Some Considerations in Post-Abortion Counselling Care
By Ruth Riddick
“Abortion is an extremely stressful event which falls outside the normal range of women’s experiences and as such leaves us open to many profound feelings. These feelings are a normal response to upheavals in our lives and the total effect does not have to be negative as generally expected. Through stress and change, we can grow and learn” 1
“Immediately after abortion, symptoms of distress and dysphoria do occur in many women. However, these symptoms seem to be continuations of symptoms present before the abortion and more a result of the circumstances leading to the abortion than a result of the procedure itself. Indeed, many studies report significant positive feelings after the abortion … Longer term studies show similar trends; the majority of women express positive reactions to the abortion, and only a small minority express any degree of regrets. Similarly, negative feelings present before the abortion disappear, with normalisation of various scores. “2
Grief and loss are commonly thought to be inescapable consequences of abortion, even where abortion has been a positive choice. Much post-abortion therapeutic practice is based on this assumption, especially where strong social taboos exist against elective termination of pregnancy. The purpose of this article is to examine this assumption, and the actual experience of women in so far as it can be known.
Most Irish people consider abortion to be a grave sin, to be a dreadful undertaking pardonable only by overwhelming pressure of circumstance or understandable only in the context of severe social deprivation. The only public support ever shown to an Irishwoman seeking abortion was for the 14-year old rape survivor “X”. In this case, outrage was focused on the overburdening intervention of the forces of the state in the private affairs, even in the abortion decision, of her family. The proposition that she, or any other woman, might have a right to autonomous decision-making in respect of her pregnancy was not an issue in public discourse. These preliminary remarks set the context for our discussion.
To begin, we need, as counsellors and therapists, to ask ourselves a number of hard questions:
How do I feel about abortion ? Am I angry that I might unintentionally become pregnant? (e.g. rape, contraceptive failure) Are there any circumstances in which a pregnancy would be disastrous for me? Why do I think women have abortions? How do I feel about women who have abortions? Why do I expect grief and loss to be inescapable consequences of abortion?
These questions are not easy. They cause us difficulty and pain.
Yet, if one of the fundamental principles of our work as counsellors and therapists is that we must be non-judgmental, it is imperative that we clarify our own values and feelings, especially on these questions.
In approaching this work, it is also important to clarify our definitions: a crisis pregnancy is a pregnancy which is unplanned, unexpected and unwelcome, and it is always the pregnant woman who identifies the pregnancy as a crisis. A legal termination of pregnancy is an elective procedure to which a woman must formally consent by signing a Consent Form in advance of the abortion. (Minors under 16 years of age must have the consenting signature of a parent or guardian.)
Post Abortion Counselling and Therapy
“There are themes common to women who have experienced abortion – depression, guilt, anger, sadness, euphoria, relief, resentment, anxiety and grief. The duration and intensity of these feelings varies between individuals, and how we cope with them is a personal process. Often, however, our feelings are ignored, misinterpreted or repressed, which can lead to emotional upheaval and possible difficulties in our relationships, or even physical illness.” 3
It seems to me to be more useful for counsellors and therapists to see abortion as an unplanned event in the whole life rather than as a dreadful aberration for which suffering and atonement are required. Clearly, the experience is one of crisis, a stressful episode which requires coping, as Nancy Adler et al discuss:
“From the perspective (of stress and coping), unwanted pregnancy and abortion are seen as potentially stressful life events, events that pose challenges and difficulties to the individual but do not necessarily lead to psychopathological outcomes. Rather, a range of possible responses, including growth and maturation as well as negative affect and psychopathology, can occur.”4
It would suggest that unplanned pregnancy, experienced as a crisis, whether it results in abortion or not, is more often an extreme symptom of life-crisis, of loss of control; a defining event.
I am aware that this view challenges the mainstream perception of abortion which scapegoats the abortion in order to avoid exploring deeper issues of personal redefinition and loss precipitated by the crisis. However, it does offer counsellors and therapists a holistic alternative to cultural prejudice.
As counsellors and therapists, we must ask and consider a number of questions, for example: Why did this woman (my client) become pregnant at that time?
Women report a range of motivations towards becoming pregnant – however unwanted the pregnancy – from the desire to demonstrate fertility to a need for commitment in the relationship. The unattainability of these goals may be known, at least subconsciously, in advance, possibly predisposing towards abortion.
Joanne Hayes, the young woman at the centre of the Kerry Babies saga, writes:
“I have been asked many times why we weren’t using contraception in view of our precarious situation. The truth is that we never considered it. I was deeply in love and to use contraception merely to have sex would have been placing a barrier where emotionally I felt none. My commitment was total and unlimited.” 5
In her Community Studies thesis, Dr. Mary Short reported that a number of couples studied who had come to the IFPA for advice on contraception none of them had used contraception for the first 18 months of their relationship. Yet, in a list of fifteen problematic moral issues, Dr. Margaret Fine Davis found the use of contraceptives to be the lowest in terms of perceived moral culpability, and commented: “One wonders why [it] engendered so much debate and controversy leading to legislation.” 7
Many unplanned pregnancies are blamed on contraception: method failure, user incompetence, lack of availability, moral opposition. Yet, in a study of Irish women seeking abortion in the U.K. Dr. Colin Francome listed no fewer than eight further reasons for non-use of contraception at pregnancy, of which the most statistically significant is “had intercourse unexpectedly: (39%) 8 However, the majority of clients presenting at pregnancy counselling services report that the crisis pregnancy has arisen within a committed relationship.9
Reasons given for these findings include the following: clients may feel that their essential femininity or masculinity is threatened by use of contraception or that preparedness for a sexual encounter, even with a committed partner, indicates a moral laxity; clients may feel that all heterosexual activity must be open to the procreative possibility, even where the intercourse is less than fully chosen or where a resulting pregnancy would be a “disaster”. (Counsellors also report that women who defined the presenting pregnancy as “unwanted” or a “crisis” did not intend to use contraception subsequent to whatever resolution was undertaken in the present situation.)
One theory advanced, particularly in the U.S. to explain the gulf between availability and use of contraception is the idea of “the decision not to contracept”, whereby women and men do not passively fail to use contraception in situations of pregnancy risk, but actively – not necessarily in an acknowledged manner – decide that the use of contraception is inappropriate.
Post-abortion counselling and therapy will need to address these issues.
What was her emotional landscape at the time of the pregnancy?
“No woman becomes pregnant in order to have an abortion, and abortion is always a difficult decision. The greatest psychological stress is before the abortion during the decision-making process.” 10
Relationships with parents, partner, family, friends all have an influence on the decision to terminate, as will a woman’s material circumstances at this time. No pregnancy is without a wider personal and social context and very often the crisis of unplanned pregnancy brings unresolved issues into relief.
Vanessa Davies observes that: “Those [women] who appear to suffer [post-abortion], from moderate to severe feelings, tend to be women who:
– have little support from family, friends and partners; – wanted the baby but were pressurised into having an abortion by others; – are already stressed, e.g. a recent bereavement; – have a psychiatric history; – show ambivalence during the decision phase; – do not involve their partner in the experience; – experience late abortion; – are young; – consciously or unconsciously use the pregnancy to resolve conflicts, e.g. bring their relationship back together; – are deserted by their partners as a result of their pregnancy”¹¹
Whatever a woman’s individual circumstances, a crisis pregnancy is very often a cause of a loss, or multiple losses – of relationships with partner/family/friends, of material stability, of the pregnancy itself. These losses may need to be recognised and acknowledged, and your client may want to mourn them.
As Vanessa Davies writes:
“Abortion can be both a symbolic and actual loss. For some of us, terminating our babies’ lives can indicate the loss of our own childhoods, the loss of trouble-free relationships, the loss of control over our bodies, the loss of our pre-motherhood state and so on, resulting in symbolic loss. Other women see abortion as an actual loss – the loss of a potential baby, a part of ourselves.” 12
For some women, the crisis presents the first opportunity for adult decision-making. This decision-making is likely to be undertaken in private, alone; possibly the first life event not shared with family.
Many women report an absolute unwillingness to tell their parents about the pregnancy (67% in a recent IFPA Client Profile report), thereby calling into question the nature of this primary relationship.13
By contrast, the majority of women appear to tell their partner (76%-78% in the same IFPA report). Men are inescapably present in pregnancy, even though one of the common factors in crisis pregnancy is the absence, withdrawal or retreat of an individual man. Some 17% of partners in the IFPA report were reported as being not supportive of the pregnant woman, or supportive only of a termination of pregnancy, irrespective of the woman’s attitudes and values.
“Termination of an unwanted pregnancy may reduce the stress engendered by the occurrence of the pregnancy and the associated events. At the same time, the abortion itself may be experienced as stressful. As with pregnancy, the circumstances surrounding abortion (e.g. the woman’s feelings about the morality of abortion, support for abortion by the partner and others who are close to the woman, and the actual experience she has in obtaining the abortion) are likely to influence later responses.” 14
Anger at being pregnant may well remain unresolved after the abortion and may be one of the compelling reasons for seeking post-abortion care, and these are among the many and diverse issues which need to be addressed in post-abortion care.
Learning to grieve these tangible and intangible losses arising through abortion is also an important aspect of working through abortion-related conflicts and may play a significant part in the prevention of additional unplanned pregnancies.
How did she make the decision to terminate?
“I have only ever heard one reason for having an abortion: the desire to be a good
mother. Women know when we don’t have the resources to be the mother we expect
to be. These resources could be lacking because of rape, incest, alcohol, youth,
poverty or an abusive relationship, but the despair is the same. Women have
abortions because they are aware of the over-whelming responsibility of motherhood.” 15
Post-abortion evaluation is, in my experience, absolutely centred on the decision-making process which led to the termination.
Women who felt pressured into abortion (by parents, partner or social circumstance) are most at risk of distress. Their experience of unplanned pregnancy (experienced as a loss of control) has been compounded by a number of further pressures, mostly outside of their control, leading to an event about which they may harbour unexamined and ambivalent attitudes and feelings.
Dr. Henry David noted in his recent address to the World Federation for Mental Health Congress that mental health problems are common among women forced to abort for medical reasons, or among those who lost their husbands and partners. He pointed out, however, that less than 2% of women who have abortions suffer from mental health problems and argued that claims of higher levels of psychiatric disturbance are ill-founded.16
In his literature review of sequelae of therapeutic abortion, Dr. Paul Dagg takes up this point:
“Abortion for medical or genetic indications, a history of psychiatric contact before the abortion, and mid-trimester abortions often result in more distress afterward. When women experience significant ambivalence about the decision or when the decision is not freely made, the results are also more likely to be negative. 17
The cultural context in which the decision to terminate is made is also a factor. Abortion remains a taboo subject in Ireland, and carries a strong social sanction. The majority religion – Roman Catholicism – regards abortion as a serious sin sometimes requiring confession to, and absolution by, a cleric of more senior rank than an ordinary confessor.
Furthermore, as one woman describing her abortion experience comments: “I think it is more difficult for women now to contemplate termination than when I had mine (1968) because of all the adverse so-called ‘pro-life’ pressure being exerted.”18 Irish society has been gripped, for over a decade, by hysterical “debate” on abortion; this “debate” has been conducted in the hearing of women with crisis pregnancies.
Irish women having abortions are acutely aware of offending against these religious and social norms, and post-abortion ambivalence is to be expected.
Profiling the post-abortion behaviour of IFPA Pregnancy Counselling clients, Catherine Conlon writes:
“A woman’s feelings of low self-esteem may contribute to her inability to continue the pregnancy. The subsequent perception she has of herself can become focused on the abortion, but may well have actually contributed to the decision she made in the first place, as opposed to being a consequence of her decision.“19
The task of the counsellor or therapist, then, is to reconcile, where possible, these elements so that your client may acknowledge and accept her experience as a life-event and as a learning process.
The Conlon study found that, of a total of 193 clients who chose abortion, only 15 (7.7%) presented for post-abortion counselling (as compared with 75 women who returned for the recommended medical check-up). An additional three women who had not previously been seen by the IFPA also attended for post-abortion counselling in the period under review.
The women who attended counselling:
“did so for a variety of reasons … either because they associated negative aspects of their lives with their recent experience of abortion, or because they felt it was the only safe place for them to discuss their feelings about the abortion. For a third of these women, however, their distress was not rooted in the abortion but in other aspects of their lives; rather, the abortion represented a manifestation of these aspects. Three women returned to the IFPA because there was nowhere else or nobody else to whom they could express their relief at having made the right decision in the face of a crisis pregnancy. The others came because the decision they made was not the right one for themselves. Rather, that decision was made in the interests of something other than their own well-being.”
Similarly, women who have had the opportunity of making genuine decisions, however painful, may present with a simple need to have their experience validated. This is the particular work of the IFPA Post Abortion Support Group, a peer group which meets weekly with facilitation by the IFPA senior pregnancy counsellor. The experience of this group suggests that for the majority of women who attend, abortion has been a generally positive outcome of the crisis. Discussion in the group tends to focus on the women’s individual stories, including the sharing of details of the trip to England and of the procedures at the nursing home. Women’s sense of isolation about their abortion decision is dispelled by this process of sharing. It is rare for any woman to attend more than a very few group meetings. Occasionally, however, the group offers an opportunity for an individual woman to decide that a more formal counselling approach would be appropriate in her situation.20
What are her attitudes and values about abortion?
This is a question which should ideally be explored in advance of abortion. Cultural standards in our society are very negative towards abortion and it is very likely that these views are shared by your client. She may not have internalised this negativity and your task will be to help her reconcile her experience with her values, and to take responsibility for her experience.
How will she incorporate this experience into her whole life?
“Belief in one’s ability to cope has been found to be causally linked to postabortion emotional responses. An experimental study of counselling interventions documented that enhancing self-efficacy for coping, combined with a regular counselling session, was effective at lowering women’s risk for depressive symptoms after abortion (Mueller & Major, 1989).” 21
This is your particular task as a counsellor or therapist. You will want to give your client the space to positively acknowledge the experience, to consider the conscious and unconscious elements which brought her to this place and to help her forgive herself, mourn or grieve (as necessary), to learn about her needs and expectations as revealed by this experience, and to face the future as a hopeful, whole person.
The experience of abortion is a cause of isolation and silence for Irish women, many of whom have no counselling support at the time of a crisis pregnancy. Counsellors and therapists, in common with Irish social norms, are likely to be ambivalent about, if not actively hostile to, abortion. Women who present for post-abortion counselling care have no need of our ambivalence or hostility. Rather, they are seeking a safe environment in which to integrate their socially taboo experience into the totality of a life worth living. Our only responsibility is to help.
Ruth Riddick has been involved in the provision of non-directive pregnancy counselling services since 1981 as Director of Open Door Counselling. She is currently Education Officer of the Irish Family Planning Association. She is author of the Right to Choose: Questions of Feminist Morality (Attic Press).
1. Vanessa Davies, Abortion & Afterwards, ISBN 1 85398 0168 p.119.
2. Paul K.B. Dagg, MD, ‘The Psychological Sequelae of Therapeutic Abortion’, American Journal of Psychiatry 148:5, May 1991, p.583.
3. Vanessa Davis, op cit, p.121.
4. Nancy E. Adler et al, ‘Psychological Factors in Abortion, A Review’, American Psychologist, October 1992, p.1197.
5. Joanne Hayes, My Story, Brandon 1985.
6. Dr. Mary Short, Community Studies thesis, Trinity College, Dublin.
7. Dr. Margaret Fine Davis, Third Report of the Second Joint Committee on Women’s Rights, July 1988.
8. Dr. Colin Francome, Some Characteristics of Irish Women Seek Abortion Abroad, Open Door Counselling, 1988
9. Data from Open Door Counselling and the Irish Family Planning Association.
10. Dr. Henry David, Director, Transnational Family Research Institute, in his paper Unwanted Pregnancy in Mental Health Perspective to the World Federation for Mental Health Congress, Dublin, 15 August 1995
11. Vanessa Davies, op cit, p.129.
12. Vanessa Davies, op cit, p.149.
13. Ruth Riddick, Profile Report The First 100 Clients, IFPA Pregnancy Counselling Service, April 1993.
14. Nancy E. Adler et al, op cit, p.1197.
15. Dr. Elizabeth Karlin, Director, Women’s Medical Centre, Madison, Wisconsin, USA writing in Woman’s Journal, September 1995, p.43.
16. Dr. Henry David, op cit, p.583.
17. Paul K.P. Dagg M.D., op cit, p.583.
18. Therese Cahert, Choosing to Tell, MPhil Thesis, Trinity College, Dublin.
19. Catherine Conlon, The Reality of Abortion for Irish Women, Irish Family Planning Association, 1994.
20. Personal Communications.
21. Nancy E. Adler et al, op cit, p.1201.