Measuring resilience in women experiencing infertility using the CD-RISC: Examining infertility-related stress, general distress, and coping styles

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Abstract

Psychological morbidity concurrent with fertility problems has been the focus of substantial scientific inquiry. However, researchers have largely overlooked psychological resilience within this population. This study explored the associations between resilience, infertility-related and general distress, and coping behaviors in forty women from nine fertility clinics throughout the United States. Participants completed the Connor–Davidson Resilience Scale (CD-RISC), Symptom Checklist-90 (SCL-90), Beck-Depression Inventory-II (BDI-II), Fertility Problem Inventory (FPI), and Ways of Coping Questionnaire (WCQ). Women with fertility problems evidenced significantly lower resilience scores than published norms. This study established evidence for the reliability and convergent validity of the CD-RISC with infertile populations. However, similar to other studies using this instrument, the factor structure reported by Connor and Davidson [Connor KM, Davidson JR. Development of a new resilience scale: the Connor–Davidson resilience scale (CD-RISC). Depression and Anxiety 2003;18:76–82] was not well supported. Resilience was negatively associated with infertility-specific and general distress. Engagement in action-focused coping skills was positively correlated with resilience. Implications for enhancing resilience with this population as are discussed.

Introduction

Resilience has been broadly defined as the capacity of individuals exposed to a negative event to “maintain relatively stable, healthy levels of psychological and physical functioning” (Bonanno, 2004, p. 20) and to “cope flexibly with life’s challenges” (McMahon et al., 2007, p. 1169). Despite the myriad definitions used to operationalize this construct, resilience appears to serve as a protective factor to reduce the impact of stressors. Moreover, resilient persons are better prepared to use active and social coping methods (Li, 2008, Yi-Frazier et al., 2009).

Early investigations of resilience were primarily focused on childhood development in the face of adversity or individual responses to extreme trauma (Rutter, 1985, Suedfeld, 1996, Werner and Smith, 1992). More recently, healthcare scientists have begun to appreciate the possible associations between resilience and psychological and physical illness as well as the importance of understanding wellbeing, positive functioning, and self-actualization (Richardson, 2002). Bonanno stressed that resilience facilitates the preservation of functioning and is a marker of wellbeing rather than simply the “absence of pathology” (2004, p. 20). Despite this distinction, resilience appears to decrease the propensity to experience depression and anxiety (Bonanno, 2004, Connor and Davidson, 2003). Similarly, characteristics of resilience have been associated with decreased disease susceptibility, improved prognosis, and better adaptation to chronic conditions such as cancer (Carver, 2005), HIV (Farber et al., 2000, Taylor et al., 2000), cardiac disease (Kubzansky et al., 2001), arthritic pain (Wright et al., 2008), and diabetes (Yi et al., 2008). The benefits conferred by resilience may be direct or indirect. For example, neurochemical, neuropeptide, hormonal (Charney, 2004), and genetic (Caspi et al., 2003, Gervai et al., 2005) foundations of resilience have been speculated. As noted, resilient individuals may be more likely to engage in active coping skills. The use of particular active coping strategies, such as self-care behaviors, may limit the likelihood of disease acquisition or lead individuals to be more likely to adhere to healthcare recommendations (e.g., Fife et al., 2008, Pence et al., 2008).

Specific to the field of infertility, there is continued debate related to the most accurate conceptualization of psychological features associated with fertility problems (Berg and Wilson, 1990, Edelmann and Connolly, 1998). Based on the empirical evidence, it appears that the stress of infertility is related to increased rates of depression and anxiety (Greil, 1997). However, the vast majority of individuals coping with fertility problems do not exceed clinical thresholds for these disorders. In fact, some individuals may thrive as a response to this stressor. For example, in a large study of 2250 individuals dealing with challenged fertility, two-thirds of women and nearly three-fifths of men agreed that infertility strengthened their relationship and brought them closer together (Schmidt et al., 2005). Consistent with biopsychosocial models of infertility, the reactions to fertility problems may be best characterized as contextually determined by the interplay between interpersonal relationships, physiological parameters, risk and protective factors, cultural expectations, and individual coping resources.

For those dealing with fertility issues, in addition to the stressors related to the experience of involuntary childlessness itself, medical treatment is often additionally quite taxing. Care may involve multiple and invasive treatment cycles that are commonly unsuccessful, economically and personally draining, and generally without a clear endpoint in the absence of parenthood. Psychological factors and difficulties coping with the emotional demands of treatment have been implicated in the high rates of treatment dropout (Olivius et al., 2004, Rajkhowa et al., 2006, Smeenk et al., 2004). For example, Hammarberg et al. (2001) reported that women who did not become pregnant through assisted reproductive treatments (ART) cited psychosocial factors as principle reasons for discontinuation of medical treatment including having “had enough” (66%), “emotional costs” (64%), “not being able to cope with treatments” (42%), and “physical demands” (39%).

Specific to this population, Peterson et al. (2005) investigated the relationships between specific coping strategies assessed by the Ways of Coping Questionnaire (WCQ; Folkman and Lazarus, 1988), infertility-specific stress, and depression. They observed that the Social Support Seeking (SSS) and Planful Problem Solving (PPS) coping subscales were negatively related to infertility-specific distress and depression while the reverse was demonstrated for escape-avoidance (EA), accepting responsibility (AR), and distancing (D) strategies.

Unlike coping, resilience has yet to be examined in the context of infertility, despite the known relationships between resilience and other medical conditions. Connor and Davidson (2003) developed a 25-item questionnaire, the Connor–Davidson Resilience Scale (CD-RISC), which has potential to be the gold standard with which to measure this construct. Connor and Davidson found the full-scale reliability and validity of the CD-RISC to be psychometrically strong with community populations, primary care and general psychiatric outpatients, and with individuals receiving treatment for generalized anxiety disorder and posttraumatic stress disorder. Furthermore, they described a 5-factor structure consisting of ‘personal competence, high standards, and tenacity,’ ‘trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress,’ ‘positive acceptance of change and secure relationships,’ ‘control,’ and ‘spiritual influences.’

The CD-RISC was subsequently used in several studies that demonstrated resilience in patients with PTSD could be potentially enhanced through the use of psychopharmacology and psychotherapy (Connor and Davidson, 2003, Connor and Zhang, 2006, Davidson et al., 2005). Additional studies have supported the reliability and validity of the CD-RISC total scores with adolescent (Jorgensen and Seedat, 2008), young adult (Campbell-Sills et al., 2006), older female (Lamond et al., 2009), and Chinese populations (Yu and Zhang, 2007). While the psychometrics of the full-scale CD-RISC have been impressive, the factor structure has not been fully supported with subsequent populations (Campbell-Sills and Stein, 2007, Jorgensen and Seedat, 2008, Lamond et al., 2009, Yu and Zhang, 2007).

Given that women dropping out of fertility treatment often attribute their attrition to stress, better understanding the associations between resilience, distress, and coping behaviors may provide useful information about the medical management of fertility problems as well as the phenomenological experience of infertility itself.

Given the stress experienced by individuals dealing with infertility, we hypothesized that resilience would be lower in infertility patients than general norms. To further evaluate the psychometric properties of the CD-RISC, we explored the factor structure of the CD-RISC with ART-seeking women and compared our results to other factor analyses using this measure (Connor and Davidson, 2003, Jorgensen and Seedat, 2008, Lamond et al., 2009, Yu and Zhang, 2007). In order to research the utility of the CD-RISC with women with challenged fertility, the measure was compared to stress and coping scales to establish convergent validity. Resilience was predicted to be negatively related to both infertility-specific and general distress. Based on the relationships between specific coping strategies and mental health in those with fertility concerns empirically identified by Peterson et al. (2005) and the aforementioned conceptualization of resilience as the ability to cope adaptively with adversity, engagement in active coping strategies was posited to be positively associated with resilience while the opposite association was expected with increased use of emotion-focused coping.

Section snippets

Participants and procedures

Participants for this study (N = 40) were primarily recruited from two fertility clinics (n = 32). Given considerable difficulties with study recruitment, an additional seven clinics later assisted with enrollment. Subjects were enrolled as part of a larger study aimed at reducing stress in women undergoing medical assessment and/or treatment for infertility. Interested women were eligible if they were at least 18 years of age, were able to read English, and had access to the Internet. Women were

Sample characteristics

The characteristics of study participants closely resemble those described in other research involving ART-seeking women. The mean age of participants was 33.3 years (SD = 5 years). Ninety percent identified as Caucasian. Ninety-five percent were married. The overwhelming majority (97.5%) possessed at least some college education. Most (65%) estimated their household income as ⩾$100,000. Women reported trying to conceive for an average of 34 months (SD = 30 months) and had undergone 6.9 prior

Discussion

The results of this study suggest that resilience in treatment-seeking women with fertility issues is lower than that observed in the general population. In fact, our participants evidenced CD-RISC scores nearly a standard deviation below norms reported by Connor and Davidson (2003). Instead, resilience levels in this study were most similar to those described for psychiatric outpatients (M = 68.0, SD = 15.3). This is noteworthy given that experiencing severe levels of depression was an exclusion

Conflict of interest

There are no actual or potential conflicts of interest to disclose.

Contributors

Minden Sexton designed the research as part of a doctoral dissertation study, developed the protocol, collected and analyzed data, and wrote the preliminary manuscript. Michelle Byrd was involved in study design, data collection, and manuscript preparation. Silvia von Kluge was involved in study design and manuscript preparation. All authors have approved the final manuscript.

Role of funding source

The authors have no funding sources to disclose. Participant honoraria were paid by the first author.

Acknowledgements

The authors wish to thank Drs. William Keye Jr. and Bradley Miller for their valuable support with the development and implementation of this study. We are grateful for the generous contributions of the research participants. The authors thank Amy Drayton and Marya McCarroll and the clinical staff who assisted with recruitment during the study. We gratefully acknowledge Karen Saules and the contributions of anonymous reviewers whose assistance significantly improved the quality of this

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