ACCEPTANCE AND COMMITMENT THERAPY

Using Acceptance and Commitment Therapy to Treat Infertility Stress

By Brennan D. Peterson & Georg H. Eifert

ABSTRACT: Women and men diagnosed with infertility experience a variety of infertility-related stressors, including changes to their family and social networks, strain on their sexual relationship, and difficulties and unexpected challenges in their relationship. Infertility stress is linked with depression and psychological distress, and can lead to premature dropout from medical treatments and unresolved feelings of loss and grief. The current study examined the effectiveness of treating infertility stress using Acceptance and Commitment Therapy (ACT), a promising new behavior therapy that targets experiential avoidance through mindfulness, acceptance strategies, and value- directed action. This single-case study followed a couple experiencing infertility-related stress following a failed in vitro fertilization (IVF) procedure. The couple completed 6 self-report measures at 7 time points, including a second failed IVF attempt and a 1-year follow-up. Measures included both distress-focused instruments and therapy process-related questionnaires. The female participant reported higher pretreatment stress and depression scores compared to her partner. She reported significant decreases in global infertility stress, social infertility stress, sexual infertility stress, psychological distress, and depression from pretherapy to 1-year follow-up. She also reported a decrease in infertility stress following her second failed in vitro fertilization (IVF) attempt. The male participant reported significant decreases in sexual infertility stress. The study suggests that acceptance-based therapy shows promise in treating infertility stress in patients experiencing infertility who undergo medical treatments. The data from this preliminary case study also suggest that ACT may be helpful for couples following IVF treatment failure. Treatment gains were maintained 1-year posttherapy, indicating that an ACT approach to treating infertility has the potential to produce lasting change.

QUOTES:

(I have bolded certain passages.)

  • Infertility- related stressors include, but are not limited to, changes in a couple’s social and family networks, alterations in the endurance and quality of their interpersonal relation- ships, and decreased spontaneity and satisfaction in their sexual relationship (Newton et al., 1999; Peterson, Gold, & Feingold, 2007). These stresses often contribute to grief, depression, and anxiety in both men and women (Daniluk, 2001; Fassino, Piero, Boggio, Piccioni, & Garzaro, 2002).
  •  The growing literature base has examined a range of topics including the link between infertility and depression, gender differences in stress and coping, and treatment strategies for mental health professionals working with infertile couples.
  • Although significant advances have been made in the literature base, there remain a lack of studies examining the effectiveness of psychosocial interventions used to treat infertility-related distress (Boivin, 2003).
  • There is a significant gap between the number of treatment outcome studies (6%) and the number of studies that provide general treatment recommendations (94%; Boivin, 2006). Because of this stark disparity, there have been calls for additional research examining the effec- tiveness of psychological interventions to treat infertility stress.
  •  In a study that randomly assigned 184 infertile women to a cognitive-behavioral therapy (CBT) group, a support group, or a control group, women in the CBT group experienced decreased anxiety, depression, and marital distress at 6-month follow-up. In addition, participants in the CBT group had continued improvement at 1-year follow-up and showed the greatest positive change when compared to participants in the other two groups (Domar et al., 2000). A randomized control trial comparing CBT and pharma- cotherapy found that although both treatments were efficacious, CBT was superior to pharmacotherapy in reducing depression and anxiety in women diagnosed with infertility (Faramarzi et al., 2008).
  • Mindfulness-based therapies have demonstrated efficacy in reducing stress and depression in patients diagnosed with physical disorders such as cancer and arthritis (Foley et al., 2010; Zautra et al., 2008). A randomized control trial found that mindfulness-based cognitive therapy was effective in reducing depression, anxiety, and distress in patients diagnosed with cancer when compared with wait-list controls (Foley et al., 2010). Because patients diagnosed with infertility report similar levels of depression and anxiety when compared to patients diagnosed with cancer, the usefulness of testing mindfulness-based therapies with infertile patients would also be valuable (Domar, 2002).
  • Acceptance and Commitment Therapy (ACT) is an experiential acceptance-based behavior therapy that targets psychological inflexibility, experiential avoidance, and efforts to reduce and/or manage unwanted aversive experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). These authors define experiential avoidance as a tendency to engage in behaviors to alter the frequency, duration, or form of unwanted internal experiences (i.e., thoughts, feelings, physiological events, memories) and to avoid the situations that trigger such thoughts and feelings. This is one of the main reasons why ACT could be potentially useful for couples experiencing infertility distress. ACT could help couples accept and come to terms with feelings of disappointment, failure, and inadequacy rather than continuing to engage in behavior designed to get rid of such emotional experiences. Likewise, ACT could help clients end their struggle with their judgmental thoughts and evaluations about their inability to conceive by learning to simply observe such evaluative thoughts, thus decreasing their believability. At the same time, ACT could help couples commit to and progress toward value-directed behavior.
  • Indeed, the use of avoidance coping is strongly correlated with increased amounts of infertility stress, marital dissatisfaction, and depression (Peterson, Newton, Rosen, & Skaggs, 2006a; Peterson, Newton, Rosen, & Skaggs, 2006b). Family events and social activities associated with young children now become painful situations to be avoided at all costs, and these avoidance efforts contribute to feelings of social isolation (Domar, 1997). Additionally, prolonged periods of infertility stress can strain a couple’s interpersonal relationship (Berg & Wilson, 1991).
  • Thus, activities that once provided the couple with intimacy and security now become the catalyst for increased stress and anxiety (Peterson, Newton, & Feingold, 2007). Overall, a couple’s sense of vitality is greatly reduced and ultimately replaced by a narrow set of behaviors that couples find isolating.
  • These avoidance strategies take up a great deal of time and energy and ultimately result in couples feeling helpless and not in control of their lives (Daniluk, 2001). According to ACT, avoidance strategies are related to and fueled by cognitive fusion (Hayes, Strosahl, & Wilson, 1999), which can be described as “buying into” one’s thoughts and feelings about infertility. This process of taking thoughts literally and acting on them to change them or make them go away contributes to personal suffering and increased infertility distress. ACT uses acceptance strategies and cognitive defusion techniques (e.g., metaphors, mindful- ness exercises) to teach clients to respond more flexibly and less literally to infertility-related thoughts and create a healthy distance between themselves and their internal experiences. Instead of trying to dispute or otherwise change thoughts such as “It’s unfair that we can’t have a baby” or “We must have done something wrong for this to happen to us,” clients learn to acknowledge these thoughts as mere thoughts that can simply be observed that don’t need to be acted upon.
  • ACT’s ultimate goal of helping men and women live lives consistent with their values and goals. Infertile couples experience a significant inconsistency between what is important to them and their actual life situation because living out their key value of becoming and being a parent has been thwarted. This creates a great challenge for these couples. It should therefore be helpful for couples to learn to become more mindful of their cognitive and emotional responses to infertility stress and related situations by practicing compassionate acceptance toward their experience, responding less literally to their thoughts and feelings regarding infertility, and ultimately learning to approach infertility-related thoughts, feelings, and situations they previously avoided.
  • Her husband’s sister had a child and Brooke found she could neither hold her nephew nor spend time with her sister-in-law. Additionally, this put a strain on Brooke and Aaron’s relationship as Aaron felt torn between his wife and his sister. Brooke also found it impossible to be in the presence of friends and their children, and her stress and anger about her infertility began to escalate.
  • Creative Hopelessness: One of the first interventions was to let Brooke and Aaron experience the futility and high personal costs (“unworkability”) of their previous attempts to resolve infertility stress. From an ACT perspective, infertility stress is heightened as one tries to control emotional and cognitive reactions to infertility and actively avoids infertility-related thoughts and feelings that result in avoidant behavior. The Chinese finger trap metaphor, a standard ACT intervention, was adapted for infertility to illustrate that efforts to control uncontrollable events (such as thoughts and feelings) are unhelpful and ultimately counterproductive to coping with infertility (see Hayes, Strosahl, et al., 1999). The therapist gave Brooke and Aaron a Chinese finger trap, asked them to put one finger in each end of the trap, and then attempt to remove their fingers. The more they struggled to get their fingers out, the tighter and more restrictive the finger trap became. To get out of the trap, they had to push their fingers in. This counterintuitive movement provided a basis for approaching infertility stress in a different manner than in the past. By resisting infertility stress and pulling away from it, they had eliminated much of the flexibility and space in their lives and thereby increased their distress. Thus, in order for new solutions to emerge, both Brooke and Aaron had to experience the effects of “moving into” the stress of infertility, rather than avoiding or pulling away from it.
  • Initially, acceptance exercises were difficult for Brooke and she would cry through them, saying, “I cannot accept the pain of infertility because that would mean accepting we would never have a baby of our own.” However, over time, she learned that acceptance of infertility stress did not imply giving up on her journey toward parenthood, but was rather a way to create space for her to think and feel her infertility-related thoughts and emotions without having to resist and avoid them. Eventually, she realized that accepting her reactions to infertility and her desire to be a parent were two different issues.
  • Ironically, it was the couple’s intense desire to become parents, and the dominance this value had in their lives, that ultimately contributed to their high levels of infertility stress. Thus, the more they moved in that direction by pursuing infertility treatments, the more stress they experienced when a treatment attempt failed. As a result, clarifying all aspects of the value of parenthood allowed Brooke and Aaron to explore the many ways to build a family (e.g., continued treatments, adoption, third-party reproduction using donor eggs, donor sperm, or a gestational carrier). Although they valued biological parenthood more than any other family building option, the act of clarifying their values in this area gave Brooke and Aaron more room to consider other alternatives and examine their reproductive decision making with more flexibility.
  •  The “watching thoughts on leaves” exercise (see Eifert & Forsyth, 2005) was an intervention aimed at helping Brooke and Aaron defuse from their thoughts by becoming mindful of them as they watched their thoughts drift by like leaves floating down a stream. Rather than getting fused with the content of these thoughts, the couple learned to view the thoughts as products of their minds and themselves as mere observers of the thoughts. Brooke reported that this exercise was perhaps the most helpful to her in all of the therapy and she routinely practiced it at home and at work.
  •  Brooke and Aaron imagined being in previously avoided situations such as attending a family gathering with young children. When infertility-related thoughts and feelings showed up, they were encouraged to observe, accept, and make space for them rather than struggle with or try to avoid them. For outside practice, Brooke and Aaron engaged in activities that were linked to critical life values they had previously avoided because of infertility stress. These activities included attending family gatherings with young children present, attending an award ceremony for their friend’s daughter, and attending the dance recital of their friend’s children. The couple completed records for these situations, rating the intensity of sensations, infertility stress levels, willingness to experience the stress, and degree of struggle with and avoidance of the experience.
  • Brooke reported significant decreases in all five types of infertility stress from pretherapy to 1-year follow-up. These findings are encouraging and provide initial preliminary support that ACT may be effective in treating infertility stress.
  • An examination of the data from this case study shows that ACT may work to reduce a woman’s global infertility stress, social infertility stress, sexual infertility stress, and need for parenthood.
  • Social infertility stress is one of the most common aspects of infertility stress and occurs when couples experience significant changes to their family and social networks, are embarrassed about questions from others regarding infertility, and negatively compare themselves to others with children (Newton et al., 1999). At the onset of therapy, Brooke experienced extreme amounts of infertility stress––greater than 98% of infertile women. We hypothesized that her normal and expected pain of social infertility stress turned into unnecessary suffering as a result of her attempts to avoid it at all costs (see Hayes, Strosahl, et al., 1999). As Brooke increased her accep- tance of infertility-related stress over the course of therapy, the level of distress she experienced in social and private situations decreased. Brooke’s improvement in this area is reflected by a reduction from the 98th percentile rank at pretreatment to the 50th percentile following her IVF treatment failure. This is a critical and encouraging finding because individuals typically experi- ence increased infertility stress and depression after IVF treatment failure (Eugster & Vingerhoets; 1999; Newton et al., 1990; Olivius, Friden, Borg, & Bergh, 2004; Verhaak et al., 2007). Following IVF treatment failure, Brooke reported increases in mindful acceptance, from 3.2 at pretherapy to 4.7 post-IVF failure––a level that is comparable to Zen practitioners (Brown & Ryan, 2003), and her levels of thought suppression decreased from a pretherapy level of 58 (above average) to 33 (below average; Wegner & Zanakos, 1994). Brooke also indicated to the therapist that learning to become more mindful, accepting of, and defusing from previously avoided thoughts and emotions contributed to a reduction of her social infertility stress.
  • Following the second IVF failure, Aaron’s psychological distress and global infertility stress increased. Aaron’s levels of mindful acceptance also decreased to its lowest levels (2.9 post-IVF failure compared to 3.4 pretherapy) and his levels of thought suppression spiked from 32 to 52. It is possible that Aaron may have been less engaged in the treatment because he viewed himself in a more supportive role rather than as a client. Following the IVF failure, however, Aaron reported that the infertility stress was also taking a toll on him and he became more engaged in the therapy. Following this new commitment to treatment, Aaron reported increased mindful acceptance and decreased thought suppression—a trend that continued to be evident at follow-up. This is an important finding as infertility is a couple’s issue and should be conceptualized as such. Although men may not report as much infertility-related stress as women, mental health professionals and physicians should be aware that men do suffer distress related to infertility (Peronace, Boivin, & Schmidt, 2007). Furthermore, while both men and women use a variety of strategies to cope with infertility distress, it is important to understand that the coping patterns of one partner have a direct and immediate impact on the stress of their partner and that both men and women’s coping strategies can directly impact their partner’s levels of infertility stress (Peterson et al., 2009; Peterson, Newton, Rosen, & Schulman, 2006; Peterson, Pirritano, Chris- tensen, & Schmidt, 2008; Peterson et al., 2003; Schmidt, Christensen, & Holstein, 2005).
  • In light of this study, we recommend that therapists working with couples experiencing infertility stress design treatment plans that integrate mindful accep- tance, cognitive defusion, and the pursuit of value- directed behavior to alleviate the unnecessary suffering these couples experience. Qualitative interviews with 65 couples whose medical treatments for infertility ulti- mately failed reveal that, in hindsight, most couples believed that there were tremendous costs associated with infertility (Daniluk, 2001). These costs were not limited to the substantial financial costs they incurred, but also extended to emotional suffering and the costs of putting important relationships with others on hold. Couples reported that their lives became so dominated by the infertility experience that they stopped making choices consistent with their life values and goals. One woman reflected, “How much longer did I want to live my life excluding everything I value about it . . . at the expense of my marriage and my relationship with my family, my schooling, my career, friends?” (Daniluk, p. 128.) Another woman reflected, “Before you realize it, you’ve put your life on hold for five or six years . . . I could have had a fuller life during that time” (Daniluk, p. 128).
  • By helping couples confront experiential avoidance when they are immersed in the infertility journey, clinicians can not only assist couples in reducing the immediate symptoms of infertility stress, but also help couples regain control of their lives by making choices that are more consistent with their deeply held values.
  • In addition to these clinical recommendations, researchers and mental health professionals should continue to work closely with physicians to help educate patients regarding the impact of using acceptance and mindfulness techniques in dealing with infertility stress. Furthermore, supportive and collaborative relationships between physicians and mental health professionals should continue to be developed so that patients may benefit from both the medical and the psychological treatments available to infertile couples.
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