The Menopause in Therapy

Image credit: Emma Palmer, Autumn Equinox

How might we respond to clients living through the perimenopause and beyond? How can we help narratives move beyond the ‘keep calm and carry-on’ message of everyday patriarchy? How do we create a supportive space, as we would for anyone whose experience has been subjected to invisiblising forces, finding words and language as we go? 

In this blog, I want to discuss both what is universal and what is acutely unique to people experiencing perimenopause and menopause – the latter being the point at which we’ve ceased bleeding for a calendar year. For some, it will be about meaning making. For others, it might be about the happy surrender of meaning making and a loosening of constricting, societally ascribed roles. We are likely to encounter an ocean of different responses from grief to liberation – often, of course, in the same client.

My most reoccurring role working with perimenopausal clients, as they experience the range of physical and emotional manifestations it can bring, feels akin to working with bereavement. I offer steady witnessing and a basic reassurance of “no, you’re not crazy”. This is potent, given that perimenopausal people experiencing hot flushes and other changes are often told by GPs they are “too young”.

Even without misleading medical advice, perimenopause can bring such uncertainty. Making it unlike any other life stage, we only know for sure we have become menopausal a year later. I have known clients and trainees who have wanted to hurry the process along. Given that it can last up to a decade, sometimes more, it may be helpful to offer a sense of pacing and an adjusting of horizons. Six years into ‘the change’, I have personally found an emerging sense of acceptance invaluable. The nearest thing I have experienced is adolescence, except this time everything’s drier and heading south.

The implications around identity, often but not always linked to reproductivity, can also be huge. It is pretty commonplace to hear clients report their invisibility. This is welcome for some, highly unwelcome for others, and echoed in the overarching invisibility of the whole subject of menopause in wider society. 

Personally, being childfree by choice, the prospect of the end of menstruation delights me. But some clients report feeling ‘redundant’ because they can no longer bear children. Having spoken to many childless and childfree folk for my book Other Than Mother, I am also acutely aware that perimenopause can bring fresh grieving for those unable to have children, while others describe a strange sense of closure. 

For those of us who have experienced childhood sexual abuse and other adverse childhood experiences, perimenopause can be bewildering in further ways. Our experience of being a body changes at this time, as our cycle and hormones re-arrange themselves. This can be disorientating. The unusual body sensations, including the changes in smell some experience, can be additionally triggering. I’m reminded of a client who was struggling to know what and who they could trust at a time when their body – which they were just starting to live more easily in – felt fragile and unreliable. 

Having the chance to process the vivid physicality of the perimenopause – hot flushes, flooding and mood swings – may be helpful for any client. Much of the mainstream advice around perimenopause constellates around whether or not to take HRT (hormone-replacement therapy). As with other medical interventions, it can be useful to check our own assumptions here. 

Having acknowledged and supported exploration of the difficulties, what would it look like if, as a trade, we could lead the way in hailing menopause as a rite of passage process – a celebration of what’s been, a welcoming in of elderhood, and a reclaiming of this role in a society still shaped and constructed by patriarchy and youth? 

In a culture that has largely lost supporting rituals, how might therapists support the carving of a new potency in our menopausal clients?

I offer this up somewhat tenderly, knowing how I can feel creative and free one minute and metaphorically murderous the next. But six years into perimenopause – and yes, despite the state of the world – I notice a whiff of magic and delicious possibility.