The Arts in Psychotherapy 73 (2021) 101758

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The Arts in Psychotherapy

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Research Article

Using artistic activities within experiential psychotherapy to alleviate the

psychological consequences of female infertility
Ligiana Mihaela Petre *, Maria Gemescu, Diana Bulgari
Faculty of Psychology and Educational Sciences, University of Bucharest, Sos. Panduri Nr. 90, 050657, Bucharest, Romania

A R T I C L E I N F O A B S T R A C T

Keywords: Female infertility is associated with a wide range of psychological consequences, including heightened depres­
Infertility sive and anxiety symptoms, impaired quality of life, and self-esteem. Considering the paucity of data regarding
Experiential psychological interventions tailored for female infertility, this case study is aimed at providing preliminary
Psychotherapy
evidence related to the treatment protocol and outcomes of an experiential psychotherapy intervention that uses
Artistic activities
artistic activities tailored for female infertility. The Short Form Health Survey (SF-36), Fertility Quality of Life
Meditation
Art genogram International (FertiQoL), Ways of Coping Questionnaire (WCQ), Dyadic Adjustment Scale (DAS), and California
Psychological Inventory, Femininity Scale (Fe-CPI), were used pre- and post-treatment for assessing psycho­
logical correlates of infertility. The psychological treatment consisted of three psychological assessments and
seven experiential psychotherapy group sessions. Experiential techniques, mindfulness techniques, and artistic
activities were used during the group sessions, in order to modify psychological maladaptive mechanisms
associated with female infertility. Self-report results showed that the experiential psychotherapy intervention
enhanced the quality of life, coping strategies, and femininity personality trait. Throughout the experiential
intervention, the participant redefined her perspective on infertility and motherhood. On the other hand, the
participant reported lowered levels of dyadic adjustment at post-treatment. This case study illustrates the
beneficial effects of using artistic activities in experiential psychotherapy for female infertility.

Introduction significantly higher scores on depression, infertility-related stress, so­

The road to parenthood is expected to be a simple one, but in fact, it
could be paved with great challenges for some adults. This is the case for
up to 26.4 % of couples, who are experiencing infertility at some point in
their lives (Boivin, Bunting, Collins, & Nygren, 2007). Infertility is a
“disease characterized by the failure to establish a clinical pregnancy
after 12 months of regular, unprotected sexual intercourse or due to an
impairment of a person’s capacity to reproduce, either as an individual
or with his/ her partner” (Zegers-Hochschild et al., 2017, p. 9), its
prevalence rates ranging amongst countries. Due to its unpredictable
and uncontrollable nature, infertility represents a major source of psy­
chological distress for both men and women (Kiesswetter et al., 2019;
Simon, Keitel, Bigony, & Park-Taylor, 2020; Vayena, Rowe, & Griffin,
2001).
The resulting distress manifests itself as heightened levels of
depressive and anxiety symptoms, compared to fertile controls (Lakatos,
Szigeti, Ujma, Sexty, & Balog, 2017; Salih Joelsson et al., 2017).
Moreover, comparative studies have shown that infertile females report
matization, obsessive symptoms, phobias, interpersonal sensitivity,
stigma, and shame, as well as lower scores on quality of life and
self-esteem, when compared to their masculine counterparts (El Kissi
et al., 2013; Kim, Shin, & Yun, 2018; Ying, Wu, & Loke, 2015).
Furthermore, gender acts as a moderator in the relationship between
anxiety, negative affect, interpersonal resources on the one hand, and
emotional maladjustment on the other (Ramírez-Uclés, Del
Castillo-Aparicio, & Moreno-Rosset, 2015). Adding to this,
infertility-related stress can greatly affect the fertility-related quality of
life of women (Li, Zhang, Shi, Guo, & Wang, 2019). In turn, reduced
fertility-related quality of life of infertile women is negatively associated
with treatment compliance and could cause a latent economic burden on
families and communities (Gameiro, Boivin, Peronace, & Verhaak,
2012).
Thus, women have higher risks of emotional maladjustment to
infertility, which means that the experience of female infertility spreads
its impact beyond domains of physical and mental health, existentially
provoking the person to question and redefine her identity, personal

* Corresponding author.
E-mail addresses: ligiana.petre@fpse.unibuc.ro (L.M. Petre), maria.gemescu@gmail.com (M. Gemescu), diana.bulgari95@gmail.com (D. Bulgari).

https://doi.org/10.1016/j.aip.2021.101758
Received 2 December 2019; Received in revised form 13 December 2020; Accepted 31 December 2020
Available online 13 January 2021
0197-4556/© 2021 Elsevier Ltd. All rights reserved.
L.M. Petre et al.
resources, and social roles (Ying et al., 2015). In this sense, infertility is
considered to be a transformational experience, giving rise to unknown
and untapped creative potentials (Gonzalez, 2000).
The increased level of distress experienced by females could be
accounted for by biological, psychological, and social factors. Some of
the proposed psychosocial factors in the literature pertain to gender
roles and gender attitudes (Cserepes, Kollár, Sápy, Wischmann, &
Bugán, 2013), meaning that parenthood may be more important for
individuals with feminine attitudes or traits, hence the enhanced re­
sponsibility that women tend to assume regarding the experience of
infertility (Peterson, Newton, Rosen, & Skaggs, 2006). Moreover, female
infertility is associated with lowered emotional detachment, psycho­
logical flexibility, and self-compassion (Pinto-Gouveia, Galhardo,
Cunha, & Matos, 2012), which draws attention to a new line of research,
showing that unpleasant psychological processes and experiences are
handled by infertile women with a judgmental attitude and that the
contact with the present moment is diminished, giving rise to mal­
adaptive, rigid behaviors that do not reflect current situations or per­
sonal values. In addition, fostering self-compassion in infertile women
seems to play a protective role with regard to self-criticism and
self-blaming tendencies (Pinto-Gouveia et al., 2012).
Recent meta-analytic research concluded that psychological in­
terventions are effective in adjusting the psychological distress of
infertile women, as well as in increasing pregnancy rates, presumably by
reducing anxiety levels (Frederiksen, Farver-Vestergaard, Skovgard,
Ingerslev, & Zachariae, 2015). Extant literature on arts therapies shows
that the combination of art-making, therapeutic guidance, and
self-reflection has the potential to foster the development of adaptive
coping strategies in female infertility, thus helping infertile women
replace maladaptive, passive strategies with more adaptive and active
ones (Streeter and Deaver, 2018). According to Streeter & Deaver
(2018), personal symbols that are expressed through the artistic prod­
ucts function as metaphors that can aid women in discovering a creative
perspective towards the experience of infertility.
Apart from being the main focus of arts therapies, artistic activities
are also increasingly being used in various types of psychotherapies,
such as schema therapy (Hodge & Simpson, 2016), cognitive behavioral
therapy (Morris, 2014), and mindfulness-based therapy (Monti et al.,
2006). Another psychotherapeutic tradition that incorporates artistic
activities is experiential psychotherapy, which uses artistic media
(drawing, painting, modeling, collage, photographs) as as symbolic
means that aim to promote the processes of psychological restructuring
and personal growth (Mitrofan & Petre, 2013a; Mitrofan & Petre,
2013b). Nonetheless, the effects of using artistic activities within expe­
riential psychotherapy for female infertility have yet to be investigated.
This case study’s overarching aim is to provide preliminary evidence
related to the treatment protocol and outcomes of an experiential psy­
chotherapy intervention that uses artistic activities tailored for female
infertility. More specifically, this study seeks to examine quantitative
changes on quality of life, fertility-related quality of life, coping strate­
gies, dyadic adjustment, and femininity personality trait of the case
discussed, while also providing a qualitative description with respect to
the participant’s process of developing a new perspective on infertility
and motherhood.
Method
Design
This study adheres to a case study design, the unit of analysis being
an infertile female participant who self-referred and presented to group
psychotherapy with marked signs of emotional dysregulation. The
single-subject design was considered to be more suitable than a
multiple-subject design, given that the main aim of this study was to give
an in-depth presentation of the psychological treatment protocol, filling
an important gap in research on psychotherapeutic strategies tailored
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for female infertility.
While quantitative data compared psychological changes from
baseline to post-treatment, qualitative data concerned an enhanced
understanding of the participant’s process of developing a new
perspective on infertility and motherhood. Qualitative data was used for
supplementing data obtained from self-report psychological
instruments.
Participant characteristics
For confidentiality purposes, the participant was given a fictional
name: Mrs. A. At the age of 42, Mrs. A. self-referred to the psychological
treatment. Mrs. A. was a Romanian female, with a tertiary education
level. At the time of the study, she was in a romantic relationship and
worked as an economist, in a bank institution.
Although all participants to the psychological treatment gave their
consent for the publication of collected data for research purposes, this
article was focused on this member of the group, in order to report the
use of artistic activities within experiential psychotherapy, in a case of
primary and idiopathic infertility. This particular case was considered to
be of interest to the research community, because it exhibited psycho­
logical consequences that are commonly encountered in psychological
interventions designed for female infertility, such as maladaptive coping
strategies, feelings of fear and anxiety, and depressive tendencies
(Streeter & Deaver, 2018).
Instruments
At pre-treatment and post-treatment timepoints, quantitative data
was collected from self-report instruments, measuring general quality of
life, fertility-related quality of life, coping strategies, dyadic adjustment,
and femininity personality trait.
Psychiatric comorbidity was only assessed at baseline, using Millon
Clinical Multiaxial Inventory-III (MCMI-III). MCMI-III is a 175-item,
true-false, self-report inventory. This inventory contains 24 clinical
scales, arranged into four distinct categories: Clinical Personality Pat­
terns, Severe Personality Pathology, Clinical Syndromes, and Severe
Clinical Syndromes. MCMI-III has three stages of validation, is closely
aligned with the DSM-IV classification system and is associated with the
comprehensive and evolutionary theory of Theodore Millon (Saulsman,
2011).
The Short Form Health Survey (SF-36) is a multidimensional self-
report inventory, used in its short form to measure participant’s qual­
ity of life. This instrument has eight subscales, which address: physical
functioning, social functioning, pain, role limitations due to physical
problems, role limitations due to emotional problems, energy or fatigue,
emotional well-being, and general health. SF-36 is considered to have
good construct validity, internal consistency (Cronbach’s α > .85), and
test-retest reliability (except for Social Functioning = .74, each scale
ranked above 0.75) (Brazier et al., 1992).
Fertility Quality of Life International (FertiQoL) is the first instru­
ment tailored for infertile individuals that is able to assess the following
dimensions: quality of life during fertility medical treatment, overall
physical health, satisfaction with quality of life, impact of infertility in
emotional, mind-body, relational, and social domains. The emotional
domain reflects the extent to which the individual experiences negative
emotions associated with the experience of infertility; the mind-body
domain includes physical symptoms and cognitive or behavioral dis­
ruptions; the relational domain refers to the extent to which components
of the marital relationship or partnership have been affected by fertility
problems (e.g., sexuality, communication, commitment); finally, the
social domain pertains to the functioning of all social interactions that
are relevant to the person. Items are grouped together, into Core Ferti­
QoL and Treatment FertiQoL. Besides these items, two additional items
reflect perceived overall physical health and life satisfaction. All sub­
scales proved to have acceptable internal consistency (Cronbach’s α
L.M. Petre et al.
ranging from 0.72 to 0.92) (Boivin, Takefman, & Braverman, 2011).
Ways of Coping Questionnaire (WCQ) is a 66-item instrument, that
assesses thoughts and actions used for coping with a stressful situation. It
contains eight subscales: Confrontive Coping, Distancing, Self-Control,
Seeking Social Support, Accepting Responsibility, Escape-Avoidance,
Planful Problem Solving, and Positive Reappraisal. The measure of the
total score achieved good internal consistency throughout multiple
clinical and non-clinical samples (Cronbach’s α = .86) (Lundqvist &
Ahlström, 2006).
Dyadic Adjustment Scale (DAS) is a self-report multidimensional
instrument, which assesses couple satisfaction and the perception of
both partners regarding their marital relationship. It comprises four
subscales: Dyadic Consensus, Affectional Expression, Dyadic Cohesion,
and Dyadic Satisfaction. Scores on these subscales are added to compose
a total index of Dyadic Adjustment (Spanier, Iliescu, & Petre, 2010).
California Psychological Inventory, Femininity Scale (Fe-CPI) was
used for assessing femininity personality trait. California Psychological
Inventory (CPI) is a frequently used self-report personality instrument,
originally developed by Harrison Gough (1966), which has been revised
three times. The most recent version of CPI is the third edition: CPI 434
(Boer, Starkey, & Hodgetts, 2008; Gough & Bradley, 1996). Fe-CPI has
38 items and assesses beliefs, which are traditionally masculine or
feminine, describing a personality dimension that is conceptualized as
‘feminine’ at one pole and ‘masculine’ at the other pole. This scale shows
impressive cross-cultural validity (Gough, 1966) and has good internal
reliability (0.73) and test–retest reliability (0.84) (Boyle, Matthews, &
Saklofske, 2008). In addition, the validity of the Fe-CPI scale has been
confirmed on the Romanian population (Pitariu, 1981). In a review,
(Ferguson, David, & Madelay, 2002) claimed that CPI was the most
commonly used personality instrument in medical education (Hojat,
Erdmann, & Gonnella, 2013).
Procedure
First, the participant was informed about the aim of the study: to
measure the effectiveness of a psychological intervention, designed to
alleviate the psychological effects of infertility and to modify psycho­
logical maladaptive mechanisms associated with female infertility.
Second, the participant enrolled in the psychological treatment, by
signing an informed consent. Third, the participant was assigned to the
psychological treatment, which started with two sessions of pre-
treatment psychological assessment, continued with seven sessions of
experiential group psychotherapy, and ended with a session of post-
treatment psychological assessment.
The first two sessions were focused on completing the psychological
assessment, building the working alliance, explaining the therapeutic
framework and guidelines regarding the treatment plan. Thus, the pre-
intervention assessment followed two phases: a) a semi-structured
clinical interview, accompanied by a personality assessment; b) an on­
line assessment, based on aforementioned psychological inventories.
The first phase was set within a clinical setting, where the general
mental health state of the participant was evaluated. Through a semi-
structured clinical interview, the following criteria were assessed: psy­
chiatric antecedents; medical, educational, occupational, and marital
history; communication patterns. Further, this phase of the evaluation
continued with a personality assessment, the participant responding to
the items in Millon Clinical Multiaxial Inventory III (MCMI-III). During
the second phase of the evaluation, the quality of life, coping strategies,
dyadic adjustment, femininity personality trait were assessed through
an online evaluation.
After the end of this pre-intervention assessment, the participant
attended experiential psychotherapy group sessions. The post-
intervention assessment consisted in filling in the same self-report
measures from baseline, except for MCMI-III.
The research Ethics Committee of the University of Bucharest
approved the current study (IRB no. 13/27.02.2019). The study
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The Arts in Psychotherapy 73 (2021) 101758
procedure complied to the ethical standards of the College of Psychol­
ogists from Romania and the American Psychological Association. Par­
ticipants gave their written informed consent and pseudonyms were
used to protect their anonymity.
Psychological treatment plan
The psychological treatment consisted of 7 weekly group sessions of
150 min each, over the course of three months. Eight participants with
idiopathic infertility took part in the experiential psychotherapy group
sessions. The experiential psychotherapy group sessions were led by two
certified experiential psychotherapists and have been entirely audio
recorded.
The psychological treatment followed a structured intervention
program of experiential psychotherapy. As an adjunct to main inter­
vention components that are specific to experiential psychotherapy,
artistic activities were used (Karkou & Sanderson, 2006), in order to
harness the psychological benefits of art-making, based on preliminary
research that has shown the effects that the creative process of
art-making has in developing adaptive coping strategies in female
infertility (Streeter and Deaver, 2018). The artistic activities were
tailored to the psychological mechanisms, needs, and consequences
associated with female infertility, as reported in the psychological
literature (Cserepes et al., 2013; El Kissi et al., 2013; Lakatos et al., 2017;
Salih Joelsson et al., 2017).
The treatment protocol followed four stages, designed according to
the following psychotherapeutic aims: a) fostering group cohesion,
empathic adjustment, and validation; b) reconnecting with psychologi­
cal experiences associated with infertility, through mindfulness tech­
niques or psychotherapeutic scenarios based on a semi-structured script
and a visual artistic medium (drawing, modeling, collage); c) increasing
awareness of maladaptive coping mechanisms associated with infer­
tility, reprocessing and restructuring psychological experiences, identi­
fying and practicing adaptive emotion regulation and coping strategies,
through individual experiential analyses adapted to a group format; d)
integrating the psychotherapeutic experiences, through discussing with
the participants about their insights, psychological acquisitions,
thoughts, feelings, and intentions related to the group or to themselves.
The psychological treatment included seven intervention compo­
nents, in line with the protocol of humanistic experiential psychother­
apy (Angus, Watson, Elliott, Schneider, & Timulak, 2015; Glisenti,
Strodl, & King, 2018; Mitrofan & Petre, 2013a):
1 Empathic adjustment and validation were used for setting an authentic
therapeutic relationship, thus encouraging the participants to
develop emotional resilience and a deeper understanding of their
psychological experiences.
2 Mindfulness meditation was based on a semi-structured psychothera­
peutic script. The script was created by the psychotherapists, ac­
cording to main psychological themes found to be associated with
female infertility. The aim of incorporating mindfulness meditation
was to enhance the connection with the present moment and to in­
crease awareness of current psychological experiences. Adhering to
the principles of mindfulness-informed psychotherapies, the psy­
chotherapists encouraged participants to develop compassion to­
wards themselves and to observe all arising experiences with
curiosity and acceptance (Gemescu, 2019).
3 Art genogram (Mitrofan, 2004; Mitrofan & Petre, 2013a; Mitrofan &
Petre, 2013b; Petre, 2013), a technique in which family dynamics
and psychological roles are graphically represented and afterwards
analyzed, was also used. More specifically, this technique was
developed as an extension to the classic genogram (McGoldrick,
Gerson, & Petry, 2008; Schutzenberger, 1998), by incorporating
artistic activities. Compared to the classic genogram, art-genogram
used natural elements as symbols and was simultaneously facili­
tated by creative meditation, having a musical background. The
L.M. Petre et al.
psychotherapeutic process of using the art-genogram comprised the
following phases: visually representing transgenerational narratives
and relational patterns, reconnecting with past important events
through role playing, and finally reappraising experiences, emotions
and cognitions related to relational patterns that were previously
represented.
4 Experiential unfolding, using a visual artistic medium (such as draw­
ing, collage, modeling), aimed to facilitate the access to emotions,
cognitions, and behavioral patterns related to difficult psychological
experiences.
5 Experiential focusing was used to enhance awareness of deeper and
non-conscious dimensions of psychological experiences, by helping
participants maintain an authentic contact with their feelings and
thoughts.
6 Empty chair work was used to bring to surface participants’ emotions,
which might have remained otherwise captive in past unresolved
relationships, situations or experiences. Through this process, par­
ticipants were encouraged to recover and activate untapped psy­
chological resources.
7 Two-chair work was used for expressing, activating, and integrating
disconnected parts of the self. The goal was to resolve the conflict
between two opposing sides, by understanding the positive and
negative role of both of them, the meaning and the effects of that
psychological conflict in the personal life narrative.
The main goal of the psychological treatment was increasing
fertility-related quality of life. This main goal was pursued through
secondary goals, as follows: a) developing adaptive coping strategies; b)
exploring the individual meaning of parenthood and infertility, c)
remodeling maladaptive ways of relating to pregnancy; d) developing a
clearer and more stable self-image; e) integrating the relationship be­
tween the inner child and the nurturing parent; f) harmonizing gender
role behaviors, attitudes and traits.
Results
Course of psychological treatment
Sessions 1− 2: Pre-intervention psychological assessment and building
working alliance
In the first phase of the psychological assessment (Session 1), results
of the clinical interview revealed that the diagnosis of primary and
idiopathic infertility was not associated with any psychiatric anteced­
ents. Mrs. A. did not undergo any medical treatment or intervention for
infertility. However, the familial and marital history showed that
commitment and intimacy difficulties, encountered by Mrs. A. in her
couple relationships by then, could have been favored by an adverse
childhood experience: the death of her mother when she was six years
old. Amidst her six brothers, Mrs. A. developed a maternal role towards
them, possibly compensating for the loss they all suffered. According to
Mrs. A, the experience of abandonment was relived three years prior to
the psychological assessment, when one of her brothers died. This was
also when she met her current partner.
Mrs. A. further described that losing her brother was like losing a
child, as she used to protect him like a mother would. In this context, she
hypothesized that the relationship with her romantic partner could have
been connected with the attachment to her lost brother. After three
years, the participant was still cognitively and emotionally processing
the experience of loss, which could have had a role, among other factors,
in her form of idiopathic infertility. The spontaneous answer of Mrs. A.,
that she still lived in her place of birth, even if her residence had changed
during the last 23 years, could be a sign of an emotional difficulty related
to a difficult psychological experience. More exactly, as a response to the
reflective listening technique used by the psychotherapist (Arnold,
2014), Mrs. A. replied that she sometimes acted like she was being
trapped in the past. Adding to that, she manifested signs of marked
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emotion dysregulation: crying outbursts, psychomotor agitation (rest­
lessness, muscle twitching), accelerated speech followed by abrupt
pauses.
In the second phase of the psychological evaluation (Session 2), the
online assessment measured the quality of life, fertility-related quality of
life, coping strategies, dyadic adjustment, and femininity personality
trait. This assessment showed functional levels of general quality of life,
fertility-related quality of life, and couple functioning. The Ways of
Coping Questionnaire revealed that the participant frequently used both
adaptive and maladaptive coping strategies, such as: positive reap­
praisal, self-controlling, distancing, and avoidance. The most frequently
employed strategy was self-controlling, indicating a tendency to rely
primarily on herself, in order to regulate thoughts and emotions.
Sessions 3–5: activating and integrating the inner child
Sessions 3–5 were focused on the behavioral activation and inte­
gration of the inner child, within the bigger theme of the desire for
motherhood. Taking into account that the desire for motherhood could
be linked to the ego state of the inner child (Sjöblom, Öhrling, & Kos­
tenius, 2018), the first group sessions were focused on exploring the
relationships between the inner child, on the one hand, and the
nurturing or punitive parent, on the other.
During session 3, Mrs. A. discussed her anxiety towards pregnancy,
which she considered to represent a blockage in her desire for mother­
hood. She described feeling as if a part of her remained anachronical,
still in the past, being afraid of pregnancy, while at the same time, her
adult self was fixated on being a parent. She described her psyche as
being highly controlled by cognition, while her body as being under the
influence of anxiety.
Through psychotherapeutic guidance and experiential focusing, the
avoidant coping strategy was explored. Mrs. A. investigated how this
mechanism emerged in her life narrative and the adaptive role it had for
her until then. Mrs. A. understood how avoidance contributed to the
physiological reactions of arousal and anxiety. In order to restructure
this maladaptive coping mechanism, a more active coping strategy was
reinforced, based on a role model, which the client desired to emulate.
While exploring this role model, the client shifted her attitude towards
her anxiety states. By distinguishing the physiological reactions associ­
ated with anxiety from cognitive appraisals, Mrs. A. made steps in
increasing her ability to withstand these emotions, which were observed
in her changed, more open body posture, and increased verbal fluency.
Session 4 was aimed at: exploring the intrapsychic relationship be­
tween the inner parent and the inner child, identifying the needs of the
inner child, and activating new strategies of satisfying those needs. In
the first phase of this session, the psychoeducation technique was
employed, in order to offer evidence-based answers to the questions
posed by the participant, regarding the psychological consequences of
female infertility and the psychological mechanisms that may be
contributing to infertility. The psychoeducation challenged the cogni­
tive resources of the adult self, thus preparing the ground for the next
phase of this session, which incorporated a creative meditation with a
visual artistic medium. Moreover, the creative meditation facilitated the
somatosensory and emotional contact with the inner child, by inviting
the participant to choose an image, with which she identified, because it
reminded her of her childhood experiences. The image that was chosen
by Mrs. A. can be seen in Fig. 1, portraying two girls next to each other,
with the sky in the background: one girl with a smile on her face, her
chin and her mouth pointing up; and the other girl, with a frown, her
eyes staring at a distance, her chin and her mouth pointing down. Mrs. A.
found similarities with both girls from the image, but she rejected and
avoided the negative emotions displayed by the girl from the right.
Session 4 continued to emphasize this process of getting in contact
with the inner child. The participant acknowledged her inner child’s
need of having an emotional contact within a secure support network.
When Mrs. A. was challenged to receive feedbacks from other group
participants, she noticed a pattern: she tended to react skeptically to
L.M. Petre et al.
Fig. 1. The image of the inner child that Mrs. A. chose during session 4.
those feedbacks, ruminating on the possible meanings and implications.
Thus, she became aware that she needed to receive the contact with
other people, opening herself up to the present moment and to the
emotions she felt.
Session 5 grew out from the previous one, exploring the inner child,
from a different perspective: its relationship not with the inner parent,
but with other figures of authority. Thereby, this session was aimed at
exploring and activating the rebellious child, a highly energetic and
creative part of the self. Once again, the psychotherapeutic technique
used was creative meditation, based on the Six Parts Story script (6PSM)
(Lahad, Lahad, Shacham, & Ayalon, 2013; Lahad, 2017), but this time
with drawing as a visual medium. The drawing followed the story that
Mrs. A. created about an imagined hero and how the hero fulfilled his/
her mission. For Mrs. A., the hero took the form of a child, not just any
child, but her niece, with whom she identified very deeply. The char­
acter’s power was also her vulnerability: emotional reactivity. Triggered
by the abandonment of her father, Mrs. A. described that, when she was
a child, she started to protect her own emotional reactivity, considering
that it was a sign of weakness, which could have been judged as a flaw,
in various social contexts.
In the beginning of this sequence, Mrs. A. mentally represented her
emotional reactivity, in terms of the traumatic events that had happened
to her, responding from the inner, wounded child perspective. From the
perspective of the child, social isolation represented a defense mecha­
nism, against the unfairness that the child perceived. Rebelling against
her father’s abandonment, she also withdrew from other supportive
groups around her. While talking, Mrs. A. began to see her emotional
reactivity as a personal resource. By verbally reframing and anchoring
emotional reactivity as a personal power, the psychotherapeutic guid­
ance and experiential focusing continued to facilitate participant’s
awareness and contact with the strength and creativity, lying untapped
in the rebellious inner child.
Sessions 6− 7: activating and integrating gender role behaviors, attitudes and
traits
The next stage of the intervention (sessions 6–7) was aimed at inte­
grating psychological gender role behaviors, attitudes, and traits. The
focus was on the psychological integration of gender roles (sessions 6
and 7), through different mindfulness techniques and artistic activities,
such as creative meditation and role playing, using drawing and
modeling as visual artistic media. The psychological gender roles were
explored in the context of Mrs. A.’s couple relationship, in order to have
a deeper understanding of how the couple functioned and how the
masculine-feminine psychological gender roles outlined their relation­
ship dynamics.
During session 6, the functioning within the couple relationship, as
well as the participant’s role of “architect” in building the relationship
were explored through creative meditation and drawing. The creative
meditation was guided by the psychotherapist and it was based on a
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semi-structured script, which contained a metaphorical expression of
the participant’s psychological difficulty: the integration of psycholog­
ical gender roles. Through the creative meditation, the participant was
invited to draw a place, her own "personal ground": “(…) Take a moment
to observe, from a distance at first, where you feel like sitting. Is it
somewhere closer to the edge, is it right in the center or elsewhere?
Notice how much space you want to take - a large space, all of it, a tiny
one, maybe even an invisible one. Then, allow yourself to draw its
boundaries, so that this space receives you, represents you, as you feel,
as you know yourself or simply as your gut tells you. Make it clear that
this is your place, as if it could show who you are and how you are like.
Now, that you have drawn your space, by revealing with clarity
where you are, what is yours, how big you are and what form you take,
with smooth or sharp edges, it is time to pay attention for a few moments
to where your partner might be placed. Find a space for him or her too!
Draw this place, their own territory, as you envision it, as you feel like,
as you think it suits them. Make it clear it’s their ground, their personal
space where they can move, think, love, make plans, where they can act
or simply be. Mark it on the paper, however you feel like doing it.”. The
psychotherapeutic script also facilitated an enhanced awareness of the
process of creating these spaces: how the participant chose them, where
she placed them, how she drew them, how she took hold of them - did
she hurry to draw, maybe shaping them spontaneously or on the con­
trary, she was more concerned with other details, not to spoil the
drawing, not to make mistakes, to draw it in a certain way, or maybe she
was trying to avoid anyone’s attention, taking just enough space not to
get herself noticed. More than that, the participant was guided to pay
attention to the relational space (i.e., the space of her couple relation­
ship). Mrs. A. represented the relational space, by drawing a clear and
firm line between the identity space of each partner (Fig. 2). On the top
of the drawing, she left a common space where the two partners came
together. There was no outer contour to mark off their spaces from the
rest of the environment. With psychotherapists’ attentive and non-
directive guidance, during the phase of experiential analysis, Mrs. A.
mentioned: “I’m like this; I need my space both literally and meta­
phorically. I don’t like to expose myself completely, even in the rela­
tionship with my life partner.”. When asked how her partner would
represent their relationship, she replied: “I think if he drew this, there
wouldn’t be this line, or there would be a dotted line, or something.
Yes… a dotted line. And I think he would frame everything. He’s the one
with bordering things.”.
Fig. 2. The drawing of the couple’s space that Mrs. A. made during session 6.
L.M. Petre et al. The Arts in Psychotherapy 73 (2021) 101758

She described herself as maintaining distance from others, going in During session 8, most elements used by Mrs. A. in the space of the
her “safe space” which, she said, served her as a “shelter”, where she felt art genogram (see Fig. 4, Phase 1) were hard, enclosed elements. She
safe to process her emotions and thoughts. represented herself, by using a walnut and her partner, by using a
In this session, Mrs. A. became more aware of her avoidant behavior chestnut. She said that “the nutshell protects them, but at the same time
associated with relational patterns, which maintained her need of prevents them from taking the risks of intimacy”. The experiential
emotional connection at an unfulfilled state. In addition, she gained new analysis also focused on exploring the “fertile soil”, where seeding was
strategies of opening her mind and soul, in order to rediscover authen­ possible. Through this, we explored Mrs. A.’s integration of the maternal
ticity in her relationships with herself and others, thus putting herself in role, which was symbolically understood as the ground for “fertilization
a position to receive and contain more of what she needed. Therefore, and seeding”. Mrs. A. did not choose any seeds as part of the art geno­
she could diminish the quasi-constant uncertainty she felt, as a result of gram, but instead she represented some children by three fruits near the
avoiding to share or clarify experiences related to other people. Within couple, which she wanted to think of as her own:
the framework of experiential psychotherapy, the aim and the effect of
“A.: ‘I don’t know, I saw some children playing in the yard.’
this session consisted in activating cognitive, emotional, and behavioral
T: ‘Who are these children?’
resources for a more adaptive regulation in relationships and, implicitly,
A.: ‘I do not know…’
for an overall psychological growth.
In session 7, the way Mrs. A. established contact with others was
further explored. Guided by a creative meditation, she shaped the clay
modeling in Fig. 3 and afterwards, she was invited to hand her artistic
product to the group, so that others could make adjustments if they
wanted to. Through this, the dynamics of exchange was emphasized, of
offering and receiving a gift, but also of how Mrs. A. received changes,
with adaptability or rigidity. As a result, Mrs. A. shaped an empty heart.
At that moment, the psychotherapeutic intervention was focused,
metaphorically speaking, on the “filling of her heart”. In psychological
terms, the psychotherapeutic process aimed to facilitate an authentic
contact between Mrs. A. and her emotions. More specifically, this aim
was achieved by activating courage, as a psychological resource to
counterbalance fear. Using role playing and the two-chair technique, the
participant’s contact with her emotions was enhanced, in order to
develop and practice an adaptive strategy to regulate and cope with her
emotions.

Sessions 8− 9: activating and integrating behaviors, attitudes and traits

associated with motherhood
The goal of the final stage of the intervention (sessions 8–9) was to
complete the process of psychological growth, through exploring core
psychological themes and gender roles (masculinity, femininity, moth­
erhood). We used the art genogram, a psychotherapeutic technique
designed for exploring and representing the psycho-genealogical tree,
incorporating natural elements as symbols (Mitrofan & Petre, 2013a;
Mitrofan & Petre, 2013b; Petre, 2018). The art genogram’s framework
offers the means to represent and integrate transgenerational experi­
ences, relational patterns, and personal difficulties, such as psycholog­
ical blockages, vulnerabilities or untapped resources. Various materials
were used to create the art genogram, each representing a natural
symbol: for water symbols (bottles), for fire symbols (candles), for
mineral symbols (stones, crystals, sand, metal, shells), for vegetal and
animal symbols (leaves, flowers, seeds, fruits, branches and natural
fabrics, feathers, wool).

Fig. 3. The modeling that Mrs. A. made during session 7. Fig. 4. Construction of the art genogram during sessions 8-9.

6
L.M. Petre et al.
T: ‘Have they already been contained, born and raised by …someone
else?’
A.: ‘I do not know.’
T: ‘When you built this, you wanted to have those fruits. You have
something fruitful. There is a potential for fruit-bearing represented
here, but these fruits right here are already being raised by someone
else.’
A.: ‘And why can’t I be fruitful?’
T: ‘How would you answer this question?’
A.: ‘I don’t know.’
T: ‘Let’s rephrase it to make it easier. How could you be fruitful?
What would you need to be fruitful?’
A.: ‘I think I’m afraid. The fear of… I don’t know… of the world. I am
afraid of the world, I think.’
T: ‘Fear of the world or of yourself?’
A.: ‘Maybe of myself too, I don’t know if I could handle it at some
point.’
T: ‘Yes, that’s what it’s about. In order to know if you can handle it,
to confirm to yourself that you can handle it, maybe you just need to
stop running from yourself.”
This sequence showed a common maladaptive coping strategy used
by Mrs. A.: she avoided sources of discomfort, which kept her at a dis­
tance from a direct contact with reality. Mrs. A. needed to learn how to
stay in touch with reality, how to experience her emotions, instead of
running from herself.
Session 9 of the intervention was dedicated to enhancing the thera­
peutic effects obtained during the intervention and integrating the
newly acquired strategies of assuming the maternal role, which had been
identified previously. Mrs. A. was invited to arrange a garden (see Fig. 4,
Phase 2) with the natural elements chosen within the art genogram, and
then pick the most representative season for her garden. Then, she noted
3–5 features of that season, which symbolically represented her personal
resources. She picked spring as the main season, although it was poorly
represented by chosen natural elements, and listed prosperity, life, hope,
and expectations, as season’s attributes. This illustrated her psycholog­
ical potential and desire: Mrs. A. wanted to feel like it was “spring”. She
had some blocked psychological potential because she used to look for
safety, instead of novelty. In order to unlock that potential, she created a
life plan, listing strategies of manifesting those spring like attributes,
which also served in anchoring the therapeutic work in reality.
Mrs. A. also integrated the modeling made during session 7 in the
garden. Moreover, Mrs. A.’s ability to support and contain were dis­
cussed, as observed through the final artistic product (see Fig. 4, Phase
Fig. 5. SF-36 baseline and post-treatment raw scores.
7
The Arts in Psychotherapy 73 (2021) 101758
3). Through psychotherapeutic guidance, Mrs. A. became aware of the
difference between support and containment, exploring how she could
activate and maintain her maternal potential.
Session 10: Post-intervention psychological assessment
Session 10 consisted in a post-intervention assessment, including an
online evaluation of the same outcomes measured at the beginning of
the treatment protocol: quality of life, fertility-related quality of life,
coping strategies, dyadic adjustment, and femininity personality trait.
Quantitative analysis
Results of the post-intervention assessment suggest an increased
adjustment to the psychological aspects of infertility, as follows.
Increased quality of life
With regard to the quality of life, the post-treatment SF-36 scores
show that vitality, physical, and social functioning have remained above
average, but an improvement was reported on emotional well-being
(pre-treatment = 80; post-treatment = 84). These scores (see Fig. 5)
indicated that the states of irritability, anxiety and depression might
have been diminished.
Overall, the Core FertiQoL scores show that the negative conse­
quences of fertility have also been reduced. The post-intervention
assessment of the separate subscales of FertiQoL showed some prom­
ising, albeit mixed effects regarding fertility-related quality of life (see
Fig. 6). On one hand, judging from the scores reported on the Emotional
Subscale (pre-treatment = 62.5; post-treatment = 45.83), the impact
that emotions have on Mrs. A.’s life increased, which could be a result of
accessing suppressed emotions and thoughts associated with infertility,
during the psychological intervention. On the other hand, scores on the
Mind/Body Subscale (pre-treatment = 66.67; post-treatment = 70.83)
showed that the participant learned how to sustain more adaptive be­
haviors and cognitions, by maintaining awareness on the relationship
between psychological processes and physiological reactions. Moreover,
through the psychological exploration in the group setting, couple
functioning was enhanced and social withdrawal was reduced, based on
the post-treatment scores from Relational (pre-treatment = 70.83; post-
treatment = 87.5) and Social Subscales (pre-treatment = 70; post-
treatment = 70.83).
Adjustment of coping strategies
The relative scores of WCQ showed marked changes in the coping
strategies of distancing, self-controlling, seeking social support, and
accepting responsibility (see Fig. 7). The tendency to use distancing
L.M. Petre et al. The Arts in Psychotherapy 73 (2021) 101758

Fig. 6. FertiQoL baseline and post-treatment raw scores.

Fig. 7. WCQ baseline and post-treatment raw scores.

coping decreased, meaning that efforts and actions performed to sup­
press difficult experiences were diminished (pre-treatment = 14.87;
post-treatment = 4.64). Results also showed an increase in the use of
self-controlling coping (pre-treatment = 15.93; post-treatment =
23.09), which indicates a greater ability to regulate thoughts and be­
haviors. Nonetheless, the use of social support decreased (pre-treatment
= 9.29; post-treatment = 4.64), signaling a change in how Mrs. A.
approached social groups and norms. Accepting responsibility coping
increased (pre-treatment = 8.36; post-treatment = 17.42), which could
mean that the participant has gained a better understanding of her own
role and commitment towards infertility and difficult experiences.
Taken together, these particular changes in coping strategies suggest

Fig. 8. DAS baseline and post-treatment T scores.

8
L.M. Petre et al.
Mrs. A.’s repositioning towards the challenge of infertility.
Dyadic adjustment
Results of the post-intervention assessment, as assessed by the
Dyadic Adjustment Scale (see Fig. 8), showed a significant decrease
regarding couple functioning. Scaled scores indicated a substantial
decrease in dyadic consensus (pre-treatment = 70; post-treatment = 48),
pointing to an increased occurrence of perceived disagreements with the
romantic partner, especially regarding time spent together and sharing
of responsibilities. Moreover, lowered dyadic cohesion (pre-treatment =
68; post-treatment = 60) could also point to a critical phase in the
relationship, when common interests and passions were being ques­
tioned. As we did not have access to the scores of Mrs. A.’s partner, the
assumption only remained valid for the perspective that she had on the
couple’s dynamics. From her point of view, it seemed that the deterio­
ration of the relationship was also visible in the affective domain (pre-
treatment = 61; post-treatment = 40), marked by difficulties to express
her emotions or her sexual desire. Thus, these scores, associated with the
projective results from the drawing in session 6, showed high levels of
uncertainty in couple functioning.
Femininity personality trait
As reflected by post-treatment scores (see Table 1) obtained on
California Psychological Inventory, Femininity Scale (Fe-CPI), the
femininity personality trait showed an increase (pre-treatment = 23;
post-treatment = 24). This could indicate the development of Mrs. A.’s
ability to receive emotional and cognitive support from others, by
allowing herself to consolidate her autonomy in healthier ways. She
explored and accepted her needs of psychological growth, and checked
if the existential contexts surrounding her are suitable for those needs.
Qualitative description
Development of a new perspective on infertility and motherhood
Building on previous research that emphasized the effect of art-
making on developing a new perspective on infertility and mother­
hood. (Streeter & Deaver, 2018), qualitative data was extracted from the
verbatim transcriptions of the 10 groups sessions, in order to identify if
the participant’s perspective on infertility and motherhood changed
after the psychological treatment. At the beginning of the intervention,
while exploring the meaning of infertility, Mrs. A. reflected on how her
fears blocked her desire for motherhood, describing this as “being
pregnant with her fears”. Throughout the psychological process, the
participant learned how to activate and integrate the relationship be­
tween fear and courage, by exploring: when they appeared, how they
manifested, what benefits they brought, where their physical sensations
were located in her body, what thoughts and behaviors they were
associated with.
By increasing self-awareness, the participant gained access to her
courage, which proved to be a psychological theme that she associated
with motherhood. At the end of the intervention, the participant
developed a new perspective towards motherhood: she became more
aware of how her ability to receive and preserve was manifesting.
During the last session, Mrs. A. explored how she could psychologically
activate her maternal potential and created a life plan, consisting of
emotional, cognitive, and behavioral strategies, to help her anchor this
therapeutic work in reality.
Discussion
This case study was aimed at presenting the treatment protocol and
outcomes of an experiential psychotherapy intervention that uses
artistic activities tailored for female infertility. The case study design
facilitated both the quantitative measurement of psychological effects
and the qualitative description of participant’s process of developing a
new perspective on infertility and motherhood.
9
The Arts in Psychotherapy 73 (2021) 101758
The results showed improvements in participant’s quality of life,
fertility-related quality of life, coping strategies, femininity personality
trait, and perspective towards infertility and motherhood. Following the
psychological treatment, a significant decrease was observed in
perceived dyadic adjustment.
The experiential techniques, mindfulness techniques, and artistic
activities allowed the participant to visibly express emotions that were
difficult to cope with, such as fear and sadness. Moreover, the artistic
products, such as drawings, collages, clay models, served as tangible
reminders of the insights gained during the psychological intervention,
as highlighted by other studies in the literature (Streeter & Deaver,
2018). Although these results appear to be in contrast with those ob­
tained on the Emotional Subscale of FertiQoL, considering participant’s
coping strategies of self-controlling, avoidance, and distancing, the
processes of experiential psychotherapy could have brought to surface a
diverse range of intense emotions and feelings that the participant used
to suppress and deny. Moreover, as Kwong, Ho, and Huang (2019) have
emphasized, the adequate awareness and expression of negative emo­
tions represent key markers of psychological well-being.
Results in the mind-body, relational and social domains of fertility-
related quality of life are similar with those reported by other studies
on participants with various medical conditions, such as asthma (Beebe,
Gelfand, & Bender, 2010), cancer (Monti et al., 2006; Svensk et al.,
2009), and dementia (Cowl & Gaugler, 2014). Effects on the Mind-Body
Subscale of FertiQoL could be attributed to the mechanism of sustained
relaxation that occurs during art-making, which also enables adaptive
forms of cognitive processing (Czamanski-Cohen & Weihs, 2016). Thus,
working with artistic media is theorized to involve sustained relaxation,
while the participant is processing difficult psychological experiences,
such as infertility.
Effects on the Relational Subscale of FertiQoL could be accounted for
by the processes of activating psychological gender role behaviors, at­
titudes and traits, thereby supporting the participant to integrate both
the masculine and the feminine psychological gender roles within the
couple dynamics. As other studies on infertile patients have shown
(Cserepes et al., 2013), rigid feminine gender roles predict relationship
difficulties related to infertility. As such, the integration of masculinity
and femininity could be linked with lower levels of infertility-related
stress and higher levels of fertility-related quality of life. Moreover, re­
sults show a slight increase in femininity personality trait, which could
also be accounted for by the adaptive integration of psychological
gender roles.
On the other hand, results reported on the Social Subscale of Ferti­
QoL might be explained by experiential group psychotherapy’s function
of social support, enacted through normalizing and validating common
feelings and thoughts associated with the experience of infertility. Thus,
various forms of social support appear to have strong direct and indirect
correlations with social, sexual, and relationship domains of infertility-
related stress (Martins, Peterson, Almeida, & Costa, 2011).
Following the intervention, self-controlling and acceptance of re­
sponsibility coping increased, while distancing and seeking social sup­
port coping seem to have been reduced. These results could be attributed
to changing the perspective towards difficult experiences and infertility,
which was facilitated by artistic activities. Thus, through drawing,
modeling and art genogram, Mrs. A. was able to visually modify the
artistic products, while also replacing maladaptive avoidant coping
strategies with adaptive ones, according to the psychosocial needs that
she had identified during the psychotherapeutic sessions. These effects
are of great significance, when linked with findings from literature.
Research suggests that infertile women tend to avoid, repress and deny
negative feelings associated with infertility (Fassino, Piero, Boggio,
Piccioni, & Garzaro, 2002). Experiential avoidance, the process by
which someone avoids staying in contact with aversive inner experi­
ences, is considered to be a common response in infertile women
(Cunha, Galhardo, & Pinto-Gouveia, 2016). This is of great concern
because psychological defense strategies might operate as a risk factor
L.M. Petre et al.
for medical conditions, given that de Klerk et al. (2007) showed there is
a correlation between low levels of affect displayed by women under­
going treatment and negative in vitro fertilization outcomes.
The change in perspective can also be seen towards the couple
functioning, as shown by the results reported on the Dyadic Adjustment
Scale. By drawing the relational space of the couple, Mrs. A. identified
her personal boundaries and reflected on psychological mechanisms that
might have hindered emotional intimacy within her couple relationship.
The overall positive changes provided by this experiential psycho­
therapy intervention are congruent with prior studies which incorpo­
rated artistic activities in psychological interventions for female
infertility. The findings of this study, together with those provided by
Streeter and Deaver (2018) and Hughes and da Silva (2011), offer evi­
dence for positive psychological effects in infertile women: decreasing
depressed mood and hopelessness, adjusting coping skills, improving
quality of life, increasing self-awareness, and developing new perspec­
tives towards infertility and motherhood.
While these results seem promising, they are preliminary in that they
may have been affected by several methodological limitations. First, the
single case study design does not allow the results to be generalized to
the entire population of infertile women. Instead, these results should be
interpreted in light of this study’s aims: to observe and describe the
naturally occurring changes in the variables of interest at post-
intervention, while also presenting the treatment protocol of experien­
tial psychotherapy using artistic activities tailored for female infertility.
Second, as the design did not employ randomization, the participant
voluntarily engaged in the study and the intervention, which could
correlate with several factors associated with the effectiveness of a
psychological intervention: increased motivation, self-awareness, and
self-regulation. Third, considering that the participant’s scores were not
compared with scores from a control group, this study measures
changes, but cannot precisely specify if the observed changes are due to
the psychological intervention or to confounders. Fourth, the use of
various intervention components also hampers determining which
component explained most of the variance in the results.
These results provide support to our hypothesis, that the use of
artistic activities within the context of experiential psychotherapy is
suitable for addressing the psychological correlates of infertility. Current
results suggest that the use of artistic activities within experiential
psychotherapy offers infertile women an optimal therapeutic context for
depth-oriented work, which could be effective in alleviating psycho­
logical consequences associated with female infertility. Thus, artistic
activities embedded in experiential psychotherapy could be effective in
increasing quality of life, reconstructing the broken identity of the per­
son, and finding meaning in the unpredictable experience of infertility.
Our findings also suggest that an experiential psychotherapy inter­
vention using artistic activities encourages adaptive emotional expres­
sion and could be beneficial in addressing the psychological difficulties
and psychosomatic expressions of inner conflicts in infertile women,
thus possibly bridging a current gap between the medical treatment and
the mental health needs of this population.
Future case studies documenting experiential psychotherapy in­
terventions using artistic activities for female infertility could benefit
from incorporating multiple timepoints in assessing the psychological
correlates of infertility, thus monitoring outcomes throughout different
stages and phases of the intervention. Moreover, case studies could also
assess the reliable change index, in order to determine if changes in
reported outcomes are attributable to psychotherapy or to measurement
errors.
Going further, future studies should also use experimental research
designs, including randomization and a control group, in order to in­
crease the probability of generalization. Research in larger samples
would also be highly needed. Through experimental designs, studies
might investigate mechanisms of change produced by artistic activities
within experiential psychotherapy, elaborating on previous theoretical
frameworks presented in the literature (Czamanski-Cohen & Weihs,
10
The Arts in Psychotherapy 73 (2021) 101758
2016).
Conclusion
The results of this case study suggest that the use of artistic activities
within experiential psychotherapy may be effective in improving the
quality of life, fertility-related quality of life, coping strategies, and
femininity personality trait in female infertility. Moreover, the effects of
the psychological intervention were also grasped by identifying the
change in participant’s perspective towards infertility and motherhood.
At the beginning of the intervention, the participant tackled the expe­
rience of infertility with fear, whereas at the end of the intervention, the
participant activated her courage to face the experience of infertility.
This study extensively presents the treatment protocol of the expe­
riential psychotherapy intervention, tailored specifically to the psy­
chological mechanisms, needs, and consequences associated with
female infertility. The treatment protocol for female infertility is unique,
in that it is focused on activating and integrating two fundamental sets of
psychological roles: a) the inner child and the inner parent; b) the psy­
chological gender roles of masculinity and femininity. By presenting the
application of the treatment protocol for a single case, this study outlines
the implications that these psychological roles pose for the treatment of
female infertility.
As it can be seen from this case study, artistic activities embedded in
experiential psychotherapy can address these psychological roles, while
at the same time strengthening the quality of life, coping strategies, and
femininity personality trait in female infertility. Working with artistic
media could help women reconstruct their identity after the crisis of
infertility, showing them different strategies of coping with unpredict­
able and seemingly uncontrollable experiences. After practicing those
newly acquired coping strategies in the therapeutic environment,
infertile women can transfer their insights and apply them to other social
contexts.
Funding
This research did not receive any specific grants from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
None.
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