When seeing patients, I always recommend people to gather their Fertility TEAM. T is for therapist, and I’m so excited to have Dr. Loree Johnson share her valuable info with us.
In this conversation, we’re going to be talking about some of the mental health impacts of being a fertility patient. I’ll be asking Dr. Johnson about the difference between Infertility Stress and Infertility Trauma, we’re going to talk about grief as it relates to fertility (and how it’s different than other grief), and she’ll share how to navigate the stress of being pregnant after having loss.
Dr. Loree Johnson is a Licensed Marriage and Family Therapist (LMFT) with more than 25 years of experience as a clinician, educator, and clinical supervisor. After her first-hand experience with fertility challenges taught her the importance of self-care for managing the physical and emotional stress that come with the fertility process, Dr. Loree found her purpose supporting individuals and couples on their path to parenthood. She and her husband welcomed their rainbow baby in 2021 after 8 years of trying to conceive, three losses, and one TFMR (termination for medical reasons.)
Dr. Johnson had so many wonderful insights to share, both from her own personal experience and from working with her clients. I was so honored to spend time with her and to share this conversation with you!
Transcript
Dr. Aimee: I’m so excited to have you share your valuable information with our audience. Will you tell us a bit about you and what brought you to become a therapist?
Dr. Loree Johnson: I always feel like I was a therapist before I got the title. I was the resident counselor amongst my friends and the secret keeper. I was also really fascinated by human behavior, so it was just a natural progression to study human behavior in graduate school. Then I became what I’d consider kind of a professional student. I got my master’s degree, and then decided I wasn’t done, and went for my PhD, also in marriage and family therapy.
I was just really excited to contribute to the field. I just really love what I do. I love being there, and holding space for people just feels like a natural part of who I am. That’s kind of why or how I came to be a therapist.
Dr. Aimee: What about your specialization in fertility? Tell us about how that came to be.
Dr. Loree Johnson: That’s a very interesting progression. When I first started my career, I thought I was going to be a mental health therapist in community mental health. I really enjoyed working with that population. Then I decided I needed a different challenge and started working in private practice.
It was really the shift that I started to see in my private practice where there were more professional women who were coming to me who had pregnancy losses or just various stages of their family planning journey or fertility journey. I was involved in the infertility community kind of by proxy. I didn’t necessarily consider myself an infertility therapist or a grief therapist at that point.
It wasn’t until I got married – I got married later in life, so kind of mirroring the experiences of the individuals who were coming to me. I naively thought I could grow my family when and how I wanted. And it didn’t happen. When I started to experience loss after loss, especially my TFMR (termination for medical reasons), that experience alone was really jarring.
In totality, it was hard to find support. I kept thinking if I’m having trouble finding support as a person of color, I can only imagine what it’s like for other patients going through this journey. Once I came out on the other side, I dedicated myself to holding space for those in our community. And here I am.
Dr. Aimee: Thank you for doing it. Being a fertility patient is so stressful. What are some of the things people can do to develop a long term fertility self-care plan?
Dr. Loree Johnson: I like the term “long term self-care,” because I think sometimes when we think about the science of it, we think that it will go quite quickly, or it could go really quickly. For some people where the treatments work on the first try or first cycle, that’s great. But for the majority of us, that’s not the case.
I always encourage people to think about cultivating a really firm foundation around mental health issues. For me, the pillars of mental health are nutrition, stress management, exercise, sleep, and those are things that are within our control, and then also managing one’s mental health. I think having a strategy for each of those elements of your life is part of the foundation for having some longevity when you’re dealing with fertility issues and treatment, because it’s stressful, we all know that.
I think as long as you have a sense of what your basics need to be… Sometimes I keep telling people let’s go back to the basics, what are the basics right now. We’re getting too out there or too caught up in the right diet or needing to do this exercise or that. I think there are lots of great things out there for people, adjunctive pieces to the treatment process, but it’s what is right for you.
Dr. Aimee: You mean you’re not supposed to be on Google at 2:00 in the morning? I remember you saying that Google is your fake best friend. What do you think is the healthy balance between internet research and relying on your doctor for information?
Dr. Loree Johnson: Oh my goodness, the elusive word “balance.” Right? Google is very seductive because it gives you information at the drop of a dime. I have a love/hate relationship with it. I think it’s a wonderful resource. I know my doctor has pulled up things from Google or what have you.
I think the key is healthy balance or healthier balance, because let’s face it, a lot of us are anxious, we’re going to be doing that research. But I think the balance includes your doctor’s guidance because so much of the information is presented without context, and I think that when we read that information without the context that is the expertise of our doctors or our treatment team, then we place the lens on it that is not necessarily meant to be placed, and that can take us to a very different place.
Healthy balance to me means you might be doing that, but also what does your doctor say, because your doctor is the one who has gone to school for this, they’re the experts, they’re the ones guiding this process. I think it’s paramount to have their input and to have them be the lead on this.
Dr. Aimee: Throughout the process, you can be stressed and you can experience trauma. How do you differentiate between those things, fertility stress and trauma, and how do you define them?
Dr. Loree Johnson: That’s a great question. Stress in and of itself is basically the body’s response to pressure, to life events. We’re really adaptable beings, so stressors really let us know what changes we need to make. Stressors in the infertility world can look like difficulty sleeping, eating, or drinking too much, being consumed with lots of fertility issues, energy issues, things like that. Sometimes what we notice with stressors is they resolve on their own over time.
Now, trauma can be defined as what I just listed above, but it might easily be summed up as an emotional response to a horrible event. Infertility trauma in and of itself is troublesome because we’re seeing depression, anxiety, and stress responses that are not resolving over time. When they don’t resolve over time is when they typically can develop into a traumatic reaction where we’re seeing more physiological responses that are just not healing.
I think when we’re diagnosing trauma, it’s such an individual experience. I know there is a lot of information on the internet about what to look for, what it looks like, but it’s going to look differently for each person. I think it’s important to make sure that you’re consulting with your therapist and your team to help you understand: is this more of a stress response or is this a trauma response for you, because then the approach would be different.
I think it’s hard to differentiate for people because they can look very similar. I just think that the trauma of infertility is also encompassing the loss of these hopes and dreams and these expectations for life and how you grow your family, and those are so central to our identities as people. That’s where I think the personal experience is important in terms of really trying to differentiate between the two and understanding the person’s lived experience.
Dr. Aimee: What do you recommend, what can patients do to cope with infertility stress?
Dr. Loree Johnson: I think that coping is going to look different for different people. Of course, nutrition, sleep, and exercise, the foundational tools for mental health, can sometimes be the first elements to go. I think it’s important to seek help early on, whether it’s through a support group or finding a buddy who is going through the process with you, or talking to a therapist or coach who is well versed in fertility issues.
If one element doesn’t work for you, please don’t hesitate to find something else because it’s really important to figure out what makes you feel supported, more importantly, and make sure that you have those in place as you’re going through it and not to white-knuckle it, so to speak, and think, “I can do it on my own, no big deal. It shouldn’t be an issue,” but it really is for a lot of people and there is no shame in that whatsoever.
Dr. Aimee: Are there any particular groups that you recommend to your patients?
Dr. Loree Johnson: RESOLVE has a number of groups right now. Fertility Rally is another resource that I use for patients. RESOLVE will let you know about more professionally led groups and some peer led groups. Fertility Rally is more peer led. There is nothing wrong with either group. Just know that sometimes when you’re with a therapeutic group versus peer led it might feel a little different. I think it just depends on what you need at that moment. Not saying one is better or worse. Everything is just different. Those are the two places that I go initially. Of course, if I have a colleague that I know is running a fertility support group or an IVF group or pregnancy loss group, I will make those referrals as well.
Dr. Aimee: What are the benefits of seeking therapy while going through fertility treatment?
Dr. Loree Johnson: We all know that fertility treatments are stressful. Studies show that if you have appropriate stress management techniques in place, we can’t always control outcome, but we can make sure that we feel good about the fact that we’ve done everything that we can do to have the best outcome. I see it as making sure that all of those resources are in place so that you can give yourself the best shot.
It also helps you work through any feelings of depression, worry, or anxiety, self-esteem issues that can pop up. I don’t want to say it can derail treatment, but it can impact how you feel about your treatments, which I think can impact treatment at the end. It’s really about making sure that you’re keeping your mental health intact and tending to that in a holistic way.
Dr. Aimee: Also, relationships. I imagine you also navigate the complexity of being a fertility patient and a marriage, for example.
Dr. Loree Johnson: Exactly. You don’t want to forget about your relationship. It’s very easy to become consumed by treatments, the procedures, and the appointments, especially when they’re happening to your body and with your partner not necessarily experiencing the treatments in the same way, that can create some tension from time to time. That can be a wonderful place to explore all of that and to figure out what your relationship needs.
Dr. Aimee: I read on your website about EMDR. For people who don’t know what that is, can you explain that to us?
Dr. Loree Johnson: EMDR stands for eye movement desensitization and reprocessing. It’s a form of psychotherapy, a method that we use to help people heal from trauma or distressing events. One of the things that I really love about this is because sometimes we don’t always have words to put to the intense experiences that we’ve had, and you don’t really need them in order to do the work around EMDR because it really operates under the assumption that your brain is wired for healing.
We don’t necessarily have to focus on changing thoughts or behaviors or anything like that, so I really love this modality. Ironically, I was first introduced to it really early on in my career before it had all of the longitudinal data, and I didn’t necessarily get trained in it until I came through the other side of my journey. It’s like wow, it’s powerful. I’m a testament to it, and obviously love it and use it with a lot of my clients.
Dr. Aimee: I feel like everyone should at least know what it is and how to do it. If you’re dealing with trauma and stress, it can definitely help you. How exactly does it help, can you explain that again for us?
Dr. Loree Johnson: When clients are feeling really burdened by loss or just the heaviness of treatments, it really impacts or helps the body heal naturally. The body can’t heal or process certain events when the stressors keep coming. When you think about fertility treatments and the nature of treatments in and of itself, it can make it really hard to before the next appointment or what have you, there’s another stressor happening. What it does is it helps you learn to coexist.
When you’re in these really stressful or traumatic kind of moments, your body is in this fight or flight state. What it helps is to reduce that so that you can look at the stressor, realize it’s there, it’s manageable, it’s not overwhelming. Akin to if you’re at a campground and there is a bear or something, immediately you’re fearful, you’re ready to scream, your fight or flight. It’s like okay, the bear is right here, it helps calm your system so that you can be more present.
When we’re more present, we’re able to find more adaptive ways of coping. You’re able to say this treatment cycle didn’t work out the way that I had hoped, I didn’t like that, I don’t like it, but I’m going to be okay. As opposed to oh my gosh, this treatment cycle didn’t work out, my life is over, I don’t know how I’m going to move on. You still might have those moments, I don’t want to pathologize that, it’s just a way of helping you move through it that is a little bit more gentle and honors what your body is already trying to do naturally but just might need some assistance with.
Dr. Aimee: I imagine one of the bears could be an immediate diagnosis, like your pregnancy sadly has stopped growing, and that obviously causes a lot of grief. I feel like grief just isn’t talked about enough. How is this grief different from other grief?
Dr. Loree Johnson: Grief within the infertility and pregnancy loss community is very akin to what we call disenfranchised grief. Disenfranchised grief is basically a loss that’s not widely recognized or supported by our larger communities or society. When you think about grieving, we normally think about someone who has passed away, maybe an elder, we have rituals to honor that loss, we know what to do or how to respond, for the most part.
When the loss occurs based on an early pregnancy loss or a termination for medical reasons, you don’t have the physical symbol of loss that people are used to seeing, so people don’t know what to do with that. I think those of us in the loss community don’t know what to do with it sometimes, let alone people on the outside. We don’t have the language for it. Disenfranchised grief is what we call it, and usually it’s because we think that it’s not necessarily viewed as worthy of acknowledgement.
It really pushes people, I think, further into their grieving processes along the margins, because when we don’t have the language to talk about it, it makes it hard to move through it.
Dr. Aimee: How can they work through it and move through it, what do you recommend?
Dr. Loree Johnson: I recommend, first and foremost, be comfortable or learn to be comfortable with your narrative around grief. Give yourself time to do the work. I do see people who have suffered miscarriages or pregnancy losses and rush to try to get pregnant again before they’ve emotionally had an opportunity to heal. Grief is not just an action or stages of these feelings that we might go through, but it’s kind of toggling back and forth between these periods of normalcy and these periods of intense emotions.
I think understanding what grieving looks like can really help normalize it. One day you might be okay at work and it’s okay to be distracted, and another day you might just be so foggy and disconnected and irritable with people. It looks different for everybody, but it’s an action, it’s a process. I think giving yourself time to do the work. I think it can be hard to figure out how to talk about it, but I just feel like there is so much power in words and naming what you’re going through. Sometimes that can be frustrating in and of itself because sometimes people get tired of it, and that’s okay. Honor what your narrative is and what your story is about grief, and tell it over and over again.
Dr. Aimee: How do you wish fertility doctors could do a better job when it comes to knowing how grief impacts their patients and recognizing it?
Dr. Loree Johnson: I think in the same way that doctors are stressing the importance of mental health. I think continuing to ask questions about how their patients are feeling emotionally holding space. I feel like there are so many doctors that are doing a fabulous job of that.
Continuing to point them in the right direction, because I think that you all have a lot of power. When you ask, “How are you really doing,” and you demonstrate that sense of empathy, you’re really showing your patients that you’re a safe place to go to, and therefore you’re a point person to refer them to other professionals that can help them do the intensive work that you might not have time to do or that might not be in your purview to do, but you’re still showing that you’re aware.
Dr. Aimee: For a patient who right now is dealing with anxiety, stress, grief, what can they do right now to help themselves?
Dr. Loree Johnson: Make sure that you’re connected with a team, a supportive team. For people who are pregnant after loss, I think one of the ways that we as therapists encourage patients is to talk with their doctor about their anxiety, and sometimes it might mean increased monitoring and asking about the appropriateness of monitoring, because sometimes that can do a lot to reduce anxiety or help manage the anxiety.
Working with a therapist can help people develop what I call a window of tolerance for anxiety. They know if I’m within this particular window, that’s normal, that’s to be expected. If I start to inch closer to the higher part of the threshold, this is when I need to XYZ, and then develop a plan for what that might look like specific to the person.
There are so many resources and strategies that can be developed and personalized in sessions that can really help people feel as grounded as possible. The goal, you might want to be anxiety-free, and that doesn’t necessarily come right away for the majority of people. So, if that’s not happening for you, you’re in good company. It’s making sure that you have the support in place that can help normalize what you’re going through and also adjust whatever strategies you have in place.
Dr. Aimee: I feel like so many people go into treatment not realizing how hard it is, and they don’t have the strategy. Then they wish they had known about all of the strategies upfront. So, I strongly encourage my patients to be in support groups and to have a therapist from the very beginning.
The hardest part for me is delivering that bad news. I’m going to put you on the spot. Do you have any advice for me as far as what is the best way to deliver bad news to patients, whether it be your embryo stopped growing or, another scenario, your pregnancy stopped growing?
Dr. Loree Johnson: I think there’s a lot that you can do in terms of tone and language. The language that you used right now, I think was very gentle, it’s very warm. I think leading with that compassion is really powerful.
Taking a moment. Just saying, “I’m just going to let you have a moment right now. I know this isn’t what you wanted to hear. We can talk all the medical stuff later, but right now let’s make sure that you have some support in place,” and just sit and listen for a few minutes. Then obviously following up with a call, text, or email later on, “How are you doing? Did you get connected to your therapist? How is that going? Thinking of you.” I think that does a lot to close the emotional gap.
But I think the language and tone is important. If you’re feeling empathic, you can demonstrate that empathy and that sense of care. And I know that you do because I’ve worked with a lot of your patients and they love you, so I think you’ve got this down pat.
Dr. Aimee: My other thing is what if a patient isn’t getting that and she just found out some bad news, what can she do? That’s just so hard when the person who is supposed to be helping just isn’t providing that support.
Dr. Loree Johnson: If she’s not, maybe what you do is you have another referral or another place for her to gather some support. If it’s not already in place, it might be a nice point to suggest let’s think about getting you connected. If this connection doesn’t work, then there are plenty more, but we’ll find something for you. Really assuring her that there are options out there and giving her some space to figure out who is going to work for her or not. I know it’s not uncommon for some people to not have that therapeutic support in place and they need to find someone.
Dr. Aimee: I couldn’t agree more. Thank you so much for coming on today and talking to us about this topic. It’s near and dear to my heart. How can people find you and work with you?
Dr. Loree Johnson: You can look at my website, DrLoreeJohnson.com, or I do hang out on Instagram primarily @DrLoreeJohnson. I do consultations and you can schedule one through my website if that’s something that speaks to you. I look forward to seeing you all at some point.
Dr. Aimee: Thank you, Loree, so much. I really appreciate your time.
Dr. Loree Johnson: My pleasure.
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