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SART Fertility Experts - Why do I need to see a mental health professional?

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This episode of SART Fertility Experts features reproductive psychologists Dr. Danielle Kaplan and Dr. Julie Bindeman. They discuss the role of reproductive psychologists in supporting individuals and couples undergoing infertility treatment, including those using donor gametes. It clarifies that mental health consultations are not gatekeeping measures but opportunities for education and support, focusing on the complexities of raising donor-conceived children and managing the emotional challenges of fertility care. The conversation addresses common misconceptions, the diverse backgrounds of patients, and the importance of cultural competency in mental health care. Cost and equity issues related to fertility counseling are discussed, emphasizing the need for specialized training among providers and the value of building rapport with patients. The dialogue concludes with practical advice for seeking qualified reproductive mental health professionals.

Good morning, I'm Dr. Danielle Kaplan, and you're listening to an episode of the SART Fertility Experts podcast. I'm here this morning with Dr. Julie Bindeman, who is a reproductive psychologist and the chair of the Mental Health Professionals Group for the American Society of Reproductive Medicine. And Dr. Bindeman and I will be talking this morning about why a person might be referred for mental health care if they're undergoing infertility treatment.

Dr. Bindeman, good morning. Good morning, Dr. Kaplan. I'm so happy to be here.

We're so happy to have you. So you said you were a reproductive psychologist. Can you start by explaining what that is? Absolutely.

So I have my graduate doctorate in clinical psychology, which is the basis of my education. From there, I got specialized training and consultation in the field of infertility counseling, as well as birth trauma and pregnancy loss and postpartum issues. So when I talk about being a reproductive psychologist, it's an umbrella term for all things reproduction.

And it's important to note that there are other mental health professionals of other disciplines like counselors, marriage and family therapists, and social workers that also receive this specialized training and consultation too, within this field. Fantastic. So you and I belong to the same organization for the sake of disclosure.

We're both psychologists. But if you're referred for reproductive or fertility counseling, you can see somebody with any of those degrees or levels of licensure, as long as they have specialized training in the field. Yes? Correct.

Okay, fantastic. So now let's get to the big question. Why is it that people who are undergoing infertility treatment are referred for mental health care at all? Well, Dr. Kaplan, as you know, going through infertility treatment is a really stressful process.

And oftentimes, it brings out doubts and fears and negative beliefs in people that they might not have ever experienced before. I often think of it too, as the first crisis that many couples experience together. And so it might be the couple coming in for therapy because their communication has been strained, or it might be individuals coming in because they need to make decisions about treatment or just getting support as they go through this really grueling ordeal at times.

And to make note, not all infertility treatments are so grueling. But I think when people are doing more than one retrieval, more than one transfer, that's when it starts to be hard. That first cycle, people are so hopeful, so excited.

And if it doesn't take that first time, that's when I think that fear and doubt really starts to settle in. Yeah, absolutely. And I think what I would add to that is that there are some people who know from early on that they're going to need help building their families.

A hundred percent. And some people who that has always been the plan. So I think about people who might not have certain reproductive parts, whether that was just through their own genetics, or whether that is because they're assigned male at birth, and they identify as trans woman, or they're assigned female at birth and identify as a trans man, or they're a queer couple, or a lesbian, gay, you know, so many different families, a single parent, all of these different kinds of families will know at the onset that in order to create a family, they're going to need our help.

Yeah, which doesn't make it any less stressful, by the way, it makes it a very different kind of stressful. And that's one of the things that I really want to emphasize is that not all infertility is created equal. The impacts of infertility are not the same for everybody.

And the stresses of receiving and needing care are not the same for everybody. Absolutely. Okay, so somebody gets to your office, how do they get there? Oftentimes, they are sent to me by either their RAI, by their OBGYN.

If they're going through the process of needing to use donor conceived gametes or donor gametes, they might have their lawyer refer them to me. So there are lots of different ways people might find me, they might find me through my website, they might find me through different kinds of directories, but looking for people that have this specialized kind of training. Okay, so I want to just note something here.

SART has in their social media area, something called Misconception Mondays, where they talk about all the things we think are true of fertility and infertility that aren't. So I want to name a misconception here, which is that if your doctor refers you for mental health support, it's because they think you're too stressed, too sad, too anxious, and unless you get treated, they won't refer you or they won't continue with you in care. Such a good misconception to point out, because it's so true.

Oftentimes, you know, and one of the things that us as mental health professionals are doing is we're really helping our RAI colleagues recognize the stressors that can happen for clients. And when we can help their patients, our clients, it makes the process for everybody better. Yeah, and we, you and I do similar work, we enter into this at different parts of the process.

So I will sometimes see people if they're going to consider using donor gametes, I'll sometimes have ongoing therapy patients who find out that their family building isn't going the way that they thought it would. So we step in at a lot of different points in the process. Yeah, I mean, I've had ongoing clients that I've seen for lots of time, nothing to do with infertility.

And then they come up to that being in that reproductive age time frame, and for different reasons have also then needed my support because of a reproductive challenge. Yeah, something that I say a lot is if you look at the average person who goes to therapy, it's female identified people in their 20s, 30s and 40s. And guess who's often trying to build their families, female identified people in their 20s, 30s and 40s.

So we're doing a lot of crossover work. All right, so that's how people get to you. I'm going to try to break it down for just a second, because we do so many different things.

What about the people who are referred to you specifically because they find that they would benefit from donor eggs, donor sperm, sometimes donated embryos? What does it look like when those people land in your office? That's a totally different circumstance. And I'm really glad you differentiated it as such. And I think we're talking too about different pieces of that circumstance.

So I might see an individual or a couple who needs to use donor gametes. They're coming into my office, not because I am making a decision about whether or not they can be parents. They're coming into my office for a really thorough psychosocial consultation, so they can understand the lifelong nuances of what it means to raise a child that doesn't share genetics with both parents.

Okay, so let's say that again and mark it with a big yellow Invisible Podcast highlighter. Are you ever saying that anybody would be a terrible mom, a terrible dad, they shouldn't proceed, they're too anxious to proceed, anything like that? So very rarely. I don't want to say never.

Very, very rarely. And it would be because there's something that would be getting in the way of them. Or I would have a concern, a very, very valid concern about the safety of a potential child.

And oftentimes it's not so much that I'm saying, no, you can't do it. What I'm saying is, I think you might benefit from X, Y, or Z prior to beginning your journey. Right.

And so when I do these consultations as well, I'm talking about all the things you're talking about. And sometimes I will switch hats and I'll say, look, I'm trained as a fertility counselor. I'm also trained in perinatal mental health.

Do you mind if we talk about support for you? That's not a gatekeeping function. That's an, I want everything to be wonderful and happy and healthy as far down the line as we can see. So I'm in the business of trying to help you look down the road.

It's not, I'm in the business of saying yes or no. Absolutely. Okay.

So are you testing people who are receiving donor eggs, donor sperm? Meaning intended parents? Yeah. Oh, absolutely not. Because again, this is not a gatekeeping kind of endeavor.

This is a psychosocial consultation. Okay. And we're, we're hammering on this point over and over and over again, because I think nine times out of 10, when somebody calls me for this work, they say, my doctor said, I need a psych eval because I need donor sperm.

Yes. And what I would beg for our REI colleagues, if you're listening to this, is spend a little bit of time explaining that the meeting with us is not because we are determining a yes or no. It's because we're giving some vital education that will not only serve the parents, but also serve that future potential child.

Right. And that's interesting, right? Because we're thinking about people who aren't here yet and what they might need and what their experiences might be. And it's so hard when you're in this position, because all you want is the take home baby.

Yes. Yeah. So I actually start a lot of my meetings by saying, I know it's us that's meeting.

And I want you to imagine sitting behind you is that future potential child who has the opportunity to hear what we're talking about today. Wow. That's really lovely.

Can I steal that? Absolutely. I mean, I stole it from a colleague too. Okay.

Fantastic. With permission. Okay.

Thank you for the permission and the attribution. All right. So that's what the meeting looks like.

What is the clinic here afterwards? So I tend to write a really brief letter that speaks about the content of the meeting, not the specifics. So I'll start the letter out with something really specific to the people I'm meeting, some background information, how they found themselves here. And then I will speak in terms of generalities, in terms of the content.

So we talk about disclosure issues. We talk about what future parenting might look like. We talk about all different kinds of things.

And so I have that kind of itemized in my letter to the clinic. And then at the bottom, what I basically say is that I see no reason for these people to not proceed forward. It's a lot of double negatives.

Lots of no's, lots of negatives, but it's a good thing. Basically, this couple should proceed forward just to simplify it. Yeah, absolutely.

I was listening to a talk here at the conference that we're both attending, where somebody said she begins these consultations by saying, tell me your love story. Yes. I do too.

Yeah. And it's wonderful. And it never shows up in the report, by the way.

So that's one of the things that I want to really emphasize is that a lot of these things that get discussed are just for the benefit of the person sitting in the room with us. Absolutely. And the benefit too of establishing rapport, because it does feel like a gatekeeping role.

And it's just someone asking you a list of questions and they're not doing anything to get to know you and where you came from, where each of you came from, how the two of you met and how you got to this point thus far. Yeah, absolutely. Okay.

So let's talk money. Okay. This costs some.

Yes? It does. Yes. Okay.

So fertility care is expensive. Insurance doesn't always cover it. It doesn't always cover, in fact, it often doesn't cover the piece of the work that we are being asked to do, unless you have somebody at your clinic who is sitting in the same offices where your REI sit, who does this care in-house.

We both work, it's hard not to use the term, we have a colleague who calls it working outhouse. So we both work outhouse instead of in-house. Yeah.

Yes. So this is an extra expense. And I think we need to own that, that that's an equity issue and it's a cost issue.

Absolutely. And what I really do try to do with people is I give them a super bill and I code it in a way where it is a code that could be reimbursable. Every individual insurance plan is different, so I can't speak to that.

But also I talk about if there's a health savings or flex spending, those are other ways in which you can pay for this. Okay. So I'm going to take the role for just a second of a patient undergoing fertility care who has already sought out mental health support in their life.

And if I'm that patient, I'm going to say, I have a great therapist. We have a great rapport. He, she, they have been holding me through this entire process.

Can't they just write a letter? And I would say, I wish that was the case. And if your therapist also is trained in this, a hundred percent, have them write that letter. Although having your partner come in might complicate your individual relationship with your therapist.

And it might not make your partner feel comfortable to speak with someone who knows you inside and out. And, you know, any complaints you might've had along the way about your partner that therapist knows too. So it's often useful to find someone who's a neutral party to both people.

And again, I'm making an assumption. There's a couple, there can be more than two people that might come into this. There can be single people that come in for these meetings.

So I want to just be really, really clear that partner's not always involved. But what I want to come back to is that there's really specialized training and I did not receive that in grad school. I don't know about you.

Oh, not at all. No. I got one sentence on mental health and gender full stop.

Yeah. I think that might've been it for us too. And so, as I mentioned, this is specialized training and there's so many nuances when we're thinking about donor conception.

I mean, we're here at this conference learning about even more of the nuances that we may or may not have already known and thought about just through the workshops we're attending. Yeah, absolutely. And I'm going to add, by the way, that this is a large part of my therapy practice.

It's supporting patients through infertility care, the perinatal period, the postpartum period. In fact, I almost never do these consultations for my own clients, even though I have specialty training. And that's because frankly, I am rooting for them so hard.

I just want them to have that take home baby so badly that the things that the intended parent recipient psychoeducational consultational piece of my head wants to say might get lost in the, I just want this for you. So I think it's often really helpful to have a Absolutely. And now what's interesting is the converse can be true for me, which is someone I might meet initially for a recipient consultation might then pursue future therapy with me.

Yeah, yeah, absolutely. That happens too. Okay.

So we're talking about cost as an equity issue and I want to raise another equity issue, which is that back in the day, infertility care used to be the province of cis, het, white, married couples. And more and more, the patients that we are seeing, in fact, some might argue that really the people who benefit from donor gametes the most, the patients who use infertility care in higher and higher proportions are LGBTQ plus patients, single parents by choice. So when I talk with these folks, I say to them, if you had all the parts in your house, you'd never be here.

So why are we making these families, these people who are hoping to build their families do these consultations with us because they don't have the parts in their house? I love that you're asking this question because so many times when I meet with someone who identifies as LGBTQ plus, they come in annoyed and frustrated that they have to be there and might even say, this feels like an obstacle that if we had all the parts, we wouldn't. And how I clarify it is I say, this is a meeting for anyone that's using donor gametes, regardless of your sexual orientation, regardless of what your partnerships look like. So anyone who needs donor gametes, there are important nuances in raising a donor conceived child because we are talking about someone else's identity.

And how do you talk to that child again, across their lifespan? Because this is not a like, hey, you have the conversation and that's it. We're good. I disclosed.

I checked the box. Yeah, right. It's not a check the box.

This is something that needs to be woven into their identity and as a parent, it can really be a wrestling thing with, well, am I legitimately that person's parents because I don't share genes with them? What happens if they might sit there and say, well, you're not my parent. I don't have to do what you say. I'm not even related to you.

And those kinds of things can come up because we all have feelings and we all get frustrated and angry and gosh, kids say a lot of things when they're feeling frustrated and angry. As an aside, my kids also tell me they don't have to do what I say. 100% true.

All kids do it. And I think when they sort of add that piece though, that kind of the dagger in the heart. I like to give people a sense of hearing that language so that they are prepared to have potential responses.

Yeah. One of my much-loved, much-missed favorite patients of all time was a queer woman who was partnered with a trans man. And so they always knew that they would have to build their family with the use of donor gametes.

And at some point, talking about something entirely different in the session, she was not in therapy for this. She was in therapy for a whole different thing. She said to me, there's loss there.

Everybody says there's no loss there. Oh, there's absolutely loss. Yeah.

And we talk about that too. And what is it going to be like to see your partner pregnant? And there are some people who might have uteruses and ovaries who never want to be pregnant. And so it might be a relief to them, but that's still a feeling.

And I think also where loss comes to is what is my role as the non-gestating partner in all of this? Well, and also, what does it mean that this person that I have come together with and love and want to build a family with, and we have every intention of being parents, that we now have to go through a medicalized process when our best friends and neighbors down the hall didn't? Yeah. So there's a loss there too. There's a loss in the privacy, the desire for how you thought your family would be created, all of that.

Okay. So we've spent a lot of time digging into this recipient consultation. And I want to go back for just a second to the question of when else, if you could rule the world of referrals and mental health, when else would you say it's a good idea for somebody to come in and see a reproductive mental health professional? I think it's also a good idea.

So for so many people, they've gone through a reproductive journey. And I would say that our profession is becoming more and more popularized because I can tell you in grad school, I knew nothing about this. This was not even a potential field for me to pursue.

So I also see people who have previously experienced reproductive trauma and then finally come back to process it because that wasn't available to them then. So that would be another time when somebody might come. Somebody might come to see me because they've had a history of mood disorders and they want to get pregnant and they want support during that pregnancy and postpartum because they have a history of mood disorders.

That's right. And just as a reminder that we're trained therapists first, the other reasons that people sometimes come in to see me is they want to get pregnant and they need to quit smoking. Oh, yeah.

I do that one a lot. Or they're afraid of needles. Oh, they're afraid of needles, right? How do we do that? Oh, actually, I know.

So for those of you out there who need to know, take a fidget, take a squishy, squeeze it really hard in your hand. It's called applied tension training and it will get you through. So there you just saved my fee for a session.

All right. So we've only got a couple of minutes left and I want to do sort of a speed round review for our take home points. Okay.

So we're just going to shoot out some yes, no's here. If your REI refers you for mental health support, does that mean that they're worried that you're too crazy to treat? No. All right.

If you go to Dr. Bindeman's office or my office and you do a recipient-intended parent psychoeducational consultation, I can't even say the words even though I do them all day, does that mean that one of us is going to decide that you're going to be a terrible parent and you can't go forward? No. Okay. Are there possibly ways of financing this care? Absolutely there are.

All right. Are there ways of finding providers who are sensitive to what your family looks like in terms of your visible and invisible identities? Absolutely there are. Okay.

Yeah. One of the things you and I have been pushing really hard for is to make cultural competency a core competency in reproductive mental health. Absolutely.

And I know just knowing you as I do, both of us have such a commitment to equity in mental health as well. Okay. So before we wrap up, anything else that you would want to tell somebody who's contemplating seeking mental health support in this journey? Absolutely.

One of the things I think is really important is it's so easy to check the box on many of those directories that say, yes, I am trained in infertility counseling. So before you make the assumption that that is truthful, ask somebody what that looks like, ask somebody how long they've been doing it. Because as I mentioned, there is specialized training.

Please do not assume just because someone is a perinatal mental health certified therapist that they know anything about third party work. They are not typically trained in that to get that kind of certification. So I think doing some research, certainly the ASRM directory can be a useful place to start.

And I would still ask those follow-up questions. And I have one to add to that, by the way, which is within this area, what do you specialize in? I'm really good at certain things. I really don't do certain things very often.

And that's when I call you. Absolutely. Yes.

Okay, Dr. Pindaman, thank you so much for being with us and sharing your wisdom today. Thanks so much for having me, Dr. Kaplan.

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