American Association of Therapists Treating Abortion Related Trauma
Professionalizing the treatment of abortion related trauma
Bridging the gap between research and practice
Bridging the gap between research and practice
The decision to abort a child is often not taken lightly. It usually comes after many weeks and sometimes months of terrible anxiety about what to do. There are so many thoughts that go though both the male and female’s mind. In past articles and blogs, I have written about how traumatic finding out one is pregnant can be and the impact that can have on the behavior of both the female and the male. How being caught off guard can cause a fight or flight response that is driven by the limbic system. Both males and females can have this response and it can greatly impact their ability to make a rational decision. Oftentimes they both are wanting a decision that would bring relief from their brain being stuck in this state. Unfortunately, later when the “relief stage” wears off and their rational brain begins to kick in, they begin to feel and think differently about what they just did. I have also previously written about the topic of how previous trauma can impact the trauma of the decision and put the person at greater risk of a fight or flight response, versus someone who did not have previous trauma.
In this month’s blog, I want to talk about how coexisting disorders of impulse can have an impact on the abortion decision. A common diagnosis that I often assess for in my clients is Attention Deficit Hyperactivity Disorder (ADHD). Since I work with many clients who present with addictions, I know this is a first place to start. The reason is that many of the symptoms of ADHD create a high-risk factor for clients who present with an addiction history. In addition, I know that clients who have this diagnosis often have a lower level of dopamine. Due to lower levels of dopamine they will then seek out ways to raise their level of dopamine through addictive substances and behaviors. As a therapist, I began to wonder how many of my clients who have an abortion decision in their history, may have been impacted by symptoms consistent with ADHD and may have never known. In other words, it is very possible that if their ADHD symptoms would have been treated or diagnosed, they may have not made an impulsive decision to abort their child.
How is this information helpful when working with clients who have an abortion decision in their history and a diagnosis of ADHD? To begin with, a common stage clients go though in the healing process is being able to forgive themselves for the choice they made. I have found that when clients receive a diagnosis of ADHD and they truly understand the symptoms, especially impulse control problems, they are better able to forgive themselves through that lens of understanding. In addition, it is also an important opportunity through psychoeducation to teach coping skills to prevent a future crisis pregnancy.
I encourage you as a therapist to consider any type of impulse control disorder when working with clients who present with an abortion decision in their history. A proper diagnosis can often bring both relief and healing to a client that may have for years condemned themselves for making an impulsive decision in the moment of the crisis pregnancy. This information alone can be a turning point in your client’s healing journey.
Healing in Their Own Way
I admit that most personality assessments show I score high on the need for organization and structure. Over the years this has helped me in the counseling field but in other ways it has hindered me. Sometimes I want to plan a client’s stages of recovery in a way that would fit some perfect model. After all this seems to line up with what most books would recommend. These books often recommend taking clients through the stages of grief and loss as a basic framework. I realize I may be simplifying what many of these books and group manuals suggest, but many fall back on the basic tenants of grief and loss work and the stages that are involved in that.
I have worked in the addiction field since 2003, and I have developed a very structured program for the identified addict, the spouse and the marriage. This program often lasts for one full year. The program has been highly successful over the years and many clients report outcomes that were transformational. My need for organization and structure as it relates to this program has been very beneficial. There are other times, it seems like my need for a step by step healing process, gets in the way of allowing a client to heal in their own way.
I was recently working with a woman who had an abortion as a teenager with her now husband. I had a sense that she came to counseling to me because she knew that was one of the areas I specialized in. We had briefly gone over the abortion experience on the intake form, but in my mind, there were other major issues that she needed to work on first prior to working on the abortion issue in counseling. One day she came into counseling and reported that her and her husband were beginning to talk about the abortion experience that they had years ago for the first time. She also began to report that they felt closer than they ever did before as a couple. I was surprised to hear this. The structured part of me as a therapist thought, that it may be the wrong time and it was not what I had planned. I was thinking all these things in my head as my client sat before me. In that moment I thought to myself, she began healing in her own way, without me suggesting a structured program or a support group based on a book format etc. There was something powerful that happened by her starting the counseling process alone that gave her permission to start healing with her husband in their own way.
I wonder as clinicians how many times, we get in the way of our clients “healing in their own way”. We think we know better. We think they should follow our set programs, and when they don’t we have a reaction or resistance. I believe there are millions of men and women who have experienced an abortion decision in their life that may need permission to begin healing in their own way. It can be as simple as a client being first validated for what they have experienced and later being given permission to start healing in their own way.
I am thankful for the structured personality that I have because it works well for me to create programs that transform lives. I am also grateful for these small lessons I can learn from my clients about healing in their own way and in their own timing.
I am always amazed how fast the time goes between Thanksgiving and Christmas. I love seeing a Christmas tree in the house with all the different lights. I am the one who hesitates to take the Christmas tree down until the very last day. There have been times I have been tempted to keep it up until the end of January. Those are the times I think that maybe the neighbors would wonder when, if ever, I had planned to take it down. As I sit here on January 11, 2017, I have to admit that I took the tree down on New Year’s Day. This year I resisted and decided to look at it as an opportunity to explore the emotions that might be underneath the resistance. The opportunity allowed me to discover and work through emotions that I had been feeling but not quite identified. What I had been feeling was a longing to hold on to a memory of Christmas past, when parents were still alive, and the childlike excitement of Christmas morning was still there. I think I discovered that keeping the Christmas tree up symbolized not letting go. What I experienced was, the same thing I ask of my clients. I ask them to sometimes sit with their emotions and try to figure out what might be at the root of the avoidance of them. I often frame it to them that they have an opportunity to change versus seeing it through a negative lens.
As I reflect on this group and the New Year, I think about new opportunities. I think about opportunities to help our clients discover things about themselves, just as I did. With that discovery, brings opportunity to change. I also think about the opportunities that we as a group have to educate and provide resources for our clients, who may be experiencing the loss of a child due to an abortion decision. Some of those clients will come to us with trauma symptoms, and we have to be prepared to not only assess for that, but to provide high quality evidenced based practice.
I also think of the opportunity that this group has this year in educating other therapists through trainings and workshops. We as a group can begin to look at providing CEU’s for therapists that need them to fulfill licensure requirements. I believe the more we educate other therapists as to how to do a proper assessment for trauma symptoms due to an abortion decision, the more likely clients will receive both the validation and mental health services they deserve. It is unfortunate that too often therapists see this issue also as a political or religious issues versus a mental health issue. Some therapists think that just asking about a previous abortion decision, would somehow send the message that they had an agenda, versus just being compassionate in asking. Many of these therapists choose to keep the question off their intake form and never do ask. I can’t tell you how many men and women who have come into my office and said, “Thank You” for asking. Often these clients had been to many different therapists for years.
I am excited about the opportunity we have as a group in 2017. Sometimes the work seems hard, and it can feel overwhelming. What I do know is that there are millions of clients who have experienced some form of trauma from an abortion decision, and deserve every minute of our hard work. The work that we do can help them receive the services they deserve. Even if we only train ten therapists this year, imagine the number of clients who can be helped. This opportunity is a blessing.
Christmas Brings Memories
Over the years of doing counseling many of my clients would report a gradual downhill feeling of depression during the time from Thanksgiving to Christmas. For others, they would report a joyous time with their family and would look forward to creating new picture perfect memories. The group of clients that struggled with depression seemed to have some things in common. In this month’s blog, I want to talk briefly about what they had in common and offer some encouragement for those that might need it during this time of year.
Christmas, like other holidays, brings both reminders and memories. Many clients who come to counseling present with early childhood trauma. That trauma often would steal from the innocence of Christmas day. What was supposed to be a joyous fun filled day with relatives and friends, often turned to just another day for that child to live in fear of something bad happening. That could include some form of rage, a violent interchange between parents, or another day to watch mom or dad drinking, just to name a few.
As adults, these memories can creep back in during the holiday season. A client may have PTSD from early childhood trauma, and during the holiday season they may experience intrusive thoughts, flashbacks or nightmares. In addition, the holiday season may be a reminder to some clients of how they may have repeated some of their past childhood trauma in their current relationship. A client may have said they would have never wanted to be like their parents were, may sit and face the fact on Christmas day that in many ways they became just like their parent. This realization is never so greater as they look into the fear of their children’s eyes and remember the same fear that was in their eyes as a child.
Christmas time as adults can also bring reminders of the many losses one may have experienced. These losses can include the death of a family member, or the loss of a child due to a reproductive loss such as a miscarriage, still birth or an abortion.
This week a client shared with me how difficult the week of Christmas was for her because last year at this time she had just found out she was six weeks pregnant. She later went on to have an abortion and is now suffering a year later and meets the full criteria for a diagnosis of PTSD. Just as childhood trauma would often steal the innocence of Christmas day for many of my clients, abortion trauma had now stolen the innocence of the holiday season for my client. The reliving of her trauma a year later not only stole her happiness during what is supposed to be a joyous time of year, but challenged her in the ability to be present for her current child. You see, her trauma now threated to steal from her current child’s Christmas day.
Let us not forget our clients during this holiday season. Don’t assume a “Merry Christmas” to all. Maybe another statement would be more beneficial than a canned statement. Perhaps, you might want to say to your client, “What will Christmas be like for you this year?” “I will keep you in my thoughts during this time because I know that this brings back memories for you.”
This Christmas I am thankful for each therapist that has been involved in this organization. I am also thankful for the many others who come to our website regularly to read the information that we present. I am also so thankful to be able to validate millions of men and women’s pain due to an abortion decision, when we live in a culture of invalidation. Validation often becomes the first step in reaching clients who come to our website for support. They are able to find therapists that not only validate their pain but provide professional evidenced based services to help in their healing.
As 2016 comes to a close, instead of saying “Merry Christmas”. I will say to you, “How are you doing during this time of year?” “It’s okay and I understand”.
The fall season has set in with cooler temperatures, even here in South Florida. This week is the first week of cool nights and lower humidity. Before you know it Halloween will be here. As I was reflecting on Halloween, the idea of ghosts came to my mind. As I sat down to write this blog, I was reminded of something I had read years ago about the concept of, “Ghosts in the Bedroom.” The concept was referring to what it might be like for couples who have had an abortion together, to enter back into sleeping in the same bedroom and having sexual intimacy again. What would the effects be on a couple who had conceived during the sexual relationship in a bedroom, to now enter back into an intimate relationship in the same bedroom.
In my work with couples who have recently had an abortion, or any kind of pregnancy loss, I often suggest stopping the sexual relationship until they have gone through enough of the recovery process together. I have found that if the sexual relationship continues without enough time for the couple to work through the trauma and possible PTSD symptoms, the risk of re-experiencing trauma in the sexual relationship is pretty high. In fact, the risk of one or both partners, dissociating during sexual intimacy is also great. Unfortunately, it doesn’t take long for their unconscious at an attachment level, to begin to perceive their partner as the enemy. This is especially true if either of them have sexual abuse in their background. If this goes on long enough, one or both partners will literally shut down and that usually means the end of the relationship.
If you are a therapist who works with any type of pregnancy loss, I would recommend that you assess for the degree of trauma that the couple may have experienced as a result of the often sudden loss. In assessing the couple, it might be important to be involved in recommending the stopping of the sexual relationship for a period of time so the couple can heal first. Remember the bedroom itself often represents the loss, and sexual relations in that bed can also bring back memories of the conception and later loss. Ghosts in the bedroom are a real thing for couples who have experienced any type of pregnancy loss. As a therapist you can be a critical component in making therapeutic recommendations at the right time. These recommendations can not only prevent further trauma but often prevent the relationship from ending.
A recent study from Barna Research reported that 27% of older Millennials started viewing porn before puberty. Another recent study reported that young adults between the ages of 18 to 24 seek out porn more than any other generation. They also found in the same study that this age group had more guilt about not recycling than watching porn. What I find interesting is that the Guttmacher Institute also reported in 2014, that patients ages 20-24 obtained 34% of all abortions in our country. As a therapist who specializes in sexual addiction, I have to only wonder how a young person’s exposure to pornography prior to puberty, in addition to later viewing porn in their early 20’s, may impact their sexual behaviors and added risk to a crisis pregnancy with their partners. If the age group that seeks out porn the most is also the age group that has the most abortions, it would make sense that there could be a correlation. So what does this mean for therapists who treat clients who are Millennials? Are you properly screening for porn use, possible sexual addiction and risk factors for a future crisis pregnancy as a result of what this research shows us?
If you are a therapist that works with Millennials, it would be important for you to add to your intake assessment questions about early exposure to porn, and current use. This is a critical stage to begin looking at risk of a future sexual addiction prior to marriage. It is unlikely that a male will report any addictive behaviors as it relates to porn use to their future spouse prior to marriage. As I mentioned earlier Millennials tend to minimize the use of porn as a problem. They tend to see it as quite normal. So why would they need to bring it up to their future spouse? In fact, their future spouse may think of it as normal also, since they grew up in the same generation. As a therapist you have an opportunity to help a client who presents with problems related to porn use before it escalates to a full addiction and causes problems in future relationships. What I have found is many female Millennials will act as if it is a normal part of their generation until it hurts them, or they “allow it” to hurt them. What they often find is they bought into a generational norm that goes against the very nature of wanting to be respected and not objectified. They are only able to hang onto that norm for a short period before they realize they can no longer defend against what should normally be expected from a trusting relationship. If after doing an assessment, you find that a client appears to have an addiction, it might be better to refer to someone who specializes in sexual addiction if you don’t think you are qualified to treat.
In addition, if you identify a Millennial client that currently uses porn or is addicted, it will be important to not only screen for an abortion decision in their past but to also assess how their current use of porn may have an impact on a future crisis pregnancy. You see, when a client becomes addicted to porn, they quickly learn that there is no need for emotional intimacy or connection in order to have a sexual experience. This later leads to being able to have sexual relationships without any emotional connections. This generation might call this, “friends with benefits”. It would then make sense that they would have more sexual partners, without any sense of commitment. This would most likely add to the risk of a crisis pregnancy. The disconnect and lack of emotional intimacy would also contribute to how one would respond to finding out their partner is pregnant. They would act disconnected from the reality of an unborn child that was now conceived.
Another factor to consider is the viewing of pornography tends to affect how a person acts in the sexual relationship. Not only can porn affect what they want to do with their partner sexually but it can also cause more sexual aggression. Often their partner does not understand the changes in their partner’s behaviors toward them, especially if they don’t know they view porn. With increased aggression, comes a greater risk of a crisis pregnancy.
We therapists need to be prepared to work with a new generation of problems related to internet porn use, and the risk factors that might contribute to a crisis pregnancy and a possible abortion decision. What we know from research is, this generation views more pornography than any other age group. We also know this generation has more abortions than any other age group. To think that there isn’t a correlation, would be ignorant.
Many clients who come to see us in counseling have a very hard time forgiving themselves. I remember a client recently told me that he would never be able to forgive himself. He had struggled with an addiction most of his life and was now in his 60’s. He was at a developmental stage where he was beginning to look back over his life and reflect on what his life had been like. Of course as all “good” therapists try to do, I offered some encouraging words. I told him that it is possible to forgive himself and let go of the self-condemnation. I knew if he didn’t eventually, he would be stuck in the cycle of addiction that often begins and ends in shame. He was having no part of what I said. He looked sternly at me and said he can’t. What I had learned over the years was, I had to accept him where he was. I knew one day he might be able to look at things different. It was a timing thing and I had to let him just be where he was at in his thinking and emotions.
Most of the time clients, eventually come to a place where they see the benefit of forgiving themselves, staying present and having a future focus. In my work with clients who have had an abortion in their past, they often have a hard time forgiving themselves. Most clients report that the most difficult thing for them is that they not only are responsible for the decision, but it was a decision that could never be changed no matter what they did or thought.
Years ago when I began to understand the brain and how it is affected by both current and past trauma, I discovered an important factor to offer a client in their healing process of being able to forgive themselves. I learned that the pre-frontal cortex basically decreases activity and the limbic system increases, not only at the time a person finds out they are pregnant, but also if they have had previous trauma. Being able to offer this information to my clients, was the first step in helping them understand why they made the decision they did back then, and how they now look at the decision differently. Understanding that if a person has had previous trauma in their life leading up to the abortion decision, their brain would basically go off line and they would act out of their fight or flight response.
Several years ago I developed a tool that I call the “fly over”. This tool is basically used to help the client imagine that they can get in a plane and fly back through their past. Almost like in the movie Back to the Future. In flying back, they are able to write down all the things that happened to them prior to the abortion decision. This tool combined with their understanding of the brain research, has been highly effective in helping clients forgive themselves through the eyes of empathy. They are then able to understand what led up to their choice and why their brain may have caused them to think in an irrational way at the time of crisis.
If you are a therapist that works with clients who have a hard time forgiving themselves, whether because of addiction or a traumatic decision, I would encourage you first to assess the timing when your client is ready to consider self-forgiveness. I would also encourage you to find a tool like I did. You can also help your client fly back over their life and not judge themselves for just the decision. With eyes of empathy, they are better able to see themselves as to what led up to the decision in a new way.
Too Painful to go There
Over the years as a therapist I have watched clients report little or no effect to what was normally very traumatic for others. I knew as a therapist all the right things to do about not imposing any agenda on my clients. I knew I had no right to impose my thoughts as to whether they should feel a certain way about a particular trauma. I realize there are many reasons why clients report little or no effect on them for something traumatic they have experienced. For this blog I want to focus on why clients are scared to talk about the past and the emotions that might come up.
The first thing I want to talk about is the fear of the unknown. What I mean is that many clients have stuffed so many painful memories as a way to survive horrific things. To visit these memories again brings with it many unknowns. Those unknowns include, whether they will be able to handle the emotions that come up. They may also fear that they will go into a deep depression, or experience more shame than they can handle. They see no reason to want to feel more pain when they appear to have moved on from the past.
The second thing I want to mention is the fear of expressing emotions in general. Many clients grew up in homes where emotions were not expressed. They often did not have parents that modeled or expressed emotions in a healthy way. If emotions were expressed, sometimes it was only through bursts of anger or violence. They also may not even have the words to express their emotions about the trauma. I am always amazed when I have to bring out a “feelings wheel” for a client who have never learned how to label their feelings. Some clients had to grow up as a “parentified child”. They had to be strong and be like a parent often to their siblings, or even to their own parents. They learned to not show weakness. They got used to taking care of others emotions and often not their own.
For the millions of men and women who have lost a child due to an abortion decision in their past, many will report little or no effect. This is also true of many other issues that are often traumatic such as sexual abuse. Should we automatically think they are in denial or using some other defense mechanism? Is it possible it is as simple as some are not as affected as others and people just like to avoid pain? Let me explain it to you this way. Imagine you just saw the scariest movie ever and then you go to a therapist for help and the therapist tells you that how you are going to heal is to repeat the scary movie over by talking about it.
I do believe there is no easy answer for these questions with the clients we serve. As a therapist I have to be sensitive to any resistance I may feel with my clients about revisiting a trauma. The resistance is trying to tell me something related to their fears of going there. As therapists who work with clients who have an abortion in their history, sometimes the best you can do is sense where your client is at during the time they come to you. It might be a timing thing. In my experience, many clients are really just trying to tell you, “Not now”. In other words, their plate is full at the time and they can’t add anymore to it. Listen, listen, listen. If you don’t listen you may find your client not coming back.
It may be true that the clients who come to you with many different types of trauma, including abortion trauma, may use every defense mechanism in the book, to act as it didn't affect them. However, “It might be too painful to go there”, at least for now. Honor that.
It's All About Attachment!
As a therapist who works with addictions, I learned over the years that the etiology of addiction most often has it’s roots back in the first two years of a child’s life. This is the time that the right brain is developing and there is little left brain development. The left brain doesn’t really start to develop until the baby begins to speak which is about the age of two. If a child develops an insecure attachment at this young age, they learn several things. One is they learn that they may not be able to trust another person will meet their needs. They also learn whether they are lovable. If a parent is unresponsive to a child’s needs, the child can begin to feel unlovable. It is also at this time, that a child learns to regulate emotions. If a child develops an insecure attachment, one's ability to regulate emotions is impacted. The later inability to regulate emotions due to an insecure attachment is what often leads to addiction later in life.
Abortion is a loss of attachment for both the mother and father. How does the inability to attach to the child, combined with the loss of attachment later also lead to addictive behaviors both in men and women? It would only make sense that if early attachment trauma in childhood is a high risk factor for later in life addiction, that the loss of attachment due to an abortion decision, would also lead to a risk of addiction due to that attachment loss and the emptiness that results in the inability to bond.
While working with clients who present with addictions, I often will assess what kind of attachment style they are based on their family history. This understanding of attachment style not only helps me in understanding the etiology of addiction but it also helps me understand the relational dynamics in their marriage or couple relationship. Their attachment style will also have an impact on whether they can attach to the loss of their child due to an abortion decision or not. It will impact their ability to attach to their emotions, their partner, other children etc.
The goal of working with those who have had early attachment trauma or later attachment trauma with a child they lost due to an abortion decision, is to include in your treatment planning the goal of a movement toward a more secure attachment. Not only will the risk of addiction go down, and their ability to attach to their partner go up, but as they attach to their emotions, they can also begin to attach to the child they lost. As a therapist, remember this important lesson, it’s all about attachment. I promise you can’t lose as you approach your client through this lens.
The Secret on my Intake Form
Over ten years ago I began to include a question on my intake form about abortion. The first question read, “Have you lost a child due to an abortion decision?” The following questions were then focused on symptoms as a result of the decision. I would also ask the question whether they had told anyone or if they ever had counseling to address the loss. As you can imagine, I had many different responses over the years. The responses ranged from ignoring the question, to crossing out the word child, to answering the question as honest as they could. How a client answered the question, usually told me a lot about where they were in the grieving and healing process. I had committed to myself as a therapist that clients deserved to be validated for the loss of their child due to an abortion decision, despite what culture was telling them of it being no big deal. I knew in my work with clients over the years that just because a person doesn’t talk about a trauma doesn’t mean it is no big deal. I wanted to honor their loss by asking the question. I wanted to give my client’s a different message than the sense of disenfranchised grief that they often lived with in silence. I also wanted to begin to give my clients hope and a plan of recovery and healing.
Last week as I was looking through a series of new intake forms, I noticed several things. One is the power of secrecy and shame that many women and men carry on a daily basis and never talk about it with anyone. The comments I read on these new intake forms were that they either have told no one or that they only told one or two people. They also reported a lot of pain and sadness still, often after many years. They rarely report they have had any counseling to deal with it in the past. I continue to be shocked today that many of these clients have attended counseling for years and were never asked about an abortion in their history. I can’t tell you how many times I have heard the same story. Let me just say one thing loud and clear. Our clients deserve better. They deserve to be validated for their secret pain despite the cultural message. If we don’t at least validate their pain, then who will?
If you are a therapist and are reading this blog, do me a favor. Validate your clients and include this question on your intake form. It is no different than including a question about another trauma such as childhood abuse. If you don’t ask the question, you are basically saying to the client the same thing that culture says to them. “It isn’t a true trauma and they shouldn’t be hurting.” How sad that the mental health world caves into political pressure, various groups with agendas, and ignores the real pain of the client. After all wouldn’t the mental health world want to validate a client who may have experienced sexual or physical abuse? Wouldn’t they want us to ask these type of questions on our intake form? Clients who have experienced possible trauma due to an abortion decision, deserve the same.
Gregory Hasek MA/MFT is a Licensed Professional Counselor in Oregon.