back on the treadmill of constant activity and productivity, “or do I want to start thinking about what I was saving for someday and do it now?” he says.

Regardless of whether they choose to return to the treadmill, stepping off of it even temporarily has granted many people clarity about their relationships, Peluso observes. Some have grown closer to their partners during the pandemic, whereas other couples who were gritting their teeth and staying together for the sake of the children beforehand are asking themselves whether it’s worth the price they are paying.

Some couples are reassessing how they were choosing to spend their time prepandemic, he says. “I think especially early in the pandemic, when there was a hard stop to a lot of activity, it created a window of opportunity to just build some new rituals for connection,” Peluso says. “Couples were able to do things together — tasks, projects around the house.”

This ability to slow down — rather than charge through a list of chores — allowed some couples to rediscover pieces of each other that may have been subsumed in the daily grind, Peluso says. “For a lot of them, it forced them to look at some places where they had been neglecting relationships,” he adds.

“While this year has been incredibly challenging, it has also been an invitation,” Thaier says. “An invitation to slow down, to be together more, to take stock of what we’re doing and how we spend our time. To be at home more. To rest. To see our limitless creativity and resilience and strength. To acknowledge that our lives really could look different at a moment’s notice. To learn to be together in new ways. To be outside more. To take less for granted.”

“I wouldn’t say it’s been ‘worth it,’” she continues. “That would disrespect all of the loss and tragedy and, frankly, just wouldn’t be true. But there’s good here too. And there’s invitation in every holding pattern to see something that is waiting to be acknowledged. There’s a mirror here, if we’re willing to look into it.    

“I’m thankful for the invitation, and I’m hopeful about what’s next.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Books & DVDs (imis.counseling.org/store)

  • Theory and Practice of Couples and Family Counseling, third edition, by James Robert Bitter
  • Mediating Conflict in Intimate Relationships (DVD) presented by Gerald Monk and John Winslade

Continuing Professional Development (aca.digitellinc.com/aca/specialties/56/view)

  • “Creative Counseling for Couples: Using the Integrative Model” (webinar) with Mark Young
  • “Imago Relationship Therapy” (podcast) with Susan Hammonds-White

International Association of Marriage and Family Counselors (iamfconline.org)

IAMFC is a division of the American Counseling Association that embraces a multicultural approach in support of the worth, dignity, potential and uniqueness
of families.

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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.

Perinatal health: Education and screening in counseling

By Rebekah Lemmons December 2, 2020

Perinatal health encompasses multiple women’s mental health issues related to pregnancy and the postnatal period. During these times, clients may be at increased risks for depression, anxiety and related mental health needs. Perinatal care providers often see clients for other needs such as infertility, miscarriage and infant/child loss and grief. 

Why is this important for clinicians to know?

Clinicians can provide preventative care and screenings to access for specialized service needs. Early intervention can help minimize the impacts of these issues on the mother and child. Maternal health services can also provide support for life changes as a part of routine perinatal progression.

Many women receive benefits such as education and planning related to finding a trauma-informed provider, developing a birth plan that is empowering and fits their lifestyle, and planning for support needs during and after pregnancy. Providers can also aid in finding and advocating for appropriate support services (e.g., physical therapy for pelvic floor wellness) during and after pregnancy.

Similarly, early intervention and preventative care impacts the development of the child and can serve as a protective factor. The Adverse Childhood Experiences studies and related studies provide the rationale for providing a healthy, safe and nurturing environment for children. This includes the period of being in the womb because epigenetics and maternal health impact a developing child in many ways. In this aspect, preventative care for mothers acts as a protective factor for children. 

How can I tell if my client needs specialized services?

Proactive and ongoing mental health services have an array of benefits for clients. As part of your services, providers can monitor and assess the need for specialized perinatal care.

The first step is to receive education on the risk factors and what to look for when working with this population. Risk factors for perinatal issues include a history of mood disorders or related mental health conditions such as depression, anxiety, posttraumatic stress disorder or obsessive-compulsive disorder. Physical symptoms such as hormonal imbalances or prior complications from a past pregnancy, labor, delivery or loss of a pregnancy can also increase these risks. Social factors, such as a lack of support from family or friends, or stressors such as poverty can also heighten the risks for perinatal support needs.

Warning signs may include mothers who are experiencing feelings of guilt, hopelessness or anger, sleep disturbances and related physical symptoms. This can also manifest as mothers having thoughts of hurting themselves or the baby and experiencing a loss of interest in activities that used to bring them joy.

See the screener at the end of this article for added specifics on what to look for with perinatal clients. This screener can be used to assess the need for specialized referral services and can also help you, as a provider, to gather information and monitor ongoing changes during the client’s perinatal period. This helps you to effectively plan for treatment and any related support services, as appropriate.

How do I know if a counselor is trained to provide perinatal services?

PMHC is the official credential for perinatal mental health counseling. If you have access to a certified professional in your area, you can recommend them for perinatal services as part of stand-alone or support services to use in conjunction with the current therapy the client is receiving.

Some locations have limited certified professionals in their area. Other geographic areas have no certified professionals for this population. Clinicians can recommend competent service providers after asking the providers about their training, experience and credentials related to providing these services. Some providers are not certified but still have training in this area or are receiving supervision/consultation to become certified in this specialty.

How can clinicians receive further education and support to provide perinatal services?

Clinicians can attend specialized trainings and also engage in consultation and supervision to build competency in this area. Many continuing education providers now offer trainings related to women’s issues and provide sessions on postpartum depression or anxiety. These can help to increase your awareness of women’s issues.

For clinicians wishing to provide services exclusively to this population, certification is another great way to build your skills for this focused area of counseling. Perinatal mental health certification is available at https://www.postpartum.net/professionals/certification/.

Integrative screener for perinatal health and well-being

The purpose of this screener is to provide a brief reference guide for the identification of specialized service needs. Adjustments and changes to typical routines and day-to-day life are part of pregnancy and postnatal times. To help best meet your needs during this time, a certified perinatal mental health provider can evaluate and assess your specific mental health needs and goals.

This screener can be utilized along with the PHQ-9 and Edinburgh Postnatal Depression Scale. This questionnaire more broadly encompasses base-level indicators for postnatal depression, postnatal anxiety and traumatic birth syndrome symptoms. This screener can be self-administered or administered by a provider, spouse or friend. Please remember that regardless of your screener results, proactive and maintenance counseling can be part of an integrative health plan to help your reach your wellness goals.

Please rate the below statements based on a scale of 1-4: 1 being strongly disagree, 2 being somewhat disagree, 3 being somewhat agree and 4 being strongly agree.

 

  1. A) Postnatal depression symptoms

__ I regularly engage in activities that I enjoy.

__ My relationships are as strong as they were before pregnancy/childbirth.

__ I feel as happy as I did before pregnancy/childbirth.

__ I can acknowledge my strengths and appreciate myself as much as I did before pregnancy/childbirth.

__ Total score

 

  1. B) Postnatal anxiety symptoms

__ I am able to accept my mistakes and do not dwell on them.

__ I let things go and do not spend time worrying about things I cannot control.

__ I feel as calm and centered as I did before pregnancy/childbirth.

__ I have the skills needed to manage concerns as they come up.

__ Total score

 

  1. C) Traumatic birth symptoms

__ I had a positive birth experience.

__ I felt listened to and heard during my birth experience.

__ My wishes were respected during labor and delivery.

__ My providers and supports met my needs during labor and delivery.

__ Total score

 

  1. D) Recovery complication symptoms

__ I have recovered physically from labor and delivery.

__ I have recovered mentally and emotionally from labor and delivery.

__ I have the support needed to fully recover.

__ I have the resources needed to fully recover.

__ Total score

 

  1. E) For pregnant women only

__ I appreciate my body as much as I did before I was pregnant.

__ I have a healthy perspective.

__ I have the emotional support I need to be well while pregnant.

__ I have the resources I need to be well while pregnant.

__ Total score

 

Scoring criteria for all indicated areas:

Scores of 3 and 4: Continue your current wellness plan. Continue to monitor symptoms using the screener as needed. Remember to seek a specialist if you feel it is needed, regardless of your scores.

Any scores of 1 or 2: Seek a perinatal specialist.

 

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Rebekah Lemmons strives to improve outcomes for children, emerging adults and families. For the past decade, her practice and research have primarily been based in the nonprofit sector, with an emphasis on conducting program evaluation, teaching, engaging in service leadership, consulting and providing supervision to clinicians. Contact her at rebekahlemmons@yahoo.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.

Uncovering the root cause of mother-daughter conflict

By Rosjke Hasseldine January 8, 2020

An experienced counselor recently admitted to me that she felt out of her depth when a mother and adult daughter both came to see her for help with their incessant arguing. She said that she struggled to identify the core reasons for their arguments, and she knew that the communication skills and boundaries she tried to instill in them did not address the core reasons for their relationship difficulties.

Sadly, this counselor is not alone. Colleagues frequently tell me that they feel unprepared when it comes to working with mothers and daughters. They blame the absence of specialized training. This lack of focus on the mother-daughter relationship creates unnecessary anxiety among counselors and psychotherapists, and frustration for female clients. For example, only in 2016 was the Adult Daughter-Mother Relationship Questionnaire developed (for more, see Julie Cwikel’s article in The Family Journal). And in my office, all too often I hear mothers and daughters voice their frustrations about the lack of specialized help.

In this article, I share two insights that will help counselors understand the dynamics between a mother and daughter of any age. These insights come from the mother-daughter attachment model I have developed through my 20-plus years of listening to thousands of mothers and daughters of all ages from different countries and cultures. The model makes the complicated dynamics between mothers and daughters easy to understand, explains why mothers and daughters fight, and teaches how mothers and daughters can build strong, emotionally connected relationships.

I chose to specialize in the mother-daughter relationship back in the 1990s because that relationship is central to women understanding themselves. My relationship with my mother had shaped who I was, and when my daughter was born 30 years ago, I knew I had to change the harmful themes that were being passed down the generations. What began as a personal quest became my professional mission.

Mothers and daughters frequently tell me that they feel ashamed about their relationship difficulties. They feel that they “should” be able to get along because popular wisdom tells them that mothers and daughters are supposed to be close. This societal expectation makes mothers and daughters blame themselves for causing their relationship difficulties. The truth is, if my years of experience providing therapy are any indication, many women currently experience mother-daughter relationship conflict.

Based on the inquiries I receive from mothers and adult daughters from different countries, I believe that a larger, societywide dynamic is contributing to their relationship conflict. Often, I hear “hormones” being blamed as the cause for relationship problems, whether it is the teenage daughter’s or pregnant daughter’s hormones, or the menopausal mother’s hormones. Another common reason mothers and daughters give to explain why they are not getting along is their differing or similar personality traits. I have never found hormones or personality traits to be the core reasons for mother-daughter relationship conflict, however. Rather, I have concluded that society sets mothers and daughters up for conflict.

In the first insight, I show that the mother-daughter relationship is not difficult to understand once we realize that mothers and daughters do not relate in a cultural vacuum. In recognizing that mothers and daughters relate within a sociocultural and multigenerational environment, the dynamics between them become easier to grasp. We see how life events, restrictive gender roles, unrealized career goals, and the expectation that women should sacrifice their needs in their caregiving role all shape how mothers and daughters view themselves and each other and how they communicate. To illustrate this dynamic, I share the story of my work with Sandeep, a young college student from England (name and identifying details have been changed).

In the second insight, I explain how patriarchy’s way of silencing and denying what women need is the root cause of most mother-daughter relationship conflict in different cultures around the world. To illustrate, I share my work with Miriam, a doctor from Sweden who comes from a feminist family (name and identifying details have been changed).

Miriam and Sandeep come from different countries and cultural backgrounds, and their families are on opposite ends of the women’s rights continuum, yet their core relationship problem is the same. Both Miriam and Sandeep come from families in which women have not learned how to ask for what they need.

Insight No. 1: Mothers and daughters relate in a sociocultural environment

As is the case with any couple, mothers and daughters rarely fight over what they say they are arguing over. Sandeep and her mother were no exception to this rule. Sandeep was a young college student who lived at home. Her parents immigrated to England from India before Sandeep was born. Sandeep had three brothers, but she was the family’s only daughter.

Sandeep came to see me because she was feeling depressed about how critical her mother was. She was struggling to juggle her college work with the housework her mother and family expected her to do. She said her mother would accuse her of not being a good enough “housekeeper” and not caring enough for her mother when she was ill, which was often.

Sandeep had consulted a counselor before me who had suggested that her mother might be suffering from a personality disorder. I never got to meet Sandeep’s mother and work with her clinically, so I was unable to validate whether this might be the case. Regardless, even if Sandeep’s mother did have this diagnosis, it did not provide Sandeep with the answers
she needed.

Instead, Sandeep needed to understand the multigenerational sociocultural environment in which she and her mother lived. She also needed to understand what was going on in this environment that apparently caused her mother to be so angry and critical, and what caused Sandeep and her mother to believe that it was Sandeep’s responsibility to do all the housekeeping.

When I start working with new clients, I map their mother-daughter history. This is the primary exercise in the mother-daughter attachment model. It is an adaptation of the genogram exercise that family therapists use. The maps focus on the three main women in the multigenerational family, which in Sandeep’s case was Sandeep as the daughter, her mother and her grandmother. I map the experiences the three women have had in their lives, including the gender roles that have defined their lives and limited their choices and power. I also map how the men in the family treat their wives and daughters. Mother-daughter history maps provide an in-depth analysis of the multigenerational sociocultural environment in which the women in the family live and what is happening within that environment to cause mothers and daughters to argue, misunderstand each other, and disconnect emotionally. (Detailed instructions on using this exercise with clients are available in my book The Mother-Daughter Puzzle.)

Sandeep talked about her grandmother’s and mother’s lives and arranged marriages and shared how verbally abusive and controlling her father and grandfather were. She said the males in the family were encouraged to go to college and build their careers, while the females were expected to stay at home to help their mothers. As Sandeep provided these details, her family’s patriarchal structure came into sharp focus. Sandeep represented the first woman in her generational family to finish school and go to college.

Sandeep’s family believed in what I term the “culture of female service,” a global patriarchal belief system that views women as caregivers, not care receivers. Families that subscribe to the culture of female service expect mothers and daughters to be selfless, sacrificial, self-neglecting caregivers. This belief system does not recognize women as people with needs of their own.

Although I never met Sandeep’s mother, it was apparent to me (based on Sandeep’s descriptions) that she had internalized this family belief and did not know any other way of being. This meant that she did not understand Sandeep’s desire to go to college or her fight for her independence. I suspected that Sandeep’s independence felt threatening to her mother. Several reasons explain why Sandeep’s mother was so critical of her daughter and why she behaved in an emotionally manipulative manner — for example, by becoming ill just when Sandeep was busy with an assignment or exam.

First, Sandeep wanted to live a different life than her mother and grandmother had lived, and this likely made Sandeep’s mother feel alone and abandoned. Her only understanding of being female was that of women as caregivers and of “good daughters” stepping into their mothers’ shoes and walking repeats of their mothers’ lives. Sandeep’s mother had done that, her mother had done that, and she expected Sandeep to follow in that role. I suspect Sandeep’s wish for a different life and different relationships felt like a rejection to her mother. It made her feel that her daughter was criticizing the life and values she believed in as a mother.

Second, Sandeep’s mother could have been jealous of her daughter’s freedom and opportunities, even though she probably was unaware that her criticism and anger were rooted in jealousy. Sandeep’s freedom and opportunities might have been an uncomfortable mirror for Sandeep’s mother, reminding her of the freedom she never had and the dreams she had to relinquish.

Third, the mother’s attempts to keep Sandeep from graduating and leaving home could have been linked to her own fight for emotional survival. Sandeep reported to me that she was the only person who gave her mother love and care, so the thought of Sandeep leaving home must have been terrifying to her mother.

For mothers and daughters to build a strong, emotionally connected relationship, it is optimal for both parties to engage in couples therapy. However, if one person is not able, or willing, to participate, healing is still possible. In Sandeep’s case, her mother did not want to participate in therapy. This did not prevent Sandeep from working on understanding and improving her relationship with her mother, however. When one person changes their behavior, the relationship changes to incorporate the new behavior. Of course, Sandeep and I had little control over how her mother would respond to the changes Sandeep needed in their relationship.

My work with Sandeep involved teaching her how to listen to her own voice. Sandeep had become an expert on responding to what her mother needed and being a “dutiful daughter,” but she had little idea about what she wanted for herself, beyond finishing her degree. Sandeep did not know how to ask herself what she thought, felt, or needed emotionally because that conversation was not spoken in her family. My role as a mother-daughter therapist was to help Sandeep uncover the sexism she had inherited from her mother and grandmother that had silenced her voice. I helped her understand the gender inequality her family and culture normalized, and I taught her how to claim her own ideas of who she wanted to be and what she needed in her relationship with her mother — and in all her relationships.

I also helped Sandeep navigate the pushback she got from her mother and father when she stopped complying with their demands to be the family’s unpaid housekeeper. I helped her to understand her mother’s and father’s perspectives so that she had empathy for them and encouraged her to recognize that their anger and criticism weren’t as personal as they felt, originating instead from their cultural beliefs. Alongside Sandeep’s increased understanding of her family’s sociocultural environment, I helped her increase her entitlement to speak her mind, reject unreasonable demands, and carve out her own life path.

Sadly, Sandeep’s parents did not react well to her behaving differently from what they expected of a “dutiful daughter.” After Sandeep left home, her family’s anger and accusations that she had dishonored the family became alarming, leading her to obtain a restraining order against her parents and siblings. Through her therapy, Sandeep learned the degree to which her family members did not tolerate women challenging their long-held beliefs about what women could and could not do and could and could not wear. I had to help Sandeep stay safe and grieve the loss of her family even as she gained her own voice and life.

Insight No. 2: Mothers and daughters fight over their denied needs

My clients have taught me that the denial of what women need, especially when it comes to women’s emotional needs, ripples below most mother-daughter relationship conflict. As I write in The Mother-Daughter Puzzle, when a family does not speak the language that inquires after what women feel and need, mothers and daughters are set up for conflict. It creates an either-or dynamic in which the mother and daughter fight over who gets to be heard and emotionally supported in their relationship because they do not know how to create a normal in which both are heard and supported.

In every mother-daughter history map I draw, I see how the silencing of women’s needs harms women’s emotional well-being, limits their ability to advocate for themselves in their relationships and workplaces, and perpetuates gender inequality. I see how this dynamic makes women invisible, and how being invisible makes women hungry for attention. The inability to openly and honestly ask about what they need creates emotionally manipulative behavior between mothers and daughters and sets daughters up to have to mind read their mothers’ unspoken and unacknowledged needs.

Miriam, a client from Sweden, contacted me for help with her adolescent daughter. Miriam and her mother had benefited from the women’s movement fight for women’s rights. Miriam and her mother were doctors, and Miriam’s husband and father were extremely supportive of their careers. But just like Sandeep and her mother, Miriam and her mother had internalized and normalized the culture of female service, and Miriam’s daughter was angry about her mother’s selflessness.

Miriam’s daughter felt that she had to mind read what her mother really felt and wanted, and she was tired of it. She desired an emotionally honest relationship with her mom. She wanted to feel free to say what she felt and needed and for her mother to speak her mind and stop the guessing games. Miriam’s daughter did not want to feel responsible for meeting her mother’s unvoiced and unacknowledged needs.

The silencing of women’s needs is an intergenerational dynamic that gets passed on from mother to daughter because the mother is not able to teach her daughter how to voice her needs openly and honestly. When the daughter is expected, often unconsciously, to listen for and meet her mother’s unvoiced and unacknowledged needs, the daughter is learning to become an expert on understanding what her mother needs, not on what she needs herself. This means that the daughter will grow up to be as emotionally mute as her mother, thus setting up her future daughter to try to learn to interpret and meet her unvoiced needs.

Women’s generational experience of being emotionally silenced and emotionally neglected is a common theme between mothers and daughters. Happily, I am seeing a huge shift from adult daughters in their 20s, 30s and 40s who are waking up to this patriarchal theme and wanting change. These daughters recognize that they have learned — from their mothers and from society in general — to be far too tolerant of being silent and practicing self-neglect. More daughters are asking their mothers to join them in therapy so that together they can change these inherited behavioral patterns. Mothers and daughters are teaming up and pioneering a new normal in their families — a normal where women are speaking up and demanding to be heard. And they are passing on this new normal to the next generation of sons and daughters.

Mothers and daughters have always led the call for women’s rights. When we understand that mother-daughter attachment disruption or conflict tells the story of how sexist beliefs and gender role stereotypes harm women’s voices and rights, the mother-daughter relationship becomes an unstoppable force for change at the worldwide and family levels.

Sadly, Sandeep’s mother was not able to join Sandeep in her fight to challenge her family’s sexist cultural beliefs. I inferred that too much neglect made Sandeep’s mother emotionally unable to think her way out of her powerlessness. Miriam, having had a far more supportive and empowering upbringing, was able to join her daughter to find a new normal for women within their family. This mother and daughter team coached each other as they decontaminated themselves from their internalized sexism and self-silencing habits.

The mother-daughter relationship has tremendous power to change women’s lives around the world. When mothers and daughters band together, they create an impenetrable wall of resistance against family members who are threatened by women claiming their rights. I have had the honor of working with many pioneering mothers and daughters who dared to dream of a reality in which mothers and daughters are no longer starving for attention and fighting for crumbs of affection. These brave mothers and daughters recognize the harm that patriarchy, sexism, and gender inequality inflict on women, and they have decided that enough is enough. In essence, they are saying, “With us, it must end.”

 

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Rosjke Hasseldine is a mother-daughter relationship therapist, author of The Silent Female Scream and The Mother-Daughter Puzzle, and founder of Mother-Daughter Coaching International LLC (motherdaughtercoach.com), a training organization. She blogs for the American Counseling Association and has presented her mother-daughter attachment model at professional conferences, on Canadian television, and at the United Nations Commission on the Status of Women. Contact her at rosjkehasseldine@gmail.com or through her website at rosjke.com.

 

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.

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.