How to Look on the Bright Side (Part 3)

This is the part where I try to sum up a lot of thoughts about the "encouragement card" given to a woman by her clinic (Part 1) and the study that led to the card's creation (Part 2). Let's start with the obvious, alright?

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The encouragement card (PRCI) did not work for me.

Apparently, I'm in the minority of women who—given only the two choices that were offered in the study—prefer the PMI affirmations over the PRCI card.

It's not that affirmations like "It's great to be alive" feel especially true right now. Actually, that's kind of the point. I see them not so much as true or untrue, but simply as ideals, maybe even fantasies where I can briefly escape. Living with them for a moment is all that's required. Because it's so easy to do, the affirmations somehow bypass the tangled hairball of thoughts in my head and just make it easier to breathe for a minute or two.

In contrast, the PRCI statements get my guard up right away. They tell me to do something that I don't know how to do, and they make it sound easy.

It's not easy. What ARE the "positive aspects of the IVF experience" or infertility in general? It hasn't brought me the closer relationships mentioned as an example (in Part 2). It has led to some wonderful new relationships, while putting others under strain.

I am aware that just being able to try "the most advanced fertility treatment" makes me compare "favourably with others who are less well off," and I'm grateful for that chance, but I'm also aware that it's only a very small CHANCE to do what most people do naturally. A chance is NOT (repeat, NOT) any kind of guarantee. And when it doesn't work, then what?

What have I gained? About 15 lbs. Also, several containers full of used needles. Possibly, on the best days, a slightly better sense of humor and awareness that everyone is fighting some kind of battle, whether it's visible or not. What have I lost? Most of my life's savings, half a decade of my time, and all of this.

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The intention was so good that I hate to criticize the execution.

The introduction to the study (Part 2) does a good, detailed job of explaining exactly what's stressful about IVF. Because infertility can create so much stress and pain, I'm truly glad to see attention being focused on mental health in this context. These people recognized a need and made quite a serious effort to address it. That's great!

Also, just because the PRCI doesn't work for me doesn't mean it doesn't work. Other patients apparently do feel helped by it to some degree. Honestly, those results rattled me, making me question whether bitterness may be obscuring my judgment. After more thought, though, the way I see it now is just that different people prefer different tools, and the two covered in this study are by no means the only ones that exist.

Even if I can't think up "positive aspects" of IVF—the main way these researchers envisioned women using the PRCI card—it did help in one way. It prompted me to make my own encouragement card (in Part 1), remembering other methods I've used to look on the bright side more authentically.

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But let’s be honest: there are problems with the execution.

I see two problems with the PRCI card and, to a lesser degree, with the PMI affirmations. The PRCI's vagueness and repetition (all the variations on "be positive") are the most obvious issue. Underneath is the unquestioned assumption that being positive should be an IF patient's main mental-health goal.

Isn't it important to maintain a healthy attitude? Well, of course. It's one of my main goals every day, and I'll always be willing to try any strategies that are aimed at genuine healing. ALL of them. The more the better! The thing is, I don't always equate "healthy" with "positive."

In Part 1, two commenters wrote about the need to acknowledge all of our emotions, dark and light, as the only way to get through them (not over or around them), and I agree. Forced positivity can invalidate people's real experiences. Positivity becomes forced, I think, when these impulses are at work in the person who's giving the advice:

• Enforcing a smiling decorum
  This mode prioritizes seeming good over feeling good. Some people are just uncomfortable with grief. They want us to feel better. They may think that by acting like everything's OK, we may come to believe it, or at least we'll avoid bothering anyone else. But it comes to feel draining and fake. Suppressed feelings tend to leak out anyhow, sometimes in more damaging ways.
• Lecturing with "at least" statements
  Saying that we can't be sad because someone else has it worse is like saying that we can't be happy because someone else has it better. Actually, it's possible to feel happy AND sad (or other emotions) all at the same time. Appreciating the good doesn't require denying the rest. Denial just makes a habit of disassociating from reality, which can also interfere with feeling good.
• Blaming circumstances on attitude
  Of course, the choices we make contribute to some of the outcomes we have. On the other hand, sometimes shit just happens. But if people can think up a "reason," they can feel smugly assured that similar things won't happen to them if only they don't make the same "mistakes."

I doubt that the people who developed the PRCI were motivated by the impulses above. They were, I'm sure, sincerely trying to help, and the tool they created was based in part on feedback from the study participants.

But I still worry that the shallowness of the statements in the PRCI promotes putting on a happy face (decorum) more than true healing.

One of the stated intentions was to help people focus on "comparing oneself more favourably with others" ("at least" statements), especially other IF patients. While it isn't inherently wrong, I guess, it hardly seems complete. What I hear is, Hey, we know the situation sucks enough that you need encouragement, but let's pretend it's not true by focusing EXCLUSIVELY on the 5% that's OK. That feels delusional.

Finally, acting as if a simple attitude adjustment is all that's needed may leave people blaming themselves (blaming circumstances on attitude) if they end up still struggling.

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Can I frame all this in a more "positive" way?

My goal is to feel not so much positive as whole, which means somehow integrating the most unpleasant truths in my life without getting overwhelmed by them (lost in self-pity, depression, and so on).

How to do that? Well, I'll start by acknowledging that it's not easy! It's probably the work of a lifetime, in fact. Seeking that balance has been the driving force behind this blog for over 100 posts now, and it feels like I've made just the barest beginning. I'm nowhere near done.

And my personal "encouragement card" (Part 1) is not intended to be the final word. It's the result of one evening's worth of brainstorming. It's an attempt to start a conversation.

So again ... what would you add? What strategies have kept you relatively healthy and whole when dealing with the hardest parts of infertility? Also (and this is much harder than it sounds), can you summarize them in a few words that would fit in a pocket-size list?

What would be on your personal encouragement card?

How to Look on the Bright Side (Part 2)

Last time I mentioned an "encouragement card" that another woman received from her clinic. Now, as they say, here's THE REST of the story!

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I've come to learn that the original card wasn't just one clinic's kind but quick attempt to be helpful. In fact, the card was carefully developed and evaluated as part of a double-blind study.

Researchers at Cardiff University in Wales were hoping to help women find effective ways to cope with the stress of IVF. The goal was to develop a "Positive Reappraisal Coping Intervention (PRCI)" card that was based on respected theories, inexpensive, simple to use, and generic enough to be used by other types of patients later. Here's what the researchers proposed:

"One meaning-based coping strategy that seems particularly likely to make (re)appraisal more positive is positive reappraisal coping, which may be understood as 'cognitive manoeuvres' or cognitive efforts ... that change the meaning of the situation. Finding positive meaning may involve appreciating the benefits that the situation has brought to one's life (e.g. closer relationships), comparing oneself more favourably with others who are less well off, or redefining the situation such that it seems more positive ... individuals may focus more on positive aspects of a situation rather than ruminating about (or conversely trying not to think about) negative and distressing aspects. Such efforts in the IVF context may involve focusing on the fact that the most advanced fertility treatment is being tried, or that a partner is especially loving and supportive."

The research subjects were women undergoing embryo transfer at a large urban hospital in the UK. Of the 55 women, 28 were given the PRCI card and 27 (the control group) were given a Positive Mood Induction (PMI) card. The women were instructed to read the cards at least two times a day during the 2WW, and then evaluate the cards' effectiveness. Here's the content of the two cards:

(source)

Sure enough, the PRCI was rated to be more helpful and suitable than the PMI, and to have more enduring effects. On the other hand, although the women rated the PRCI the highest of the two, their endorsement of it still seemed fairly lukewarm:

(source)

The researchers suggested that the PRCI may work because the "focus on positive aspects of the IVF experience" (using the PRCI) requires more cognitive processing than focusing on affirmations, which may or may not feel true to the individual (using the PMI).

When affirmations don't feel true, they may even be counter-productive. The researchers cautioned that the perceived benefits of the PRCI, in comparison to the PMI, may be due partly to this effect, and/or to the fact that the PRCI simply provides a distraction from worries.

Along with thinking of benefits and repeating affirmations, simple distraction is also a recognized coping strategy. While the researchers found the PRCI to be promising, they also allowed that different people prefer different coping methods.

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Coming next: my attempt to sum up a whoooole lot of thoughts and feelings about this study.

How to Look on the Bright Side (Part 1)

On a private forum recently, a woman who's been TTC for a while wrote about receiving an "encouragement card" from her clinic. It was a pocket-size card that listed these suggestions:

1. Try to do something that makes me feel positive.
2. See things positively.
3. Look on the bright side of things.
4. Make the best of the situation.
5. Try to think more about the positive things in my life.
6. Focus on the positive aspects of the situation.
7. Find something good in what is happening.
8. Try to do something meaningful.
9. Focus on the benefits and not just the difficulties.
10. Learn from the experience.

Do you see a pattern here? Except for numbers 8 and 10, these tips all seem to be variations on "Be positive." (If there's a difference between "See things positively" and "Look on the bright side," it's too subtle for me.)

Several of us on the forum had the same reaction: after the second or third cliché, we started feeling put off, maybe even patronized. We heard echoes of the infamous "Just relax!" Because while everyone agrees on the need to, say, "make the best of the situation," the huge daily question is HOW.

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Of course, to be used in this format, the "how" needs to be as brief and universal as possible. I know how hard that is, and I appreciate the clinic's effort, since (in the interest of being positive, not just pointlessly snarky), I took a shot at it myself.

How to translate platitudes into actions that I actually know how to DO? Here's what's worked for me personally, or at least as much of it as will fit into a tiny, pocket-size list. (Obviously, whole books could be and are written about each point, and your own points may differ!)

1. Focus on the things I can control, and act decisively.
2. Maintain balance by continuing to do non-TTC-related things that make me feel good.
3. Maintain perspective and connection by sharing support with others who are also struggling in some way. 
4. Allow myself to hope for success, to the extent that doing so feels more uplifting than painful.
5. Consider that what seems like a setback now may have some positive results that are not apparent yet.
6. Consider that, even if I don't have success, growth and joy are still possible in my life.
7. When good things happen, however small, pause to savor them in that moment.
8. Seek out things that make me laugh, not to put on a happy face, but because it feels freeing and brave.
9. Notice what tools help me feel and function better, and make them priorities.

I can only come up with nine points. Is there something you would add, to make it an even ten (or more)?

Also, coming next: some surprising background on the encouragement card!