I have just attended a fantastic two day Foundation Course for Infertility Counselling CPCAB Accredited (Counselling and Psychotherapy Central Awarding Body). This was run by the British Infertility Counselling Association (BICA). BICA is a registered charity and the only professional infertility counselling Association recognised by the Human Fertilisation and Embryology Authority (HFEA) and the British Fertility Society in the UK.
What struck me is how unique and multi-layered the role of an infertility counsellor is and it prompted me to want to share my thoughts and some of what I learnt. I do not claim to know all the facts nor have I included them all but my aim is to give a snapshot of how intense both the training and the role are.
Attendees were encouraged to ask themselves a lot of questions which were aimed at opening up their minds to the multitude of difficulties facing those who are battling infertility. At times it became overwhelming to think and this gave an insight into the journey faced by many. I do not doubt that what is written below will trigger many feelings, some more painful than others. They are very real and despite acknowledging it will be hard to read and digest, I hope too that it may also bring relief and perhaps even give permission to own your feelings and know you are not alone in them. This in turn is one of the aims of therapy.
The unspoken, unwanted and unwelcome feelings that accompany infertility
To know that you, your partner or both are infertile is more than enough to have to come to terms with. Sadly, this is by no means the end of the battle ahead. To accompany this process are many feelings which are not always obvious at first and can creep up on you when you least expect it. This is why counselling is beneficial; counselling can help you make sense of your feelings. Feelings are explored in a safe environment and doing so can bring validation.
Why do people want a baby?
This may seem obvious to some, but in fact there are a multitude of reasons and it is interesting to explore some of these with your counsellor. In doing so, the importance of finding out why people want to have a child suddenly becomes very important. What I discovered is that there are in fact a whole range of reasons.
I thought I would attempt to address some of the more obvious ones, before I share some perhaps less spoken about, maybe because they are harder to accept and admit to yourself that’s how you feel. Perhaps having read this you will feel less alone with your thoughts and take some comfort in knowing there are others out there who are feeling in a similar way.
There is of course the biological drive to consider; that to a lot of couples, heterosexual and same sex, having a baby feels like the natural next step for them to take once they marry. To others, having a child may bring status and give them a purpose which perhaps before becoming a parent they felt was lacking in their life. It may also bring validation to a relationship, not to mention the unconditional love which we get from children. Having a child brings with it the rite of passage into parenthood and not achieving this in life may leave some feeling stuck in the role of somebody else’s child.
I am aware that what I say may stir up a host of reactions in readers but I learnt the importance in gaining clarity for the reason(s) why a person wants to have a child. For example, if a couple want to have a baby to save a relationship, what support do they need in deciding whether having a baby is right for them at that time and how does one go about suggesting that perhaps couples counselling could be an option for them first to ensure they both want the same thing and for the right reasons. This is not to say they will not then go on and try to have a baby, but that they do this at a time that is right for them.
Couples come to counselling wanting to expand their family due to cultural expectations. However they may be young and not quite ready to become parents, yet have come as a result of parental pressure. Exploring this in counselling offers a private space to share feelings which may feel shameful or hard to voice. There is a pressure on women to have children and women may succumb to societal expectations. They come for therapy filled with resentment which they have been unable to share and express. The potential damage this may do if these feelings are not thought about before embarking on the fertility process could be detrimental to both the mother and any future child or children she may have. Additionally the relationships she is currently in.
Other women may feel the need to fill a void and think this can be achieved if they have a baby. Upon having a baby they soon discover this is not the case and counselling can help issues such as this arising. To some people having children becomes almost a hobby or dare I say an addiction. Being pregnant can bring a woman some sort of comfort or sense of purpose that it becomes something they need. The danger of this both to the mother’s body and any future children she may have becomes increasingly worrying with the frequency of her pregnancies.
On the flipside, it is interesting to think about those who choose not to have children. There is a huge stigma attached to this. To some it is incomprehensible, perhaps even selfish, to want a career and for that to be more important than procreation.
The journey through treatment
Counsellors can support the clients through the journey, which will be extremely unique to each individual. The counsellor will follow the language of his/her client. They work respectfully in a non-discriminatory way, without expressing personal opinions.
Their work involves helping clients make sense of how they are feeling, gaining a different perspective on their feelings in a non-judgemental way and helping them manage the enormity of the emotional load they are going through. Expressing opinion can influence decisions made by clients which is why this is discouraged. The thoughts spoken about in counselling must remain those of the client(s).
A client who has been told they need to come for counselling needs to have some awareness of why they have been told to come. The counsellor must ensure not only that they know but that they understand what they need to know about the process. A personable approach is necessary in order for the counsellor to get to know the client. The counsellor will show interest, asking about their experience so far, when they started and how long they have been trying for so far. What is important, if it is a couple, is that both of the couple answer the questions. The counsellor needs to develop an understanding of what it means to each of them and how emotionally prepared they are, as well as be alert to signs of trauma.
Sensitive but necessary questions
Clients come full of mixed emotions. Aware of this, counsellors still need to broach topics which are incredibly sensitive but important to think about. This must be done with sensitivity, in a gentle and caring manner. What is important is that the counsellor must be robust, so that the client is able to not only think about what is being asked but answer it. Counsellors need to think with their clients about how many treatments they may consider. The implication being that it might not work straight away, something which is hard but necessary to think about. Even more difficult to approach is asking if they have ever envisaged life without children. There is no knowing the reaction a question such as this will be met with.
A counsellor needs to remain curious about the impact the fertility issues have had on a couples’ sexual relationship and sexual functioning. These are highly personal questions but must be addressed in order to get as full a picture as possible.
Layers of issues
This is not written with the intention of overwhelming you, but to open your mind. Counsellors may ask how you intend to approach telling work about your fertility issues. Some people wish to remain private. There are implications to consider with both approaches. It is the job of the counsellor to help their client manage their expectations. This involves taking into account the patients’ perspective. Counsellors listen to their clients to gauge where they are at on their journey. In order to feel listened to, counsellors will reflect back to the client and help them think about where they are at and what the best approach is for them to take in order to move on with their journey.
Infertility counselling encourages couples express their feelings to each other. Seeing the impact of not sharing their feelings in the presence of a counsellor can help untangle issues between a couple and help them feel more connected and ready for the journey they face.
Counsellors must consider gender issues. It is not always but often the case that men are more able to envisage life without children. This demonstrates there are so many factors to consider in the work as a fertility counsellor.
Short term/long term
Although a great deal can be achieved in short term work, a counsellor with limited sessions must be cautious in their approach. They must consider the frequency with which they see somebody to be able to focus on the therapeutic work significantly. In addition, the counsellor must be aware of the limitations of their role. It may be frustrating for a counsellor who is only given one session to work with a couple, as this feels rushed and impossible to cover all the ground they wish. Being left with this frustration, it is important they have an awareness of how they feel, as well as an outlet for these emotions.
The emotional impact on
- the clients
Many difficult emotions are brought to counselling. Counsellors will discuss a clients’ expectations with them and help them manage these. If they have suffered a loss they can help reframe expectations into part of the grieving process. The aim is to help people understand the reasons for why they are behaving the way they are. For example, they may feel a changed person due to sadness or jealousy. Others may worry about becoming bitter. It is the role of the counsellor to help put these issues into perspective. That they are feeling the way they do as a result of what they are going through. One cannot underestimate the impact this can have. To know that in fact, what they are feeling is to be expected. The role of a counsellor is crucial in helping people feel they are not alone. The support and guidance that can be offered is invaluable and can really change peoples’ perspectives and approach to their fertility struggles.
- the counsellor
As well as the client needing support, so too does the counsellor. BICA offers regional groups, training workshops, conferences and informal networks. It is also the responsibility of the counsellor to be aware of new developments and explore and reflect on current issues. Additionally, counsellors attend supervision, giving them an essential outlet in which to take feelings which have been stirred up for them.
Counsellors talk to clients about the importance of self-care, which they too must practise. Not only does this model good practise but it helps them too fulfil their role in a more productive manner. It is a coping strategy which often gets dismissed due to lack of time. However, once boundaries are employed and clients have identified what might work for them, it ca help people cope. The counsellor will explain that in order to try and make the process work, self-care is vital. This in turn offers a client validation which they may not get elsewhere.
Knowing the facts
It is also the responsibility of the counsellor to know about egg and sperm donation as well as surrogacy.
Getting to the point at which an egg or sperm donor is needed is really tough. A counsellor will think alongside the client(s) what it was like when it was suggested to them, how they feel about it and how they coped with the suggestion. It may not be that it was suggested and this then too can be thought about. It may mean something different to them if it was not suggested but a decision which came from them.
Again, sensitive questions must be considered. What are their thoughts about using a donor, what they think it might be like. There is also the fact that the baby will not look like them, something which they might not have reached the point of realising. The counsellor must be mindful of this yet remain open to helping them think of all these factors.
There are also legal rights both as parents and donors which the couple must be aware of. It is crucial that they are well informed. For example in relation to future contact with the donor and their family once the child is over eighteen. All this must be explored in advance. The donor too can withdraw consent right up to when the embryo is implanted which can have devastating effects on the prospective parents.
The clients may know their donor, not know their donor or even choose to go overseas. This too has legal implications, all of which an infertility counsellor needs prior knowledge and understanding of. The process of finding a donor and then being matched with them can be lengthy and emotionally exhausting too.
The HFEA Code of Practise offers guidance as to what must be discussed and guidelines which must be adhered to. The counsellors’ job involves exploring the impact of this information. One example is related to telling and talking. This refers to telling the child their origin early in childhood because if they are not told it can be emotionally damaging. Throughout this process, the couple can be supported and guided by their infertility counsellor. The counsellor must do this with an awareness of the culture, faith and societal background of the clients as this will influence their capacity to discuss the issue with their child.
If it is a prospective donor who is being offered counselling, the counsellor must ensure they ask their motivations for becoming a donor. There will be psychosocial and generational differences for this. The expectations a donor has of their recipients must also be explored. There are then implications regarding the legal rights of the children the donor has prior to becoming a donor.
Surrogacy is even more complex due to the fact that it involves more people and more families. There are many religious implications too. As I mentioned earlier, I do not intend to cover all the facts. Merely to point of how much responsibility lies with becoming an infertility counsellor.
This can have an enormous emotional impact on both the client and counsellor. It will also vary depending on whether treatment has had the desired outcome or not. The amount of attempts to achieve this will also play a role in the feelings stirred up at the end of treatment. Some people will have a perspective on ending, whilst other just do not. It is the job of the counsellor to support their client to cope with this ending as best they can an in the way in which is right for them, taking into account that everybody’s experience is different.
The job of an infertility counsellor can be extremely rewarding. To embark on a journey alongside a couple and watch them achieve their dream is very special. However it also involves watching and in turn helping many people bear much heartache and disappointment. The responsibility of making sure yourself as the counsellor is up to date on the latest developments as well as the clients is paramount. For these reasons and many more it is not a career to choose to embark upon lightly but must be done so with great thought, ensuring just as the clients require a strong support network in place, you too as the counsellor have the same.