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In her brilliant article, Bethany Bray speaks to counselors in the field about the isolation and
heartbreak that often accompanies infertility and miscarriage. She writes about why these experiences can be so all-consuming and goes into depth regarding ways to help facilitate hope and healing. Please find the original article, published in the September 2015 edition of Counseling Today here: http://ct.counseling.org/2015/09/empty-crib-broken-heart/ This past summer, Facebook CEO Mark Zuckerberg and his wife, pediatrician Priscilla Chan, announced that they are expecting a baby. This celebrity baby news grabbed headlines for a different reason than most, however. The couple’s announcement included a candid acknowledgment that they had been trying to have a baby for several years and had suffered three miscarriages along the way. “It’s a lonely experience,” Zuckerberg wrote in a July Facebook post. “Most people don’t discuss miscarriages because you worry your problems will distance you or reflect upon you — as if you’re defective or did something to cause this. So you struggle on your at sharing our experience will give more people the same hope we felt and will help more people feel comfortable sharing their stories as well.” Zuckerberg and Chan’s post resonated with millions of people (witness the post’s 1.7 million “likes,” nearly 112,000 comments and 49,000-plus shares as of the end of August) and helped raise the curtain on some painful yet common issues that are rarely talked about openly. Although many people who face miscarriage and infertility feel alone or isolated, statistics show the circumstances are much more common than people may think. Miscarriage, defined as the loss of a pregnancy before 20 weeks, occurs in 15 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists. The U.S. Centers for Disease Control and Prevention reports that about 12 percent of women ages 15 to 44 have “difficulty getting pregnant or carrying a pregnancy to term,” while an estimated 7.4 million women in that same age bracket have used fertility services. “Trying to make sense of it all is really, really challenging. The depth of the pain and the challenges you go through are hard to put into words,” says Kristin Douglas, a licensed professional clinical counselor and American Counseling Association member in Kentucky who has personal experience with infertility and multiple miscarriage losses. “You don’t ‘get over’ these kinds of losses. You work through them, but you don’t get over them.” Mourning what might have been A person or couple can’t help but think about the future, even if cautiously, after a fertility treatment or positive pregnancy test. Considerations from possible baby names to how the mother might be “showing” by a certain month naturally spring to mind. “When that is taken away” — either through miscarriage or an unsuccessful fertility treatment — “you’re not grieving the past, you’re grieving what was going to be. You’re grieving the future,” says Valorie Thomas, a licensed marriage and family therapist and licensed mental health counselor in Florida. “With pregnancy loss and infertility, each time it doesn’t happen, you’re grieving … for all the ways you were thinking it was going to be. Helping the client to see that can be eye-opening — acknowledging that it’s real, it’s a loss [and] it’s gut-wrenchingly painful.” Thomas knows this pain firsthand. She has been pregnant 10 times, but only one — her sixth pregnancy, a now 16-year-old son — was carried full term. Thomas and her husband also have a 7-year-old daughter whom they adopted. Unlike when other family members, friends or acquaintances die, miscarriage and infertility can leave clients without memories to grieve. Often, people don’t even realize that they have the right to grieve, says Thomas, an ACA member who has a small private practice and is an adjunct professor at Rollins College in Winter Park, Florida. It’s the type of loss “that’s hard to understand,” she says. “You [typically] think of a loss as something that was already here, and you’re grieving it [no longer being here].” With fertility treatment, she says, “You get the call from the doctors saying, ‘The pregnancy test was negative, we’ll see you next month,’ and they hang up,” leaving the individual or couple reeling with a flood of emotions, from anger and frustration to sadness and embarrassment. Clients who are struggling with infertility or grieving a miscarriage can present with a range of issues in a counselor’s office. Depression, anxiety and intense stress are very common, Douglas says, as are feelings of guilt, anger, disappointment, frustration and fear. It is also possible for these clients to wrestle with trauma symptoms associated with their loss, she says. It is not uncommon for couples or individuals to have experienced both infertility and miscarriage. Miscarriage, or “the inability to carry a pregnancy to term,” may be part of the infertility experience, Thomas says. But even when there is no overlap, couples who experience a miscarriage may share some of the same emotional responses as those who are having difficulty conceiving, she says, including a sense of helplessness, desperation and loss of control. Because miscarriage and infertility can be taboo subjects, clients may not realize that they can — and should — acknowledge a pregnancy loss. For example, Thomas says, perhaps a client feels “down” every autumn but doesn’t know why. It could be that she experienced a miscarriage years or even decades ago during the fall that she never processed. Professional counselors can provide help and support in a variety of ways to those who have experienced infertility or miscarriage. This might include helping clients work through the pain and stress of disappointment, self-doubt and even family or cultural expectations. It might also encompass encouraging these clients to practice self-care and teaching them coping mechanisms to help them get through the bad days. Above all, counselors must familiarize themselves with infertility and reproductive issues if they are going to be sensitive and effective helpers for these clients, says Ebru Buluc-Halper, a mental health counseling graduate student at Pace University who runs a support group for couples and individuals going through infertility. “If [a counselor] doesn’t know what they’re talking about, it’s a huge turnoff,” says Buluc-Halper, an ACA member who led a poster session on multicultural considerations in infertility counseling at ACA’s 2015 Conference & Expo in Orlando, Florida. She has friends “who were very frustrated by [a therapist’s] lack of knowledge and were turned off from therapy because they wanted to be understood. It doesn’t happen to everyone, but it does happen.” “People want to be heard and want someone to talk to,” says Buluc-Halper, who has personal experience with miscarriage and fertility treatment. “They are deeply in need of empathy and understanding, which they’re not getting from the people around them, sometimes even from their partners.” Counselors who don’t understand miscarriage and infertility — at the very least possessing a basic knowledge of the processes, terminology and biological factors surrounding these issues — risk reinjuring and alienating clients, agrees Douglas, an assistant professor of counselor education and coordinator of the counseling clinic at Murray State University in Kentucky. People who disclose their miscarriage or infertility struggles are often subject to the well-meaning but hurtful comments and assumptions of others, she says. Among the statements that are common: “If you just relax and de-stress, you’ll get pregnant”; “Just give it time, it will happen”; “At least you weren’t that far along to get attached”; “Maybe you should just adopt”; and “Maybe it’s not in your cards.” Comments such as these are often completely untrue and very upsetting to the receiver, says Douglas, who wrote her doctoral dissertation on miscarriage at the University of Wyoming. “The last thing a person wants is to talk to a counselor who is going to say some insensitive and hurtful things in response to what that person experienced,” Douglas says. “There is a fear of what a counselor might say. Are they going to say the insensitive things that everyone else says? Things that are so hurtful or that minimize the loss?” Handle with care One of the most important things counselors can keep in mind is that no two clients’ experiences are the same, says Courtney Armstrong, an ACA member with a private practice in Chattanooga, Tennessee. Each client will attach a different meaning to what she or he is going through. “Everyone’s experience with infertility is different. You can’t just make assumptions,” says Armstrong, a licensed professional counselor who accepts client referrals from a fertility clinic in her area. “You have to respect that it’s a process for people to come to terms with their infertility. It’s not something you can help them reason their way out of. You have to treat each person individually because every person is going to respond in a different way.” Counseling and therapy must also be individualized in cases of miscarriage. Douglas says she finds it much easier to talk about her first miscarriage, which involved triplets, than her second, which was a single baby. “People would never compare the death of a sibling or a parent to that of an uncle or other relative,” Douglas says, “but somehow, [people] just lump all the miscarriages together. Each failed fertility treatment is not the same either.” There is no one-size-fits-all way to address a client’s infertility or miscarriage in counseling, agrees Thomas. “It’s important that the counselor be aware [of] spirituality and traditions and culture. Your clients are bringing all of that to you,” she says. “You can’t just [use] a cookie-cutter approach.” Thomas terms miscarriage a “silent sorrow,” saying that the loss typically goes unacknowledged by society. Too often, she says, the message that women who have experienced miscarriage receive is: “Get over it. You’ll be fine. Don’t worry about it.” “But depending on your spiritual beliefs, depending on what that meant to you at the time, what it signified, what does family mean to you, what does creating a family [mean to you], how bad you wanted it — all those things play into your reaction,” Thomas says. Paying careful attention to the language the client uses can provide counselors clues about how the person is processing the loss, she says. For example, does the client say, “I was 10 weeks pregnant, and I lost the baby,” or does she use another word? If the client or couple isn’t ready to use the word “baby,” the counselor shouldn’t refer to the pregnancy that way either, Thomas advises. After going through pregnancy loss and several rounds of in vitro fertilization, Armstrong and her husband made the choice to be child free. Making that conscious decision was empowering, she says. “The choice piece is the really important part — deciding if this is the best and right thing for me,” she explains. Likewise, Armstrong says, in counseling it can be empowering for clients to find meaning and realize they still have the ability to make choices in an unwanted situation. Wanting to be a parent and wanting to be pregnant are two different things, and helping clients to uncouple those two concepts in their mind can be helpful, she says. “If they’re going to explore infertility treatment, adoption or other options, is this about having a child or having a child that’s biologically connected to you? The most important thing is that they feel they have the freedom to make a choice,” she says. Thomas’ experience with infertility caused her to rethink the assumptions she’d held growing up in a Catholic family with nine brothers and sisters. “In my family, it was just assumed we’d all have large families,” she says. “When that didn’t happen for me, I had to revisit [that] and ask myself if I’d be OK if that didn’t happen. Then I came to grips [with the realization] that you can create family in different ways. It was OK that I had other parts of myself to be a whole person. I realized that it may be different for me.” How to help Heartbreak can accompany miscarriage and infertility. But so can hope and healing. Here are a few ways counselors can help clients who are processing these experiences. Storytelling and narrative therapy: Two of the most important things counselors can provide to these clients are a listening ear and empathy. “It’s just so important to listen to their story, really listen to their story,” Thomas says. “Every one of them is so different. Each one has a different journey. Listen compassionately and really be present.” Douglas recommends inviting clients, but not pressuring them, to talk about their loss experiences, such as where they were and how they felt when they learned they were pregnant, what it was like to be pregnant, what happened during their miscarriage and what feelings they had when they learned their pregnancy was over. “Just like with other types of trauma, you want to be sensitive to not retraumatize clients by having them share their story over and over again,” she says. “But at the same time, if clients feel it would be healing to share their story, invite them to share it and process it as many times as they feel they need to. It can be healing to remember, to talk it through, to process these things with other people, especially if clients did not feel their loss was acknowledged or if they did not have the opportunity to share their story in full with anyone.” This hit home for Douglas as she wrote the narrative of her first miscarriage for her doctoral dissertation. It was the first time she had written out the entire story, start to finish, she says. Afterward, she read the four-page narrative aloud to her own counselor in a therapy session. “It was such a powerful moment. I just sobbed and sobbed as I read it,” Douglas says. “It was then that I realized I had shared my story with lots of different people but never the whole thing beginning to end — only parts. That was huge for me. I had a further glimpse into the power of story, the power of vulnerability, the power of giving voice to nebulous experiences and the power of validation. Sharing my story beginning to end was emotional but very healing.” The empty chair approach: This Gestalt technique can be helpful for processing “unfinished business” — something all too common for those who have had a miscarriage, according to Douglas. Counselors might ask clients to speak to an empty chair as if their child who was miscarried were sitting there. Or use the empty chair to have clients speak to whomever they need to — perhaps a co-worker who made an insensitive comment or a doctor who came across as callous, sterile or impersonal. The empty chair can also provide a means for clients to speak to their deity, even venting frustration or another emotion. “This can be a way to give the client a voice or provide a degree of closure,” Douglas says. “It not only helps clients work through complex feelings as they process lost hopes, dreams and frustrations, but also helps them have an important, needed voice.” Journaling and letter writing: Writing a letter can provide clients an outlet to tell their miscarried baby that they miss and love the child. Similarly, clients can write themselves a letter from the baby, Thomas says. “At some point when they’re ready, have the client write a letter from the baby to the parents. They can say, ‘I’m still here. I love you.’ That’s very healing, but it shouldn’t be done right away,” Thomas warns. “It takes time. [The parents] have to be ready for that.” Creating a journal can also help clients process a pregnancy loss by encouraging them to explore the loss and what it meant to them, Thomas says. Each experience will be different, whether it is the client’s first miscarriage or third, whether the client already has children at home, whether it was an unplanned pregnancy and so on. Expressive arts and other creative therapies: Douglas displayed copies of some of the pastel chalk drawings she created as part of her own way of coping with her miscarriage loss when she co-presented a session at the ACA Conference in Charlotte, North Carolina, in 2009. She advises counselors to pay attention to their clients’ creative interests and incorporate those interests into the therapeutic process, if appropriate. For example, if the client likes to garden, planting a tree in honor of a child who was miscarried might be healing for the client. If the client has a flair for design, perhaps she could design a bracelet with charms that represent the pregnancy. Douglas finds that expressive arts or other creative therapies not only help clients work through challenges associated with their loss, but also assist in making the intangible tangible. Douglas had one client who enjoyed scrapbooking. Creating scrapbook pages became her version of a journal and helped her find meaning in the miscarriage she had suffered. Scrapbooks or other creative projects can include ultrasound images, hospital bracelets, photos of baby gifts that were received or a narrative written by the client about what it felt like to find out she was pregnant. “One of the challenges of miscarriage is the intangibility,” Douglas says. “When you have such few items, those ‘artifacts’ such as an ultrasound photo become very important in validating your experience and your loss. You cling to those things.” Mind-body and wellness approaches: Thomas says mind-body approaches such as yoga, relaxation techniques, meditation, deep breathing, guided imagery and repeated prayer can be helpful to clients who have experienced miscarriage or infertility. In one case, Thomas used guided imagery with a client before her fertility treatment, instructing her to envision that her grandfather, who had passed away, would be with her to support her throughout the procedure. In addition, encouraging clients to pursue a wellness lifestyle, including eating healthy food, exercising regularly and getting enough sleep, can be helpful, both because of the health benefits provided and because it gives clients a new area of focus. Spending time on healthy cooking, for example, can divert a client’s energy and focus away from frustrated or anxious thoughts. Assure clients that they are working to be “in the best place they can be to ride this roller coaster,” Thomas says. The thought becomes: “I am doing the best I can to make my body healthy so I have a chance of conceiving.” Encouraging clients in the practice of self-nurturance, such as taking 30 minutes each day to do something they really enjoy, can also help refocus their energy away from the stress of fertility treatments. Thomas instructs clients to think of 10 things that they enjoy doing and that make them happy. Then she asks clients, “How many of these things are you doing? You’re allowed to enjoy things during this time. Look for ways to enjoy yourself.” Developing signals: Sometimes social situations can be overwhelming for individuals who are going through infertility or who have experienced a miscarriage. Buluc-Halper and Douglas both suggest that counselors have these clients develop a signal to let their partners or trusted friends know when they need to change the subject or take a break during social gatherings. But clients also need to be realistic about what they can and cannot handle, Buluc-Halper says. “Going through this experience is a good time in your life to put yourself first,” she says. “[When] you’re expected to show up at a dinner or a baby shower and you emotionally, truly, cannot handle it, it’s OK to put yourself first and say, ‘It’s not a good day for me.’ Put yourself in touch with what you’re feeling. You’re in such a fragile state. There are days when you wake up and you know that you can’t go, and others when you are strong enough.” Externalize the problem: Buluc-Halper suggests that counselors help clients remove the word infertile from their vocabulary. Infertility is not their identity, she explains. “We don’t say, ‘I’m cancer.’ We say, ‘I have cancer,’” she says. “Infertility doesn’t define them. It’s just part of their journey. Finding a way to externalize that does make it easier to go to the dinner, the family gathering, the baby shower, [knowing] this is just part of my journey. Everybody will go through something in their lives, and this [infertility] is one of the things that we just happen to be going through. … Everybody will find some sort of resolution, whatever that may be. As in every experience, there will be a resolution. It might not be the resolution you envision, but you will find some kind of closure.” The trusted friend: When clients are hesitant to tell family and friends about what they are going through, Buluc-Halper suggests that they pick one person, such as their mother or a favorite sister or cousin, to confide in. Ideally that person should be able to serve as a buffer when awkward or painful subjects or questions are raised at family or social gatherings. In Douglas’ case, she had a trusted friend who would intercept baby shower invitations for her, knowing she wasn’t ready to face such a baby-focused event. A cultural perspective: A client’s cultural background can play a huge role in how that person views and deals with miscarriage or infertility. At the same time, counselors should never assume that individual clients will experience these issues within the cultural norms of their respective backgrounds, Buluc-Halper says. Doing a cultural genogram with clients can help counselors get a better idea of the role that cultural background plays in a person’s life, she says. Thomas agrees, noting that she asks clients about their spirituality and family of origin at intake. “The very, very important part for all counselors to remember when working with infertility clients from a cultural perspective is to be very aware of their own cultural biases,” Buluc-Halper says. “Be cognizant not to distort the couple’s experience based on how you assume that culture perceives infertility in terms of its ideologies, in terms of its experiences or in terms of the resolution. … They might not be experiencing infertility the same way you might expect them to based on their cultural background.” Taking a break: For clients who are going through fertility treatments, each stage brings a series of decisions and procedures that can be exhausting, Armstrong says. Counselors can offer their clients reassurance that if they decide to take a break from treatments, it doesn’t mean they are giving up, she says. “Maybe take a month off, regroup and then go on to the next stage [of fertility treatment]. Tell them, ‘You’re not giving up. You’re just backing off for a minute to get some perspective and come back,’” Armstrong says. Internet forums: Numerous websites and online forums are available for people going through infertility and reproductive issues. Although these sites provide helpful information and a way to connect with and find support from other people facing similar issues, the sites can also cause clients to spend more time focusing on issues that cause them anxiety, stress or sadness. In Armstrong’s case, she stopped visiting online forums while she was undergoing in vitro fertilization because they were provoking her anxiety. Although such forums can offer support in many situations, Armstrong found they could also act as a platform to swap “horror stories” or misinformation. “Some people find them very helpful, while others find it makes them feel worse,” she says. “It helps them know that they’re not alone, but there can also be a risk because it can make them more worried.” If online forums don’t appear to be serving clients’ best interests, counselors can suggest that they take a break and attend in-person support groups instead. Support groups, whether online or in person, can play an integral role in breaking through the isolation that often accompanies experiences of miscarriage and infertility, Buluc-Halper adds. Grief: Douglas theorizes that women grieve miscarriage loss developmentally. “This is a life that would have been,” she explains, “and you will most likely grieve in different ways and different stages for what that child would have been like [as it aged]” — such as when the child would have started walking and talking or when the child would have started kindergarten. Missed milestones may be extra emotional as time passes. As a result, grief may resurface over and over again, but in different ways, complicating the healing process, Douglas says. Anniversaries: In cases of miscarriage, multiple dates can be painful, such as the day the couple found out they were expecting, the baby’s due date, the date they lost the pregnancy and so on. Counselors might suggest that clients engage in extra self-care on those anniversaries or commemorate the dates with rituals such as playing a meaningful song, lighting a candle or sending up a helium balloon with a letter inside to their miscarried child, Douglas says. Control: One of the most difficult aspects of dealing with infertility or miscarriage for clients is accepting that what has happened or is happening is largely out of their control. “A lot of people blame themselves and think, ‘I’m not doing enough or could be doing things differently,’” Armstrong says. In cases of infertility, some clients will do things to try to take control of the situation, such as cutting gluten out of their diets or taking their temperature daily. Counselors need to be sensitive to the fact that these clients may have devoted a lot of time and energy to finding different methods that might increase their chances of conception, Armstrong says. If the methods are giving them more confidence or security about their situation, that can be good, Armstrong says, but if the methods are only serving to make clients blame themselves further, that can be harmful. “Be mindful and aware of helping clients find what makes sense and what may not be influencing whether or not they get pregnant,” she says. In cases of miscarriage, Armstrong says she most often points to biology with clients. The human body is designed to abort a pregnancy that could be harmful, she says. “I really try and bring it back [to the fact] that we don’t understand all the reasons why [women miscarry], but it’s purely biological,” she says. Offering hope: Individuals receive very straightforward — and sometimes upsetting -- information from medical doctors about their infertility, including the slim percentage they may have of getting pregnant or the complications that could happen as a result, Thomas says. On the other side of that coin, a counselor’s focus on the positive can provide clients an antidote to discouragement, she says. “Hope is such a big factor. … Put [clients] back in charge of their life,” she advises. “Offer hope that there are some coping strategies [available and that the client is] a normal person responding to the struggles of creating a family. [Tell them], ‘You need to give yourself permission to be angry and cry. … Keep the faith. If you want a family, it will happen. It may just not be the way you envisioned.’” Couples: It takes two Spouses or significant others will naturally deal with miscarriage or infertility in different ways and process things at different rates. In fact, it is common for a counselor to see relationship partners who are in two very different states emotionally, Armstrong says. One partner may have already accepted what has happened, while the other is still in a bargaining stage, thinking, “Surely there is something we can do” to change the situation, Armstrong says. Counselors can help by educating couples that the grief that accompanies a miscarriage or infertility will come in waves and that each partner is likely to be at a different point along the grief spectrum. Once couples understand that it is natural to feel differently about what they are experiencing, they often express a sense of solace, Armstrong says. “They’re relieved [because] they don’t see themselves in conflict, just at different stages in the process. Then they can understand and be more patient with each other,” she says. “Help them understand that they’re in different stages and how to communicate and best support each other” wherever they are in the process. Differences in spirituality level or religious background can threaten to divide a couple during a miscarriage, notes Thomas. For example, one partner may consider a miscarried baby to have a soul, while the other does not. “Spirituality can be very healing or create a lot of conflict if they’re coming from different perspectives,” Thomas says. “One may feel it’s ridiculous to grieve, while the other feels it’s necessary. Work with them to be respectful of each [other’s perspective].” It can be helpful for counselors to suggest that a female client bring her partner to medical and therapy appointments when possible, Buluc-Halper says. It is important that the client learn to rely on her partner for support throughout the entire process, not just during times of extreme anxiety, she points out. “Partners don’t always understand how all-consuming this [infertility] experience is,” Buluc-Halper says. “You’re the one that is doing blood work, and your arm is purple from all the injections. It’s not to diminish the male experience of this, but they don’t always understand why the female can’t really detach herself from the issue.” As important as empathy is for counselors, it is equally important to teach that skill to couples, Thomas says. She often has couples hold hands as they tell each other what the miscarriage journey has been like for them. The counselor is there to assure both partners that whatever they are feeling is valid, real and quite possibly intense, Thomas says. “Give them a safe place to explore what this has been like for them — sometimes for the first time,” Thomas says. “What does that loss mean to them? [They are] really seeing each other describe what happened and how they’re feeling right now. Because they grieve differently, it’s important to validate their experience and [explain] that it may trigger some previous losses and intensity that might scare them.” “With infertility, they can get stuck and not want to move on if they’ve had a pregnancy loss and not really grieved it,” she says. “They need to slow down and experience what they need to experience before they go on to the next step.” Breaking the silence By inviting conversations about miscarriage and infertility, counselors can play an important role in removing the stigma and isolation that surround these issues. Douglas cites the example of breast cancer, a once-taboo subject that is now openly talked about and advocated for with well-publicized campaigns and fundraisers. “Invite the conversation and break the silence,” Douglas says. “Help give women and men permission to grieve miscarriage losses and give voice to those losses. Give them a safe, nonjudgmental place to share their stories. Invite those stories. Take time to listen to those stories over and over again, as many times as people need.” For more information
Bibliotherapy resources for clients and practitioners
Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.
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