In the mid-1980s when Martha Diamond, PhD, and her husband were having reproductive difficulties, they started talking to other couples who shared their struggle, and one thing became clear: The medical technology available to treat infertility was rapidly advancing, yet the psychological support to help these couples lagged far behind.

In response, Diamond and her husband, David Diamond, PhD, along with their colleague Janet Jaffe, PhD, formed a study group at Alliant International University in San Diego to research strategies to help people who were dealing with the trauma and loss associated with reproductive difficulties. In 1996, the trio launched the Center for Reproductive Psychology in San Diego to help people who have suffered infertility, miscarriage, high-risk or premature birth, and postpartum depression. They offer psychotherapy for individuals and couples, community education presentations, and in-service training to medical providers in the United States and abroad on the psychological needs of their patients.

"Struggling to have a biological child is a complicated grief process because it's often an invisible loss," says Diamond. "There are not rituals or public ways to honor these losses, and people often don't talk about it. They feel like something is wrong with them, and these situations can deliver a painful blow to someone's self-esteem."

These clients may also feel shame that they cannot conceive, sometimes exacerbated by guilt when they dread the next baby shower or feel envious of friends who are getting pregnant.

Psychologists help couples understand the emotional, psychological and physical issues of infertility treatment.Diamond says one of her critical roles is helping clients acknowledge that reproductive difficulties are a form of trauma that stems from the fact that many people begin imagining their futures as parents long before they try to become pregnant. Their reproductive stories may start when, as children, they hear messages like, "Someday, when you have kids…" or when they picture themselves passing along family traditions. When life diverges from these longstanding narratives, there is loss on multiple levels, Diamond says.

"Patients feel the loss of the experience of pregnancy, baby showers, birth, feeling healthy and normal, and the sense of belonging," she says. "There are also the losses of opportunity, such as leaving a legacy for the future or healing through the experience of parenting a child in healthier ways than one received personally."

Through therapy, Diamond and her colleagues help patients understand that reproductive trauma is just one part of the story, and that they can write the coming chapters. She also encourages her clients to see that infertility is not their identity, but rather a medical condition. One patient, for example, had been a successful teacher for years when her struggle with infertility began to erode her confidence at work. She started believing that she was not running her classroom well and that other teachers disliked her.

"These patients are often highly successful people, and this is often the first time in life they are faced with the fact that hard work and being a good person doesn't result in success," Diamond says. "I focus on the idea that conception is not a skill, and infertility does not define who they are as people."

Although demand for her services is high now, in the early stages of her practice she promoted her services by reaching out to fertility doctors and pediatricians who were seeing patients who might benefit from them. She also wrote articles about her work for journals and general audience publications. Most of her reproductive counseling clients pay out of pocket and most then get reimbursed by their insurance companies. Diamond admits that it can be difficult at times to work with people whose pain is so palpable, but says that it's deeply gratifying to help "healthy people with a lot of strengths to whom something bad has happened," she says. "The interventions provide so much relief, which empowers them to make fertility treatment decisions and recalibrate their relationships."

Rebuilding couples' connections

Lucille Keenan, PsyD, was motivated to specialize in reproductive counseling after she experienced infertility. She was seeing a therapist as she waded through a three-year journey with multiple reproductive treatments, but "I didn't feel understood, because it's a pretty specific experience," says Keenan, whose practice is based in Raleigh, North Carolina.

After earning a doctorate in clinical psychology in 2006, she decided to learn more about this specialty by joining the Mental Health Professional Group within the American Society for Reproductive Medicine. The group's members urged her to pursue more training by completing a six-month rotation with Julia Woodward, PhD, a psychologist in the Duke Fertility Center in North Carolina. After the rotation, Keenan started seeing clients who were facing losses related to stillbirths, miscarriages, failed adoptions and infertility.

About 25 percent of her clients are grappling with these issues, and the rest of her practice is devoted to helping couples and individuals in their relationships. One area she focuses on is helping couples whose relationships have been damaged by their reproductive issues. "There is so much pressure to have a child, and this affects intimacy," says Keenan, who eventually had a son through IVF. The hormones involved in fertility treatments can also intensify emotions, she says.

Partners often respond differently to the stress and grief, which can create a negative cycle. One partner may avoid the pain by withdrawing from the relationship, while the other may cope by intensifying emotions to connect with their partner. "I help people recognize when this cycle is happening in the relationship so they can stop and try to understand one another," says Keenan, whose clients pay out of pocket for her services. She uses emotionally focused therapy, a research-validated approach based on the principle that people all seek to connect with each other and do much better when they are in secure, connected relationships.

"I love helping couples get to a place where they can begin moving to the next step of their journey, whether it be child free, continuing with another aspect of fertility treatment, pausing treatment or building a family in another way," says Keenan.

Preparing couples for treatment

While many couples turn to counseling after months or years of struggling with infertility, Marjorie Blum, PhD, sees patients before they begin fertility treatments. She receives referrals from several fertility practices in Atlanta that encourage patients to consult with a psychologist before initiating infertility treatments.

During the consult, she seeks to educate couples about what to expect psychologically during treatment and to ensure both partners are comfortable with the decision to launch what can be a physically and emotionally taxing process.

Blum also assesses whether couples or individuals have support systems available to help them face potentially difficult outcomes. "People might experience loss after an unsuccessful treatment cycle, and then they are faced with deciding whether to pursue another round of the same procedures, a more complex procedure or move beyond biological pregnancy," Blum says.

To help couples prepare, Blum teaches stress-management techniques and the importance of self-care. She also tries to identify issues that could make fertility treatment particularly difficult, such as uncertainty about pursuing the treatment or relatives who disagree with their decision to undergo medical procedures to have a child. If these issues are significant, she urges couples to think about how they will handle the challenge, and to consider further counseling.

She also helps patients navigate decisions related to sharing information about their treatment with family and friends. Partners can differ in their desired levels of privacy, and Blum helps them understand one another and decide how to proceed.

The price of a consultation usually exceeds insurance coverage rates, so clients typically pay out of pocket. Demand for these services has increased since she started seeing clients more than 20 years ago. Blum started researching the impact of infertility in 1980 by interviewing couples undergoing fertility treatment.

Initially, Blum says she was one of a few psychologists offering these consultations in Atlanta, and now she's one of roughly 20 fertility therapists in the area. While most of her practice is dedicated to individuals in life transitions and couples dealing with relationship issues, about 25 percent of her practice is fertility consultations, which gives her an opportunity to work with people who might not otherwise typically see a psychologist.

"I've seen hundreds and hundreds of couples who are facing the personal, relationship, financial and existential pain caused by infertility," Blum says. "It's really rewarding to give them tools to go through the upcoming fertility treatment in an optimal way."

"No Insurance Required" explores practice niches that require no reimbursement from insurance companies. To read previous installments, go to www.apa.org/monitor/digital.aspx and search for "No Insurance Required."

Additional reading

Reproductive Trauma: Psychotherapy With Infertility and Pregnancy Loss Clients
Diamond, M., & Jaffe, J., 2010

Infertility Counseling: A Comprehensive Handbook for Clinicians
Covington, S., & Hammer Burns, L., 2006