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
I recently moved to Southwest Florida. One of the things I first noticed was the number of people that walked dogs in my neighborhood each evening. I wondered if it had to do with the weather and how it draws more people outside than my experience in Oregon where it rained a lot. I also wondered if maybe it had to do with the number of elderly people that live here and how they are kept company by their pets, since many had lost spouses and their children maybe lived up north somewhere. I have always been very curious about the high value our culture will put on animals. Not that I am against having pets. I have had a couple of cats myself and valued them greatly. The question that perplexes me though is how can we as a culture get more up in arms about the protection of an owl or a fish, than an unborn child?
I spent 20 years in Oregon. Oregon is known for being progressive and is very concerned about the environment and protection of animals. There seemed to always be some debate about saving the salmon, the eagle, pets that were mistreated etc. As a therapist who works with men and women who have been traumatized by an abortion in their past, I would wonder what they felt. How did they feel when there was more news coverage about saving a salmon that a child in a mother’s womb? How did we get to this place in our society where this is very normal and accepted?
I could bore you with Psychological theory and theorize how we could get so disconnected from the reality of what is happening before our eyes, but I won’t do that. If you would like to hear that, I suggest you attend one of my workshops in which I address this very issue. I am more concerned for our clients who each day are bombarded with news that so invalidates the pain that they may be experiencing compared to the death of a “salmon eaten by a sea lion”.
You don’t have to have a Master’s Degree in Counseling to know that our society survives the reality of abortion through the use of basic defense mechanisms such as denial, minimization, rationalization etc. I wonder if distraction is another that is used. Focusing on the rights of animals over the rights of unborn children seems like a big distraction from what we as a society should be focusing on. But wait, that would be too painful. So….”How cute is that dog. What is his name?”
That’s where we are. Sad but true. As therapists who treat men and women who have been traumatized by abortion, I encourage you to be aware of how this disconnect might be affecting them. Allow them to talk about it. Encourage them to find places of validation where human life is valued over a fish or dog, because remember they themselves may have bought into culture’s message also and may be confused with what they feel or should feel.
Yesterday the Rand Corp released the results of their study of 40,000 cases of military veterans who had been diagnosed with PTSD. They found that only a third of troops with PTSD and less than a quarter who are clinically depressed receive the minimum number of therapy sessions after being diagnosed. (Rand Corp. 2016). Rand claims that it is the largest independent examination of mental health treatment in the military. Some believe that the reason the follow through was low because either the soldier saw seeking treatment as admitting weakness or that many were in denial about their symptoms.
As therapists who work with men and women who might present with PTSD as a result of an abortion decision, there may be some parallels to learn from. Based on the number of those that have had abortions, it is a high likelihood that a client will present with an abortion in their history on a fairly regular basis. In my work with men who have had an abortion decision in their past, just like in the Rand Corp. study, they often would have a difficult time connecting with the pain of their loss or admit that their PTSD symptoms may be related to the past abortion. They also buy into the both social and gender conditioning about stuffing their emotions and being strong. Many would hang onto denial as a way of avoiding the pain if they were to really accept what happen. As I have mentioned in my previous writing, often times how men express their pain is not by admitting it or showing emotions but by externalized symptoms such as addictions, anger etc.
The Rand Corp. also admitted the need to provide therapy more quickly after the diagnosis of PTSD. The longer PTSD goes untreated the more complex it can become. I have to wonder what ways we as therapists could intervene earlier in client’s lives after they have experienced an abortion decision and what might that intervention look like?
I remember after 911, there was a large movement to get therapists to take Critical Incident Stress Debriefing training. I remember taking the training and what I learned lines up with what much of the research in PTSD studies show. The earlier a traumatized person is able to debrief and receive support the less chance of being diagnosed with PTSD or a more complex PTSD.
I can only imagine the loneliness many feel after an abortion decision. How lonely and isolated that many feel after the “relief stage” wears off. Perhaps we as therapists need to do a better job in partnering with organizations that might come into contact with clients not long after their abortion. We could offer ourselves as resources. Perhaps within the walls of our office we can do our part to normalize and validate clients who present with PTSD like symptoms and may be afraid to admit their relationship they may have to the abortion. For those that work with men, giving them permission to come against social and cultural conditioning. We can respect and not push a client past denial but look for small windows to ask maybe some open questions that may help the client connect with some emotions.
Lets all take note of the Rand Corp Study and see how we might learn some valuable insights and perhaps tools with clients who might present with PTSD symptoms as a result of an abortion in their past or some other trauma that is not easy for clients to talk about, let alone admit the possible correlation of the externalized symptoms that might bring that client to your office in the first place.
Rand Corp. 2016 Report, “Quality of Care for PTSD and Depression in the Military Health System
It is hard to believe that it is already January of 2016. It was a little over a year ago that this organization was formed. The group formed as an outgrowth of discussions over a period of several years between therapists who had experience in already treating abortion related trauma. The discussions focused on the need to both professionalize the treatment of abortion related trauma by using evidenced based practice and also to begin to provide trainings for professional therapists in the field.
It is exciting to see the goals of the organization are already being met in the first year. The three main goals that were set for the first year were to: 1.Grow the organization by adding member therapists. 2. To begin to provide professional articles and writing on the topic. 3. To begin to do trainings for other therapists.
We have grown as an organization and have written some wonderful articles that will begin to provide material for the use of evidenced based practice in treating those clients who present with possible abortion related trauma in their past. We are excited about beginning the process of writing a manual for professional therapists to use in treating clients within a group format. This will be the first of it’s kind published that specifically uses evidenced based practice and sound psychological theory for the treatment of abortion related trauma. The manual will be offered to therapists as a guide and can be used in a variety of setting such as private practice, mental health centers, jails etc. By using an evidenced based practice manual, this would further legitimize abortion as a potential trauma since it would be treated as any other trauma using evidenced based practice. This would further bring respect to the work that we do. Those clients who don’t come from a faith background would have more opportunity to access this type of service also. An additional benefit will be the ability to gather data as to the effectiveness of the group by doing pre and post tests on symptoms etc.
Our next goal will be to produce a book for therapists on treating individuals and couples who present with abortion related trauma in their past. This book will not only include the use of evidenced based practice for trauma but will also have separate chapters and/or sections that are based on the use of different theories such as Cognitive Behavioral and Emotionally Focused Therapy, just to name a few.
This is going to be an exciting year! If you are a therapist that is interested in joining, you are welcome to contact me through the website.
Dr. Cara Barker (2010) wrote a wonderful blog about how to support a loved one who is experiencing grief during the holidays. She says this, “Bridge Building. Keep it simple. The real issue beneath loss is that love needs an outlet and a means of contact. When someone dies, physical connection seems broken. Love's flow gets interupted. Now, you know what happens when a river gets obstructed: cess, turbulence, and disturbance. Holding back your compassion, for fear of "blowing it," only makes matters worse. The bereaved are not looking for perfect. They are longing to re-establish connection with what heals their heart. Be this bridge.
I wonder how much more difficult it may be for a person who is experiencing the disenfranchised grief of the loss of a child due to an abortion decision during the holidays. Dr. Barker suggests above that “the real issue beneath loss is that love needs an outlet and a means of contact”. Since abortion is a disenfranchised grief that often is kept secret, it makes it very difficult for a person to find some form of validation for their loss and pain in our culture. It is then extremely hard to admit their pain and expect to find someone to provide an outlet where love can be expressed and some form of attachment or connection is received in return.
Dr. Barker goes onto to say that “when someone dies, physical connection seems broken.” What does this statement mean for a person who has lost a child due to an abortion decision? Most likely that person will suffer in silent grief, if they even allow themselves to do so. What will later serve the role of a physical connection that was lost, when there has been no human attachments to support this person during the grief process? Perhaps this person may choose a false attachment, such as in the form of addictive behavior. They may choose this form of escape.
If we are to offer a bridge to the many men and women who have experienced the loss of a child due to an abortion decision, each of us will need to take responsibility in fighting the disenfranchised grief both on a macro level in our society and on the many micro levels within our smaller communities, groups and families. Perhaps this small change can provide enough validation for the person grieving to reach out to someone who can be that loving bridge and connection.
As we celebrate this holiday season, as you look around at the faces, ask yourself the question, is this a time to celebrate or grieve for the person you may encounter? In some small moment you might have the opportunity to “mirror” and validate what they have not shared with anyone else but you. To this end, you become the bridge a safe attachment where healing can begin.
Barker, C. (2010). Huffington post. Retrieved 8, December, from http://www.huffingtonpost.com/dr-cara-barker/holiday-grieving-how-to-b_b_789813.html
The scene is often too familiar. A woman and man frantically go to the local drug store in fear that the woman is pregnant. They knew that they were taking chances but thought it could never happen to them. They buy a pregnancy test and hurry to go home so they can see if she is truly pregnant. Maybe she has missed her period and there is concern. At this point both are already in a state of anxiety. Each of their brain’s limbic systems may be saying, “fight, flight or freeze”. One may want to just run and the other may just want to fight or blame the situation on the other. At this point their relationship has reached a crisis stage. They both are seeking a form of relief in finding that the pregnancy test says that she is not pregnant. But what if they find out she is pregnant and the test is positive? What if there is no relief? What will they do then? Will they keep the child; choose adoption or abortion as an option? As I am writing, it is not difficult to feel your heart beginning to beat faster. I think we all can understand the stress of that moment. It is like watching a scary movie in which the music in the background seems to play louder and more intense. Let’s imagine for a moment the woman is pregnant. What now?
Remember, most likely both are now in a state of fight, flight or freeze. They were hoping for some form of relief by finding out that she was not pregnant by taking the test. Since she is pregnant and the positive sign of the pregnancy test is now etched in their brains for the rest of their life, what will they do? What factors will affect their choice? In this blog, I want to just address the factor of the limbic system and the brain. How might the limbic system contribute to the choice when both may be in a state of trauma from finding out that she is pregnant?
Just as before finding out she is pregnant, now a cry for relief from the limbic system is even louder. The need to make a decision to end the current crisis begins to take it’s toll. The prefrontal cortex begins to decrease activity allowing the limbic system’s influence to become much stronger. As a result, there is little logical long term thinking but more immediate reaction to the cry for relief from the limbic system. The brain begins to scream the message of NOW vs cause and effect or long term thinking. As many that have found themselves in this situation, they begin to listen the limbic’s greater influence. This is a very similar process that a person who struggles with an addiction goes through. The pleasure part of the brain seeks something to feel good from the emotional pain they might be feeling. As they begin to seek the “feel good” their prefrontal cortex decreases activity driving them to often irrational addictive behavior. Later they wonder how they could have done what they ended up doing. This is often the same question those who make the decision for abortion ask themselves.
When working with clients who present with abortion related trauma in your office. It is important to remember to communicate to your client your understanding of the complexity of what let up to the decision they made. This complexity includes the understanding of how the brain operates when faced with an unplanned pregnancy crisis. Helping a client understand this process can contribute to their ability to forgive themselves more easily.
Understanding the “cry for relief” from a brain perspective can ultimately lead to relief in our client’s mind of how they could have made such a decision in the midst and shock of an unplanned pregnancy.
Stanley Milgram was a social psychologist who is known for doing a famous controversial experiment on obedience during the 1960's. The reason he performed this experiment was the result of his fascination with why during the holocaust did people follow Hitler and torture and kill 11 million people. He wanted to know why normal every day people would go against their moral and ethical beliefs to the extent of killing innocent people. As many of you know, during this experiment volunteers were asked to administer shocks to a man that was sitting in another room. He was to receive the shock if he answered the questions wrong. What the volunteers didn't know was the man was playing a part of the experiment and he was not really getting shocked. The man would just play a series of recorded reactions to being shocked. In the experiment, 26 out of the 40 participants administered the full range of shocks up to 450 volts. He not only found that they went against their moral and ethical code to follow authority but they tended to shift responsibility to the test taker and not themselves. They rationalized their behavior as just fulfilling a role.
So what does this experiment have to do with working with those who have abortion related trauma in their past? Often times one of the questions client's struggle with the most is , "How could they have got to the point where abortion would be a possibility for them?" People choose abortion for various reasons. Those reasons may include: not having a supportive partner, economics, not being ready, already having children, previous trauma and the impact on the choice, fear of others finding out etc. What people often don't consider is how one's decision may have been impacted by reasons learned from social psychology. In the experiment mentioned above, Milgram learned that people will violate their moral and ethical code for reasons such as obeying authority or fulfilling a role.
What is it about people who will violate their moral and ethical code to choose abortion? Is it that we are influenced by authority such as a government that sanctions it as legal? Is it possible that we are conditioned and desensitized to the reality of what is actually happening? We know that soldiers can be conditioned to not "feel" the impact of killing through video games etc. We know now that many of the soldiers who come back from serving in war zones come back to the same reality, that those who choose abortion do. That reality is the same. The reality of the question, "How could I have got to a place where I thought what I did was ok?" Often after both groups comes to this realization, is when defense mechanisms break down and the realization of the trauma of what they did hits.
As therapists working with abortion related trauma, it can be powerful in the healing process of clients, to talk with them about all that may have impacted their choice. This may include some of the things we have learned from social psychology. When a client is ready to look at the stage of forgiveness, they then can look at all the contributing factors with grace filled eyes. When a client looks back at their decision with better understanding and grace , they then can begin to answer the often painful and confusing question, "How can I have got to this place where I made such a decision?"
Perhaps Milgram could have taught us all some things...
The past few months we have witnessed the release of many undercover videos of interviews with planned parenthood staff members. Many of these videos have been graphic and shocking. As a therapist, my greatest concern is for the millions of people that have watched the videos who have had an abortion in their past and how these videos may be affecting them. This month's blog will focus on what happens to a person when certain defense mechanisms no longer work.
Defense mechanisms serve a purpose in helping us survive the difficulties each one of us will go through throughout our lives. They may help one of us make it through the death of a loved one for example. Denial or rationalization may be ones that are used to make it through that difficult time. They may also help us get through any type of trauma. Minimization or intellectualization may be used as a way of surviving a trauma so as to to be overwhelmed or immobilized by the trauma. Sometimes these defense mechanisms allow us to repress or suppress the overwhelming pain of the reality of what has happened to us. These defense mechanisms help us all survive and get through.
For those who have experienced the decision to abort a child, similar defense mechanisms are used. They may include, denial that the unborn child was really a life or growing human being, minimization or rationalization that it wasn't a good time to have the child, or the child would be better off. Often times the reality of the choice for many is suppressed or repressed deep down in the psyche in order to survive without facing the reality of what happen in choosing to end a pregnancy. This is true for both men and women.
The recent release of the videos has the potential to destroy some of the defense mechanisms people have put in place. The reality of seeing or hearing what actually takes place in an abortion clinic can break through some of those defenses or cause some to experience overwhelming symptoms of trauma as a result. This is why ultrasounds are often used as a deterrent in making a decision in a crisis pregnancy. The client is often able to see the baby developing in the womb and the defense mechanisms of rationalization or denial no longer work.
As therapists working with clients who present with abortion related trauma in their past, we need to be more vigilant in both our screening and treatment process these next few months with our clients. Some of them may walk into our office with defense mechanisms that have been destroyed. They may be overwhelmed with their emotion that can no longer be suppressed or repressed. We need to be aware of how we might need to take extra time to walk with our clients through
these emotions. We also need to be aware of how they may be experiencing a wave of PTSD symptoms. We may need to work with them on coping skills to manage these symptoms. We may need to screen for depression and anxiety and any suicidal thinking. We should also screen for any increase in addictive behaviors as a way of coping with these new symptoms.
I believe wisdom and forethought is needed as to when people are able to handle certain realities. As a therapist who works with those who present with abortion related trauma, doing it in such a public way may serve the cause for some, but it's the client's who I am now concerned about.
Mark Zuckerberg, founder and CEO of Facebook recently shared his story nationally about his wife's multiple miscarriages and how it affected him emotionally. He shared that he and his wife Cilla had been trying to start a family for seven years and went through three miscarriages before their current pregnancy. A major focus of the article was on that men just don't talk about the miscarriages they have and the impact that it has on them and their spouse or partner. It was like Mark had come against the cultural norm and he was being acknowledged and praised for doing that.
As I read the story, I began to think about last month's blog on how abortion affects men and how most often times, you wont know how because of gender and cultural conditioning to name a few reasons. The next thing I wondered was would Mark have had the same response from both men and women if he had came out and said that they had had three abortions. What would the difference in response look like? Why? Would there be compassion for a man that had experienced the loss of a child due to abortion, just as if a man had experienced the loss of a child due to miscarriage.
I do know that Mark had something right in that the loss of a child due to miscarriage is a disenfranchised grief just as much as the loss of a child due to abortion is. The only difference in both these scenarios is in abortion, there is a willful choice to end the pregnancy. It is elected. This isn't true in miscarriage. So maybe the idea that abortion is an elected choice, affects how people view one through empathy versus judgement possibly?
In summary as therapists, working with men and women clients who present with either the loss of a child due to elected abortion or the loss due to a miscarriage, there are a few things to consider. First it is important to validate the client's experience and courage for any client that is able to move past the disenfranchised grief the culture creates and seek help for an issue not many are willing to talk about. Both types of clients need to be validated for their loss in a culture that is so invalidating. Abortion loss is unique in that one was involved in electing to end the pregnancy, so as therapists we will need to know how to treat that client in a uniquely different but similar way.
Mark, thanks for sharing your story as a man. You shared your vulnerability and came against a cultural norm. My hope is that this will continue to happen more often especially for men who have experienced an elective abortion and they too will receive praise for their vulnerability in a culture that makes it very difficult for men to be vulnerable.
In the video above, Nick Nolte in the movie Prince of Tides, demonstrates to Barbara Streisand his therapist, how often times a man is afraid to open up about the trauma they have experienced in the past. Streisand asks Nolte at one point how he feels. He pauses and is not sure how to answer. This is very typical of a man in that he is more likely to respond from his rational brain through thinking versus feeling. He is also more likely to act his pain out versus talk about it. It is more likely to come out in symptoms versus talking about feelings. Streisand is able to get past Nolte's defenses and he finally breaks down crying in her arms. Nolte is a good example of how men often deal with trauma in their past. They are more likely to stuff it or act like they are okay in order to not show weakness. In this month's blog, I will be addressing the question of whether men really hurt and experience trauma from an abortion decision in their past.
I have been specializing in how abortion affects men for over 10 years. In that time, I am often asked the question, does abortion really affect men that much? Can it really be just as traumatic for them as women even though they are not the one's carrying the unborn child, or experience the abortion procedure to their body? If so, how come they never admit to it or seek help?
The first thing I want to say is the way one measures the impact trauma has on a man needs to change. To begin with, one needs to understand why men don't seek help in the first place for any trauma or difficulty they have gone through in the past. Kurt Smith LMFT (2010) gives 5 reasons why he believes men don't go to counseling. They are: because men are problem solvers, they see it as a sign of weakness, pride, fear of change and control. Neil Chethik (2004) wrote a book called FatherLoss. In the book he interviewed 70 men whose fathers had died. He found that 90% of them did not seek grief counseling. He suggests that men avoid grief counseling because often the services do not reflect their style of grieving. It seems like men are influenced the most by both gender and cultural conditioning when it comes to the idea of seeking help. So to begin with, answering the question of whether men hurt from abortion and experience trauma, can't be determined by whether men seek help or not for their previous trauma.
Judith Herman in her book Trauma and Recovery states, "The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma. When truth is fully recognized survivors can begin their recovery. But far too often secrecy prevails and the story of the traumatic event surfaces not as a verbal narrative but as a symptom." (Herman, 1992). Over the years of working with men who present with sexual addiction, often times the men also experienced some form of trauma in their history. The trauma may have been childhood trauma but also many of these men presented with an abortion decision also in their history. It was often hard to tell whether the childhood trauma or the abortion decision had a greater impact on the presenting problem of sexual addiction. What I do know is many clients seem to escalate in their addiction after the experience of abortion, even if their addiction already had an etiology in childhood trauma.The second thing that needs to be considered when determining whether men hurt and experience trauma from an abortion decision, is to consider the most effective way to measure the effect. Measuring the effect might include first looking at the symptoms that men seem to get help for, and then looking at previous trauma that may be impacting those symptoms in order to begin to make correlations. Men are more like to seek help for a crisis, as a result of their symptoms and unlikely to seek help because of an abortion decision in their past. In the beginning of counseling, men will often not be able or willing to make these connections. The encouraging part is that as treatment progresses, they are often later able to see that previous trauma had and is impacting their presenting symptoms. They are then able to see the importance of working on those past issues in order to see improvement in their presenting problems or symptoms.
In summary, men do hurt and can experience trauma from an abortion decision. The way to measure the impact needs to change and adjust. Answering the questions need to first take into account why men are less likely to report an effect or seek counseling in the first place. Finally, a better way to measure the impact previous trauma, including an abortion decision has on men, is by assessing previous and current symptoms that appear post trauma and determining the possible correlation. Determining symptom correlation may be a better indicator than a man's self report because of the mentioned issues.
Chethik, N. (2004). FatherLoss, Hachette Books
Herman, J. (1992). Trauma and recovery, Basic Books
Smith, K. (2010). Counseling Men Blog. Retrieved From the Guys' Stuff: Counseling and Coaching Website
In the book Healing Together, the author writes about the importance of healing together in a marriage when one person has PTSD. The author walks the reader through what to expect and offers strategies of how to not only cope but heal from the effects of PTSD together. This book comes from a systemic approach to treating PTSD rather than an individual deficit model.
Family System’s Theory was originally developed by Murray Bowen. His theory suggested that people present with symptoms that are the result of the system they come from and not the individual alone. As a result, treatment then needed to be focused on the system also and not just the individual. Needless to say, there is a lot more to Family System’s Theory, but I won’t go into that in this blog.
The theory was tested early on in inpatient hospital settings for clients that presented with alcoholism. What they found was if the patient was treated in the hospital and they established sobriety, they often would relapse when they got home because the family system was not treated also. The system itself attempted to go back to what seemed “normal”.
In my work with sexual addiction over the years, I would always see both the male and their partner both individually and as a couple. It didn’t make sense to me to just see the male who presented with the addiction, when their spouse was often traumatized also. The partner needed counseling and support also and so did marital relationship. If this didn’t happen, the risk was that the spouse would become stuck in their healing process and often times the couple would become stuck in a “trauma cycle” of interaction. If this trauma cycle isn’t addressed, the dynamics of the cycle often increase the risk of relapse. The dynamic of the couple system remind the addict of what it was like often times growing up in their own family, thus encouraging the return to a negative way of coping or survival.
Over the years, there have been many programs that have reached out women who have experienced an abortion and provided opportunities for healing through faith based Bible study programs and services through Crisis Pregnancy Centers etc. Many of these programs helped a lot of women, but were not systemic in their focus both in assessment and treatment. As a result, women could be at risk of experiencing further trauma if their marital or family system at home was able to support the working through of a possible trauma. In addition, many would go through the healing experience alone, which could further breed a feeling of detachment.
Attachment theory suggests that we are wounded in relationships and we should heal in relationships. It is my belief that an abortion wound is an attachment wound at many different levels. The abortion happen in the context of a relationship and it would make sense that the healing process should happen in the context of a relationship.
As therapists treating abortion related trauma, I believe it is critically important that from the intake process, to assessment and treatment planning, we need to integrate Family Systems Theory into everything we do. If we don’t, we risk causing further pain for our clients. Just like with any trauma issue, amazing healing can happen in the context of a securely attached relationship. If that is not present, then we as therapists need to be wise in the approach and timing of any work that we do regarding the abortion issue. Sometimes, our first goal might be the stabilization of the couple system first before any trauma work happens.
As we develop evidenced based programs for the treatment of abortion related trauma in the future, Family Systems Theory will surely be part of the models that are developed.
Gregory Hasek MA/MFT is a Licensed Professional Counselor in Oregon.