Theoretical perspective

Infertility is not a single event, it is a process where the magnitude, breadth, uncontrollability and the consequences of infertility may all contribute to the stress experienced. Infertility can be conceptualised as a “relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1984, p i 9). The theoretical framework of Lazarus & Folkman (1984) on stress and coping has been applied in understanding infertility (e.g. Stanton 1991, Stanton et al, 1991, 1992; Glover, 1996). This framework proposes that stress consists of three processes:

primary appraisal (the perception of a potential threat), secondary appraisal (the

perceived ability to cope with that threat and consideration of a response), and coping

(the process of executing that response to the perceived demands and threats of the

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mediating process of stressful person-environment relationships. Lazarus & Folkman (1984) suggest that situations characterised by unpredictability, negativity, uncontrollability and ambiguity are most likely to be appraised as stressful where the appraisal and coping strategies are central in how the event is experienced. Stress and its relationship to coping is very subjective in nature. It is a continuing process where the flow of influence is multi-directional through feedback loops that constantly change (Morse & Hall, 1987).

Lazarus (1993) proposes that a key appraisal component in emotion is motivation. In order for an emotion to exist there must be an active goal. Emotions result from the way events are evaluated in terms of their significance for our well-being. If our goals are thwarted a negative emotion results, whereas a positive one results from achieving or making progress towards our goals. Since psychological stress derives from a subjective cognition evaluation, not an objective event, it seems conceivable that the appraisal of stress will be an important moderating variable in the experience of and emotional response to infertility (Band et al, 1998).

1.6.1.1 Appraisal

A person appraises a situation in two ways. The primary appraisal involves assessing

what is at stake, what are the threats and challenges and what will be lost. In

secondary appraisal of that situation the person assesses what, if anything, can be done to prevent harm or increase prospects for benefit. The extent to which the event is controllable is assessed during this stage and the coping options evaluated. The

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conclusions reached during the appraisal process would therefore be expected to contribute to a person’s psychological adjustment.

1.6.1.2 Coping

Coping is the response a person makes after appraising a stressful situation, with the aim of reducing the stress of that situation. It refers to both the thought processes and the actions which are used. Lazarus & Folkman (1984) defined coping as one’s “constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands which are appraised as taxing or exceeding the person’s resources” (p 141). They argue that coping strategies are neither inherently adaptive

or maladaptive. This coping process may therefore promote or hinder positive

adjustment to infertility. So when “demands are perceived to exceed [their] abilities to cope, individuals label themselves as stressed and experience a concomitant

emotional response” (Cohen et al, 1995, p6). Coping can thus be viewed as a

mediator of emotions. Lazarus and Folkman (1984), postulate that coping has two major functions: addressing the problem which is causing the distress (problem- focused) and regulating emotion (emotion-focused).

1.6.1.3 Adjustment

Primary indicators of adjustment are an individual’s abilities to maintain well-being and manage distress. There is evidence that cognitive appraisals may be important determinants of how well people adjust to stressful encounters (e.g. Folkman et al, 1986a; Folkman et al, 1986b). For example Folkman et al (1986a) have shown that

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appraising a situation as potentially challenging, rather than accepting it, is associated with positive outcomes. The set of processes in a stressful transaction is therefore an ongoing cycle, where an outcome of one process may re-invoke a preceding process. Appraisal and coping strategies are not fixed, since these patterns change in response to changes in the demands of the stressor or threatening event (Folkman & Lazarus, 1985). With infertility there is a constant ambiguity about the ultimate outcome. This is an important feature of life stress that influences psychological reactions and has implications for adjustment (Dunkel-Schetter & Lobel, 1991).

Lazarus and Folkman’s (1984), problem-focused and emotion-focused coping styles theoretically overlap with approach-avoidance styles despite the fact that emotion- focused coping can involve both approaching and accepting responsibility as well as distancing or avoiding. Much of the current research in infertility has focused on approach-avoidance techniques, such as efforts to actively approach and resolve the threatening situation or engaging in activities unrelated to the problem, rather than

drawing on coping models per se (Band et al, 1998). The studies that have

investigated stress and coping among infertile individuals support both the applicability of Lazarus and Folkman’s theory and the need to further examine the interaction between stress, appraisal and coping among infertile populations.