The psychologist's role in surrogate mother arrangements is approximately sixteen years old. Despite the sixteen years and the approximately 4,000 cases, there is very little research exploring long-term issues. There are doctoral dissertations and other studies that address surrogate mother's psychological profile. Given the focus of psychology, most of this research has attempted to identify the psychopathology of the surrogate mother population. Yet, this research to date has not identified any psychopathology. The current research is focusing on designing a salient assessment protocol and on the long-term effects of those who have participated in surrogacy.
The psychological screening and counseling of participants is thus mostly based on clinical observations and collaboration with colleagues. It is important to note before addressing specifics, that psychological assessment and counseling is still optional. Unless a program, the physician or the patients deem it necessary, surrogacy agreements can proceed without the benefit of mental health professionals. However, most of the IVF clinics in my area and the program with which I am associated do mandate psychological screening. This role of gate keeper is controversial. Over my twenty years of evaluating surrogate mothers, prospective couples, and, more recently egg donors, it is clear that the assessment and counseling is effected by one's perspective on openness, child welfare, women's issues, child development and the pains of infertility.
SCREENING OF SURROGATE MOTHERS
The psychological screening of surrogate mothers is very similar for both traditional artificial insemination surrogates and IVF gestational surrogates. The important differences will be addressed at the end of this section. In both programs, it is crucial that the candidate already have at least one child that she has given birth to and parented. If she has not had pregnancy and parenting experience, it would seem impossible for her to give any level of informed consent and it may be difficult for her to empathize with the parents and the child. Additionally, it seems risky for a doctor to endorse women without such obstetrical histories. We also do not accept women on government aide, in major life transitions, or who do not have a stable income. This role criteria is an attempt to prevent collusion with denying important feelings because of an immediate need for money.
One role of the psychologist is to help the candidate see if being a surrogate will serve a positive functional purpose or a negative dysfunctional purpose in her life. Thorough assessment can prevent collusion with pathology, exploitation, and unhealthy degrees of denial.
The clinical interview reviews her history in an attempt to screen out women who have traumatic histories from which unresolved feelings may surface during crisis or during stressful conditions. It is interesting to note, one study conducted on surrogates discovered no differences in early attachment and loss histories of surrogates and non-surrogates (Resnick, 1987). The clinical interview also addresses motivations. Studies across the nation seem to report similar motivations (Hanafin, 1987, Parker, 1983, Resnick, 1989). It is crucial that the candidate obtain something for herself beyond financial remuneration. If she cannot focus on what being pregnant and relinquishing a child can do for her, then traits such as low self-esteem, low intelligence and martyr patterns should be evaluated carefully.
Related to motivations are the candidate's expectations concerning her relationship with the prospective parents. It is crucial to explore her needs for contact and her hopes for openness. This issue can reveal such dynamics as unrealistic expectations, an attempt to use surrogacy to fill void in her life, fragility or mistrust, and an inability to predict her own behavior. Specifically, a woman who assumes she will be an "aunt" or a woman who wants no contact are of concern. An ability to do reality testing, an ability to understand boundaries, and an ability to trust herself to set limits are vital variables. Furthermore, what a surrogate's wish list and criteria as it pertains to the new parents is very revealing and can provide some predictive information.
Of course general mental health is an obvious necessity. Psychological testing, clinical interviews, observations in a group setting, and feedback from others involved in the case are all important. Specifically, it is important to eliminate sociopaths, depressed persons, borderline personalities, and those who have little ego strength. It is important to assess their coping mechanisms, defenses, and resiliency especially when under duress. Surrogates also need an intellectual ability to do abstract thinking, conceptualizing, and retain a lot of information. It is vital that she have the ability to think independently, as well as take care of herself so to prevent exploitation.
Over the years, evaluating a surrogate's support system, resources, and immediate family has become increasingly important. Assessing the husband's beliefs and thinking is most revealing. A surrogate with minimal to no resources or minimal ability to use resources is often indicative of a person with poor judgment who will need a lot of case management. Furthermore, her children are of utmost concern. Discovering how she plans to tell her children, and assessing how much life trauma the children have undergone are important considerations for surrogacy to proceed safely. If a candidate answers that she may not tell her children the truth or if her children have a history with much loss and/or trauma it is often best not to accept her. As mental health professionals we have a responsibility to protect children psychologically where possible. For a child's mother to be a surrogate is of unknown consequences, therefore it is best to eliminate families who have come to surrogacy with minimal support and/or painful histories.
ASSESSMENT AND TESTING
The challenge in testing surrogates has been that their norms are often similar to the general population's norm. Historically, my practice has given the MMPI. Candidates usually score within the normal limits. The MMPI has helped to eliminate psychopathology but because the scores are usually within normal limits, we need to turn to other measures to gain a fuller understanding. Projective tests such as the Rorschah and sentence completion often help asses how a client copes under stress and how easily she remains integrated. Dr. Suppes (1993), Carol Wolfe, MFCC and Dr. Rice (1991) have each administered over twenty Rorschah tests. They have revealed an intimate picture of the candidate response to stress and change, as well as their perceptual accuracy and defenses. Administering projective measures or personality tests based on non-psychiatric populations is recommended.
In addition to clinical interviews and testing, it can be helpful to do reference checks and/or a criminal background check. Furthermore, often crucial pieces of information are shared by doctor's offices or other professionals involved in the case. Observation in a support group setting allows the psychologist to further asses the candidate's personality style, anxieties, retention of information, and ability to get her needs met.
AI v. IVF
As stated earlier, the important variables for screening are very similar in both AI and IVF programs. However, when evaluating and counseling women there are some program-specific issues that need to be addressed in the initial interviews. An IVF gestational surrogate needs to be able to manage a taxing amount of medical information, injections, and logistical inconveniences. Coping with impositions, sacrificing a lot of time, and being flexible are vital. Furthermore, beliefs in selective reduction, perspectives on multiple gestation, and beliefs about pregnancy termination all are very pertinent in this population.
On the other hand, AI (artificial insemination) surrogates need to address feelings, beliefs, and fantasies about their genetic birth child. The genetic link is a real one, despite the fact that many candidates tend to minimize it. The child to be conceived will have a birth family, including half-siblings, Again, though many surrogates and prospective couples tend to minimize this fact, it is important to explore. Surrogates relinquishing a child that is genetically linked also tend to receive more negative feedback than non-genetic surrogates. Their reaction to critical judgment by others needs to be assessed.
SCREENING THE PROSPECTIVE PARENTS
One will quickly notice a long-standing difference in the evaluation of prospective surrogate mothers versus the evaluation of prospective parents. The inequity with which these two populations are screened is an ongoing discussion in my practice. The reasons for the inequity are somewhat obvious: (1) the surrogates are the group volunteering to do the usual behavior about which we understand very little (2) the prospective parents' desire to parent appears to be a normal desire and thus has not been as scrutinized, (3) the programs historically presented themselves as providing a service to the infertile couple and thus are reluctant to make them uncomfortable, (4)philosophically most physicians and program directors do not see screening or gatekeeping as their role (5) surrogate mothers are seen as and do have a tremendous amount of power and control over the situation both as the legal mother and caretaker of the child and therefore have been viewed as more threatening. There is only one study of which I am aware that attempts psychological assessment of couples (Schwartz, 1989).
As with surrogates, the psychological screening of couples in my practice does attempt to assess the general mental health. In order for surrogacy to be successful, it is important that the couples are empathic, flexible, and respond to new situations with resilience and ego-strength. Participants who need unrealistic amounts of control, who are narcissistic, depressed, or have notable personality disorders put themselves, the surrogate, the practice, and the child at risk. I find clients who are very mistrusting and/or do not understand the importance of the process and just focus on the end result are likely to sabotage and be angry. Asking questions about how they make decisions, observing how they treat you and staff, and a review of history and lifestyle often reveals personality traits that may put the clients at risk.
Again, often the tool that is most revealing is a full discussion of the issues surrounding surrogacy. It is important to assess how they have come to this choice. Questions should be addressed if one spouse is pursuing this option, if the choice is an informed one, if they have exhausted other options, and what they believe surrogacy can realistically provide for them. As with the surrogate population, why they are choosing surrogacy is very revealing. There are probably inappropriate reasons, i.e. one spouse refuses to consider any other option consequently perhaps forcing an uncomfortable choice on the other. Most couples pursue surrogacy because of a desire for a genetic connection, a desire to be participants in the pregnancy and birth process, a desire to know and feel comfortable with their child's birth mother, a need to avoid fears about returning the infant to birth parents, or the lack of adoption opportunities in their state or country.
Another important area of assessment is the couple's perception of the surrogate and their desire for contact. If the couple is threatened by and is avoidant of the surrogate mother, I have observed a dramatic increase in people getting hurt. It is crucial to the peace and resolution of all parties that the prospective parents be able to interact with, trust, like, and be appreciative of the surrogate. The intense and complex process of achieving conception, the long poignant pregnancy, and the future years of reflection and wondering need to be based on the couple being comfortable with the surrogate. If a couple cannot envision themselves in some sort of open relationship with a surrogate of their choosing then they should not involve that surrogate and her young family in their lives.
The evaluation of couples also includes their beliefs about the future, what they may tell the child, and what they will tell others. Obviously, this assessment needs to be culturally sensitive. But again, the answers can provide insight to the couples' resolution and readiness to proceed. Often the assessment is spent helping couples sort through the conflicting and confusing feelings about openness, about who is the mother, and about the others' responses.
Additional assessment can include psychological testing. I have administered the MMPI periodically if the initial interview raised concerns. Follow-up interviews or a second interview by a colleague can be helpful. Of course, interviewing spouses separately, as well as together, can be enlightening. As with the surrogates, feedback from other professionals and reading their answers to various questionnaires does highlight patterns. Additionally, as a service to the clients and as part of their informed consent process, I ask them to make contact with other couples participating in surrogacy and to attend to a reading list that I provide.
For the purposes of this paper I will divide the counseling issues into four categories. The role of a mental health professional can be vital to both parties obtaining a maximum degree of peace, resolution and empathy for the other.
As previously stated, client's assumptions and beliefs about the role of openness in surrogacy is an important and ongoing issue. Initially, it is necessary that the wishes of all clients be part of the criteria on which they choose to work together. It is sad, stressful, and hurtful if the two families have dramatically different agendas. The surrogate typically needs to see the parents-to-be responding like parents from the beginning. The surrogate's reward, job and comfort with relinquishing the baby are all increased if she is able to see and hear that the couple is eagerly preparing for and anticipating parenthood. Surrogate mothers often describe a bond with the prospective parents rather than with the baby. Post-partum reactions most typically include missing the couple, again, as opposed to missing the child. Misunderstandings about the nature of their relationship need to be addressed skillfully. Increasing empathy for each other and pondering specific guidelines is helpful.
Counseling may highlight that the surrogate and the prospective couple often have different life experiences, have different views of mother nature, and may have cultural differences. Speaking to all these issues directly increases empathy and minimizes painful misunderstandings. For example, surrogates often need to be educated about the common dynamic that the author Ellen Glazer describes in the Long Awaited Stork. This being that the pains of infertility do not end with a positive pregnancy test, but rather there is a most cautious approach to pregnancy. The surrogate is positive and assumes all will go smoothly, while the couple is much more guarded.
My clinical observations and initial follow-up studies of surrogate mothers and the new parents reveal insights regarding contact and counseling. Participants reported the importance of professional assistance and the positive impact of an open relationship with the parents. (Forest, 1989; Hanafin, 1987; MacPhee, 1990).
The prospective parents have to do a lot of "letting go" in order to reduce anxiety. No two women conduct their prenatal care identically, no surrogate can make up for the loss the couple has suffered, and probably no amount of money can substantially alter one's feelings or behavior in regards to a baby. It can be challenging for some to contain anxieties so not to be overly intrusive.
Both clients should only work with someone they trust and with whom open discussions are comfortable. Counseling should ensure these communications and can minimize the likelihood of power struggles. Additionally, counseling addresses the dilemma of "my body, your baby" versus "my baby, your body." This control dilemma is raised over such issues of prenatal care, medical interventions, birth plans, and genetic testing. Providing accurate information for all clients and increasing empathy for the other's perspective is usually constructive.
As professionals, we can often help individuals understand the importance of obtaining some sense of closure. Perhaps, one of the clearest and most important examples of this issue is the birth plan and good-byes at that time. Given the awkwardness, the exhaustion, the anxieties, and the newness of it all, it is all too common for the long awaited "ending" not to be as well planned as other stages. My partners and I find ourselves giving more and more attention to birth plans, simple rituals, symbolic and tangible acknowledgments. Surrogates need to feel validated and trusted, not rushed. Couples need to be present with her and create a feeling of safety and comfort for themselves. A respectful, warm, and moving birth/hospital stay helps the surrogate to minimize feelings of exploitation or emptiness. Attention to closure helps the prospective parents reduce anxieties about the unknown, helps them feel secure in the relinquishment, and provides a positive story to tell their child. Additionally, having some clear understanding about the post-birth contact frees both parties from misinterpreting behavior.
The role of mental health professionals in the counseling of surrogate mothers and prospective couples raises difficult ethical dilemmas. The most obvious one is a conflict of interest between the prospective parents who are probably paying for the services and the surrogate mother who you may be counseling more directly. In this field, one needs to be very clear as to whose best interests prevail. If all parties are well screened and it is a good match, the dilemmas can be minimized. Focusing on what best serves the child in utero and other children involved provides a helpful guideline.
Another struggle for professionals is the issue of exploitation. This concern comes from two directions. One, opponents of surrogacy state that we are exploiting the clients by assisting them in this process. It is not difficult to find desperate infertile couples and well-meaning naive women who may be drawn to surrogacy. Secondly, clients exploiting each other is also a possibility. A couple not providing proper compensation for time and energy expended by a surrogate or a surrogate exploiting the couple's vulnerable position while she is carrying the child are dynamics about which one needs to be vigilant.
A final ethical dilemma in counseling is the cultural and historical bias we bring to the practice. For example, women who volunteer to become surrogates have been easily tagged as women who are not whole and must have substantial unresolved issues. We view surrogacy and maternal attachment from a 20th century industrialized nation perspective. It is intriguing to look at times in history, at other cultures, and at case studies where women did not attach equally to all children conceived, but were not automatically labeled as pathological for not attaching to and raising all their children. Surrogacy expands and challenges our knowledge about the variables that effect attachment behavior.
Counseling and screening these clients is a never-ending process of questioning what role we should have in determining the fate and behavior of others. Being involved in such a pioneering field requires constant evaluation, need for colleague contact, and clarity with what you are comfortable participating in and most importantly requires a continual vigilance for the children to whom we need to explain all this and from whom we are already hearing.
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