Social Skills and Perceived Maternal Acceptance-Rejection in Relation to Depression in Infertile Women

Infertility is commonly defined by physicians as the inability to conceive after one year of unprotected intercourse (1). Infertility has been characterized as creating chronic stress that can arise due to a variety of psychological difficulties (2, 3). It is sometimes accompanied by crises and emotional tensions such as depression, anxiety and interpersonal problems (2, 3). Greil (4) noted that distinctions between infertile and fertile populations were most pronounced in measures of depression, anxiety, and self-esteem.

Infertile people are more susceptible to depression due to specific factors related to their infertility. It is expected that demographic factors, as a part of social background, are paramount in how an individual meets the problems resulting from infertility (5). It seems that the incidence of psychological disorders in infertile women is much higher, compared to infertile men and their spouses. The psychological consequences of infertility for women are severest (6). It is likely that women's response to infertility is influenced by social and personal factors like parental acceptance or rejection and the women's social skills. Accepting parents are defined as those who show their love or affection toward children physically and verbally. Rejecting parents are defined as those who dislike, disapprove of, or resent their children (7).

Unacceptive parent-child interaction may lead to decreased adjustment in adulthood (7). It means that receiving unacceptive responses from parents (rejective, ambivalent, ambiguous parenting) might lead an individual to appraise the stressor as more threatening, which in turn may have a detrimental impact on adjustment.

Social skills are an individual personality trait that can have profound effects on the nature of interaction with other people as well as on one’s own psychological well-being. Indeed, these two phenomena are theoretically related as the nature of social interactions can affect and be affected by a person’s state of mind and mental health (8). Deficits in social skills have been implicated in depression (8). Social skills are defined as the ability to interact with others in a way that is both appropriate and effective (8). Healthy interpersonal relationships are necessary for healthy psychological development. The inability to present one's authentic self in one’s significant relationships can lead to suppression of self with resulting depression (9).

Many studies have focused on the importance and prevalence of depression in infertility, but very little research has been published concerning preventable predictors of depression among infertile women. The aim of this study was to first identify social (perception of mothers’ acceptance or rejection) and personal (social skills) predictors of depression in infertile women, and then to examine their interaction with depression.

This was a correlational study. The study population included all infertile couples visiting the Isfahan Fertility and Infertility Center and Shahid Beheshti Fertility and Infertility Clinic between April and August 2009. All women had been infertile for four years and above. Follow-up treatment for infertility was at least one year. First, 150 infertile women were selected based on cluster sampling (simple random selection) and then assessed for depression. Informed consent forms were signed by all patients.

The Beck Depression Inventory (BDI), which includes 21 aspects of depression, was created by Beck in 1961 (10). It is a self-report instrument and the reliability (0.96) and validity (0.89) of this test were confirmed during the first decade following its introduction. Scores range as follows: no depression, 0-16; mild depression, 17-27; moderate depression, 28-34; and severe depression, 35-63 (11, 12).

Based on the score in BDI, 30 women with depression and 30 women with no depression were randomly selected. Then these 60 women completed the Social Skills Inventory (13) and Parental Acceptance-Rejection Checklist (mother form) (14).

The Social Skills Inventory is a self-report instrument designed to measure elements of social skills. It was created by Riggio and Canary in 2003 (15). It has six factors and 30 items. It contains statements that assess elements of social skills such as social expressivity, emotional expressivity, social sensitivity, emotional sensitivity, social control, and emotional control.

The Parental Acceptance-Rejection Questionnaire (PARQ) is a self-report instrument which assesses adults’ perceptions of their mothers’ treatment of them when they were about seven through twelve years old. It contains 60 items and two factors. The two factors are acceptance and rejection. It was constructed by Goldberg in 1972 (14). The reliability of the scale was judged as 0.91.

In the current study Cronbach's alpha values for the two instruments were computed. In the Social Skills Inventory, Cronbach's alpha values ranged from 0.68 to 0.89 and in the PARQ they ranged from 0.62 to 0.70. To assess construct validity, the Pearson correlation within each instrument (each subscale and total score) was calculated (16). In the Social Skills Inventory, the correlation between each factor and the total score ranged from 0.34 to 0.90 and in PARQ from 0.88 to 0.97.

To translate PARQ and the Social Skills Inventory into Persian, one bilingual American and one bilingual Iranian worked together in an iterative process from the English instruments. When the Persian instruments were completed, to fit the two scales to Iranian culture, a convenience selected sample of 30 Iranian people and three Iranian psychologists were interviewed. The instruments were then adjusted according to the feedback received in these interviews (Copies of the final instruments are available by request from the author).

Classification of factors for analysis in PARQ: in the original questionnaire, the factors of this checklist were classified into high and low groups based on the average of each factor, and four combinations were found: (1) acceptance; (2) rejection, (3) ambivalence and (4) avoidance (Table 1). In the present research the above four combinations were also used based on the average score of each factor.

These data suggest that perception of mothers’ rejection, as well as poor social skills, are the key factors which make infertile women prone to depression.

According to Schmidt et al. (17) the experience of infertility is shaped by a variety of social interaction. Talking to others can be an important coping strategy for infertile women. Infertility-specific unsupportive interactions would be significantly associated with increased depression symptoms (18, 19). Thus, distancing and unsupportive social interaction, which reflects behavioral and emotional disengagement of the infertile women, appears to be a strong predictor of depressive symptoms and overall psychological distress. This rejection (distancing unsupportive social interaction) may intensify the sense of stigma (disqualification from full social acceptance) associated with infertility and the corresponding psychological sequelae (20). Research indicates that regardless of infertile women’s social skills and their perceptions of their mothers’ acceptance-rejection, it is unclear why some women experience a more powerful sense of stigma from being infertile than other women and why others experience more depression as a result of this stigma. However, the results of the present study show that infertile women had differential resources for depression based on social skills and their perceptions of their mothers’ acceptance or rejection.

The finding of this study revealed the effect of women’s perception of their mothers’ acceptance as a moderator, and mothers’ rejection and ambivalence as an aggravator of poorer social skills in predicting depression in infertile women. The results of this study also indicated a moderating effect of infertile women’s good social skills on the rejection and ambivalence of their mothers in leading to depression. These women showed fewer symptoms of depression than those with poorer social skills when experiencing their mothers’ rejection or ambivalence. Further research should be performed to corroborate these findings in other Iranian populations, preferably using a national sample.