What have you got to be Positive ABout?
Printer-friendly versionDr. Deborah Lancastle
It will come as no surprise to you that research shows it is upsetting and stressful to have difficulty conceiving, and that fertility treatment and the outcomes of treatment can be demanding too. In one study, 42% of infertile men and women were as anxious as people with an anxiety disorder, and 12% were as depressed as people with clinical depression.1 In another, 17% of women met the criteria for clinical depression after their IVF treatment failed.2 In terms of other psychological effects of infertility, couples have said that they felt they had little control over their infertility and little faith that treatment would work. Beyond stating the obvious – there is a link between infertility and stress – I shall turn my attention to the ways in which you might deal with such stress and distress.
There are many, many different ways of coping! The different types of coping mechanism have been given technical names by psychologists, although the ways in which they work will be familiar to you. One way of coping is called emotion-focused coping, which involves trying to make yourself feel better during a difficult experience, like infertility, by relieving your negative emotions. Problem-focused coping involves trying to take some kind of action to solve the problem that is making you unhappy. Cognitive coping deals with the different ways you can perceive a difficult and stressful experience, and Positive Reappraisal is a technique for focusing on positive aspects.
Emotion-focused coping
If you have a weep and chat to a friend and then feel a bit better about it all, then you have engaged in emotion-focused coping, and your coping effort has worked for you. However, psychologists have mixed opinions about this sort of coping. Although you feel better, the situation causing your distress hasn’t actually improved. You are therefore likely to experience the distress again until the problem is solved. If you suspect that you have a fertility problem, seeking help would probably be a more useful approach in the long term than just talking about it. By seeking the treatment that could help you conceive, you increase your chances of solving the problem entirely, where the relief you feel after sharing with a friend is temporary.
Problem-focused coping
Seeking help is one of a class of coping strategies that has the technical name of problem-focused coping. As you may have guessed, this type of coping involves trying to solve a problem. Your actions might improve the situation in many different ways. For example, in everyday life, if you have a headache, you might take a painkiller to get rid of it. Or you may (also) choose to stay late at work and finish the backlog of work that’s worrying you and contributing to your headache! The first action deals with a specific aspect of a problem (the headache) and the second action deals with the global problem (the backlog of work that’s the cause of the headache). Both actions are likely to improve the headache, so your coping efforts would have worked for you. However, the second action is probably a better approach as it will hopefully reduce the likelihood of your headache returning (thereby removing the need for you to use medication to relieve it). In the case of infertility, seeking help is comparable to working off that stressful backlog – you are attacking the source of the problem, and, by taking action, you may be able to successfully solve it.
With regards to fertility treatment, however, I can sense the questions or objections already forming in your mind. You might argue that there is little that you can do other than “keep taking the tablet” (and all other medications prescribed to help you conceive), since even if you know the cause of your infertility, you are hardly likely to be able to do much to solve it if medical expertise is necessary. So, in a nutshell, although acting to solve the bigger problem is the best thing to do when it is in your power, it is not always a possible course of action. Indeed, trying to change or control something that is beyond your power can add to your distress. It is probably better to act on the specific things you can do something about,’ rather than trying to stop the sun from setting.
It’s clear that emotion-focused and problem-focused strategies will not necessarily have a long term, positive effect every time, during every experience we live through. Sometimes we need to act to solve the problem, and sometimes we can’t, and need to make ourselves feel better about it instead. Finding a way to cope that fits with the demands of the situation is probably the best approach, and this requires a certain degree of flexibility on our part. For example, you may find that distracting yourself by thinking about a lovely holiday during oocyte retrieval is the best way to cope with the experience; however, it may be more helpful to try to take action before the procedure. By actively seeking information about what oocyte retrieval will be like, you can resolve some of the worry and stress that are adding to your discomfort. Basically, you may find that some strategies are more appropriate and effective at some stages of treatment than others.
There is another level of complexity to add to our understanding of how people cope with difficult life experiences, and that is personal preference or habit. It doesn’t take a psychologist to tell you that everyone is different! Just as different situations may call for different types of strategies, different people may prefer to rely on different strategies. Some of you may automatically pick up the phone and talk to friends and family when you are struggling with your infertility, and find that this helps you the most. Some may generally opt for an information-seeking approach, asking tons of questions of doctors and nurses, and reading as much as they can – because being informed helps you to deal with what is going to happen and why. Others tend towards trying not to think about the situation at all – if this is you, you may try to distract yourself and avoid people who remind you of your infertility or who ask you awkward questions.
Your personality may steer you more towards one type of strategy than another (perhaps you have always dealt with things in that way), or it may be to do with your personal circumstances (perhaps you wish to protect others from your distress and so you don’t talk to them about it). You may also be the sort of person who doesn’t really have a type of coping “style,” but switches between different strategies as the mood and opportunity dictates. It is what works for you and makes you feel better that matters; however, there is an exception to this rule. The exception is when your style of coping with a situation s detrimental to your well being over time. I’ve already mentioned that not taking steps to deal with a situation that you could perhaps improve might cause you more grief in the long run.
Cognitive coping
It’s important to examine the way you think about your problem. This falls under the technical name of cognitive coping, and less helpful strategies include denying that the problem is happening to you at all, wishing it would go away, or constantly dwelling on what might or might not happen (rumination). Ruminating may involve thinking, “Am I pregnant? Am I not pregnant? What does this symptom mean? What does that symptom mean? What will I do if I’m not pregnant? What will it be like if I am pregnant? What if I am pregnant but then miscarry?” – and so on and so forth. It is normal and understandable to wonder and worry, because the outcome is so important to you. And to some extent this sort of strategy may be protective, if you believe that worrying about all eventualities will help you prepare for the worst and deal with it if it does happen. But it is undoubtedly the case that rumination itself can get upsetting and depressing. This is partly because you are worrying about future events when you cannot predict the future, and cannot control it either. The combination of uncertainty and uncontrollability can be a major stressor. After all, how can you really work out how you will cope when you don’t know yet what you’re coping with?
Although it may be difficult, it is important not to think too much about whether you are pregnant or not during treatment, because you can’t control what will actually happen. It’s also probably unhelpful to keep checking your body for signs and symptoms that hint that you are (or are not) pregnant, as these are not always reliable. If you can stop yourself from worrying too much about future possibilities, you may feel better in yourself. Remember that you should have support and help available when you do find out the results of your pregnancy test – and at that time you will know what you’re dealing with. You may even find that your own tried and tested ways of coping with positive and negative experiences help you to deal with the outcome perfectly well.
After reading this account of different ways of coping and the ways in which they may be more or less helpful when dealing with infertility, you may wonder if there are any other ways of trying to cope with uncertainty and uncontrollability and of helping you to feel better. You may also feel that it is easy to advise people not to dwell on the possibilities during a difficult situation, but that it is not as easy to follow that advice when you are the one who is doing the worrying. This is a fair point!
Positive Reappraisal
One candidate for a positive approach to coping with infertility is a method called Positive Reappraisal coping. Positive Reappraisal can help you manage your worries by encouraging you to think differently and more positively about the situation you are in. It does not mean pretending that everything is wonderful if it isn’t. It also does not mean thinking that you will definitely get pregnant, even if that is the most positive outcome from fertility treatment that you can possibly think of! Instead, Positive Reappraisal involves actively thinking about any positive aspects of infertility or fertility treatment itself that you can come up with. You might focus on appreciating any support or kindness that friends or family show you during your fertility treatment. You might think about how your relationship with your partner is stronger now because of your shared experience. Perhaps you are delighted with the standard of medical care you have received. These are the some of the benefits that women going through fertility treatment have shared with us in the past, and they may apply to you too.
I am sure that you can add to these possibilities by reviewing some other good things that have happened to you personally during your experience of infertility. Thinking more about any positive aspects of a difficult situation, rather than dwelling on problems and on uncertainty about the future, should help you to feel better in yourself at any time, but especially during the challenges of infertility and fertility treatment. Studies looking at other stressful life experiences (e.g., caregiving and bereavement)3 have shown that such ways of thinking about a situation can benefit those living through it, because it helped them feel more positive and to carry on and keep going.4 Such benefits may be particularly welcome during the stresses and strains of infertility.
As with any new way of thinking and behaving, it can take time for Positive Reappraisal to become second nature, and you might find that thinking differently feels strange and unnatural at first. However, practice will help, so try to persevere. In time, you may find that you are not dwelling as much on thoughts that worry and upset you and that this improves the way you feel.
References
1. Lord, S., & Robertson, IN. (2005). The role of patient appraisal and coping in predicting distress in IVF. Journal of Reproductive and Infant Psychology, 23, 319-332.
2. Litt, M.D., Tennen, H., Affleck, G., & Klock, S. (1992). Coping and cognitive factors in adaptation to in vitro fertilization failure. Journal of Behavioral Medicine, 15, 171 – 187.
3. Lancastle, D., & Boivin, J. (2008). Feasibility, acceptability and benefits of a self-administered positive reappraisal coping intervention (PRCI) card for medical waiting periods. Human Reproduction, 23, 2299-2307.
4. Folkman, S. (2000). Stress, positive emotion, and coping. Current Directions in Psychological Science, 9, 115-118.
About the Author
Dr. Deborah Lancastle is a Chartered Health Psychologist and colleague of Dr Jacky Boivin. Deborah is interested in the psychological factors (e.g. personality) and processes (e.g. coping) that explain positive outcomes during stressful health experiences, and in the psychological aspects of women’s reproductive health. Deborah is currently lecturing in the University of Glamorgan, in Wales, UK.