Human Reproduction, Vol.24, No.11 pp. 2827–2837, 2009
Advanced Access publication on August 9, 2009 doi:10.1093/humrep/dep235
ORIGINAL ARTICLE Psychology and counselling
Relationships between attachment,
appraisal, coping and adjustment
in men and women experiencing
infertility concerns
T.M. Bayley1, P. Slade 1,3 and H. Lashen 2
1
Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield S10 2UR, UK 2Department of Obstetrics and
Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Jessop Wing, Tree Root Walk,
Sheffield S10 2SF, UK
3
Correspondence address. E-mail: p.slade@sheffield.ac.uk
background: Attachment style may influence distress and relationship satisfaction in infertile couples. Appraisal and coping have also
been linked to adjustment to infertility and may be related to attachment patterns. The study examined these associations in men and women
around the time of attending initial appointments at fertility clinics.
methods: Attachment, appraisal, coping, general well-being, infertility-related stress and relationship satisfaction questionnaires were
completed by 98 women and 64 men. Data were analysed by gender comparisons, correlations and path analysis.
results: Attachment anxiety was associated with well-being in women via appraisal of infertility as a loss and use of self-blame and avoidance (SBA) coping. Attachment anxiety was also linked with infertility-related stress through SBA. In men, attachment anxiety was associated
with well-being and infertility-related stress again via SBA coping. Attachment anxiety and avoidance were related to lower relationship satisfaction in women, whereas only the former was important for men.
conclusions: Attachment patterns link to couples’ relationship satisfaction and are associated with adjustment via appraisal and
coping. Identification of such patterns may assist in identifying need and tailoring cognitive interventions to individuals. Participants were
mainly white and well-educated, and wider generalization cannot automatically be assumed.
Key words: infertility / attachment / appraisal / coping / adjustment
Introduction
Infertility is the inability of a couple to achieve conception or bring
a pregnancy to birth after a year or more of regular unprotected
intercourse (WHO, 1992). Some studies suggest that infertility is
associated with elevated distress (particularly in women) whether or
not treatment is sought (Greil, 1997; Slade et al., 1997; King, 2003;
McQuillian et al., 2003). Distress may be generalized, as measured
by standard measures of anxiety and depression or may be specific
in terms of linking directly to aspects of infertility such as social or
role strain (Newton et al., 1999). However, the mechanisms
through which any elevation in distress may occur are not well
elucidated.
It has been suggested that the way individuals view their infertility
(their appraisals) and their strategies for coping may be important.
Appraisals of infertility as threat or loss have been associated with
increased distress, whereas viewing infertility as a challenge has been
related to increased well-being (Mendola et al., 1990; Stanton et al.,
1991; Hansell et al., 1998). Considering the range of coping strategies
explored in the literature, self-blame and avoidance (SBA) have been
consistently associated with greater distress (Stanton et al., 1992;
Slade et al., 1997; Peterson et al., 2006), whereas information
seeking has shown varied relationships with distress (Berg et al.,
1991; Berg and Wilson, 1995; Morrow et al., 1995, Hjelmstedt
et al., 1999). There is evidence to suggest that for women, increased
infertility disclosure is associated with higher distress (Slade et al.,
2007), whereas seeking social support has been related to increased
well-being (Stanton et al., 1992; Peterson et al., 2006). However,
the latter has not retained predictive value when other coping strategies have been entered into the regression equation (Peterson
et al., 2006). Informational and emotional support seeking (IES) have
been linked in some coping measures as a single factor (Felton
& The Author 2009. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
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2828
et al., 1984). Engaging in positive reappraisal (i.e. focusing on the positive aspects of the situation), which is sometimes referred to as cognitive restructuring (CR), has also been associated with lower distress
but again the predictive relationship has not been sustained when
other coping variables were taken into account (Peterson et al.,
2006). Studies, however, have tended to be completed at the treatment stage. Relatively little is known about the appraisal, coping and
emotional status of people who are in the early stages of seeking
help in relation to fertility concerns.
Attachment style concerns individuals’ typical pattern of relating to
others and has the potential to influence how they cope with and
adjust to stressful events (Bowlby,1980). Secure attachment, defined
as comfort with closeness and confidence in others’ love, has been
associated with happy, intimate and friendly love relationships
(Bowlby, 1988). Insecure attachment encompasses both avoidant
and anxious-ambivalent styles. The former is characterized by uncertainty about others’ intentions and preference for distance in relationships. It has been related to fear of intimacy and difficulty trusting and
depending on partners. The anxious-ambivalent style is also defined by
insecurity in others’ responses but linked with a strong desire for intimacy and has been associated with love addiction, passionate love and
fear of being unloved (Shaver and Hazan, 1993).
Infertility is a stressor which is particularly likely to activate attachment patterns, as it threatens the future of a new attachment relationship and may represent the loss of a cherished ideal/societal norm
(Feeney, 1999). However, to date, there has been little exploration
of the role of attachment in infertility. Only two studies, both considering Israeli samples, have included this concept (Mikulincer et al.,
1998; Amir et al., 1999). Mikulincer et al. (1998) categorized individuals with infertility as secure, anxious-ambivalent or avoidant and
found that secure men and women reported more well-being, less distress and more dyadic consensus (agreement in the relationship) than
those who were avoidant or anxious-ambivalent. Secure and avoidant
individuals also reported more dyadic satisfaction. Amir et al. (1999)
using similar categorizations found that secure and insecure attachment styles were positively and negatively correlated with marital
adjustment, respectively. The anxious-ambivalent style was also
related to psychological distress. More recently, there have been suggestions that attachment can be more validly assessed by using continuous variables of anxiety and avoidance in relationships rather
than categorical variables of secure/insecure styles. Shaver and
Fraley (2004) have labelled these dimensions as anxiety (model of
self as worthy, unworthy of love) and avoidance (model of others as
trustworthy, untrustworthy to provide love).
Considering how attachment may be related to appraisal and
coping, both Mikulincer et al. (1998) and Amir et al. (1999) speculate
that the better adjustment of secure individuals may reflect their
appraisal of infertility and their use of constructive coping strategies
but neither study investigated this possibility. There are no published
studies on the relationship between attachment and appraisal/
coping with infertility. However, research in other groups has documented a relationship between attachment anxiety and appraisals of
threat (Mikulincer and Florian, 1995; Meredith et al., 2005). In terms
of coping, perceptions of others as unreliable or rejecting (model of
others as untrustworthy; high attachment avoidance) have been
associated with decreased help-seeking (Feeney and Ryan, 1994;
Lopez et al., 1998) and increased avoidance and distancing coping
Bayley et al.
(Mikulincer et al., 1993; Lopez et al., 2001). Research suggests that
a negative model of the self (model of self as unworthy of love; high
attachment anxiety) is related more generally to negative appraisal
(Collins and Feeney, 2004). It therefore seems reasonable to predict
that in infertility samples, attachment anxiety may be associated with
appraisals of loss rather than challenge and a lower tendency to
engage in CR as a coping strategy. A sense of unworthiness and a
view of others as unreliable/rejecting may both be associated with a
tendency to engage in SBA coping.
In summary, there is some evidence to suggest that an individual’s
attachment style influences distress and relationship satisfaction.
There is also evidence to suggest that appraisal and coping with infertility are related to adjustment and may be related to attachment
patterns.
Understanding how attachment patterns interact with appraisal of,
and coping with, infertility may assist our understanding of the mechanisms underpinning distress. One potential model of the hypothesized relationships between attachment, appraisal, coping, global
and specific distress and relationship satisfaction is shown in Fig. 1.
This is derived from previous research in the area of adjustment to
infertility and other physical health difficulties and their relationships
with attachment, appraisal and ways of coping. This study aims to
explore relationships between attachment patterns and both appraisal
and coping. It is not a primary aim to explore the relationships
between appraisal and coping themselves in relation to Lazarus and
Folkman’s model, where stressful responses occur only when coping
responses are inadequate to match appraised need (Lazarus and
Folkman, 1984).
A better understanding of factors/processes that are related to
adjustment/relationship satisfaction at the initial contact stage may
help to identify individuals who may benefit from counselling earlier
and inform the direction of therapeutic work.
Objectives
A. To explore whether attachment is associated with well-being,
infertility-related stress and relationship satisfaction.
B. To explore whether appraisal and coping are associated with wellbeing and infertility-related stress.
C. To explore the association between attachment and ways of
appraising/coping with infertility.
D. To test the model depicted in Fig. 1 of the proposed interrelationships between attachment, appraisal and coping, and well-being
and specific distress and relationship satisfaction.
Specific hypotheses
A. Attachment associations with general and specific distress and
relationship satisfaction
(i) Attachment anxiety and avoidance will be inversely related to
well-being and positively related to infertility-related stress.
Attachment anxiety will be inversely related to relationship
satisfaction.
B. Appraisal and coping associations with general and specific distress
(i) Appraisal of infertility as a threat and loss will be inversely related
to well-being and positively related to fertility-related distress.
Appraisal of infertility as a challenge will be positively related
to well-being and inversely related to infertility-related stress.
2829
Attachment coping and distress in infertility
Figure 1 The proposed model of the relationships between attachment, appraisal, coping and general well-being, specific infertility-related stress
and relationship satisfaction. SBA, self-blame and avoidance; IES, information and emotional support seeking; CR, cognitive restructuring.
(ii) Coping methods of SBA will be inversely related to well-being
and positively related to infertility-related stress.
C. Attachment associations with appraisal and coping
(i) Attachment anxiety will be positively related to appraisal of
infertility as a threat and loss and inversely related to appraisal
of infertility as a challenge.
(ii) Attachment anxiety and avoidance will be positively related to
SBA. Attachment anxiety will be inversely related to CR, and
attachment avoidance will be inversely related to IES.
D. Relationships between attachment anxiety and lower well-being
and greater infertility-related stress will be mediated by appraisals
of threat, loss and challenge and SBA. SBA will mediate the
relationships between attachment avoidance and lower well-being
and greater infertility-related stress.
Materials and Methods
Participants
Participants were men and women attending a specialist infertility centre
for their first assessment appointment between October 2005 and May
2006 (61 men and 91 women) and visitors to fertility-related websites
between February and May 2006 (3 men and 7 women). The total final
sample of 64 men and 98 women met the following inclusion criteria:
(i) had been trying to conceive for a year or more, (ii) were on the
waiting list for or had recently attended their first appointment at a fertility
clinic and (iii) had sufficient English language to understand and complete
the measures. The sample represented 17% of new patients attending
the specialist fertility clinic during the period of data collection.
arrival at the clinic, potential volunteers were given a further copy of the
study information sheet and a study consent form. Those who were interested in taking part were asked to complete the consent form and leave
their contact details. They were then either approached in clinic or sent
a questionnaire booklet by post. Participants were asked to complete
the questionnaire booklet alone, without consulting with their partner,
and to return it by post.
Sheffield University’s Department of Psychology Ethics Committee gave
ethical approval for the recruitment of Internet participants. A short advertisement was posted on various fertility-related websites with the permission of the relevant parties. Men and women who were interested in
the study and felt that they met the inclusion criteria were asked to
contact the researcher and a questionnaire booklet was sent for them
to return by post.
Measures
Data were collected in the form of a questionnaire booklet. Demographic
information, details about current relationship, children and fertility characteristics were elicited. Self-report measures assessed attachment, primary
appraisal, coping, well-being, infertility-related stress and relationship
satisfaction.
Experiences in close relationships—revised
The experiences in close relationships—revised (ECR-R) measures the
dimensions of attachment anxiety (18 items) and avoidance (18 items)
in romantic relationships (Fraley et al., 2000). Respondents were asked
to indicate on a seven-point scale the extent to which each statement
described how they generally feel in emotionally intimate relationships.
Cronbach’s alphas of 0.88 and 0.89 were obtained for the anxiety and
avoidance scales, respectively .
Procedure
The appraisal of life events scale
The North Sheffield Ethics Committee granted a favourable ethical opinion
in relation to the recruitment of NHS patients. A letter from the medical
consultant inviting potential volunteers was included with their initial
appointment letter. A study information sheet was also included. On
The appraisal of life events scale (ALES) measures the dimensions of threat
(six items), challenge (six items) and loss (four items) (Ferguson et al.,
1999). Respondents were asked to rate on a six-point scale the extent
to which the adjectives presented best described their perception of
2830
their fertility concerns. Cronbach’s alphas of 0.87 (threat), 0.69 (challenge)
and 0.76 (loss) were obtained.
Ways of coping—revised: 29-item version for
infertility patients
The ways of coping—revised (WOC-R) (Felton et al., 1984) is a 55-item
scale in which respondents indicate on a 5-point scale how frequently they
engage in coping strategies. Morrow et al. (1995) administered the
WOC-R to infertility patients, and a principal components analysis
resulted in 29 items loading on three factors: SBA (15 items), IES (eight
items) and CR (six items). This 29-item scale was used in the present
study, with participants being asked to what extent they had used the
strategies described in response to their fertility concerns. Cronbach’s
alphas of 0.91 (SBA), 0.81 (IES) and 0.68 (CR) were obtained.
Mental health inventory: 18-item version
The mental health inventory: 18-item version (MHI-18) provides an
assessment of general well-being (total of 18 items), in addition to
anxiety (5 items), depression (4 items), behavioural control (four items)
and positive affect (5 items) (Veit and Ware, 1983). Respondents indicate
how they have felt over the last 4 weeks on a six-point scale. In the
present study, Cronbach’s alphas of 0.94 (general well-being), 0.83
(anxiety), 0.82 (depression), 0.82 (behavioural control) and 0.79 (positive
affect) were obtained.
The fertility problem inventory
The fertility problem inventory (FPI) measures perceived infertility-related
stress and assesses global distress, in addition to social (10 items), sexual
(8 items) and relationship (10 items) concerns, need for parenthood (8
items) and rejection of a childfree lifestyle (10 items) (Newton et al.,
1999). Respondents report degree of agreement on a six-point scale. In
the present study, Cronbach’s alphas were 0.92 (global distress), 0.84
(social concern), 0.83 (sexual concern), 0.75 (relationship concern), 0.84
(need for parenthood) and 0.85 (rejection of a childfree lifestyle).
Dyadic adjustment scale: modified
Satisfaction Subscale
The modified version of the Satisfaction Subscale of the dyadic adjustment
scale (DAS) is a nine-item instrument that provides a measure of relationship satisfaction (Spanier, 1976). The original Satisfaction Subscale consisted of 10 items, but one has been found to have a low item-total
correlation (less than 0.3) in previous research (Hunsley et al., 1995)
and was therefore deleted for the purpose of the present study. Cronbach’s alpha was 0.83.
Bayley et al.
all paths to prior predictors were tested using the three-step process. In
step one, the outcome variable was regressed onto the predictor variables
and the paths specified to be zero in the model were tested. In step two,
the paths that were specified to be significant in the model were examined
in a regression with the paths found to be significant from the previous
step retained. In step three, the model was re-estimated by regressing
the outcome variable onto the paths that were specified to be zero, but
were found to be significant from step one, and the specified paths that
were found to be significant from step two. P-values of ,0.05 were
taken as significant.
Results
Tables I and II present the demographic and fertility characteristics of
the final sample according to gender. Independent t/Mann–Whitney
U tests and x2 for frequency data confirmed there were no significant
associations between gender and any demographic variable or fertility
characteristic.
Gender comparisons
Table III shows there were no differences between men and women
on the dimensions of attachment or relationship satisfaction. Differences between men and women were apparent in terms of appraisal,
coping, infertility-related stress and overall well-being. Because of
these differences, subsequent analyses considered men and women
independently. The relationships between attachment, appraisal,
coping, distress and relationship satisfaction are shown in Table IV.
Considering hypotheses in turn
A. Attachment associated with general and specific distress and
relationship satisfaction
Table IV shows that hypothesis A(i) was confirmed for men, with
the exception of attachment avoidance being unrelated to
infertility-related stress. Hypothesis A(i) was also confirmed for
Table I Demographic characteristics (% and number or
mean + SD) of the sample according to gender
Men (n 5 64)
Women (n 5 98)
........................................................................................
Age (years)
34.19 + 5.34
32.64 + 5.22
Time with partner (years)
6.90 + 4.36
6.75 + 3.89
4.1% (4)
Highest qualification
No exams
3.1% (2)
Analyses and statistics
GCSE/O-Level
20.3% (13)
21.4% (21)
Analyses were conducted using SPSS 12.0, with parametric and nonparametric statistics being applied dependent on the nature of the distributions. To minimize the effects of missing data, mean scores were
used in the analysis as opposed to total scores. Mean scores were calculated in instances where no more than 20% of items contributing to a particular subscale or total scale were missing. P-values of ,0.05 were
considered significant.
The specific hypotheses were translated into diagrammatic models and
were tested using path analysis outlined by Kenny (2005). The value of
path analysis in this context is that it provides an integrated understanding
of how factors may inter-relate to lead to the critical outcomes of general
and specific distress and relationship satisfaction and therefore identifies
potential underlying psychological processes. For each outcome variable,
A-Level
4.7% (3)
9.2% (9)
Vocational qualification
25.0% (16)
16.3% (16)
Degree/further degree
46.9% (30)
49.0% (48)
White background
95.3% (61)
91.8% (90)
Other
4.7% (3)
8.2% (8)
Ethnicity
Marital status
Married
75.0% (48)
74.5% (73)
Cohabiting
23.4% (15)
24.5% (24)
Neither
1.6% (1)
1.0% (1)
2831
Attachment coping and distress in infertility
Table II Fertility characteristics (% and number or
mean + SD) of the sample according to gender
Men
(n 5 64)
Women
(n 5 98)
Table III Attachment, appraisal, coping, well-being,
infertility-related stress and relationship satisfaction
according to gender (mean + SD and t-tests and
Mann–Whitney U as appropriate)
........................................................................................
Duration of fertility concerns in
years
3.43 + 3.89
Value of U/t
Attachment (ECR-R)
None
40.6% (26)
41.8% (41)
Self
21.9% (14)
34.7% (34)
Partner
21.9% (14)
14.3% (14)
Self and partner
15.6% (10)
9.2% (9)
None
64% (41)
61.9% (60)
Female investigations
9.4% (6)
17.5% (17)
Male investigations
7.8% (5)
3.1% (17)
Male and female investigations
18.8% (12)
17.5% (17)
Previous investigations
Other children
67.2% (43)
64.3% (63)
Child from present
relationship
23.4% (15)
21.4% (21)
Child from previous
relationshipa
9.4% (6)
14.3% (14)
Attachment
anxietya
2.24 + 0.93
2.27 + 0.99
U ¼ 3112.50
Attachment
avoidancea
2.30 + 0.89
2.17 + 0.99
U ¼ 2780.00
Threata
1.76 + 1.18
2.32 + 1.30
U ¼ 2160.50**
Challengea
1.07 + 0.88
1.00 + 0.75
U ¼ 2844.00
a
1.55 + 1.11
2.27 + 1.15
U ¼ 1819.50***
SBAa
1.10 + 0.72
1.80 + 0.74
t ¼ 5.91***
IESa
1.20 + 0.69
1.86 + 0.62
t ¼ 6.31***
a
1.51 + 0.70
1.84 + 0.61
t ¼ 3.12***
Total well-beinga
4.58 + 0.78
4.10 + 0.86
U ¼ 2041.50***
Anxietyb
4.38 + 1.00
4.03 + 1.10
U ¼ 2456.00*
Depression
4.75 + 0.92
4.07 + 1.07
U ¼ 1875.00***
Behavioural
controla
5.12 + 0.92
4.57 + 1.01
U ¼ 2021.50***
4.01 + 0.85
3.49 + 0.86
t ¼ 3.75***
Appraisal (ALES)
Loss
Coping (WOC-R-29)
CR
Well-being (MHI-18)
b
a
Women
(n 5 98)
........................................................................................
Ideas about the location of the fertility problem
None
Men
(n 5 64)
3.28 + 3.24
Own or partner’s.
women, with the exception of attachment avoidance being unrelated
to well-being. In both men and women, attachment avoidance was significantly inversely related to relationship satisfaction.
B. Appraisal and coping associated with general and specific distress
Table IV shows that hypothesis B(i) was generally supported in both
genders in relation to appraisals of threat and loss and their association
with general and specific distress. However, challenge was not significantly associated with well-being or infertility-related stress in either
gender.
Hypothesis B(ii) was supported in both genders in terms of the significant association between SBA coping and both well-being and
infertility-related stress. A significant association was also found
between SBA coping and lower relationship satisfaction in women.
IES was also related to greater global and specific distress in women.
C. Attachment associated with appraisal and coping
In men, hypothesis C(i) was not supported. In women, threat and loss,
but not challenge, were associated with attachment anxiety, therefore
partially confirming hypothesis C(i).
Attachment anxiety and avoidance were associated with SBA
coping in both sexes. However, attachment anxiety was not related
to CR, and attachment avoidance was not associated with IES.
Hypothesis C(ii) was therefore only partially supported.
D. Testing the model using path analysis
Figure 1 depicts the hypothesized relationships between attachment,
appraisal, coping, total well-being, global infertility-related stress and
Positive affecta
Infertility-related stress (FPI)
Global stressa
2.68 + 0.65
3.02 + 0.73
t ¼ 3.08***
Social concerna
2.29 + 0.82
2.88 + 1.07
U ¼ 2093.50***
a
2.16 + 0.89
2.74 + 1.12
U ¼ 2188.50***
Relationship
concerna
2.26 + 0.77
2.15 + 0.73
U ¼ 2774.500
Rejection of a
childfree lifestylea
3.46 + 0.99
3.77 + 1.01
t ¼ 1.91
Need for
parenthooda
3.26 + 1.02
3.67 + 1.00
t ¼ 2.56*
Relationship
satisfaction
(DAS-satisfaction)a
4.14 + 0.49
4.14 + 0.46
U ¼ 2975.50
Sexual concern
SBA, self-blame and avoidance; IES, information and emotional support seeking; CR,
cognitive restructuring; WOC-R-29, ways of coping—revised: 29-item version for
infertility patients; ECR-R, experiences in close relationships—revised; ALES, appraisal
of life events scale; MHI-18, mental health inventory: 18-item version; FPI, fertility
problem inventory; DAS, dyadic adjustment scale.
a
High scores, high (variable).
b
Low scores, high (variable).
*P , 0.05; **P , 0.01; ***P , 0.0025 (Bonferroni adjustment ¼ 0.05/20).
relationship satisfaction. This model was tested separately for men
and women using path analysis.
The outcomes for these path analyses for men and women are
shown in Figs 2 and 3. Essentially for men, high attachment anxiety
was positively related to SBA coping and, through this, to lower wellbeing and greater infertility-related stress. Appraisal of infertility as a
threat was positively related to infertility-related stress and the use
2832
Table IV Correlations (shaded areas: men; white areas: women) between attachment, appraisal, coping, general and specific distress and relationship
satisfaction
Attachment
anxiety
Attachment
avoidance
Threat
Challenge
Loss
SBA
CR
IES
Total
well-being
Global
infertility-related
stress
Relationship
satisfaction
..........................................................................................................................................................................................................................................................
Attachment anxiety
—
Attachment
avoidance
—
Threat
0.16
20.02
Challenge
0.14
20.04
20.02
20.10
Loss
SBA
0.32**
0.33***
0.07
0.42***
0.44***
0.18
0.14
0.22*
0.26**
—
0.63***
—
0.26**
—
0.27*
0.61**
0.21
0.58***
CR
20.14
0.19
0.06
20.18
0.20
IES
20.12
20.10
0.05
20.09
0.40**
Total well-being
20.42***
20.37**
20.33**
20.01
Global
infertility-related
stress
0.39***
Relationship
satisfaction
20.41***
0.09
20.41***
0.65***
20.06
0.22
20.25*
20.18
0.46***
20.02
0.64***
20.04
0.17
20.39***
0.28**
20.34***
0.03
0.11
20.20
0.29**
20.34***
20.02
0.11
20.07
0.25*
20.57***
0.53***
20.18
0.28**
20.19
0.22*
20.01
0.21*
20.66***
0.59***
20.24*
20.73**
0.69***
20.24*
—
—
0.01
—
20.24*
—
20.43***
0.05
0.12
0.62***
0.12
0.15
20.07
0.10
20.34**
20.09
0.36***
20.03
0.01
—
—
Spearman’s are presented for consistency, as typically one variable of the pair was non-normally distributed.
SBA, self-blame and avoidance; IES, information and emotional support seeking; CR, cognitive restructuring.
*P , 0.05; **P , 0.01; ***P , 0.001.
Bayley et al.
2833
Attachment coping and distress in infertility
Figure 2 The final model of the relationships between attachment, appraisal, coping, general and specific stress and relationship satisfaction in men
(n ¼ 64) following path analysis. SBA, self-blame and avoidance; CR, cognitive restructuring. *P , 0.05; **P , 0.01; ***P , 0.001.
Figure 3 The final model of the relationships between attachment, appraisal, coping and total well-being, global infertility-related stress and relationship satisfaction in women (n ¼ 98) following path analysis. SBA, self-blame and avoidance; IES, information and emotional support seeking; CR, cognitive restructuring. *P , 0.05; **P , 0.01; ***P , 0.001.
of CR was positively related to well-being. Attachment was not associated with threat or CR.
In women, attachment anxiety was positively related to loss appraisal and greater use of SBA coping and, through these, to lower wellbeing. Attachment anxiety was positively related to infertility-related
stress through greater SBA coping. Although appraisal of threat was
positively associated with attachment anxiety, this did not form a
pathway to well-being or infertility-related stress. CR was inversely
related and IES was positively related to infertility-related stress but
neither was associated with attachment anxiety.
Attachment anxiety was inversely related to relationship satisfaction
in both sexes. In women, attachment avoidance was also inversely
related to relationship satisfaction.
Discussion
The present study aimed to determine the role of attachment security,
appraisal and coping in predicting global well-being, infertility-related
stress and relationship satisfaction in men and women with fertility
2834
concerns around the time of their first appointment at a specialist fertility centre.
Gender
differences
in
attachment,
appraisal,
coping,
infertility-related stress, well-being and relationship satisfaction were
examined. There were no significant differences between men and
women on the anxiety and avoidance aspects of attachment, a
finding consistent with normative data (Fraley, 2005) and previous
research with infertile couples (Mikulincer et al., 1998). Although previous research (Stanton et al., 1991) found no differences between
partners within a couple on appraisal of infertility as a threat, the
present study found that women reported significantly higher threat
and loss appraisals. Women in the present study reported significantly
greater use of the coping strategies of SBA, IES and CR in relation to
their infertility compared with men, despite having lower total wellbeing and greater infertility-related stress. This pattern of results is
consistent with previous research (Stanton et al., 1991; Morrow
et al., 1995; Mikulincer et al., 1998; Newton et al., 1999) and may
suggest that biological parenting is a more valued and desired role
for women (Greil et al., 1988) and forms an important part of their
life cycle (Keye et al., 1981).
The correlations suggested that men and women with a view of the
self as unworthy of love (negative model of self; high attachment
anxiety) experienced more infertility-related stress and reported
lower well-being. A view of others as unreliable or rejecting (negative
model of others; high attachment avoidance) was related to greater
infertility-related stress in women and lower well-being in men. This
suggests that general beliefs about the self and others in relationships
may be important in how people experience a long-term stressor such
as infertility.
However, the path analyses suggest that in both sexes, a view of the
self as unworthy of love impacts on general and specific distress
through a tendency to blame the self for impaired fertility and to
cope with it by trying to escape the problem. The relationship
between SBA and measures of distress is consistent with previous
research with fertility patients (Slade, et al., 1992; Stanton et al.,
1992; Morrow et al., 1995; Peterson et al., 2006) and other groups
experiencing a health stressor (Felton et al., 1984; Koopman et al.,
2000; Turner-Cobb et al., 2002).
In women, attachment anxiety also exerted an influence on wellbeing through their view of infertility as a loss, a pattern not shown
for men. Thus, women with a view of the self as unworthy of love
may be more vulnerable to viewing their infertility as a loss and this
in turn negatively impacts on their general well-being. However,
viewing others as unavailable and uncaring does not predict general
or specific distress in either gender directly or indirectly. It seems
that it is the perception of the self rather than the perception of
others that matters in this context.
The findings of the correlations concerning the relationship between
appraisal of threat and loss and distress were broadly consistent with
the proposed hypotheses and supported previous research (Mikulincer and Florian, 1995; Collins and Feeney, 2004; Meredith et al.,
2005). The path analyses showed that threat appraisal had no predictive value for global or specific distress in women but significantly predicted infertility-related stress in men. Loss appraisal was a significant
predictor of well-being in women. Although, overall, women showed
higher ratings of both threat and loss than men, it may be that men
viewing infertility in terms of threat and women in terms of loss are
Bayley et al.
key elements in predicting distress. Viewing infertility as a challenge
was unrelated to distress measures and may therefore be of little relevance in this context.
IES was a significant predictor of global infertility-related stress in
women. This suggests that both high information and high emotional
support-seeking behaviour may be associated with greater distress in
women in the early stages of consulting with medical professionals.
High information seeking (Berg et al., 1991) and greater disclosure to
others (Slade et al., 2007) have been associated with increased distress
in women in previous studies. The relationship between IES and distress
needs to be investigated further in future research by measuring information and emotional support seeking separately. High IES may result
in greater infertility-related stress, or higher levels of infertility-related
stress may encourage people to seek more informational and emotional
support. In terms of the first suggestion, one possibility is that seeking
support may result in increased distress if subsequent interactions are
experienced as unsupportive (Mindes et al., 2003).
In the present study, CR was not significantly correlated with global
infertility-related stress in women or total well-being in men.
However, CR was found to be a significant predictor of total wellbeing in men and of global infertility-related stress in women, with
CR being associated with better adjustment in both cases. Previous
research also failed to find a significant correlation between CR and
distress and subsequently excluded CR as a predictor in the regression
(Morrow et al., 1995). This example cautions against selecting predictor variables solely on the basis of their correlation with the outcome
variable and suggests that variables with potential theoretical importance should be included wherever possible. CR has been found to
be a significant predictor of well-being in other health populations
(Felton et al., 1984).
Interestingly, attachment anxiety was not related to appraisal of
infertility in men but was predictive of threat and loss appraisal in
women. This suggests that the stressor of infertility may be more
likely to activate the female attachment system, perhaps because it
is more salient for women. Alternatively, perceiving infertility as a
threat may impact on a woman’s sense of worth and value as a
person. The extent of stability in adult attachment is a contentious
issue (Feeney, 1999). Although experiences tend to be processed in
ways that are consistent with an individual’s internal working models
(Collins and Read, 1994; Collins and Feeney, 2004), there is some evidence to suggest that significant relationship experiences, other major
life events and depression can alter attachment organization
(Hammond and Fletcher, 1991; Ciechanowski et al., 2005). It is possible that the experience of infertility and the recognition that the
opportunity to form a close and caring relationship with one’s own
child may be impossible could trigger changes in attachment patterns.
The fact that attachment anxiety was low in this sample in comparison
with norms would also mitigate against this possibility but would
require exploration through longitudinal studies.
Neither CR nor IES was related to attachment in either men or
women, indicating that other variables may play a more important
role in adopting such coping strategies. A view of others as unreliable
and rejecting (attachment avoidance) was not predictive of SBA
coping, although attachment avoidance has been linked to avoidance
coping in previous research (Mikulincer et al., 1993; Lopez et al.,
2001). The SBA subscale included a greater proportion of items
measuring self-blame compared with avoidance, and this may explain
2835
Attachment coping and distress in infertility
this discrepancy. The degree to which a person feels they are worthy of
love may be a stronger predictor of self-blame than the extent to which
others are seen as unreliable and rejecting. Although SBA may be
related forms of coping, as indicated by the factor analysis carried out
by Morrow et al. (1995), it may be useful to measure them separately
in future studies examining their relationship with attachment.
Correlation analyses revealed significant negative relationships
between both attachment anxiety and avoidance and relationship satisfaction in both sexes. In the path analyses, attachment anxiety was a
negative predictor of relationship satisfaction for men and women.
Attachment avoidance was an unexpected negative predictor of
relationship satisfaction in women, as previous research has indicated
that avoidance does not adversely affect relationship satisfaction
(Mikulincer et al., 1998). Thus, individuals who see themselves as
unworthy of love report less satisfaction with their relationships.
Women who see others as unreliable and rejecting also report less
relationship satisfaction. These relationships were direct and not
mediated by appraisal or coping variables.
Limitations
Participants were predominantly white and biased towards higher
levels of educational attainment. The study under-represents the
ethnic diversity of the patients who attended the clinic where the
majority of data collection took place. The final NHS sample represented only 17% of patients attending initial appointments during
the period of data collection, as not all clinics could be attended
and only individuals expressing an interest could be approached. Nonresponders may have differed from those who participated (Robson,
1993), thereby reducing generalizability.
The study recruited men and women who were attending their
initial appointment. Men and women who are actively seeking help
may not represent the population of people with fertility problems
(Mendola et al., 1990). Berg et al. (1991) reported that people in treatment represent only 33% of those affected. Although there is some
evidence to suggest comparability in levels of distress between infertile
women who are and who are not actively seeking treatment (King,
2003), caution must be exercised when generalizing the results to
men and women who are in the later stages of the process or who
have not pursued help.
A small proportion of the total sample was recruited from the Internet. Although reservations exist about generalizability of data yielded
by Internet studies (Hewson, 2003), there is evidence to suggest
that the demographics of Internet samples are remarkably similar to
those attained using more traditional methods (Smith and Leigh,
1997). In the present study, the demographic and fertility characteristics of the Internet sample were indeed generally comparable with
those of the NHS sample.
The cross-sectional nature of the research does not allow inferences to be drawn in relation to causality and how attachment, appraisal and coping may vary over the course of infertility. Findings are
individual-based rather than within couple analyses. Peterson et al.
(2008) have suggested that coping patterns across partners may be
important and further work may wish to consider this in relation to
attachment patterns. This exploratory study suggests that the role of
attachment patterns in distress in couples attending for infertility concerns merits significant exploration in larger samples.
Clinical implications
The high levels of general and specific distress reported in the present
study in first-time fertility clinic attendees suggests that offering counselling to couples at the treatment stage may be too late. Although
longitudinal research is needed to ascertain whether men and
women who are distressed around the time of their initial appointment are those who go on to be distraught at later stages of their fertility journey, the findings of this study suggest that early intervention
should be considered. Greater use of IES in relation to infertility was
predictive of higher global infertility-related stress. This suggests that
women with a high level of need for information in a clinic setting
may be those who are more distressed.
Individuals who experience high anxiety about themselves in
relationships and blame themselves are clearly more likely to experience distress. Men’s perception of infertility as a threat and
women’s as a loss may also be important indicators and suggests
that clinicians need to routinely assess what meaning people make
of their infertility. Where distress is adversely affecting couples’ daily
life and/or impinges on treatment prospects, this warrants the offer
of psychological input potentially with a cognitive-behavioural focus.
The present study provides some support for the suggestion that
attachment insecurity, specifically attachment anxiety, is related to negative appraisal and less adaptive ways of coping. Attachment theory has a
number of implications for therapeutic work relevant to couples with fertility problems as well as other client groups. An important therapeutic
task is to provide the client with a secure base from which to explore
their experiences, thoughts, feelings and coping methods. Encouraging
the client to explore their relationship with the therapist and significant
others and to reflect on their past history may also be appropriate
(Holmes, 1993). Although it is likely that brief therapy will not offer
most clients an adequate opportunity to alter their basic attachment patterns, a more realistic aim in short-term work may be to help the client
make connections related to how their attachment may be associated
with particularly unhelpful coping patterns (Wei et al., 2003).
Authors’ roles
T.M.B., P.S. and H.L. made substantial contributions to the conception
and design of this study and were involved in the acquisition, analysis
and interpretation of data. All authors were involved in drafting/revising and giving final approval of this paper.
Funding
Funder is University of Sheffield.
References
Amir M, Horesh N, Lin-Stein T. Infertility and adjustment in women: the
effects of attachment style and social support. J Clin Psychol Med
Settings 1999;6:463– 479.
Berg BJ, Wilson JF, Weingartner PJ. Psychological sequelae of infertility
treatment: the role of gender and sex-role identification. Soc Sci Med
1991;33:1071 – 1081.
Berg BJ, Wilson JF. Patterns of psychological distress in infertile couples.
Journal of Psychosomatic Obstetrics and Gynecology 1995;16:65– 78.
Bowlby J. Attachment and Loss: Vol 3. Loss: Sadness and Depression.
New York: Basic Books, 1980.
2836
Bowlby J. A Secure Base: Parent-Child Attachment and Healthy Human
Development. New York: Basic Books, 1988.
Ciechanowski PS, Katon W, Russo JE. The association of depression and
perceptions of interpersonal relationships in patients with diabetes.
J Psychosom Res 2005;58:139 – 144.
Collins NL, Read SJ. Cognitive representations of attachment: the
structure and function of working models. In: Bartholomew K,
Perlman D (eds), Advances in Personal Relationships: Vol. 5. Attachment
Processes in Adulthood. London: Jessica Kingsley, 1994, 53 – 90.
Collins NL, Feeney BC. Working models of attachment shape perceptions
of social support: evidence from experimental and observational studies.
J Pers Soc Psychol 2004;87:363 – 383.
Feeney JA. Adult romantic attachment and couple relationships. In:
Cassidy J, Shaver PR (eds), Handbook of Attachment: Theory, Research,
and Clinical Implications. London: The Guilford Press, 1999, 355 – 377.
Feeney JA, Ryan SM. Attachment style and affect regulation: relationships
with health behavior and family experiences of illness in a student
sample. Health Psychol 1994;23:334 – 345.
Felton BJ, Revenson TA, Hinrichsen GA. Stress and coping in the
explanation of psychological adjustment among chronically ill adults.
Soc Sci Med 1984;18:889 – 898.
Ferguson E, Matthews G, Cox T. The appraisal of life events scale (ALES):
reliability and validity. Br J Health Psychol 1999;4:97 – 116.
Fraley RC. Information on the Experiences in Close Relationships-Revised
(ECR-R) Adult Attachment Questionnaire. http://www.psych.uiuc.edu/
~rcfraley/measures/ecrr.htm (retrieved 10 July 2006, date last
accessed) 2005.
Fraley RC, Waller NG, Brennan KA. An item-response theory analysis of
self-report measures of adult attachment. J Pers Soc Psychol 2000;
78:350 – 365.
Greil AL. Infertility and psychological distress: a critical review of the
literature. Soc Sci Med 1997;45:1679 – 1704.
Greil AL, Leitko TA, Porter KL. Infertility: his and hers. Gender Soc 1988;
2:172 – 199.
Hammond JR, Fletcher GJO. Attachment styles and relationship
satisfaction in the development of close relationships. N Z J Psychol
1991;20:56 – 62.
Hansell PL, Thorn BE, Prentice-Dunn S, Floyd DL. The relationships of
primary appraisals of infertility and other gynaecological stressors to
coping. J Clin Psychol Med S 1998;5:113– 145.
Hewson C. Conducting research on the internet. Psychologist 2003;
16:290 – 293.
Hjelmstedt A, Andersson L, Skoog-Svanberg A, Boivin J, Collins A. Gender
differences in psychological reactions to infertility among couples seeking
IVF and ISCI treatment. Acta Obstetricia et Gynecologica Scandinavica
1999;78:42 – 48.
Holmes J. Attachment theory: a biological basis for psychotherapy? Br J
Psychiatry 1993;163:430 – 438.
Hunsley J, Pinsent C, Lefebvre M, James-Tanner S, Vito D. Construct
validity of the short form of the dyadic adjustment scale. Fam Relat
1995;44:231 – 237.
Kenny DA. Path Analysis. http://davidakenny.net/cm/pathanal.htm (8 June
2006, date last accessed) 2005.
Keye WR, Deneris A, Wilson T, Sullivan J. Psychosexual responses to
infertility: differences between infertile men and women. Fertil Steril
1981;36:426 – 427.
King RB. Subfecundity and anxiety in a nationally representative sample.
Soc Sci Med 2003;56:739 – 751.
Koopman C, Gore-Felton C, Marouf F, Butler LD, Field N, Gill M et al.
Relationships of perceived stress to coping, attachment and social
support among HIV-positive persons. Aids Care 2000;12:663 – 672.
Bayley et al.
Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer,
1984.
Lopez FG, Melendez MC, Sauer EM, Berger E, Wyssmann J. Internal
working models, self-reported problems, and help-seeking attitudes
among college students. J Couns Psychol 1998;45:79 –83.
Lopez FG, Mauricio AM, Gormley B, Simko T, Berger E. Adult attachment
orientations and college student distress: the mediating role of problem
coping styles. J Couns Dev 2001;79:459 – 464.
McQuillian J, Greil AL, White L, Jacob MC. Frustrated fertility: infertility and
psychological distress among women. J Marriage Fam 2003;65:1007–1018.
Mendola R, Tennen H, Affleck G, McCann L, Fitzgerald T. Appraisal and
adaptation among women with impaired fertility. Cognit Ther Res
1990;14:79 – 93.
Meredith PJ, Strong J, Feeney JA. Evidence of a relationship between adult
attachment variables and appraisals of chronic pain. Pain Res Manag
2005;10:191 – 200.
Mikulincer M, Florian V. Appraisal of and coping with a real-life stressful
situation: the contribution of attachment styles. Pers Soc Psychol Bull
1995;21:406 – 414.
Mikulincer M, Florian V, Weller A. Attachment styles, coping strategies and
posttraumatic psychological distress: the impact of he Gulf War in Israel.
J Pers Soc Psychol 1993;64:817 – 826.
Mikulincer M, Horesh N, Levy-Shiff R, Manovich R, Shalev J. The
contribution of adult attachment style to the adjustment to infertility.
Br J Med Psychol 1998;71:265 – 280.
Mindes EJ, Ingram KL, Kliewer W, James CA. Longitudinal analyses of the
relationship between unsupportive social interactions and psychological
adjustment among women with fertility problems. Soc Sci Med 2003;
56:2165 – 2180.
Morrow KA, Thoreson RW, Penney LL. Predictors of psychological distress
among infertility clinic patients. J Consult Clin Psychol 1995;63:163–167.
Newton CR, Sherrard W, Glavac I. The Fertility Problem Inventory:
measuring perceived infertility stress. Fertil Steril 1999;72:54 – 62.
Peterson BD, Newton CR, Rosen KH, Skaggs GE. The relationship
between coping and depression in men and women referred for in
vitro fertilization. Fertil Steril 2006;85:802 –804.
Peterson BD, Pirritano M, Christensen U, Schmidt L. The impact of partner
coping in couples experiencing infertility. Hum Reprod 2008;23:1128–1137.
Robson C. Real World Research. Oxford: Blackwell Publishers Ltd, 1993.
Shaver PR, Hazan C. Adult romantic attachment: theory and evidence. In:
Perlman D, Jones W (eds), Advances in Personal Relationships, Vol. 4.
London: Jessica Kingsley, 1993, 29 – 70.
Shaver PR, Fraley RC. Self-Report Measures of Adult Attachment. http://
www.psych.uiuc.edu/~rcfraley/measures/measures.html (21 July 2006,
date last accessed) 2004.
Slade P, Raval H, Buck P, Lieberman BE. A 3-year follow-up of emotional,
marital and sexual functioning in couples who were infertile. J Reprod
Infant Psychol 1992;10:233 – 243.
Slade P, Emery J, Lieberman BA. A prospective, longitudinal study of
emotions and relationships in in-vitro fertilization treatment. Hum
Reprod 1997;12:183 – 190.
Slade P, O’Neill C, Simpson AJ, Lashen H. The relationship between
perceived stigma, disclosure patterns, support and distress in new
attendees at an infertility clinic. Hum Reprod 2007;22:2309– 2317.
Smith MA, Leigh B. Virtual subjects: using the Internet as an alternative
source of subjects and research environment. Behav Res Methods
Instrum Comput 1997;29:496 – 505.
Spanier GB. Measuring dyadic adjustment: new scales for assessing the
quality of marriage and similar dyads. J Marriage Fam 1976;38:15 – 28.
Stanton AL, Tennen H, Affleck G, Mendola R. Cognitive appraisal and
adjustment to infertility. Women Health 1991;17:1 –15.
Attachment coping and distress in infertility
Stanton AL, Tennen H, Affleck G, Mendola R. Coping and adjustment to
infertility. J Soc Clin Psychol 1992;11:1 – 13.
Turner-Cobb JM, Gore-Felton C, Marouf F, Koopman CKP, Israelski D,
Spiegel D. Coping, social support, and attachment style as
psychological correlates of adjustment in men and women with HIV/
AIDS. J Behav Med 2002;25:337 – 353.
Veit CT, Ware JE Jr. The structure of psychological distress and well-being
in general populations. J Consult Clin Psychol 1983;51:730– 742.
2837
Wei M, Heppner P, Mallinckrodt B. Perceived coping as a mediator
between attachment and psychological distress: a structural equation
modeling approach. J Couns Psychol 2003;50:438 – 447.
World Health Organisation. Recent Advances in Medically Assisted
Conception (World Health Organisation Technical Support Series,
820). Geneva: World Health Organisation, 1992.
Submitted on October 22, 2008; resubmitted on March 20, 2009; accepted on
April 21, 2009