Pregnancy Loss: How to respond with compassion

So, you have just learned of the pregnancy loss of a friend, a relative, a co-worker or an acquaintance. You want to offer an appropriate response, but you're not sure what that might be. In this blog we'll look at the considerations you'll want to keep in mind as you offer a comforting response.

A number of readers of my most recent blog have written to me, asking how to respond when learning of a pregnancy loss. You have acknowledged the awkwardness of not knowing what is the "right thing" to say, as well as the lack of familiarity with what the term pregnancy loss might encompass. And you are aware that, all too often, the world just turns its head when learning of a pregnancy loss. There may have been no bulging abdomen, no sonogram being passed around, maybe not even a public announcement of the pregnancy. Or there may have been all of these things plus more. What is missing in both circumstances is any ritual whereby comfort can be extended to the grieving couple. There are no Hallmark cards, no funerals, no gravestones, no memories to be shared among the mourners. Only a void. And it is into this void that you may decide to venture, with the hope that you are able to offer some support and comfort.

So let's consider a few things that will influence your thoughts about how to reach out to the couple. Keep in mind that a pregnancy loss may mean something different to each of them; also keep in mind that both are sad, so please do not fall into the trap of asking one partner how the no-longer-pregnant partner is doing. It is true that the woman has lost the pregnancy, but both of them have lost the dream of becoming birth parents to this baby, and both of them deserve a genuine expression of your sorrow.

Although pregnancy loss can mean a miscarriage or a stillbirth, it also can come about as a result of the agonizing decision of the parents to terminate the pregnancy, either because of learning the results of prenatal genetic testing or because a multi-fetal pregnancy reduction has been advised by the couple's physician who fears for the outcome of the pregnancy if the woman attempts to carry all fetuses to term. Some couples are comfortable sharing this decision with others, but many anticipate they will be harshly judged for their decision to terminate the pregnancy and they decide to present the pregnancy loss as a miscarriage. Regardless of how open the couple may be about the circumstances surrounding their loss, you will want to empathize with their sadness and to ask how you can help.

For some couples, the pregnancy loss is a dimension of their infertility. They may have had difficulty conceiving; they may have had earlier pregnancy losses; this may be a loss from an ectopic pregnancy (where the embryo begins to develop outside the uterus, often in a fallopian tube); or they may be told after an IVF procedure that, although they had a chemical pregnancy, the hormone levels did not rise sufficiently to sustain hope that the fetus would develop. For any couple grappling with infertility, a pregnancy loss is a terrifying reminder that they cannot take birth-parenthood for granted. Another, less discussed, form of loss occurs when a couple has made a plan to adopt, and the birth mother either loses the pregnancy or decides to keep the infant after its birth. The prospective adoptive couple has invested so many hopes in this adoption, that the loss will be a devastating end to what may have been years of infertility. So, with infertility as a backdrop, any form of pregnancy loss feels especially devastating.

Some people assume that the attachment to a pregnancy grows in proportion to the number of months the pregnancy was sustained. It is more accurate to let the couple tell you what this loss means to each of them, because that will enable you to understand more fully the emotions they had attached to this pregnancy, regardless of how far along it had progressed. And hearing from the couple will prevent you from saying hurtful remarks like "It's probably for the best," or "You can always try again." Instead it will feel more supportive to say "This is such a difficult time for you. Please tell me how I can be helpful/ let me know when you feel like a visit/ tell me if I can bring over some food (books, flowers) or run some errands for you." And then prepare to be a good listener.

Being a good listener is a gift, since it involves being emotionally present, accepting both anger and tears, and hearing various versions of events time and time again as the grieving person tries to make sense of this loss and what the future might hold. Although it may be tempting to offer what I call "false reassurances" ("I'm sure you'll be a parent some day," "You will begin to feel better soon,"), be aware that this response is more a reflection of your discomfort with the current sadness than it is an accurate prediction of hope for your friend. Try to be patient with the time your friend needs to absorb this sadness and to make sense of it.

Some couples decide that they want to have a quiet service to honor this baby who will never be born. Whether conducted by a spiritual leader or created by the couple and their loved ones, such a service can enable supportive friends to reassure the couple and their family of ongoing emotional support and compassion for their loss.

Some grieving couples appreciate the opportunity to talk about how they can memorialize this child whom they had hoped to parent. Keep in mind that many would-be parents have already discussed (and perhaps chosen) names, selected (or envisioned) nursery colors and decor, and begun to save items for the baby scrap book like congratulations cards and sonogram photos. For them this is not a pregnancy loss so much as the death of their dream child. In my book When You're Not Expecting, I mention couples who plant a memorial garden, donate to a children's library or a day care center, or identify a cause that they commit to in memory of their dream child.

Even months after a pregnancy loss, there can be a number of painful reminders that cause the pain to resurface. The previously-anticipated due date is one symbolic time. Celebrations of others' pregnancies and births can be emotionally difficult. Even the sight of a nursing mother or a father cuddling a newborn can evoke waves a sadness. These and other reminders of lost opportunities may be mentioned by someone who has lost a dream child, and your empathic response will be very much appreciated.

So, the take-away message to the question of how to respond with compassion is

• There are many ways in which pregnancy loss can occur. Communicate your wish to be a good listener so that you can understand the particular meaning this loss has for each member of the couple.
• Remember that the partner of the pregnant woman deserves to be recognized as someone who is entitled to grief, rather than being seen solely as the stoic comforter and protector.
• If infertility is a backdrop to this pregnancy loss, you will want to appreciate the couple's feelings of failure and desperation as they fear they may never become birth parents.
• Be patient, and let the couple know that you understand it takes time to grieve such a poignant loss and to make sense of how their lives have changed.
• Be aware of the mixed emotions couples may feel when being invited to celebrate news of pregnancies, births, or other events associated with successful reproduction.

Pregnancy Loss and Discounted Grief

The grief following a pregnancy loss is unique. Couples often feel uncomfortable sharing information about this loss and acquaintances, many of whom may not even have known of the pregnancy, are unfamiliar with how to respond. Why is this? Typically pregnancy loss can be relatively invisible unless you choose to share this information. There are no rituals to help you mourn this loss. There are no Hallmark cards. Your physician probably relates to this loss in terms of your physical recovery. So what do you do with the feelings that assail you and your partner once you realize that you no longer are "almost parents?"

Each person will experience a pregnancy loss differently, which means that you will need to be clear with relatives and friends about what they can do to be helpful. If you need privacy, say so. If you need people to run errands for you, let them know. If you need emotional shoulders to lean on, patient visitors, good listeners, then choose your loved ones carefully, because people differ in the extent to which they can tolerate your sadness without feeling obliged to cheer you up.

You also need to be prepared for the unexpected: the person who last saw you wearing maternity clothes who expresses surprise that you now have a waistline; the acquaintance who has heard about your loss and seeks to comfort you by suggesting that perhaps this is "for the best," or "you can always try again;" the person who expresses surprise that, weeks later, you are still feeling sad instead of getting back to "normal," whatever that is. And it isn't just people -- how about the advertisements for everything from diaper services to baby gear that continue to crowd your mailbox, your phone calls and your e-mail? It seems as if your pregnancy is on automatic pilot for the retail world.

There is another dimension that also is important to have in the forefront of your awareness. Typically even one's most sensitive relatives and friends will see the person who lost the pregnancy as the one deserving of sympathy and attention. Her partner, on the other hand, tends to be asked "How is she doing?" and "Is there anything I can do to help her?" What's wrong with this picture? Do people not appreciate that the partner also has had life hopes and dreams derailed? Do they not recognize the emotional upset that comes with supporting a formerly pregnant loved one as well as figuring out how to handle one's own grief? Do others really feel that you are not entitled to heart-wrenching sadness unless it was your body that bore the pregnancy?

So, along with sorting out your own emotions when others may be confused or insensitive, you also will want to talk openly with your partner about how each of you is handling this sad time in your lives. And be sure to talk about what you need your partner to do to offer comfort to you. It is important to respect that the two of you may have different ways of working through your sadness, but keeping the channels of communication open is a significant challenge.

And it is important to be aware of sources of support that are probably present in your community: spiritual leaders, professional counselors, support groups (many of which you can learn about from the social worker of your local hospital), as well as books and chat rooms that focus on pregnancy loss. This is a time to indulge yourself in taking time to regain your emotional equilibrium, even if the rest of the world seems to be expecting you to have put this loss behind you. In my book, When You're Not Expecting, I emphasize the opportunity to use pregnancy loss as a time to grow emotionally, to bond more sensitively with loved ones, and to decide how to move forward with life following this poignant jolt to your hopes and dreams. So don't let anyone discount your grief -- you are entitled to it. And, with support, hopefully you will find your own ways of weaving it into a new and more resilient emotional perspective.

Infertility Counseling: Getting the most out of therapy

If you never have been in therapy before, or if you are beginning a relationship with a new therapist, or if earlier counseling experiences have had nothing to do with your infertility, you probably are feeling perched on the brink of a new opportunity and a new challenge. Undoubtedly you already are receiving either a diagnostic workup or medical treatment for your infertility, and your decision to seek counseling is an important step in handling the many emotions that emerge in this process. So, now that you and your counselor are beginning your relationship, how can you get the most out of the therapeutic experience?

Most therapists will initially ask you to be clear about what you hope to gain from therapy. I'm going to make the assumption that you and your partner are going to the first session together, so both of you will need to think about how you would answer this question. It is not unusual for partners to have different perspectives on the challenges posed by infertility (see my video at www.connieshapiro.com/ ), so you both should feel free to speak for yourselves. Also, if some issues are more compelling than others, or if you have tried and not succeeded to make desired changes in your lives, it is good to provide that information as well.

In addition to answering questions posed by your counselor (who, for the sake of pronoun simplicity, I will assume is female), you should feel free to ask her to talk about how she sees her role as a therapist, what expectations she will have of you as clients, how she guides the counseling process with her clients, and how you and she will know whether you have accomplished as much as possible in your relationship with her. You should be listening for how open she is to your input, how she formulates goals for the counseling experience, how familiar she is with infertility, particularly issues of loss and communication difficulties, and how she evaluates whether she is being helpful in moving you toward the changes you hope to accomplish.

For you and your partner, both of you should be prepared to view therapy as work: on your relationship, on your relationships with others in your lives, on your communication skills, on your willingness to strive for insight, and on your openness to considering new options in making decisions about your future. As I have mentioned in an earlier blog, I tend to give homework assignments, and if your therapist follows this practice, it is helpful to be conscientious about the therapeutic learning that takes place both outside and inside the therapist's office. You might think of it as having ongoing practice with new skills or discussing new perspectives, which you then can review with your therapist in your regular appointments.

From this perspective, you can see that I tend to favor a therapeutic perspective that helps you to feel empowered, both in new skills you acquire and in new ways of considering how you will handle the stress and the decisions imposed by your infertility experience. This is not the only therapeutic perspective, and it may not be the most productive one for every client. So the important thing for you and your partner is to assess how you feel about your therapist's way of viewing her relationship with you, her willingness to accept your input and your questions, and her willingness to challenge you to think in new ways about painful issues. Therapy is not a full-time "feel good" experience, but it should be a relationship in which you feel both trust and confidence that your counselor has her finger on your emotional pulse and is keeping pace with your readiness to move forward.

With your infertility physician, there should be times when you pause to assess where you are and what's next. The same is true in therapy. I use every 6-8 weeks as my "pausing point" with clients, partly to check out how they are feeling about the changes we are working on, partly to give them my feedback on their new skills and the work that lies ahead, and certainly to see whether they are satisfied with the direction and the pace at which I'm encouraging them to move. I always welcome critical feedback or discussion of therapeutic frustrations at any point during therapy, but I also am a big believer that a regular pausing point helps my clients and me to be attentive to both progress and pace.

Let me spend some time now on ending the counseling relationship. Ideally this decision is a mutual one, perhaps growing out of a conversaton at one of your pausing points. In the best of circumstances it will be an outgrowth of achieving the goals you set in the course of therapy or, even more hopefully, your success in becoming pregnant (although I confess that most of my client couples have found pregnancy to have its own stresses, so many of my clients continue on a reduced schedule until they have celebrated a healthy birth). In less favorable circumstances you may find that you are dissatisfied with your therapist, efforts to address those dissatisfactions have not yielded changes, and you decide to end the relationship. Then the question becomes whether you believe that it would be constructive to identify a new therapist, in which case you hopefully will have a more successful experience. But if you are ending therapy on a successful note, feel free to raise with your therapist that, if new concerns arise, or if you find yourself needing a "booster" session, you hope that you and she could reconnect to assess next steps.

So, in the spirit of "getting the most out of therapy," I hope my perspective is helpful in your anticipating how you might begin your therapeutic relationship, as well as how to provide input as the relationship progresses.
Infertility is not a smooth road to travel, but the support and skills of a good therapist can help you feel empowered as you face emotional challenges.

Infertility Counseling: What to Expect

Individuals and couples with infertility often contemplate whether to seek counseling. Some approach this decision with ease, but many others have questions about what is involved in a counseling relationship. In today's blog, I will offer an inside view on the beliefs that have guided my counseling experiences with hundreds of infertile clients.



So when I entitle this blog as "what to expect," I probably should have added "if you seek counseling from me." Since I can only speak for myself, I hope you will gain some familiarity about general principles that guide counselors and therapists (I use these terms interchangeably), as well as questions that you can ask your own counselor in order to clarify your understanding of that person's perspective on your relationship.



In my own experience, my first contact with a client usually is in a telephone conversation. On the telephone I try to learn how the prospective client (almost always a woman) defines the problem(s) she wants to work on; what her partner's feelings are about being involved in counseling; whether she or her partner has ever been involved in counseling before; at what stage of diagnosis/treatment they are; and where they are currently getting medical intervention. I then offer a bit of information about myself, including possible appointment times that I have available; fees and insurance coverage information; my office location; as well as the request that both the caller and her partner come together for this first appointment. I also ask whether she has any questions that she would like to ask me before we meet. Then we set a date and time for the appointment, and I provide directions to my office.



In a while you'll learn enough about my approach to understand why I ask for both partners to come to the first meeting with me; if the woman is not in a relationship, I tell her that I will be interested in learning about her support network. So here are some things that are typical of my first meeting with my new clients. It is not unusual for the person with whom I have spoken on the telephone to take the lead in introducing me to her partner and in saying something along the lines of "I think I'm going crazy!" or "I don't know how much more stress I can take." And my response to that introduction is usually to point to my nearby box of tissues and to say that being upset comes with the territory of infertility. I also try to work in something about the courage it takes to begin a relationship with a counselor, since getting help will involve talking about difficult issues.



I ask both of them if they are comfortable with my taking notes as we speak, since I want to be sure to remember accurately how they portray their situations. And then I say that in my experience, each of them may have their own unique "take" on their infertility, so I will be encouraging both of them to clarify for me the dimensions of this experience that are important to them. This also opens the door for them to see each other's perspective and to learn how important it may be to keep both perspectives on the table. It is here that I say to the partner of the telephone caller how much I appreciate his/her coming to this meeting, and how much I believe that person's presence can help all of us to move forward in working on the issues connected with their infertility.



I also clarify briefly the two important issues associated with confidentiality: first, that if either of them communicates something to me when the other person is not present, I will keep that information confidential until it is revealed between the partners in a meeting with me, and, second, that I observe confidentiality unless circumstances occur when I believe there is the likelihood of a client causing harm or danger to oneself or someone else. Lastly, I say that, although it has never happened in all my years of practice, if I am subpoenaed to appear in court, I might need to reveal information that had been shared with me in counseling.



With those introductory remarks, I remind all of us that we have work to do, that our session will end in "X" minutes (I meet with clients for 50 minute sessions), and I encourage them to tell me how they hope I can be of help. I am careful to have both members of the couple speak about their own perspectives and to summarize my impressions of what seem to be the most pressing issues. I am interested in knowing how the couple has already tried to address their challenges and what successes and difficulties they have encountered. That will more than fill up the first session, and probably will spill over into subsequent sessions as well. Before ending, I ask the couple how they are feeling about the time we spent together today, whether they would like to return and, if so, whether this is a good time for regular future appointments, and whether I can look forward to having both of them at subsequent sessions. I tell them that after a few sessions I should be able to give them some idea of how many meetings we may need in order to address their concerns, and I express my appreciation for their openness in sharing with me today the challenges they are facing. I ask if they have any questions for me, which I try to answer as succinctly as I can. I then give them a homework assignment: for each to draw for our next session a sketch of their sources of support and their sources of stress (I mention family, co-workers, neighbors, friends, spiritual leaders and health care providers as potential people who may appear in their sketches).



Now for some reflections about why I do what I do in the first session. I very much hope that both members of the couple will come to each session, since they can be most constructive in addressing concerns if they each verbalize them and if they each practice the skills that I will encourage them to develop. So I am not shy about emphasizing to both that their presence together is a big help to me. I want to hear the initial information from each of them about how they see their concerns, both so I will understand where each one is coming from, and so they will be able to hear the perspectives that each of them presents. I want to reflect back to them my understanding of their issues, so they can correct any misperceptions. I want to convey that infertility can be filled with difficulties, as they well know, and that they probably have an idea of what has and has not worked in coping with their difficulties. And, in giving a homework assignment, I want to convey that getting help is not just a 50 minute session once a week, but that they need to take away from these sessions new perspectives and return to each forthcoming session prepared to build on the new learning thay have developed. Lastly, many clients are concerned that they may be in counseling "forever." I want in the first session to convey that we can decide together how long to continue to meet and what problems we will discuss, thereby conveying that this is a partnership. Typically I am able to make substantial progress on most of the most troublesome problems over 9-12 sessions. If the clients choose, they can introduce additional concerns (or perhaps their infertility will present unforeseen issues such as pregnancy loss, an unanticipated diagnosis, etc.), and they may choose to embark on additional sessions to deal with these new issues.



Now let me look ahead broadly to how I think about subsequent sessions. In my experience, I tend to think of these sessions in terms of content and process. Content, which is presented by my clients, tends to be dominated by issues of loss and issues of communication. In my new book When You're Not Expecting, I write extensively about both of these, including the ways that they tend to change over the course of a couple's infertility. Process, which tends to focus on interactions, may consist of my asking the couple to discuss a difficult issue, with me ultimately giving them feedback on my observations and some clear feedback on how they can build better communication skills into their repertoire. Then I send them home with homework that will enable them to practice these new skills and report back to me the following week how they were feeling about using these skills. Learning skills in assertive communication can come in handy as well, particularly with health care providers and well-meaning loved ones. A third topic, "resources," tends to weave in and out of discussions, depending on what the couple may have presented on their initial sketches to me regarding their sources of support.



From time to time I ask both clients to revise their sketches of sources of support and stress, so they can see how their communication efforts have made a difference -- OR so they can see that they need to distance themselves from unrelenting sources of stress. One of my goals is to help clients perceive themselves as part of an ecological infertility map, complete with superhighways of support and detours of stress. As a family therapist, I also consider it important to understand and discuss the roles that family members are playing in my clients' lives, especially fertile siblings and eager-to-be-grandparents. The more clients understand ways they can increase their support, the more resilient they become.



I do not think of myself as a therapist who lets my clients entirely drive the counseling process. I tend to be fairly interactive in offering feedback to clients on their skills and resources. I am respectful of the social work edict "Start where the client is and stay with him/her." To me this means that I should be respectful of where my clients want to focus, but it doesn't prevent me from testing whether they are ready to be pushed to new places. If they have had an infertility intervention for months that isn't working, I am likely to push them to ask their physician to make a plan with them that includes how long to continue with one intervention before moving on to a different one. If they have spent many dollars and many years on infertility treatment, I may revisit an earlier statement that they won't consider adoption or a surrogate, by asking if they would consider collecting information about either of their previously rejected options. If I see areas of difficulty on which they have not asked for my help, I may make an observation that such-and-such an issue seems to be an "elephant in the room," and I am wondering whether there is a reason they haven't felt ready to examine it. So, even as I try to stay apace with my clients' issues, I also push and prod a bit, just to see whether new growth and resilience enables them to feel resilient enough to consider new directions. If not, I step back, and I am not surprised when, weeks later, they may raise the question of the proverbial elephant for future examination.



Before closing, I will mention two last areas that are neither process or content related. The first is that, as a social worker, I believe that it falls in my realm to teach and to provide advocacy when clients are treated poorly. Occasionally, clients will report to me behavior in an infertility setting that I consider unprofessional. Often their distress is severe enough that they are considering ending treatment with that provider. In the dozen or so cases I have encountered, I have shared with the client my perception that they are on target in objecting to unprofessional communication, and that I would be more than willing either to help them think about how to address this directly or how I might (with their permission) bring this incident to the attention of their provider. In each case, the resolution has been highly satisfactory, always resulting in an apology to my clients, and sometimes resulting also in in-service training for staff so that they understand rude or dismissive remarks will not be tolerated. The second area I will mention is that, as clients and I are preparing to end our sessions, I make clear to them my continued availability if their circumstances should bring a rise in stress or other unforeseen difficulties. Sometimes clients whom I believe are ready to end our counseling relationship will be more ready to accept that encouragement from me if I offer "booster sessions" every 6 to 8 weeks, simply to reassure them that I'm there if they run into bumps in the road.



So, for those of you who are contemplating seeking counseling for any of your infertility issues, I hope that my own disclosures about the way I think of the counseling experience will help you in your own interactions with a therapist. Keep in mind that not everyone shares my perspective that client partners are the first choice when providing counseling, nor that the families of the couple may be the "elephants in the room," nor that the therapist takes as active a role as I do, nor that assertive behavior with health care providers is a place for therapeutic intervention. But all therapists should be able to be clear with you about areas in which they can offer new knowledge and skills, how they observe confidentiality, and their comfort with the ever-so-present issues of loss and mis-communication.



If you would like to see some youtube webisodes that focus on how infertility affects relationships, check out my Hopefully Yours website at http://www.connieshapiro.com/

And stay tuned for the last in my Infertility Counseling blog series: Getting the Most Out of Therapy.