Postabortion Counseling: Clinical Issues by Jennifer Wolford Psy.D
At least half of American women will experience an unintended pregnancy by age 45, and about one-third will have had an abortion (Jones, 2011). A meta-analysis conducted by Professor Priscilla Coleman, PhD of Bowling Green State University, examined twenty-two major studies published between 1995 and 2009 involving a total of 877,181 women, of whom 163,831 had abortions found that women who have had an abortion have an 81% higher risk of subsequent mental health problems compared to women who have not had an abortion. They also reported that women with a history of abortion have higher rates of anxiety (34% higher), depression (37%), alcohol use/misuse (110%), marijuana use (230%), and suicidal behavior (155%), compared to those who have not had an abortion (Coleman, 2011). Therefore, the chances that we, as clinicians, will be treating women with a history of abortion is becoming increasingly higher. An examination of some of the clinical issues related to a woman’s abortion experience that arise during the course of psychotherapy would be prudent.
Many postabortive women experience a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Such unsanctioned or “disenfranchised grief’ may become stuffed down, hidden, and unresolved (Burke & Reardon, 2002; Pine, 1989). Even Shakespeare, in his tragedy Macbeth, says, “Give sorrow words, the grief that does not speak knits up the overwrought heart and bids it break” (ACT IV, scene 3). Yet a woman’s grief after an abortion is seldom accepted or expressed, indeed it is “forbidden” (Burke & Reardon, 2002). Since many women do not present directly with distress about their abortion as the major focus, and since psychotherapy often does not occur for years after the abortion, it is not always an easy task for clinicians to recognize the connection to a previous abortion experience. In her edited book, Parental Loss of a Child, Rando (1990) included a chapter on the loss from induced abortion. In it, she described three obstacles to the clinical identification of negative responses following abortion: (a) masking of emotional responses may occur at the time of the abortion and in later contacts with professionals; (b) if grief persists, it may surface in disguised form and be expressed behaviorally or in psychosomatic complaints; and (c) if the counselor has ambivalent or unresolved feelings about abortion, this may interfere with the accurate assessment of postabortion trauma, as well as with the establishment of trust and the ability to be empathetic. Clinicians, whether for or against abortion, should be aware of their own biases toward women, abortion, and especially women who have undergone repeated abortions. These opinions have the ability to greatly influence clinicians’ therapeutic perceptions and interactions with this population (Rivera, 1998), thus potentially preventing clinicians from recognizing the importance of the abortion experience.
Women who are suffering adverse psychological problems as a result of an abortion(s), often want to avoid and deny those problems along with painful memories, while at the same time longing to find resolution and peace. The tension between this approach-avoidance conflict may often be at the heart of many of the postabortive women’s negative psychological symptoms (Burke & Reardon, 2002). Therefore, as with any trauma, postabortion counseling would seek to assist postabortive women in exposing, proclaiming, and understanding their abortion experience in its appropriate context. The goal is to ultimately “uncover the postabortive woman’s underlying wound of loss and begin to heal it through the grieving process” (Burke & Reardon, 2002, p. 43). The therapeutic setting also “involves a more comprehensive focus in that the woman is often trying to understand her abortion experience and integrate... how the experience has influenced her perception of herself ’ (Rivera, 1998, p. 329).
However, in light of the lack of abortion counseling literature and controversy surrounding PAS, it follows that the research on counseling women who experience negative emotional sequelae is exceedingly sparse as well. This author’s review could not find any empirical studies investigating the few existing theories/approaches to postabortion therapy for women. Instead the majority of the literature is based on case studies or is descriptive in nature. There are, however, a handful of studies examining group interventions for postabortive women, which will be explored in a later article.
Much of the postabortion counseling literature has generally concentrated on two factors: (a) the alleviation of symptoms of grief, anger, depression, and guilt; and (b) finding positive closure for the abortion experience (Lodi et al., 2005). Facilitating a grieving process, forgiveness issues, and increasing self-esteem have all been emphasized as well (Buckles, 1982; Magyari, Wedehase, Ifft, & Callanan, 1987; Peck, 2000; Stone-Joy, 1995). Griefwork, educational and psychoanalytic approaches, reviews of the decision-making process, and even rituals of self-forgiveness have all been proposed as possible effective treatments (Lemkau, 1988; Peppers, 1989; Stone-Joy, 1995). Most clinicians do not view abortion as a unique therapeutic issue, however, there are a few approaches to therapy found in the literature worth briefly presenting. The basic format for many of the approaches reviewed involves working cognitively to review options and decisions regarding the pregnancy and abortion, encouraging awareness and expression of feelings, specifically grief, validating experiences and giving support, and building in relevant relationship and decision-making skills (Buckles, 1982). In postabortion therapy this is quite often just the beginning.
Stone-Joy (1995) describes a psychoanalytic model of postabortion therapy, which focuses on the mourning process, as this has often been long delayed. She reports that the depressed postabortive women she saw “responded very favorably to counseling using a grief format—processing the loss of the fetus as an unresolved grief issue” (p. 376). She suggests beginning with an exploration of the psychological meaning of the “loss,” the underlying rationale and factors leading to the abortion decision, as well as the many ways the abortion has affected the client’s self-concept and self-worth. Stone-Joy (1995) also emphasizes allowing the client to give voice to intense emotions such as anger, guilt, and sorrow and suggests the Gestalt “Empty Chair” as a technique for clients to “talk” to and say goodbye to their lost child.
Reviews of the decision-making process, the various factors involved in choosing to abort, and the social context of the abortion are also important components of postabortion counseling. Backburne-Stover, Belenky, and Gilligan (1982) suggest that exploring a woman’s decision to have an abortion can bring to light developmental and familial issues, relationship conflicts, and her aspirations for education, career, and family. Lemkau (1988) proposed such an inquiry would include: (a) characteristics of the woman herself before and at the time of the abortion, (b) the nature of the interpersonal and cultural climate at the time, (c) characteristics of the medical environment and abortion procedure, and (d) any events subsequent to the abortion that may evoke regrets or conflict. Attempts should also be made to discover as much information about the recovery time and any physical repercussions of the procedure.
Clinicians treating women who meet the criteria for PAS and experience the abortion as a trauma, may choose to follow the approach proposed by Speckhard and Rue (1993). Their approach for treatment follows a standard posttraumatic stress model. The overall goal of therapy is to “recognize the traumatic loss and extricate oneself from the relationship with the aborted fetal child” (p. 8). They also note the importance of recognizing “the unique expressions of the trauma, guilt and grief reactions within the areas of sexuality, and the psychospiritual and family system dynamics” (p. 24). They further suggest that other family members, men, and children may also benefit from treatment.
Rivera (1998) describes a more neutral comprehensive approach to therapy. She describes the abortion experience as consisting of three interdependent phases: (a) the pregnancy acknowledgment phase, which is when the pregnancy is first realized and the “wantedness” is assessed; (b) the pregnancy resolution phase, which involves the decision-making process and the abortion experience itself; and (c) the postabortion response phase, which includes the emotional aftermath experienced since the time of the abortion. Rivera (1998) proposes that during the course of psychotherapy the abortion experience should be fully explored through all three phases. She also acknowledged that grieving/mourning is a crucial step in the healing process, although little investigation has been done with regard to its role after an abortion. Clearly, there is a glaring need for these various approaches/models to be empirically studied in order to determine the most effective (i.e. evidence-based) treatments for postabortive women.
References
Blackburne-Strover, G., Belenky, M., & Gilligan, C. (1982). Moral development and reconstructive
memory: Recalling a decision to terminate an unplanned pregnancy. Developmental Psychology,
18, 862-870.
Buckles, N. (1982). Abortion: A technique for working through grief. Journal o f American College
Health, 30, 181-182.
Burke, T., & Reardon, D. (2002). Forbidden grief: The unspoken pain o f abortion. Springfield, IL:
Acorn Books.
Coleman, P. (2011). Abortion and Mental Health: Quantitative Synthesis and Analysis of Research Published 1995-2009, British Journal of Psychiatry, 199,180-186).
Jones, R., & Kavanaugh, M. (2011). Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics & Gynecology, 117(6), 1358-1366.
Lemkau, J. (1988). Emotional sequelae of abortion: Implications for clinical practice. Psychology o f
Women Quarterly, 12, 461-472.
Lodi, K., McGettigan, A., & Bucy, J. (2005). Women’s responses to abortion: Implications for
postabortion support groups. Journal o f Social Work and Human Sexuality, 3, 119-132.
Magyari, P., Wedehase, B., Ifft, R., & Callanan, N. (1987). A supportive intervention protocol for couples
terminating a pregnancy for genetic reasons. Journal o f Birth Defects, 23, 75-83.
Peck, A. (2000). Forgiveness and the postabortive woman: Achieving self-forgiveness. Dissertation
Abstracts International, 65 (10-B), 5623. (UMINo. 93489-132)
Peppers, L. (1989). Grief and elective abortion: Implications for the counselor. In Doka, K. (Ed.).
Disenfranchised grief: Recognizing hidden sorrow, (pp. 137-146). Lexington, MA: Lexington
Books.
Pine, V. (1989). Death, loss, and disenfranchised grief. In Doka, K. (Ed.). Disenfranchised grief:
Recognizing hidden sorrow, (pp. 178-191). Lexington, MA: Lexington Books.
Rando, T. (1990). Parental loss o f a child. Champaign, IL: Research Press.
Rivera, M. (1998). Abortion issues in psychotherapy. In L. Beckman & S. Harvey (Eds.). The new civil
war: The psychology, culture, and politics of abortion (pp. 329-352). Washington, DC:
American Psychological Association.
Speckhard, A., & Rue, V. (1993). Complicated mourning; Dynamics of impacted postabortion grief.
Journal o f Prenatal and Perinatal Psychology and Health, 8, 5-32.
Stone-Joy, S. (1995). Abortion: An issue to grieve? Journal of Counseling and Development, 63, 375-
376.
At least half of American women will experience an unintended pregnancy by age 45, and about one-third will have had an abortion (Jones, 2011). A meta-analysis conducted by Professor Priscilla Coleman, PhD of Bowling Green State University, examined twenty-two major studies published between 1995 and 2009 involving a total of 877,181 women, of whom 163,831 had abortions found that women who have had an abortion have an 81% higher risk of subsequent mental health problems compared to women who have not had an abortion. They also reported that women with a history of abortion have higher rates of anxiety (34% higher), depression (37%), alcohol use/misuse (110%), marijuana use (230%), and suicidal behavior (155%), compared to those who have not had an abortion (Coleman, 2011). Therefore, the chances that we, as clinicians, will be treating women with a history of abortion is becoming increasingly higher. An examination of some of the clinical issues related to a woman’s abortion experience that arise during the course of psychotherapy would be prudent.
Many postabortive women experience a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Such unsanctioned or “disenfranchised grief’ may become stuffed down, hidden, and unresolved (Burke & Reardon, 2002; Pine, 1989). Even Shakespeare, in his tragedy Macbeth, says, “Give sorrow words, the grief that does not speak knits up the overwrought heart and bids it break” (ACT IV, scene 3). Yet a woman’s grief after an abortion is seldom accepted or expressed, indeed it is “forbidden” (Burke & Reardon, 2002). Since many women do not present directly with distress about their abortion as the major focus, and since psychotherapy often does not occur for years after the abortion, it is not always an easy task for clinicians to recognize the connection to a previous abortion experience. In her edited book, Parental Loss of a Child, Rando (1990) included a chapter on the loss from induced abortion. In it, she described three obstacles to the clinical identification of negative responses following abortion: (a) masking of emotional responses may occur at the time of the abortion and in later contacts with professionals; (b) if grief persists, it may surface in disguised form and be expressed behaviorally or in psychosomatic complaints; and (c) if the counselor has ambivalent or unresolved feelings about abortion, this may interfere with the accurate assessment of postabortion trauma, as well as with the establishment of trust and the ability to be empathetic. Clinicians, whether for or against abortion, should be aware of their own biases toward women, abortion, and especially women who have undergone repeated abortions. These opinions have the ability to greatly influence clinicians’ therapeutic perceptions and interactions with this population (Rivera, 1998), thus potentially preventing clinicians from recognizing the importance of the abortion experience.
Women who are suffering adverse psychological problems as a result of an abortion(s), often want to avoid and deny those problems along with painful memories, while at the same time longing to find resolution and peace. The tension between this approach-avoidance conflict may often be at the heart of many of the postabortive women’s negative psychological symptoms (Burke & Reardon, 2002). Therefore, as with any trauma, postabortion counseling would seek to assist postabortive women in exposing, proclaiming, and understanding their abortion experience in its appropriate context. The goal is to ultimately “uncover the postabortive woman’s underlying wound of loss and begin to heal it through the grieving process” (Burke & Reardon, 2002, p. 43). The therapeutic setting also “involves a more comprehensive focus in that the woman is often trying to understand her abortion experience and integrate... how the experience has influenced her perception of herself ’ (Rivera, 1998, p. 329).
However, in light of the lack of abortion counseling literature and controversy surrounding PAS, it follows that the research on counseling women who experience negative emotional sequelae is exceedingly sparse as well. This author’s review could not find any empirical studies investigating the few existing theories/approaches to postabortion therapy for women. Instead the majority of the literature is based on case studies or is descriptive in nature. There are, however, a handful of studies examining group interventions for postabortive women, which will be explored in a later article.
Much of the postabortion counseling literature has generally concentrated on two factors: (a) the alleviation of symptoms of grief, anger, depression, and guilt; and (b) finding positive closure for the abortion experience (Lodi et al., 2005). Facilitating a grieving process, forgiveness issues, and increasing self-esteem have all been emphasized as well (Buckles, 1982; Magyari, Wedehase, Ifft, & Callanan, 1987; Peck, 2000; Stone-Joy, 1995). Griefwork, educational and psychoanalytic approaches, reviews of the decision-making process, and even rituals of self-forgiveness have all been proposed as possible effective treatments (Lemkau, 1988; Peppers, 1989; Stone-Joy, 1995). Most clinicians do not view abortion as a unique therapeutic issue, however, there are a few approaches to therapy found in the literature worth briefly presenting. The basic format for many of the approaches reviewed involves working cognitively to review options and decisions regarding the pregnancy and abortion, encouraging awareness and expression of feelings, specifically grief, validating experiences and giving support, and building in relevant relationship and decision-making skills (Buckles, 1982). In postabortion therapy this is quite often just the beginning.
Stone-Joy (1995) describes a psychoanalytic model of postabortion therapy, which focuses on the mourning process, as this has often been long delayed. She reports that the depressed postabortive women she saw “responded very favorably to counseling using a grief format—processing the loss of the fetus as an unresolved grief issue” (p. 376). She suggests beginning with an exploration of the psychological meaning of the “loss,” the underlying rationale and factors leading to the abortion decision, as well as the many ways the abortion has affected the client’s self-concept and self-worth. Stone-Joy (1995) also emphasizes allowing the client to give voice to intense emotions such as anger, guilt, and sorrow and suggests the Gestalt “Empty Chair” as a technique for clients to “talk” to and say goodbye to their lost child.
Reviews of the decision-making process, the various factors involved in choosing to abort, and the social context of the abortion are also important components of postabortion counseling. Backburne-Stover, Belenky, and Gilligan (1982) suggest that exploring a woman’s decision to have an abortion can bring to light developmental and familial issues, relationship conflicts, and her aspirations for education, career, and family. Lemkau (1988) proposed such an inquiry would include: (a) characteristics of the woman herself before and at the time of the abortion, (b) the nature of the interpersonal and cultural climate at the time, (c) characteristics of the medical environment and abortion procedure, and (d) any events subsequent to the abortion that may evoke regrets or conflict. Attempts should also be made to discover as much information about the recovery time and any physical repercussions of the procedure.
Clinicians treating women who meet the criteria for PAS and experience the abortion as a trauma, may choose to follow the approach proposed by Speckhard and Rue (1993). Their approach for treatment follows a standard posttraumatic stress model. The overall goal of therapy is to “recognize the traumatic loss and extricate oneself from the relationship with the aborted fetal child” (p. 8). They also note the importance of recognizing “the unique expressions of the trauma, guilt and grief reactions within the areas of sexuality, and the psychospiritual and family system dynamics” (p. 24). They further suggest that other family members, men, and children may also benefit from treatment.
Rivera (1998) describes a more neutral comprehensive approach to therapy. She describes the abortion experience as consisting of three interdependent phases: (a) the pregnancy acknowledgment phase, which is when the pregnancy is first realized and the “wantedness” is assessed; (b) the pregnancy resolution phase, which involves the decision-making process and the abortion experience itself; and (c) the postabortion response phase, which includes the emotional aftermath experienced since the time of the abortion. Rivera (1998) proposes that during the course of psychotherapy the abortion experience should be fully explored through all three phases. She also acknowledged that grieving/mourning is a crucial step in the healing process, although little investigation has been done with regard to its role after an abortion. Clearly, there is a glaring need for these various approaches/models to be empirically studied in order to determine the most effective (i.e. evidence-based) treatments for postabortive women.
References
Blackburne-Strover, G., Belenky, M., & Gilligan, C. (1982). Moral development and reconstructive
memory: Recalling a decision to terminate an unplanned pregnancy. Developmental Psychology,
18, 862-870.
Buckles, N. (1982). Abortion: A technique for working through grief. Journal o f American College
Health, 30, 181-182.
Burke, T., & Reardon, D. (2002). Forbidden grief: The unspoken pain o f abortion. Springfield, IL:
Acorn Books.
Coleman, P. (2011). Abortion and Mental Health: Quantitative Synthesis and Analysis of Research Published 1995-2009, British Journal of Psychiatry, 199,180-186).
Jones, R., & Kavanaugh, M. (2011). Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics & Gynecology, 117(6), 1358-1366.
Lemkau, J. (1988). Emotional sequelae of abortion: Implications for clinical practice. Psychology o f
Women Quarterly, 12, 461-472.
Lodi, K., McGettigan, A., & Bucy, J. (2005). Women’s responses to abortion: Implications for
postabortion support groups. Journal o f Social Work and Human Sexuality, 3, 119-132.
Magyari, P., Wedehase, B., Ifft, R., & Callanan, N. (1987). A supportive intervention protocol for couples
terminating a pregnancy for genetic reasons. Journal o f Birth Defects, 23, 75-83.
Peck, A. (2000). Forgiveness and the postabortive woman: Achieving self-forgiveness. Dissertation
Abstracts International, 65 (10-B), 5623. (UMINo. 93489-132)
Peppers, L. (1989). Grief and elective abortion: Implications for the counselor. In Doka, K. (Ed.).
Disenfranchised grief: Recognizing hidden sorrow, (pp. 137-146). Lexington, MA: Lexington
Books.
Pine, V. (1989). Death, loss, and disenfranchised grief. In Doka, K. (Ed.). Disenfranchised grief:
Recognizing hidden sorrow, (pp. 178-191). Lexington, MA: Lexington Books.
Rando, T. (1990). Parental loss o f a child. Champaign, IL: Research Press.
Rivera, M. (1998). Abortion issues in psychotherapy. In L. Beckman & S. Harvey (Eds.). The new civil
war: The psychology, culture, and politics of abortion (pp. 329-352). Washington, DC:
American Psychological Association.
Speckhard, A., & Rue, V. (1993). Complicated mourning; Dynamics of impacted postabortion grief.
Journal o f Prenatal and Perinatal Psychology and Health, 8, 5-32.
Stone-Joy, S. (1995). Abortion: An issue to grieve? Journal of Counseling and Development, 63, 375-
376.
