When Hopes for a Happy Pregnancy are Disrupted

It happens. The early joy of a much-wanted pregnancy is suddenly shattered by something unexpected. Whether your partner (imagine former US Congressman Anthony Weiner) reveals some giant stupidity that makes you question whether you want this person in your life anymore; whether your physician delivers some troubling news (imagine a Down Syndrome diagnosis) from a prenatal test; or whether a family catastrophe (imagine being laid off from your job and losing your health insurance) takes over your life, stifling the joy that had nourished your spirit, you feel as if you are in the midst of an emotional balancing act with no acrobatic training.

So how do you cope when a joyful pregnancy is no longer in the center of your life because your partner has demonstrated an emotional betrayal, an act of extreme stupidity or some other unexpected dimension of behavior that you never would have thought possible? As you are re-grouping, you could be weighing whether to remain in the relationship, whether to continue the pregnancy or whether to consider placing the baby for adoption. Each one of these issues feels life changing and overwhelming. And, given the betrayal exhibited by your partner, you may feel reluctant to confide in close friends and family, since you don’t want to face yet more pressure from them about what actions you “should” take. You also need desperately to vent, but hopefully are careful about saying too much too soon. So here is where an excellent option is to seek counseling from a professional who practices marriage and family therapy. This could be a psychologist, a social worker, or a marriage and family therapist. Some pastoral counselors will have this training as well. As I have said in earlier blogs, as well as in chapter 7 of my book When You’re Not Expecting, there are several ways to locate a therapist: recommendations from friends or clergy, names provided by your county mental health clinic, suggestions from a hospital social worker, or contacting your local family service agency. Plan to present yourself as someone who is experiencing a crisis, which will minimize the likelihood of being placed on a wait list. And be persistent in asking for services – if you are concerned that you cannot afford them, ask whether the agency or the therapist has a sliding fee scale. But the bottom line here is that it is important to receive emotional support and guidance in this difficult time from someone who appreciates the complexity of your dilemma AND who has the professional perspective to guide you through the decisions you will face in the months ahead.

Troubling medical news from prenatal tests can be immensely disruptive emotionally. Although the opportunity to learn early about genetic or other developmental disorders is important to expectant parents, the flip side of this opportunity is that often tests cannot predict the extent to which a particular abnormality will affect the developing fetus. This places many parents in an immensely difficult position. Clearly the first goal is to learn as much as possible; medically this may involve more specific tests or a consultations with specialists; emotionally you may very well want to meet parents of children born with the disability (being sure to include children both severely affected as well as minimally affected); and you will want to learn about community support services for children with the special needs that your child may have. All of this information presents a particular challenge to prospective parents who may be considering terminating the pregnancy or placing the baby for adoption. And, of course, your view of your pregnancy is forever changed; you now are apprehensive, anxious and fearful at the same time you also may be feeling protective and hopeful. Prospective parents who make the decision to terminate the pregnancy often choose to present the loss as a miscarriage, in large part to protect themselves from the judgmental reactions of others. Some will be forthright with close friends and family about the careful thought they gave to this wrenching decision. And all will be very careful in subsequent pregnancies to receive early genetic counseling and prenatal testing, as a way of being informed about any risk factors.

In addition to partner woes or worries about the health of a developing fetus, other life catastrophes can take a huge toll on the happiness initially associated with a pregnancy. These days financial issues, unemployment, home foreclosure, family illnesses and other unanticipated crises can be a significant source of worry and uncertainty. Sometimes we have some control or influence over these situations, and other times there is little we can do. Given that anxiety is usually associated with loss of control, perhaps the one antidote is to remain as calm as possible in the figurative “eye” of the situational storm. Since it is known that the cortisol associated with stress can enter the fetus’s bloodstream via the placenta, remaining calm is for the health of the fetus as well as your own. In addition to considering counseling as one path to take in addressing sources of stress, relaxation efforts and mindful behavior also can help you to feel more centered as your pregnancy progresses. The kind of counseling that is most appropriate in dealing with situational stress is cognitive behavioral therapy, where a therapist will help you to re-frame your tensions differently and more manageably. After helping you to think about constructive ways to address the stress, the therapist will offer support and encouragement each step of the way. Not only are you learning about problem management, but you also are learning skills that will be excellent for future difficulties that initially seem overwhelming. Deep breathing exercises, yoga, and mindful relaxation are additional skills you can learn to help you calm your body and your mind when tension intrudes. It can be empowering to learn that even when you cannot change a particular situation, you can exert some control over how you respond to it and the extent to which you allow its stress to affect you.

An initially happy pregnancy can be threatened with worry or misery for a wide variety of reasons. Often our initial reaction at such a time is to turn to friends and family for help and support. After all, haven’t they been there for you in other times of stress? Perhaps. But the examples in this blog go beyond the skills and knowledge that our informal networks typically possess. So, in addition to dealing with the current disruption to the joy in your pregnancy, you also will need to stretch yourself to consider how to access necessary support and skills. Use the web, use the yellow pages, use your spiritual leader or health care professionals, and do it in the spirit of moving forward to learn the acrobatic training for this uninvited interruption in the joy you deserve to nourish.

Am I A Mothers' Day Grinch?

Am I a Mothers’ Day Grinch? Not exactly, but today I’d like to present a perspective that is different from that depicted on Hallmark cards: the perspective of families who need some extra compassion on this holiday.

With Mothers’ Day falling this year on Sunday, May 8, now is a good time to think through how the meaning of this holiday for you may differ from the meaning it holds for some friends and family members.

Families without mothers. Even as I write this title, I feel some personal sadness. My own mother died over 30 years ago, after many years of my celebrating this holiday to honor her. Not only would I send flowers and, if distance prevented our spending the day together, we’d have a long phone conversation in which I’d tell her how much she meant to me, and I’d also remind my younger brothers to be sure to connect with Mom. In those days, Mothers’ Day was about MY mother. Following her death it became a holiday with mixed emotions, as I cherish her memory while, at the same time, wishing that her life could still be a part of my life.

In my early 30’s I was diagnosed with infertility. All of a sudden Mothers’ Day was “in my face” for at least a month before the actual day occurred. Every time I opened a newspaper or a magazine I would find stories of mothers. Every time I turned on the TV or radio, there would be some attention to the approaching Mothers’ Day and the opportunities families had for celebrating it. And in all the media would be reminders to make reservations at a favorite restaurant for a Mothers' Day meal. And there I was, wishing like anything I could be a mother. Not so that I could celebrate this holiday so much but, rather, to satisfy my craving for cuddling an infant in my arms. My husband and I did find ways of escaping the holiday hoop-la, but even with our efforts to plant a garden or play some golf or take a leisurely walk in a nearby state park, I still knew that others were celebrating a holiday I could not call my own. It wasn’t fun in those days.

As many of you know from my recent book When You’re Not Expecting, I have counseled hundreds of individuals and couples with infertility. Each year as Mothers’ Day approached I would ask my clients to anticipate this holiday, think through its meaning for them, and try to find creative ways of deciding how to spend it. Some celebrated the holiday with their mothers or their mothers-in-law. Others used the day to connect with nature in some way, to indulge in a short trip, or to have a potluck dinner with other infertile friends who, like them, dreaded this particular holiday. So, while I won’t go so far as to think of myself as a Mothers’ Day Grinch, I do own up to my role in helping my clients to figure out how this holiday could be less painful for them.

Another group for whom Mothers’ Day is poignantly painful includes those individuals and couples who have experienced a pregnancy loss or an infant death. Since, with regard to pregnancy losses, there are no rituals to memorialize the pregnancy loss (and often no mementoes to save, except perhaps a sonogram photo), the mourning parents may feel especially emotionally vulnerable on a day that honors mothers. If an infant has died, there may have been a service, sympathetic loved ones, and a gravestone in a cemetery, but in American society there often is the assumption that emotional recovery equates with putting the loss “to rest.” So loved ones may not be at all aware of the emptiness of a Mothers’ Day for parents who, even years later, are grieving the death of their infant.

In my life more recently, I’ve needed to extend comfort on Mothers’ Day to my two nieces, ages 12 and 14, whose mother died unexpectedly just 16 months ago. It was especially difficult to comfort them last year, their first Mothers’ Day without her, but this year as well they remind me that Mothers’ Day will never be the same for them. And they’re right. So I talk with them and their dad (my brother) about how they can embrace Mothers’ Day in a different way than their friends’ families are doing. This year they have decided to lay flowers on her tombstone, and then to go hiking outdoors, away from the visible celebrations in restaurants. If the weather is too inclement, they have a backup plan – a movie followed by takeout food they can enjoy at home. For them, as for other families without mothers, having a plan for the family to enjoy themselves gives them an emotional cushion when faced with families in their community who are celebrating the holiday that will never be what it once was in their family.

Families whose mothers are at a physical or an emotional distance. These families could include grandparents raising grandchildren, children in foster care, children whose fathers have custody of them, children who perceive their mothers as abusive and adolescents who have left home because of family conflict. Mothers’ Day is likely to touch these family members in different ways, often with considerable ambivalence and wishes for greater closeness with this parent who does not live with them.

Another family where mothers may be physically separated from their children could include immigrant families, either because the children have not yet come to the United States to join their parent(s) or because, in the case of some undocumented Chinese immigrants, their infants are sent back to China to be raised by the grandparents until the immigrant parents in the US have enough economic security to provide a home for their young child being raised in China. Another immigrant group where parents and children may be separated for periods of time includes agricultural workers who travel entire geographical regions sowing or harvesting seasonal crops. Living circumstances can be very chaotic for these families, with low wages added to the uncertainty of living quarters.

Childfree families: In couples who have decided not to have children because they are infertile and unable for various reasons to bring a child into their family, Mothers’ Day can be bittersweet. Many couples have ultimately made their peace with being childfree, whereas others still carry feelings of sadness and regret for the door to parenthood that has closed in their lives. Other couples have a firm commitment to remain childfree, a decision they reached after careful thought and, perhaps, after bucking their parents, in-laws and loved ones who urged them to consider the joys of having children in their lives. Indeed, many childfree couples do have children in their lives, but not as offspring; they are likely to look at Mothers’ Day as an observance they can share with friends and relatives who invite them to their holiday meal.

Where do we go from here? So now I’ve elaborated on those families where Mothers’ Day evokes feelings of sadness and regret rather than the glow of happiness most people anticipate from women of childbearing age. And, as you may have gathered, my hope is to encourage readers to think about how we can be sensitive to those women who are not mothers.

I think a great deal of grief could be avoided by not wishing every female in sight a “Happy Mothers’ Day!” It doesn’t pay to assume they are mothers and, if they are, chances are they have figured out how to enjoy this day.

Be on the lookout for well-meaning folks who are possessed with the Mothers’ Day spirit. I am thinking particularly of religious leaders who, with the best intentions in the world, decide to honor the mothers in their congregations on Mothers’ Day, either by giving them corsages, having them stand for recognition, or by having a special reception after the service. I cannot tell you how many of my clients and friends have been blindsided by a religious service in which they felt invisible, not honored and generally discounted. If your place of worship is one with the tradition of honoring mothers on Mothers’ Day, perhaps you could encourage your religious leaders to revise their message by reminding their congregations that families come in many shapes and sizes, that not all families include living mothers, and that families who have experienced the loss of a mother, the loss of a pregnancy, the death of an infant or infertility deserve to feel emotionally safe when they come to worship, including on Mothers’ Day.

So, as May 8 approaches, and as you and your family think of how, or whether, you will celebrate this day, please also take some time to be thoughtful about your interactions with others. Don’t make assumptions, offer comfort when it would be appreciated and, when in doubt, ask what you can do to make May 8 a positive experience for a friend or a loved one.

"Hey, Remember Me?" Getting Your Partner's Attention

Whether it is our hectic lives, a conflict in schedules, diverging interests or more serious disruptions in our lives, it can be distressing to feel disconnected with our partner. We began our relationship hoping for a partner who would be “there” for us, who would anticipate our needs, and who would be responsive to our efforts to connect. We are especially sensitive to those feelings of emotional disconnect during unanticipated personal crises, such as infertility or cancer, which may render us unable to cope and reluctant to confide in others. What do we make of it when those connections with our partner feel frayed?

Perhaps the first thing is to see whether the two of you can have a conversation about your perception, to see whether your partner feels at all as you do. If so, then ask whether you can both find a time to talk more about what changes you would like to see in your relationship. If not, you should still propose that you find some time to talk, but be prepared to be the one taking the lead. And in either case, there are a few areas to acknowledge as potentially sensitive:
You do not want to convey to your partner a sense of blame for the distance that you perceive has been growing between you. Instead, you want to enlist creativity and cooperation to draw you closer together.
You do not want to come across as being a nag. “You never…” or “You always…” or “Why don’t you ever…” are key phrases to avoid.
It is possible that the two of you actually have different needs for emotional closeness. So at the very time you are feeling left out, your partner may be feeling as if the closeness/distance balance is just right.

So, starting at the beginning, you already are moving in the right direction if you and your partner agree on making some time to talk about the emotional disconnect that at least one of you is feeling. A caution here: it’s best to have this discussion in a private, neutral space (not the bedroom, not the table/countertop where you eat your meals, not in a place with distractions like riding in the car, and not a place that is physically uncomfortable or where you cannot easily make eye contact). Turn off all ringing, buzzing objects/alarms, so the message you give to each other is that each of you is the other’s priority.

Once the time and place have been set aside, since you’ve taken the initiative, you’ll want to explain why. How about finding an upbeat way to begin? “I’ve begun to realize that I miss the times when we had more chances just to relax and talk/ problem-solve/snuggle/hike/have a candlelight dinner/ be intimate together” would be one way to open the conversation, followed by something like “Do you ever feel this way?”

If your partner agrees, then you both can begin to explore what you would like to do to create more time together. And you’ll also need to figure out what are the factors that have contributed to the emotional disconnect you’ve been feeling. Those factors may be real life issues, like high maintenance family members/friends/co-workers/bosses/or even pets! Other factors may be physical exhaustion, illness, emotional distractions, job or school obligations, work-related travel, or any number of things that have crept unnoticed into your lives. So the combination of a mutual wish to recapture calm time together, paired with a recognition of the factors you think get in your way, should set the stage for a productive discussion on what both of you can do to set the stage for more attention to each other.

But what if your partner doesn’t perceive the emotional disconnect that has been worrying you? You still are entitled to your feelings, but understanding where your partner is coming from becomes especially important. Is it that your partner may be worried that there will be an expectation that some favorite activities will be sacrificed? Perhaps that you may want some changes that would be unwelcome? Maybe that your partner has a real commitment to some of the high maintenance people in your lives and is apprehensive you may demand equal time? As you can imagine, it’s really important to ask your partner’s help in understanding why only one of you is feeling this emotional distance. Here your partner may actually be relieved if you offer your perspective first, which may turn out to be not nearly as difficult to address as your partner initially anticipated.
So if you begin by offering that you find yourself missing the times when you had more time to spend together, and that you want to nurture that closeness and not take your relationship for granted, your partner will hopefully take that as a positive message and not a competitive one. Then, in the spirit of enlisting your partner’s participation, you might ask “I wonder what we could do to recapture some of the special times together that we used to enjoy so much?” Hopefully both of you could begin to explore together your ideas, acknowledging the inevitable demands that have interrupted efforts to spend time together. Trying to figure out how you both can shuffle/reschedule/ re-prioritize those demands will be important. You may need to call on others to help create the space you need for yourselves: parents, siblings, best friends, a religious leader or a counselor all could be resources to consider.

Realistically, we also must consider the possibility that your efforts to re-engage emotionally with your partner may be met with denial, side-steps, avoidance or disregard for your feelings. If you genuinely have avoided blaming or nagging, then your partner’s lack of responsiveness is a serious signal that you are not going to be met half way. This would be a time to encourage your partner to come with you to a marriage counselor to sort out your different perspectives on your relationship. And if your partner is unwilling, then you should seek counseling for yourself (see some of my earlier blogs or my book When You’re Not Expecting for how to find a therapist).

Relationships are sensitive territory, often changing and often needing ongoing attention. And, since the need for attention to the relationship may coincide with life changes, personal crises, family losses or other emotion laden events, you and your partner can potentially benefit if you develop a style of connecting that is open and responsive even in trying times. So if you begin by using your current perception of wanting to nourish your relationship, hopefully both of you will develop and nurture ways of staying emotionally resilient and connected for many years to come.

Infertility: How to find a good psychotherapist

The decision to begin therapy usually has a backdrop that can include stress, unhappiness, unfilled hopes and interpersonal difficulties. If infertility is at the source of the stress, there may be additional components: fertile friends and siblings; juggling employment and treatment; monthly feelings of failure; difficulty communicating (verbally and sexually) with your partner and, perhaps, the experience of mourning one or more pregnancy losses. Finding a therapist who can be helpful along all of these dimensions can feel like a huge challenge. So, in the spirit of good problem-solving, let's see how we can approach this creatively.

I am writing this particular blog now, because in my December 31st blog heralding the beginning of the new year I cautioned all readers to take care of themselves emotionally. For some this will mean gathering comfort from friends and family, and for others it could mean seeking a therapist who can help you feel empowered by sorting through the various components of your emotional distress. In my recent book When You're Not Expecting, I devote an entire chapter ("Another Shoulder to Lean On") to finding emotional sources of support. Today's blog will focus on finding a therapist.

If you are beginning this search already in the throes of emotional misery, be aware that you may need to expect some delays as you identify a therapist who feels like a good choice. The therapist may have a waiting list, may not be covered by your insurance, may have a schedule that conflicts with yours, or may have an office that requires more travel than is ideal. So let's begin with how you can initiate your search.

Most of my clients and infertile acquaintances have found that word-of-mouth in their own community often serves them very well. Good therapists acquire good reputations for all the right reasons, and your initial inquiry should include whether or not the recommended therapist has experience counseling infertile clients. Someone with this background is ideal, since s/he will probably be familiar with treatments, side effects, parenting options and resources, and will save you the time of explaining your infertility issues in much detail. If you are currently being seen at an infertility clinic, be sure to ask whether the clinic employs a mental health professional for its patients. But if infertility is not a familiar issue for a recommended therapist in your community, don't despair. Here are some of the most important areas of expertise for a therapist: couple communication, grief counseling, family dynamics, depression and decision-making. Those areas are ones in which many couples with infertility need help, and along the way you can educate the therapist about the particular aspects of your infertility that are important.

So let's imagine that trusted friends, infertile acquaintances and family have not come through for you with names of therapists to consider. Some other resources could include your county Mental Health Association, the social worker at your local hospital, a local RESOLVE representative, your ob-gyn, a mental health specialist at a nearby fertility clinic or your religious leader. You also can contact RESOLVE (the national infertility association) at http://www.resolve.org/ for names of therapists and leaders of support groups in your area. You are likely to be given names of social workers, psychologists, pastoral counselors and marriage and family therapists from these resources.

Once you have several names, it will be up to you to contact the therapist and ask for an appointment. What barriers might you encounter? You should expect the therapist to ask that you and your partner both attend the first meeting, so be sure to have two datebooks in front of you when you have this first conversation. You will be asked to describe your situation briefly, so be prepared to do this, and to ask the therapist whether s/he works with clients using the areas of expertise I mentioned above. If your prospective therapist has a full caseload of clients and offers to put you on a waiting list, you should ask how long it is likely to be before you could be seen (or, better yet, ask whether you could be fit in for an introductory appointment so you at least can determine whether you feel comfortable in conversations with this particular therapist). If the wait seems too long, or if a visit reveals that the chemistry is just not right, ask the therapist to suggest names of other therapists in the community. This process can take a while, but it is time well spent.

Another potential barrier is insurance coverage for the therapist's services. Find out in your initial telephone conversation with your own health insurance carrier what therapists are covered, and begin by contacting them. But if you find, for whatever reasons, that insurance is a problem, you have several options. One option is to ask to be seen by a therapist at your local mental health clinic or at your local family counseling agency (both may have sliding fee scales). Some therapists in private practice also have sliding fee scales. Another option is to look carefully at your savings and decide whether you can afford to pay out of pocket for these expenses. A last option is to seek a financial gift or an interest free loan from loving family members.

In terms of therapists whose schedules are a challenge or whose offices are difficult to reach, those issues are likely to be ones where you will need to adjust your life once you have decided that seeking therapy is an important priority. You can request a more convenient time if one becomes available, but the inconvenience of distance is a challenge. Occasionally a therapist might be open to a Skype session or a conference telephone call, but this is likely to be the exception rather than the rule.

So, the take-away message of this blog is that finding a therapist can take time and energy, but there are very clear pathways to follow in this quest for emotional support. And with this emotional support, hopefully you and your partner will feel increasingly energized and resilient as you face together the months ahead.

New research on stress and infertility

For years there has been a dialogue between physicians and their infertile patients about whether stress is a cause of infertility or the result of infertility. Current research has shown that the stress levels of women with infertility are equivalent to women with cancer, AIDS or heart disease, so there is no question about infertility resulting in enormous stress. The breaking news published online in the journal Fertility and Sterility and summarized this week in the Science section of the New York Times, ( Old Maxim of Fertility and Stress Is Reversed ) is that women who stopped using contraceptives took longer to become pregnant if they had higher saliva levels of the enzyme alpha-amylase -- a biological indicator of stress. Specifically, women with the highest concentrations of alpha-amylase were 12 percent less likely to become pregnant each month than those with the lowest levels.

So what are the implications of this new research? The researchers say theirs is the first study to link a biomarker for stress with delayed conception in normal, healthy women, and they suggest that identifying ways to reduce or manage stress may be a low-tech solution for some couples diagnosed with infertility. Alice Domar, executive director of the Domar Center for Mind/Body Health at the fertility center Boston IVF, responded to the research findings by saying "This is one more piece of the puzzle that's adding up to the same conclusion: that stress is not necessarily a good thing for our reproductive system." Her 2004 book, Conquering Infertility, addresses the mind/body connection and suggests practices ranging from mindful meditation to yoga that can help women reduce the stress caused by their infertility.

So we are coming full circle: acknowledging the obvious, that infertility causes stress, and now addressing the scientific evidence that stress delays time of conception in healthy women. The researchers remind us that stress is the one consistent factor that shows an effect on how long it takes to get pregnant, of all the lifestyle factors studied to date. More surprising is that even low levels of stress can have an impact on conception.

Dr. Domar advocates that mind/body techniques can decrease physical symptoms of stress such as insomnia, headaches, abdominal pain and fatigue as well as psychological symptoms such as depression, anxiety, hostility and tearfulness. She cites recent research that has shown that women who participate in mind/body programs in conjunction with treatment from their physician have significantly higher pregnancy rates than women who receive medical treatment only.

With these intriguing studies, if you are a woman hoping to become pregnant (remember that the alpha-amylase study used data from 274 healthy women who had just started trying to conceive), certainly you will want to reduce your stress as much as possible in an effort to enhance conception. If you have been diagnosed with infertility, you are already in the midst of a stressful experience; seeking an infertility clinic that incorporates counseling, mind/body interventions and stress management strategies can provide you with new stress reduction techniques. In my book When You're Not Expecting, I provide information on how to locate a counselor or a support group, as well as lists of resources for help with mental health concerns, including stress.

Each of our responses to the stress of infertility is unique to our particular circumstances. Yet this recent research is a red flag that we should actively try to address our own stress levels in an effort to assist our physicians in their efforts to help us achieve a healthy pregnancy.