Part Two: Group Therapy For Women With Medically Unexplained Infertility
Group therapy is clinically time and cost effective.
For so many women with unexplored infertility, the clock is ticking and ‘shields are up.’ Therefore it is understandable that the offer of open-ended psychotherapy over several years to explore childhood trauma is unlikely to feel relevant or manageable.
This is why we believe that therapy for women with medically unexplored infertility in a therapy group is most effective. Yalom (2005) writes that controlled studies show, “... the average person who receives psychotherapy is much improved and the outcome from group therapy is virtually identical to individual therapy.”
Research
Lorentzen (2014) published his research data, collected over 10 years, evidencing that short-term group analysis (e.g. 20 weekly sessions) is as effective (with some clinical exceptions) as long-term work for prescribed problems.
The British Infertility Counselling Association (BICA) supports therapy in a group for fertility issues and provides a written guide on group work for women with fertility difficulties (Wheeler, 2012).
That said, focused therapy groups for women with medically unexplained infertility appear to be rare, which is both a pity for access to therapy and also for research. At RSF Therapy, Sarah Hanchet is a group therapist, trained with the Institute of Group Analysis, as well as a UKCP-registered individual psychotherapist.
In group therapy, we tend to build mixed groups in order to use conflicts that arise in the group to explore individual (and societal) defence systems. Put simply, the exploration and discussion of conflict enables everyone to learn healthier ways of relating.
However, there is also a strong clinical argument for a homogenous group, such as a group for women with the same diagnosis. These sorts of groups offer unrivalled support, understanding and empathy; and they thereby act as a vehicle for helping women to build ego strength.
On the surface, women who are “the strongest in the room” may appear not to lack a strong sense of self. However, the ‘true self’ is usually undeveloped and vulnerable, which is why it is so strongly protected.
Let us turn now to some of the psychological issues that can emerge in therapy groups with this focus.
What Comes Up?
Therapy groups work on different levels:
Individuals can explore their own story.
The group can be explored as a holder of projected (disowned) emotions, as someone usually ends up feeling them.
The group culture can, with good facilitation, become the nurturing mother or parent.
Existentially/spiritually the group is often exploring how the struggle to create life contains something of the deeper struggle to be a creative self.
This sort of therapy group will inevitably focus on the process of trying to conceive, and the relationship with the assisted conception process. Raphael-Leff (2014) summarises the following key themes from her own psychoanalytic work with women over many years.
Powerlessness
Women may go into IVF as a ‘treatment consumer’ but very quickly the relationship between an “infertile woman” and her “baby-doctor” creates an unexpected power dynamic. Women often project their sense of agency/self-efficacy onto their doctor, enrolling them as the expert or indeed saviour.
While this may enable everyone (medics included) to travel hopefully, the process leaves the woman trying to conceive carrying all the unvoiced feelings for everyone - powerlessness, fear, rage, shame and sadness. For a woman with childhood trauma, this can be overwhelming and lead to unhealthy coping mechanisms.
Not-feeling
A second theme is the use of rationality as a defence against feeling. The IVF process invites us into medical rationality: measuring, counting, timing and planning. One day we haven’t heard of HCG and the next we are obsessed with our daily blood count!
For women who have experienced trauma this way of exercising control over feelings and the body is familiar and potentially dis-associative, so the very act of coping with IVF can trigger unhealthy coping strategies, in particular a disconnection from the body.
Unconscious guilt
Another therapy theme is more existential and it relates to a personal (instinctual) sense of being a woman in a long line of women who became mothers. Women with fertility difficulties often tussle with the fundamental question, “Who am I, if I’m not a mother?” Women who choose not to have children do too, but perhaps this tussle is resolvable with less guilt. Women with fertility difficulties, who want children, often struggle with feelings of guilt and shame. They seek a resolution to the (unconscious) guilt of not being able to give their mother the baby whose egg she herself created and carried to term.
Maternal ambivalence
In mother-daughter relationships where there are already deeply ambivalent feelings, the struggle to conceive can bring up repressed and frightening emotions about self-worth and being enough (loveable). This can be regressive and therefore deeply destabilising, especially during the vulnerable period of trying to conceive, and the emotional exposure of miscarrying.
Loss
A woman with medically unexplained infertility is likely to be physically and emotionally stuck because she is protecting herself from old wounds. Healing means facing her fears (women will often speak of fearing breakdown and madness); and acknowledging what she has lost. In a group, feelings are amplified (emotions can run high); and then contained and normalised both by the conductor and the group itself.
Practicalities and how to express an interest
At RSF Therapy, in addition to our individual psychotherapy work, we are building a therapy group dedicated to women with medically unexplained infertility. Here are some details:
The group is for up to eight women with this diagnosis.
It meets weekly in person at the same time, near to Great Portland Street, London (if there is enough interest we can also offer an online group).
The group is open-ended, which means it will run and run.
Women are only required to commit for one term at a time.
Terms run from mid-Sep to mid-Dec/mid-Jan to end-March /start-May to mid-July.
Women may leave at the end of a term (with notice) or opt to stay for a further term.
The fee is much lower than for individual therapy, at time of writing it is £45/session.
Women may join further to an individual psychotherapy assessment to explore their history, and their ability to take part in a group without becoming overly dis-regulated or de-stabilised.
We are operating a waiting list and women may apply at any time to join. For a conversation with Sarah Hanchet about the group, feel free to email us and see our website for more details about our work.
Resources:
Jacobs et al (2015) Adverse childhood event experiences, fertility difficulties and menstrual cycle characteristics, PMCArticles.
Joseph, DN et al (2017), Stress and the HPA Axis: Balancing Homeostasis and Fertility, PubMed.
Lorentzen, S (2014) Guidelines for Long and Short-Term Group Analytic Psychotherapy, Routledge.
Mate, G (2003) When the Body Says No, The Cost Of Hidden Stress, Vermillion.
Raphael-Leff, J (2014) Dark Side of the Womb: Pregnancy, Parenting and Persecutory Anxieties, Anna Freud Centre
Wheeler, M (2012) A Creative Approach To Groupwork For Women with Fertility Problems, British Infertility Counselling Association, (BICA) Practice Guides Series.
Yalom, I (2005) Theory and Practice of Group Psychotherapy, Basic Books