Group Analysis Application for Overcoming Infertility
Trying to overcome the difficulties with setting up a group on our own, Igor and myself got together as a pair of co-conductors for this group to be born. We find it important to mention that we both have a positive experience of parenthood and our personal matrix has been reproductive.
The key vectors of the group dynamic processes have been described based on co-leading a weekly slowly-opening group for the women with infertility for five years. During this time the composition of the group was gradually changing. Out of the 17 women, 9 got pregnant and gave birth to a baby, one participant adopted a baby. We made three attempts to let three men with infertility issues into the group one by one but they would not stay. The dynamic processes in the group reflected its role as the womb – holding and non-holding, as the mother – accepting and rejecting, as the group – inclusive and excluding.
The motives for the child-bearing and its obstacles
Freud understood motherhood as one of the means for a woman to cope with the deficiency: a woman finally acquires something – a baby who fills her up.
Mathias Hirsch differentiates three forms of the wish to have a child: 1 – a mature, legitimate and narcissistic desire to achieve identity of a grown-up person (both for a man and a woman) and the reproduction; 2 – a teenager remonstrative attempt to forcefully become an adult and separate from parents and 3 – an attempt to create a mother object for herself in the desirable child as an expression of the regressive needs, i.e. to become mother for herself in the child (a better mother than her own mother in the childhood). Leticia Solis Ponton (2002) adds: “A pregnant woman becomes a different one, she acquires a new quality, she aligns with her own mother. The figure of mother turns into a figure of the eternal competitor. Therefore, it is possible to win a victory over her mother and to become mother herself”.
According to Petter Kutter (2010), the set-up of this homogenous group was related to the request about being unable to bear a child and overcoming some status-quo rooted in the family matrix with the experience of trauma. Despite the homogeneity of the group where the female participants were connected by the common target to become pregnant and to give birth, we could observe the development of the dynamic processes reflecting various aspects of both the fertility issues and the issues of the object relations of the participants.
An integrated outlook on the infertility involves recognising many physiological and psychodynamic mechanisms. “… the infertility enters the circular flow where the mutual impact of the mental and the physical turns the movement into a spiral”, writes Leticia Solis Ponton (2002). The bodily manifestations of the participants were linked to such physical anomalies as intrauterine septum, infantile uterus and endometreosis. The mental aspect showed us the phantasies about the impossibility of communication, their own infantile deficiencies, unwillingness to grow up and to leave the paradise of freedom and irresponsibility.
From the onset of the group we noticed a special defense mechanism that we called the group somatisation. Going through the departure of one participant, changing the setting, a sudden miscarriage, or failures with in-vitro fertilization led to the group associations on the bodily level: discussing the tests, seeing various specialists, the coming or completed surgeries and medical manipulations. This mechanism caused the collapse of the space for the phantasies about the impending pregnancy and labour. Elimination of the physical factor – application of the extra reproductive technologies or removal of the intrauterine septum – has brought the task of the expanding the inner psychical space encouraging the emergence of the thoughts, ideas and phantasies about the pregnancy and the future baby.
When the participants brought the issues of infertility into the group, they shared their feelings of infantilism and unworthiness mixed with shame and guilt. They talked about the presence of the so-called communication “buffer”, preventing them from repairing relations with a husband, mother, mother-in-law and in the group – with other participants. The ambivalent feelings of the participants hindered the wish to start talking, aggravating communication barrier, since there was a simultaneous fear of changes and the on-coming “desirable undesired pregnancy” (M.Hirsch) – as if talking in the group unified by such common issue could cause an immediate pregnancy. Overcoming the communication barrier allowed to get in touch with the unconscious mechanisms of infertility.
Relationships with their own mothers
The group participants had associations ranging between pregnancy and shame. When the subject of shame connected with pregnancy used to come to the surface in the group, the participants more often than not discussed their relations with mothers.
Vignette:
Participant A: My mother still does not know that I am doing IVF and many other things. I do not want to share this with her. I am afraid of disapproval. I am not letting her into this. Mother comes from the patriarchal family. Our family has never discussed any issues related to child bearing and sex. It felt like something indecent.
The conductor: It is easy to talk about IVF as if it is something not related to sexuality. Sexual relations are considered as something disgraceful, dirty and shameful though they result in natural conception.
Participant B: Sometimes I want my mother to be near and tell me nothing.
Participant C: My mother can get very angry, she says that if I ever have children, she won’t help me, she won’t engage into their upbringing as if children are wicked; she used to beat me when I was a child.
There were memories of how disrespectful their mothers were towards the manifestations of their daughters’ femininity. Two participants said that while attending the group, they realized that their mothers prevented them from having warm relations with fathers.
Dinora Pines mentioned that the majority of the infertile women she had treated “had difficult, conflictual and disappointing relations with their own mothers”. They talked about their dependence on mothers and the need to get rid of this dependence. The hatred of mother was often hidden behind their numerous stories about “an angry mother-in-law”.
The plans for the child-bearing have been questioned from time to time: “Maybe I should not give birth to children and remain single, after all people live without kids?” The group phantasies reflected the contradictory attitude towards a child and a child-bearing. There were questions like: “Will I be able to love the child? What should I do if the baby is not healthy? Can I adopt an unhealthy child?”. The subject of giving birth to an unhealthy child emerged every time when one of the participants was about to do IVF. They explored the issue: “Adopting an unhealthy child would mean … spending a lot of time with him or her, I won’t have much free time”. These associations produced an unconscious phantasy regarding not only their own unworthiness but the deprivations the motherhood necessitates.
The need to make a choice between your own realization in the role of mother in the contemporary reality of the social life with the leveling of the differences of the gender roles has been the frequent theme in the group. This dilemma caused annoyance in the participants.
The pregnancy in the group
The occurrence of a pregnant woman in the group produced contradictory feelings: joy, envy, phantasies about the temporary limitations of the reproductive function, despair and tension. After cheerful congratulations someone would tell «an awful story» about an incurable disease or death of their relatives or loved ones. The idea of death as an antithesis to birth has been generated at the primordial level of the group work. At the level of partial object relations there was an attack on the pregnant womb and the idea of pregnancy per se, and an attempt was made to abort the pregnant participant by the womb-group. At the level of the transference relations the pregnant woman was the object of envy and hatred. At the level of actual relations there were phantasies and fears that remaining in the group could lead to the loss of the foetus and the expression of care about the participant and her pregnancy.
The reaction or the attack on the announcement about the pregnancy of a participant was expressed in such monologues: “This week on the road I have seen not very alive creatures like dead dogs, cats, birds and butterflies. Should I read it somehow?”
A pregnant woman in the group caused an intense sense of envy and was subjected to the unconscious attacks of other participants aimed at depriving her of the pregnancy. The pregnant women attending the group quite often had a wish to stop the therapy. One participant anticipating the envy of others left the group without announcing her pregnancy. Afterwards the information that she happily carried her pregnancy to term and gave birth to a healthy baby, brought the feelings of anger and envy in the group which were used as a cover to accuse this participant of using the group for the child-bearing.
There were also fears regarding the need to hold the pregnancy, a missed miscarriage or abortion together with the discussion of the pregnancy. When a pregnant woman would announce a miscarriage, the participants were seized with hard feelings of loss and despair that the goal may never be attainable. The phantasies about miscarriage often coincided with the female or male participants leaving the group.
About my countertransference
From the beginning of the group work I, being the group leader, experienced tenderness and sympathy for the problems of the participants. I had phantasies about how I could comfort and take tender care of these abandoned, rejected and needy children, how I could create conditions in the group for their proper development. The themes of mothers’ devaluation generated complex feelings – empathy for the participants as the victims of harsh treatment or mother’s rejection gave way to annoyance and anger due to the lack of gratitude towards mothers. The announcement of the pregnancy or the birth of a child caused joy and pride for the fertile potential of the group.
Thank you for your attention. I am turning it over to Igor.
The man-co-conductor in a group of women with infertility
As a co-conductor I was the only man in the group most of the time.
When the themes of difficult relationships with mothers emerged in the group, I felt as if the leading co-therapist was angry with me. I understood that this anger was connected with the processes of the group projective identification and placing in myself the horrible murderous aspects of the overbearing mother (Isobel Conlon, 1991). I thought about the participants with pity as of women immature for their age who refused to give life to a human being.
The conductors who introduced new participants into the group, on the phantasy level had been perceived as the fertile couple who was getting new female members. The more participants joined the group, the more intense the feelings became. The group interpretations helped to reveal envy and anger aimed at the conductors who seemed to encourage this tension. Later when another participant was integrated by the group, we observed the renewal of competition between the participants and the female conductor.
There were two episodes in the life of the group when the female co-conductor was absent for two sessions on end. When we announced this to the group, the fact that she would be absent caused embarrassment in the participants, a few participants blushed, someone said “we will show ourselves now”, another mentioned “it is getting hot”. The participants were excited from the anticipation of being left with the leader one-on-one. The presence of the female conductor eliminated competition with her but intensified the competition among the participants. Her absence was the signal that someone could take her place. This meant the upcoming possibility to become mother.
Special dynamics unfolded at the sessions when the female conductor was absent. At the first such session I felt excluded from the discussion. These experiences were similar to those that Leticia Solis Ponton (2002) described as the feelings of the excluded father. Asexual atmosphere appeared as a result of the suppression of incestuous impulses for the fatherly figure of the conductor in the absence of the female conductor. I felt that the participants were trying to exclude me from the group field and this hurt me. It seemed as if they were afraid of showing their femininity in my presence and I could not see women in them. When I could cope with my feelings, I managed to find an interpretation which led to the release of tension.
The changes that had happened to the participants in the course of the therapy seemed to have disappeared. This was clearly the regress towards the child-mother relationship without any space left for father. Leticia Solis Ponton(2002) writes: “Infertility protects from punishment”, “one cannot desire a man, a father”, “the punishment for this is the exclusion of father from the phantasy and symbolic field, and self-denial when it is impossible to be not only a woman but a mother as well”.
On the external level everything looked peaceful, the participants started to discuss every-day issues and seemingly got together around the family hearth where there was no place for father. A phantasy came that «mother has left and father does not know what to do with the kids and the kids don’t know how to behave».
I have remembered the movie by Mario Monicelli “Let’s hope it’s a girl” (1986) about the contrast of the female and the male where a small number of the representatives of «the stronger sex» have been shown as awkward and weak characters. In this movie a group of women lives in harmony on the farm in the countryside; «little exciting events» happen there but there is «no space for sex, fun or violence». Women have to cope with any emerging problem on their own. It looks as if men have been excluded from this community.
The participants perceive their fathers as weak people: the father of one was addicted to alcohol, the father of another participant suffered from mental disorder, the father of the third committed suicide. The weakness of father generated the phantasy that he did not need children. However, there was also longing for father who was absent in the most important moments of one’s life. This situation was symbolically represented in the group.
The fragment of 88th group session:
А: Was my father really present in my life with that male function which he was supposed to fulfil? I realized that he was not because there was a period when I was 14 years old and we could not rely on him due to his mental disorder. I used to ask mother why she needed him like he was, let’s collect things and leave. His behavior annoyed me back then. All this gave rise to the thoughts about myself being capable of solving everything on my own – to reproduce, to support and to bring up kids. I thought that father is not much needed in the married couple. I have always wanted to have a spouse who will not resemble my father. My husband is not like him but he is the same hair-splitting type. Do I need it for some reason? Why do I need children from him? Though I can rely on my husband both financially and emotionally. He is a solid guy. The absence of the male aspect since my childhood does not allow me to hand the reins over to him, to express femininity, the woman in me, the weakness that comes from nature. The lack of this part had consequences and played its’ role. Maybe I will explain that my husband cannot have children naturally, he had some illness. I use IVF and can conceive a child on my own. This week I have understood and become aware of the connection between my relationship with father in my childhood and the relationship with my spouse. I hope I will work on this aspect in relation to men and the male.
B: I also wanted a husband who would be totally different from my father. In terms of appearance they differ but as it turned out they have a lot in common. No matter how much I tried to get rid of this, I am afraid, there will be less differences with time.
С: I think it is the same with the majority of people.
D: With the majority? I never heard of this. In my case they are the complete opposites in nature but similar in appearance.
The conductor: It seems that you are referring here to the longing for a strong man…
At the second session when the female conductor was still absent, the participants began talking about sexual relations and started to question the conductor cautiously.
At this session there was an opportunity to build the relationship Donald Winnicott (1956) wrote about: “The role of father is of vital importance because he supports his wife emotionally and financially. Then he gradually builds relations with his child directly”. Here the group itself has become mother for the participants.
The return of the female conductor has caused embarrassment and some participants decided to articulate their sexual phantasies. The acknowledgment of their desires in relation to father paradoxically decreased the tension and encouraged intimacy. The reunion of the conductors enhanced the phantasies about their relations and created the conditions for the phantasies about the primal scene. Ronald Britton (1985) writes: “The phantasies of the group about the conductors connected with the primal scene should be acted out”.
The theme of sexual relations in the group referred to «the forbidden subject». Husbands were deprived of masculinity and were presented by the participants in their descriptions as infantile, irresponsible and not capable of fulfilling their fatherly role half-children. The phrases of the participants of «how I can become pregnant and give birth if my husband behaves like a child» hid the thought: «I don’t want to give birth, I want to remain a child, my husband will be giving me everything as if I were a child». Helene Deutsch (1925,1965) writes that «if a woman uses her husband as a child, this could infantilize him and, in its turn, lead to frigidity» and, consequently, to infertility. She connects this to the unconscious phantasy «against the complete acceptance of the feminine position».
Peter Kutter (1976) relates male weakness and unreliability to the hatred of a harsh mother. Psychoanalysis considers the birth to be a traumatic process in which the subject for the first time comes across the loss – the loss of the refuge of the mother’s womb and the loss of the principal part of his or her body – the placenta. In our group the placenta or afterbirth has become the symbol that was nurturing and protecting the group. The group, including the pair of conductors, symbolized such protection. It gave hope, simultaneously being the reservoir for the destructive phantasies. After all, the placenta has also been an excretory organ where the participants used to place their negative projections which needed detoxication.
The unconscious aggression towards the conductors was hidden behind the toxic stories about deaths, funerals and suicides. The fantasies of the participants did not show their biological parents as couples; there were ideas that father and mother should be separated to the utmost, as if by doing so they can be protected from «killing each other». These projections induced the split-up in the pair of conductors who often felt tension between themselves and needed to discuss and process their feelings both on their own and in the supervisions.
This integration in the pair encouraged the development of communication and gave an opportunity for the participants to perceive the group in general as a good object.
Has the group therapy helped the participants to overcome infertility? I would like to hope that it has.
Almost in all cases after the birth the participants announced that they gave birth to a child as if demonstrating it to the group, being grateful for help and support and acknowledging the role of the group in their achievement.
In one case we can specify that the birth of a child, though bringing a desirable result for the participant, has led to the return of the symptoms, the appearance of the aggressive impulses towards a child and the conflicts with husband. This supported the idea that the childbirth itself does not make a woman a mother. She becomes the mother when she begins to build up the constructive relationship with the child.
In the course of the therapy, regardless of the homogeneity of the group, we noticed the signs of the personal growth: being more confident in their female and motherly identity, the increase of the external manifestations of the femininity, becoming aware of the value of the group for yourself and the ability to feel gratitude to the group and the conductors.
As many analysts believe, group analysis does not relieve people from their problems but creates conditions for them to be solved. We can only hope that such conditions have been created in this group.
Irina Rotova is a psychiatrist, psychotherapist, Candidate of Medical Sciences. Internationally: Full member of GASi, EGATIN and EFPP delegate.
She defended her dissertation at the Faculty of Psychiatry of the Siberian State Medical University on the topic “Borderline neuropsychiatric disorders in pregnancy pathology”.
Interests include pregnancy, motherhood, infertility problems, miscarriage, reproductive psychosomatics. She conducted research on neurotic disorders and anxiety levels in women with pregnancy pathology and postpartum depression. She has published scientific articles on several issues, but especially in the field of psychotherapy and group dynamics in women with pregnancy pathology (threat of termination, eclampsia and preeclampsia, pathology of the placenta).
Igor Mikadze, psychotherapist and group analyst.
He is engaged in private practice and the practice of applied group analysis in Moscow, engaged in individual and group psychotherapy, psychological counseling.
He was engaged in addiction psychotherapy, worked as a consultant psychiatrist with dependent patients infected with HIV. He was a leader in groups of patients with idiopathic infertility. In the field of interests, therapy focused on transference. Full member of GASi.
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