Abstract
Much has been written in the popular media recently about the decision of many modern women to postpone childbearing until their 30s or 40s. Indeed, over the last 20 years, the number of women giving birth to their first child between the ages of 40 and 45 has doubled in the United States (www.cdc.gov/nchs/). In large part, this statistic is due to staggering advances in the field of reproductive medicine. For instance, how many of us were aware that there are 38 ways to have a child (maybe 39 if you count cloning) without actually having sexual intercourse? Another aspect of this statistic, however, involves the approximately one million couples who seek infertility treatment each year, and the struggle of those psychotherapists who attempt to assist them with this contemporary “problem in living.”
In their timely volume, Frozen Dreams: Psychodynamic Dimensions of Infertility and Assisted Reproduction, Allison and Jay Rosen attempt to illuminate the personal, subjective reactions of therapists who treat the wrenching anguish of infertility. They distinguish their book from other infertility treatment guides by focusing the content on therapist countertransference and its effects on treatment process and outcome. This is not, however, simply a book of personal accounts. Nearly all of the chapters contain numerous empirical citations to support authors' experiences. The list of contributing authors is impressive: a range of psychologists, social workers, and nurses working in reproductive medicine clinics and psychoanalytic institutes are represented.
The book is divided into four parts. Part I consists of an excellent chapter by Linda Hammer Burns detailing psychological changes in infertility patients, along with complicating factors such as age, remarriage, and physical illness. Her assertion, and one conveyed by most of the other contributors, is that infertility represents a narcissistic loss, and infertility counseling is a specialized form of bereavement counseling. Ultimately, the goal of therapists is to help clients “internalize and accept the unacceptable nature of infertility” (p. 26), a goal made more difficult due to the lack of a tangible object to mourn. Parts II and III make up the bulk of the volume and examine infertility patients from the therapist's perspective, along with special circumstances and treatment challenges. Part IV, while interesting, is a largely superfluous detailing of the roles of various infertility providers. I was left confused as to why these last chapters were included in this particular volume.
I believe the greatest strength of this book lies in the number of riveting case studies discussed in nearly every chapter. Moreover, the cases raise provocative ethical and philosophical questions to which there are no good answers; these questions will surely increase as reproductive technology continues to evolve. For example, as a therapist, how do you react when a patient who has undergone several in vitro fertilization cycles elects to terminate her first viable pregnancy upon learning that the fetus is a female? How do you counsel a married couple who wish to use their college-aged niece as an ova donor in exchange for financing her graduate education? Further, one of the most intriguing issues raised by the book involves delineating the role of the therapist in the infertility treatment process. For instance, reproductive freedom in most Western societies allows for fertile individuals to conceive a child without questioning their motives. In the world of infertility, however, therapists may be called upon to be “gatekeepers” to determine who is eligible to be a parent through the assistance of reproductive technology. The contributing authors of Frozen Dreams do an admirable job of addressing these difficult moral and ethical conflicts.
To assess the editors' claim that this volume offers a different view of infertility counseling, I consulted Infertility Counseling: A Comprehensive Handbook for Clinicians (Burns & Covington, 1999). This book was cited frequently by the contributors of Frozen Dreams, and I found it to be an exhaustive, “how-to” textbook on infertility counseling. In contrast, I appreciated the transparency shown by the contributors of Frozen Dreams as they shared their struggle with feelings of helplessness, anger, cyncism, and hope in their attempts to assist with the pain of infertility. I only wish the authors had been more inclusive; single women were mentionedin only a few of the case studies (primarily in one of the more weakly written chapters focusing on single mothers), and not a single case discussed a lesbian couple who sought infertility treatment. For a book that contains over 50 cases, this represents a significant shortcoming.
One of the goals identified by the editors was for the contributors to write a “jargon free” chapter about his or her experiences in the field of infertility. Some contributors did a better job of this than others, and in a few chapters, I found myself so bogged down with psychoanalytic language that I was tempted to skip over these sections. While I readily admit that psychoanalysis is not my primary therapeutic orientation, I was left with the impression that psychoanalytic theory is an excellent lens with which to view the dynamics involved in infertility. Indeed, this may be the ultimate narcissistic wound, the inability to perpetuate one's self. This point is well demonstrated throughout the book, most notably by a chapter on adoption, which points out that infertile individuals often view adoption as the “consolation prize” for their failure to reproduce. Further, a highly readable, sensitively written chapter on miscarriage and stillbirth stresses the importance of helping clients grieve a loss that is often glossed over or minimized by others in their social network.
While intended for mental health clinicians, medical professionals, and “the interested general reader” (p. xviii), the editors clearly assume a level of sophistication with psychoanalytic and psychotherapy argot. I cannot say that I gained much knowledge on therapeutic techniques to use with this client population, rather, I would consult Burns and Covington's (1999) scholarly manual for this purpose. However, this book does serve to remind us that our personal reactions to clients are crucial factors in the therapeutic process. More critically, we need to know what to do with these reactions and the “front lines” experiences of the contributors in Frozen Dreams provide a compelling resource.
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