Introduction

As we see in the Old Testament as well as many other sacred texts, spirituality has been shown to be a source of comfort and support during times of distress. One’s spiritual practices can help create meaning and bring strength to situations where it is normal to feel powerless and helpless, such as the struggle of infertility. Additionally, an individual’s religious or spiritual traditions can influence the meaning they make of the experience of infertility, and the options they are willing to consider [3]. Given this, it is hard to believe that, until fairly recently, therapists were not encouraged to discuss religion or spirituality with clients. Integrating the spiritual dimension of the person into treatment was thought to raise difficult ethical situations and blur boundaries between mental health treatment and pastoral guidance [4]. Over the past 25 years, we have seen an increased focus on the spiritual dimension. We also are aware of the need to discuss religion and spirituality with clients in an ethical manner [5].

This chapter will explore ways to address spirituality in fertility counseling, offer clinicians guidance on how to understand the degree of spirituality or religiosity in their clients’ lives, and address how or if they are related to the challenges of infertility. For the purposes of this chapter, spirituality is defined as the search for meaning, purpose and connection with self, others, the universe or a higher power outside the self. This may or may not be expressed through religious practices or formal institutions. Religion, considered one expression of spirituality, is an organized, systematic set of beliefs, practices and traditions related to spirituality, which is shared by a community or social institution [6]. These issues are explored in this chapter.

World religions and infertility

Most religious teachings speak to the significance of procreation, as well as the gender role expectations for men and women to become fathers and mothers. Through this lens, infertility can impact the self and relational identities of people wishing to become parents. Therefore, we see the risk for both a crisis of identity and of faith [7]. The relationship between religion and help-seeking for infertility is complicated [8], and continues to be a growing area for inquiry among doctors, therapists and others in helping roles [9]. Clinicians treating individuals and couples grappling with the challenges of infertility are advised to approach this dynamic with an “informed not knowing” stance, which will be explicated later in this chapter.

The body of scholarly literature on the subject of infertility and the role religion plays in decisions regarding intervention has been limited until recently. Layne demonstrates that, regardless of faith tradition, people who experience infertility may feel a sense of shame rooted in specific religious teachings [10]. At the same time, religious practices can help to manage and alleviate that stigma. There are several important writings that shed light on the attitudes of specific faith communities with regard to infertility and its treatment. In some cultures, childlessness may be experienced as punishment for some previous transgression [11]. Exploring the lived experience of Orthodox Jews in New York, Kahn describes the current rabbinical debates about what interventions are and are not permitted [12]. Important considerations include evaluating the suffering of the couple as they struggle with the principle of family and Jewish integrity. Assisted reproductive technologies (ART) are viewed as an aid to fulfilling the commandment to be fruitful and multiply; therefore Rabbis may permit many forms ART with certain limitations or accommodations. This is consistent with previous research showing that people of Jewish faith tend to be more approving of the use of ART than those of the Christian faiths [13].

Exploring the tension between science and religion, Roberts investigates the ways Catholic physicians in Ecuador reconcile religious teachings with scientific endeavors. The Roman Catholic Church has long held clear prohibitions against ART. The Vatican asserts that it represents human intervention in a domain that belongs to God alone. As scientists in a predominately Catholic culture, these practitioners overcome this divide through their spirituality. Many hold beliefs that God “is in the laboratory” and “is taking direct action” through science [14, p. 509]. They pray during procedures, and believe that, ultimately, God decides which procedures are successful [14].

Moving beyond Judeo-Christian religions, Hindus in India have been grappling with the Western view of infertility. Here ART is employed to assist God, and outcomes from treatment are not guaranteed. Many couples interviewed in Bharadwaj’s research speak of Hindu gods and goddesses they pray to for divine intervention. They recount being told by doctors and nurses to “leave things to God” after treatments [15, p. 456]. Many clinics have icons and pictures of patron saints, gods and goddesses, and some are even named for them. Pairing spiritual practices with science is seen as a form of parallel science. Like the Ecuadorian Catholic practitioners, Hindu practitioners in India speak of prayer as part of their scientific process. For those unable to conceive a child, the Hindu concept of karma can be a source of comfort; some women see their destiny to be childless as karma, or “destiny for a higher purpose in life” [11, p. 751].

Islamic law prohibits ART that involves any third party donation, as it violates teachings of the holy Q’uran related to adultery, incest and the integrity of biological descent. However, there are attempts to address this through legislation that would allow for embryo donation [16]. This has arisen through differences in beliefs between Sunni and Shi’ite Muslims in countries such as Iran, Egypt and Lebanon. Because of the cultural value placed on paternal lineage and property inheritance, there is less support for sperm donation than embryo donation [17].

African traditional religion places a strong emphasis on interconnectedness. Infertility experienced by an individual or couple impacts the entire clan. Many believe that ancestors who are not properly respected through certain rituals are angered, and curse those family members with infertility. Therefore, there are important cultural and spiritual practices that must be carried out as part of any intervention for members of these cultures. As the majority of Africans report using traditional healing before approaching more conventional medical care, these practices should be explored when working with African clients in treatment for infertility [11,18].

It is vital for clinicians to be educated about the role of religion and spirituality in the lives of clients who are coping with infertility and considering seeking help to address it. Higher levels of religiosity have been found to be associated with lower levels of acceptance of childlessness, and higher levels of intent to seek assistance with solutions to infertility [8]. It is crucial that clinicians avoid making assumptions about infertility and spirituality that may or may not apply to their specific client system. A summary of the major world religions’ positions on ART can be found in Table 5.1.

Understanding your client’s specific ideology

Clinicians working with individuals and couples struggling with infertility should determine what, if any, spiritual or religious beliefs influence clients’ decisions regarding medical intervention [19]. Social networks have been found to influence help-seeking behavior [20], and religion has been found to be both a resource and a burden when dealing with infertility [3]. Thus, it is useful to determine whether religious or spiritual communities are a part of the client’s life, and in what way. Other variables that intersect with religion and spirituality should also be explored. For example, the role gender plays may also be a factor. For some, the pull to fulfill gender expectations of manhood and womanhood that relate to having children may override religious prohibitions against ART [21].

A thorough assessment of the significance of religion and spirituality for clients addressing infertility should include exploration of their use in making meaning, coping with psychosocial distress and the presence of faith-based strengths to support them in the process [3]. Does the client experience their religious teaching, spiritual practices and community support as helping them to bear the unbearable, as a source of judgment and set of limitations on options, or both? Do conflicting religious beliefs and spiritual practices exist within a couple? If so, how does that impact decisions about ART? Not all spiritual people adhere to one specific religion or set of teachings, and individuals who identify with a specific religion may hold beliefs and engage in practices that differ from formal teachings [6]. The careful clinician will assess for these beliefs and meanings and not make assumptions based on gender, religiosity or spirituality alone. Suggested assessment questions are presented in Table 5.2.

When assessing spirituality with clients, it is common for them to inquire about the clinician’s personal views and practices. Clients may seek out a particular therapist because they assume shared religious traditions. Or they may ask specifically about beliefs and practices if this has not been assumed. Clinicians should normalize wanting to know this information as it is such an important part of life. Knowing how much of this personal information one is willing to disclose is helpful up front, to avoid awkward moments or sharing beyond what feels comfortable. This can also be a helpful moment in the engagement process, as the client is seen as unique and the clinician as wanting to understand more about what religion and spirituality means to them. Whether the clinician and client are the “same” or “different,” it is helpful to have a safe and confidential place to discuss the client’s specific, individual views and experiences. Some clients will feel more comfortable with someone who does not share the same religion because they will not judge them. Others will feel it is important that the clinician understands their beliefs and practices. Either way, the clinician can process the importance of religion and spirituality, thereby demonstrating openness to learning more from the client. In our experience, willingness to explore these themes outweighs the significance of the clinician’s personal beliefs.

Spiritually based interventions for infertility

For clients who are spiritually inclined, the crisis of infertility can ignite a simultaneous crisis of faith; others draw upon their spirituality as a source of strength; still others experience mixed feelings or confusion about previously unquestioned spiritual tenets. As each client experiences infertility idiosyncratically, so too is each client’s understanding of the intersection of infertility and spirituality unique. Nevertheless, common themes surrounding spirituality may emerge in clinical work with patients experiencing challenges to family building.

As clinicians who are open to attending to spirituality in our work with clients experiencing obstacles to family building, we have identified the following intervention strategies to help clients navigate these two very profound and complex dimensions of the human experience. These include:

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  informed not-knowing;

  
  
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  telling the story;

  
  
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  naming the losses;

  
  
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  speaking the unspeakable;

  
  
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  grieving the losses; and

  
  
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  identifying options.

These intervention strategies are not necessarily linear over the course of treatment, nor are they related to a timeline. Instead, they are thematic and intended to provide the clinician with a general guideline to treatment. In essence, they are tools to use in addition to an existing professional skill set. The client should set the pace of treatment, and feel free to return to earlier material, if necessary. The clinical vignettes presented below are fictionalized composites of case material. No identifying information is included.

Informed not-knowing

Every clinician brings his or her own professional training and personal experience to each client encounter and, at times, the circumstances of clients’ lives may seem all too familiar if the therapist has a personal history of infertility or shares similar spiritual beliefs with his or her clients. By adopting a stance of informed not-knowing, therapists are reminded that knowledge and training can provide an outline or rough draft out of which clients are able to tell their version of the story. The questions therapists ask in assessment and throughout the treatment help bring diffuse feelings into sharper focus, and continue to challenge the therapist’s assumptions. The therapist asks clients to define their experiences, rather than imposing the therapist’s own understandings upon clients. The questions the therapist asks are informed by knowledge, training and personal experiences with spirituality and infertility, but clients are the experts about their own experiences, feelings and beliefs. The manner of the therapist’s questions and interventions communicates respect, curiosity and lack of judgment about clients. Therapists are not afraid to ask for clarification if they do not understand what clients are telling them. This attitude of informed not-knowing gives clients authority to help the therapist understand their unique experiences of infertility and spirituality. (See Table 5.2 for a complete list of spiritually informed questions regarding the role of religion, spirituality and infertility.)

Melinda and her clients, Dav and Miriam, are members of the same Orthodox Jewish community (although they worship at different synagogues). Melinda has extensive professional and personal experience with infertility; she used a donor embryo to become pregnant with her only daughter, and feels no conflict between her religious beliefs and her own treatment choice. As she works with Miriam and Dav, she finds herself feeling frustrated by what she sees as Miriam’s dogmatic interpretation of Orthodox Jewish beliefs regarding ART. Melinda is aware of her feeling that were Miriam and Dav to proceed with using a donor egg, or to undergo an adoption process that resulted in adding a child to their family, Miriam would change her mind about the importance of being biologically related to the child. Melinda views her frustration as a signal that there is something she is not understanding about her clients’ experience; her awareness of the differences between her viewpoint and that of her clients reminds her to adopt a stance of informed not-knowing in her work with them.

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