{"paper_id":"41f668a4-8f3b-4ca6-ab95-7f79e0d291a1","body_text":"155\nNóra Árvai\nPSYCHOLOGICAL TREATMENT OF ENDOMETRIOSIS \nAND SUP\nPORT IN COPING WITH THE DISEASE\n1. INTRO\nDUCTION\nEndometriosis is still a mysterious disease that afflicts affected women during their ferm\ntile year\ns. In fact, the disease can appear as early as the first period and menopause may\nnot relieve the symptoms. (Rogers et al., 2009). \nThe leading symptom of endometriosis is chronic pain, which is mostly localized in\nthe lower abdomen, the pelvic area, but can also radiate to the waist. Relieving pain\nsymptoms is the main motivation for women with endometriosis to see a doctor.\n(Siinai et al., 2007)\nIt is an interesting fact that the degree of pain is not necessarily related to the size and extent of the\nendometriotic nodules.\nFertility dis\norders, difficulty conceiving, is the second most common reason for women to see a docm\ntor. It can be assumed that endometriosis can cause fertility difficulties both mechanically (by adhem\nsions, tubal occlusion, etc.) and by inhibiting ovarian migration, fertilization, and implantation (Van\nden Broeck et al., 2013). Difficult conception and possible complete infertility are symptoms that\nare also worth mentioning from a psychological point of view, as they greatly affect the selfmesteem,\ncoping ability, and relationship dynamics of those affected.\nThe disease affects 10–15% of women of childbearing age and 3–5% of women after\nmenop\nause. So it can be observed that at least one in 10 women is affected, so there are\nabout 176 million women around the world suffering from this disease (Árvai, 2012).\nThe establishment of a diagnosis often lasts for years: an average of 6m8 years, and\nan average of 8 doctors take part in providing the diagnosis. Rolling up a wide range\nof symptoms can in many cases put patients on a long patient career path until one rem\nmembers that organmspecific complaints are associated with the menstrual cycle. By the\ntime patients are diagnosed, they are often exhausted, frustrated, and because they have\ncountless completely negative findings from many places, they eventually believe that\nwe only have the problem in our “head” (Árvai, 2016). \nEndometriosis can negatively affect the quality of life, relationships, sex life, and\nability to work of affected women. Patients are more likely to report anxiety, worries\nDOI: 10.14232/sztep.chpp.2022.11\n\nNóra Árvai156\nabout the future, and are more likely to experience depression, mood disorders, and\noften strong guilt.\nThe f\nollowing case study provides an insight into my psychological work with a womm\nan with endometriosis.\n2. CASE STUDY\nFor ethical reasons, the case presented below was compiled by belnding 3 similar cases.\nMaria’s s\ntory is a good example of the importance of health psychology and health\nsociology in practical helping work.\n2.1. THE SOURCE OF THE REQUEST\nMaria is a thirtymeightmyearmold, restrainedmlooking woman who is a little embarrassed\nwhe\nn we first met, but she became more relaxed soon. The first problem to be addressed\nin the interview is that she feels worthless as a woman. She is often anxious, and she\nis also suffering from the tension associated with fertility difficulties. Although she\nmade her appointment through the online reporting system, both her family of origin\nand her partner welcomed her decision.\n2.2. ENCOUNTERS WITH THE CLIENT AND THE PROBLEM AS THE CLIENT PRESENTS IT\nDuring the encounters with the client, of course, the story is constantly forming and\nher go\nals are changing too. Maria is married. She reports anxiety and depressive sympm\ntoms, the cause of which is that her ovaries have been destroyed on both sides due to\nher illness, one has been removed and the other is impenetrable, so she is forced to rem\nsort to assisted reproduction. She had a hard time processing it, she showed signs of\nanxiety,  she folded her hand, bit the edge of her mouth, she even cried once.\nThe disease – stage III endometriosis – was revealed during laparoscopic surgery,\nwhich was performed because she had wanted to get pregnant for two years, but she\ntried unsuccessfully. Maria's doctors said she had no chance of conceiving naturally.\nShe was very scared of the fresh diagnosis, she wanted to get help to prepare for the\nIVF program, which she was quite wary about at first.\nShe said it is very difficult for her to accept that she cannot get pregnant spontanem\nously. She was afraid of the side effects of the IVF program. She heard and read a lot\nof bad things, from the recurrence of endometriosis to the risk of breast cancer later.\nInfertility has a serious negative effect on female selfmesteem, so women with endomem\ntriosis often see the disease as a constant threat, a kind of time bomb that can reappear\nat any point in their lives. In the case of Maria, all these difficulties arose. She also\nfeared that the IVF program would take away the romance of expecting a child and\nruin her relationship. She felt embarrassed to get pregnant with IVF because it meant\nshe was unable to function properly as a woman.\n\nPsychological Treatment of Endometriosis and Support in Coping with the Disease157\nIn Maria's case, it was important to assess the level of prior knowledge about the dism\nease, t\no gently correct incorrect/excessive information, to educate patients, and to teach\nthem how to use the forums and groups available on the Internet in a way that benefits\nthem, not just “The sad stories drag her down.” She read that the Catholic Church had\na rejective opinion about the IVF procedure and therefore did not know how to tell\nher parents about the problem because they are faithful Catholics.\nThe situation was aggravated by the fact that shortly after our first conversation, exm\ncerpts of an interview with a highly respected church official appeared in the news acm\ncording to which the IVF program was a sin that should be eliminated. These articles\nshattered Maria and while she was speaking about this, her voice was trembling, on the\nverge of breaking down in tears repeatedly. She called herself a “flawed” woman, strugm\ngling with guilt, fearing that due to her fault they would not have a child, and couldn’t\nimagine what other meaning could be found in life if someone did not raise a child.\nIn addition, she felt left abandoned by the health care system. She said she never had\nthe opportunity to ask questions from the doctors, was treated on a treadmill, paid tens\nof thousands for five minutes she spent in their offices, with doctors who said he saw\nonly the bill she’d pay, not a young woman yearning for reassurance. She did not dare\nto share her worries with her husband because she was afraid that Peter would mentally\ncollapse then, and she would no longer be able to bear it if she saw her husband suffer\nbecause of her illness and its consequences.\nMaria's typical way of thinking was catastrophizing. Everyone encouraged her that\neven the first IVF could be successful because her uterus had a healthy hormonal\nhousehold. For her needing an IVF already meant that she would probably never have\na child, was worthless as a woman, she was alone with her worries Her husband could\nleave her any time once he realizes this is her “fault”.\nAn important element of our initial conversations was a kind of education, in which\nI provided real, credible information about the nature and course of the IVF program\nand the real data on possible side effects because, in the vast majority of the Internet,\nI encountered negative stories. I passed the information to her by sitting down, leaning\nback, offering her a seat, too, and asking her to put questions that keep bothering her\nthat she hadn’t had a chance to ask before. This ensured that we had time to talk to\neach other. She later said she felt that now we didn’t have to stop as long as she had\nunanswered questions about IVF. That was very good for her, so we were able to overm\nwrite her previous bad experience with the way too busy medical staff. We also dism\ncussed in detail exactly how the IVF program works and thereby transformed the\nexaggerated ideas in Maria’s mind that mystify the process. We also talked about an\nIVF being neither a panacea nor a child producing factory. According to Maria, one\nsentence was very important for her which was that if a sperm did not want to “stay”\nin the ovum, it would not, not even during IVF, so this was not “rape” against nature,\njust a little help for the cells when they want to meet, but they cannot because of the\ninadequacy of the physical conditions.\n\nNóra Árvai158\nThe cold terms of stimulation, suction, fertilization, implantation were renamed the\nrendezvous o\nf the cells, which helped Maria find the missing “romance” in the process.\nIn this way, we managed to frame the IVF program itself from a violent, aggressive\nprocess to a helpful, beneficial process that would help Maria to become a mother.\n2.3. RELATIONSHIP WITH THE CLIENT\nFortunately, Maria had no trouble talking about her thoughts with someone who was\nnot r\neligious herself. This is a very sensitive topic that requires increased care on the\npart of the helper. It builds a relationship of trust between the psychologist and the\nclient, establishes the rapport when we can talk honestly about this helping relationm\nship. It was reassuring for Maria that we exchanged a few sentences about this. It is the\nindividual decision of the professional helper to decide how much and what kind of\ninformation to share with the client about themselves, and this is sometimes an intuim\ntive process.\nIn the case of Maria, these few sentences strengthened her confidence and especially\nthanked me for my sincerity. She said it was like an invisible wall had fallen between\nus. It was even important to her that I was willing to “take a step” and confirmed that\nI imagined that if there is a God, I think God is very happy that IVF exists because for\nGod life is the greatest value. Life is at the end of the process and God’s blessing also\naccompanies this process. I have tried to deal with religious issues very carefully\nthroughout our nine consultations and there was only one occasion when we were dism\ncussing these issues.\n2.4. SUMMARY OF APPLIED TECHNIQUES, TESTS, RESULTS OF OTHER EXAMINATIONS\n2.4.1. COPING SKILLS, RESOURCE MAPPING\nThe Body Sculpture Test was one of the first tests we did with Maria. This test was\nvalidated i\nn Hungarian by Fehér Pálma and used in somatic patients (Fehér, 2013).\nShe formed a fragile, thin, recumbent human figure out of clay. She worked rough,\nfast, almost in a hurry. She finished it soon. She carved three lines on the face of the\ntwo eyes and the mouth with her fingernail in a recumbent shape and punched three\ntiny holes in the abdomen, illustrating the traces of endometriosis surgery. The belly\nof the recumbent figure was convex, she looked like she was pregnant, but when Maria\ntried to set up the figure –the figure was lying when she was shaping it but it was origim\nnally intended to be a standing figure – she almost angrily emphasized that she was not\npregnant, just bloated because of endometriosis. The statue was unstable, it couldn't\nbe made stand up and Maria couldn't even let it go, because one or another limb fell\nof it whenever she tried. She repeated it for a couple of times and then became so angry\nthat she threw it all in the trash, saying this is how much the figure was worth “Just\nlike me…”\n\nPsychological Treatment of Endometriosis and Support in Coping with the Disease159\nMaria showed a lot of anger towards herself and her body at first, she felt that she\nhad f\nailed, and her body had let her down. She also felt anger toward doctors who did\nnot realize in time that her infertility may be due to endometriosis. It only added to\nher frustration and distrust of the medical staff that she felt she had not been properly\ncared for. The medical staff left her with unanswered questions.\nWe discussed who the ideal doctor would be, whom she could trust, what qualities\nthe doctor should have. What aspects were important to her, and what wishes she\nwould be willing to enter a compromise on. Based on these, the doctor who made the\ndiagnosis did not meet Maria's expectations, but an important moment was the discovm\nery that she did not have to remain defenseless, and the control over the choice of instim\ntution and doctor was in her hands. There is no point in rushing the process, nothing\nhappens if she starts the program a month later, once the right location and support\nstaff have been found.\nI used direct suggestions to describe her nearmfuture situation, instead of “if” I said\n“when you found the right doctor”, and so on (Varga, 2013). I was aware that “finding\nthe right doctor, the right institution” could potentially lead to a timemconsuming run\nfrom doctor to doctor, not being able to commit oneself, but for Maria, this was out\nof the question: she did her research for a doctor, went directly to the doctor she had\nchosen, and she had a very good first consultation with her indeed. Finding the helper\nshe trusted increased her ability to accept the situation.\nWe often went back and forth in our conversation to verbalize her goals, that her\ngreatest desire was a baby, and that the IVF program is the only way to achieve this\ngoal of hers. We formulated and stated what the purpose of the procedure was and\nwhy it was good for her. In addition to the goalmsetting, we also used the method of\npositive visualization, I made her imagine herself pregnant with a baby, and then as a\nhappy mother of it. I asked her to imagine how it feels to hold her baby in her arms,\nand her face lit up while she was imagining her dream. I said then that experience has\nshown that when she’ll hold this soft, sweetmscented, sniffling baby in her arms, her\nbaby, she won’t even remember whether that it had been conceived in an IVF or sponm\ntaneously, it won’t matter at all.\nFor Maria's difficulties sleeping problems and her anxiety complaints, even the simm\nplest methods proved to be sufficient: she developed an evening routine that included\nlogging her feelings and thoughts, sipping her favorite stressmrelieving herbal tea, rem\nfreshing her oldmfashioned autogenic training, refreshing her memories. We also inm\ncluded some simple breathing and relaxation exercises in our selfmreassuring techniques\n(abdominal breathing, complete yoga breathing, progressive muscle relaxation, conm\nscious walking).\nI only had meetings with Maria nine times. These occasions assisted her to become\nmuch calmer, more optimistic, more balanced, looking forward the IVF program with\nexcitement, surrounded by helpers she trusts. She no longer sees the process as somem\nthing devilish, but as an opportunity that will help her become a mother.\n\nNóra Árvai160\nIn the case of patients with endometriosis and fertility disorders, it is often necessary\nto h\nave a systemic approach, in which the involvement of the family and the couple\nbecomes necessary. For one of the nine meetings, I also invited her husband, Peter, to\nassess the extent of his support as a partner and the dynamics of their relationship.\nHe gladly accepted my invitation because he also had some questions about IVF, he\nwas afraid of the effect this procedure could have on his wife. He was reassured when\nhe received the necessary information that he had lacked, so education and\ninformation transfer played a key role here as well. I have witnessed Maria dare and be\nable to talk to her husband about her feelings about IVF. She found a good partner in\nPeter, I have confirmed to them what a good team they are.\nThe PRISMmD drawing test of the client is attached. The advantage of the PRISMm\nD drawing test is that it can be used quickly and easily to map the client’s disease repm\nresentation and coping factors. Visual representation of the current life situation exm\npects activity from the client, facilitates conversation with the support staff, and helps\nto look at the current situation more easily, selfmreflection. The test recording can be\nrepeated several times so that we can track the changes and the progress (Havancsák\net al., 2013).\nThe drawing shows a somcalled selfmshield constellation, things important to the\nperson surrounding the self. The function of the selfmshield is most often to “protect”\none from the disease, but here this function cannot be asserted, since Maria depicts the\ndisease, endometriosis, in the form of a uterus and ovary, as a “self”.\nIt is important to point out that Maria separates herself from her surroundings with\nseveral intersecting, thicker lines, marking some extra protection, extra detachment\nfrom her surroundings. The husband, two girlfriends, Maria’s mother and father, and\ntwo pet dogs are depicted close together as part of the “selfmshield”. All this is concenm\ntrated in a small size in the lower right corner of the page, the page is almost empty,\nthere are job, doctors, and doing sport in the corners. Halfway between the doctors\nand job, she placed the IVF in a rectangle, expressing that the it was somehow sepam\nrated, as she said, “it doesn't fit in the picture.”\nAfter talking about the drawing, Mara herself initiated that she wanted to “redraw”\nto show what her ideal layout would be, which would reveal the desired situation. In\nthis second drawing, the self is only a circle surrounded by an outline, the disease is\nfurther away in the form of a circle, and the self is not affected by anyone, nothing.\nRelevant people were given more, breezier space to “move more easily if I wanted to,”\nMaria explained. The testmtube got closer and got a circle shape, the doctors got a smalm\nler circle next to the tube. Job and sport circles remained unchanged. Overall, the imm\nage shows a much busier, fuller, more harmonious layout. I asked her what was needed\nto have it realized, and Maria herself provided solutions: talk more openly with her\nparents, trust her partner more, be more accepting of the testmtube and the doctors. I\ngave positive feedback on this action plan, as she formulated her own goals and opporm\ntunities for the near future, which increased her motivation, commitment and sense\nof control.\n\nPsychological Treatment of Endometriosis and Support in Coping with the Disease161\n2.5. THE CLOSURE OF THE CASE\nMaria's relationship towards herself also changed a lot. As she was able to open up\nmore an\nd more to his partner and firmly trust her doctor who looked at her as a partm\nner, as well as our relationship, she began to become more and more tolerant and acm\ncepting her own self. At the end of the last meeting she said that she did not think she\nshould be blamed for her illness, which is the reason of her fertility problems. She sees\nher own body as a partner who will help her to become a mother, a partner in achieving\nthis goal, and she will be happy to receive the medical help she needs towards that goal.\nThe client gave a high score on guilt questions in the first interview on the Beck Dem\npression Questionnaire (Beck et al., 1961) (I constantly blame myself. I deserved the\npunishment.). These feelings were dissolved at the end of the work. The original score\n(14 points, moderately severe) improved significantly compared to the condition rem\ncorded in the first interview (6 points, the lower limit of the mild state) by the end of\nthe process.\nAn important result is that by the end of working together, the couple will no longer\nsee their marriage as shattered by the difficulties of having children, and they can even\nimagine that they will get even closer together and deepen their relationship by overm\ncoming the obstacles together. This shows the potential for postmtraumatic development.\nMaria was able to overcome her negative experiences and put her confidence into a\nteam to help her. At our closing consultation, she said goodbye to me: “As much as I\nwas afraid of IVF, now I find myself looking forward to it… I'm open to good things\nfinally happening to us.”\n3. CONCLUSION\nBased on the reviewed research findings and the case study described, it is clear that\nthe t\nreatment of endometriosis necessitated an integrated approach that recognizes the\nrole of psychological factors. In this, adequate knowledge of the psychological aspects\nof treatment can be expected from all members of the healthcare professional. Extra\nattention should be paid to make sure that women do not feel marginalized and see\ntheir concerns belittled. They need medical staff to acknowledge the reality of their\nconcerns, and both reassurance and information play a major role in this (Slade &\nCordle, 2005) In the title of his study, Lachowsky (2012) goes as far as to ask the quesm\ntion: who should treat a patient with endometriosis: a gynecologist, a doctor, or a psym\nchologist? Physical and psychic pains – even if they don’t add up – are mutually reinm\nforcing, especially when the past is overshadowed by other difficult life events. For\nmany years, women with endometriosis have found themselves branded neurotic, hysm\nterical, not treated as “real” patients, denying the reality and significance of their nowm\nrecognized pain. A breach of human dignity can be healed if medical staff recognizes\nand acknowledges the difficulties associated with the condition, treating patients in a\n\nNóra Árvai162\nmultidisciplinary approach. While writing this chapter and practicing my profession,\none o\nf my main goals has been to achieve the team work of professionals of different\ndisciplines to work as a team for the health, present, and future wellmbeing of patients.\nREFERENCES\nÁrvai, N. (2012). Amikor a  méhem ellenem fordul – Az endometriózis [When my Womb Turnes\nagainst Me – The Endometriosis]. Medicina Kiadó.\nÁrvai, N. (2016). Nők a fájdalom árnyékában – Az endometriózis [Women in the Shadow of Pain\n– The Endometriosis]. Medicina Kiadó.\nBeck, A. T., Ward, C. H., Mendelson, M., Mock, J., Erbaugh, J. (1961). An inventory for\nmeasuring depression. Archives of General Psychiatry, 4(6), 561–571.\nFehér, P. V. (2013). A testképmszobor teszt módszere [The Method of the Bodymimage Sculpm\nture Test]. In M. Csabai, J. N. Pintér (szerk.), Pszichológia a gyógyításban [Psychology in\nTherapy. Phenomenological, Art Psychological and Bodyúimage Centered Approaches]. Fenomenoú\nlógiai, művészetpszichológiai és testképúközpontú megközelítések. Oriold és Társai Kft.\nHavancsák, R., PóczamVéger, P., Csabai, M. (2013). A PRISMmD rajzteszt kórházi betegek vizsm\ngálatában és kezelésében [The PRISMmD Drawing Test in the Diagnosis and Treatment of\nInmpatients]. In M. Csabai, J. N. Pintér (szerk.), Pszichológia a gyógyításban [Psychology in\nTherapy. Phenomenological, Art Psychological and Bodyúimage Centered Approaches]. Fenomenoú\nlógiai, művészetpszichológiai és testképúközpontú megközelítések. Oriold és Társai Kft.\nLachowsky, M. (2012). Who should treat the endometriosic infertile patient? The ART technim\ncian, the surgeon, or the psychiatrist?. Gynecologie, Obstetrique & Fertilite, 40(9), 497–499.\nRogers, P. A. W., D'Hooghe, T. M., Fazleabas, A., Gargett, C. E., Giudice, L. C., Montgomery,\nG. W., Rombauts, L., Salamonsen, L. A., Zondervan, K. T. (2009). Priorities for endometm\nriosis research: recommendations from an international consensus workshop. Reproductive\nSciences, 16(4), 335–346.\nSinaii, N., Cleary, S. D., Younes, N., Ballweg, M. L., Stratton, P. (2007). Treatment utilizam\ntion for endometriosis symptoms: a crossmsectional survey study of lifetime experience. Ferú\ntility and Sterility, 87(6), 1277–1286.\nSlade, P., Cordle, C. (2005). Psychological aspects of the management of chronic pelvic pain.\nCurrent Obstetrics and Gynaecology, 15(5), 298–305.\nVan den Broeck, U., Meuleman, C., Tomassetti, C., D'Hoore, A., Wolthuis, A., Van\nCleynenbreugel, B., Vergote, I., Enzlin, P., D’Hooghe, T. (2013). Effect of laparoscopic\nsurgery for moderate and severe endometriosis on depression, relationship satisfaction and\nsexual functioning: comparison of patients with and without bowel resection. Human Reproú\nduction, 28(9), 2389–2397.\nVarga, K. (2011). A szavakon túl. Kommunikáció és szuggesztió az orvosi gyakorlatban [Beyond\nWords. Communication and Suggestion in Medical Practice]. Medicina Kiadó.","source_license":"CC0","license_restricted":false}