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Dilemmas in adoption: Case studies of the adoptive process illustrating the role of the caseworker
CURRENT
OPINION
Pertinent comments
Dilemmas in adoption: Case studies of the adoptive process illustrating
the
role of the caseworker DONALD NAOMI Berkeley,
THE
HUMAN
H.
MINKLER,
STRESHINSKY,
M.D. M.S.W.
California
respected medical bodies, many physicians feel that their concern for the emotional as well as physical health of the patient, and a long tradition of counseling in intimate and family relationships places the intermediary role in adoptions within the scope of legitimate medical practice. Indeed many physicians assert with confidence that they feel better equipped than adoption caseworkers in making the necessary judgments involved in placing children. The avowed reasons for the physician’s reluctance to refer patients to adoption agencies range from this confidence in himself doing a better job, through personal encounters with individual caseworkers or agencies which have created a poor image of agency practices and personnel, to a general wariness of “institutionalizing” a process which the physician feels is better kept individual and personal. Whatever the reasons, the doctor or attorney who chooses to dispense with the participation of the licensed adoption agency in the conduct of adoption casesmust be prepared to face the fact that in recent years
RELATIONSHIPS~~-
volved in the adoption of a child are of a profound and lasting importance, and the medical profession is privileged to play a significant role in this process. The doctor’s responsibility in adoption may include the investigation and treatment of infertility, the obstetrical management of the natural parent, the immediate appraisal and subsequent pediatric care of the adoptee, and the psychiatric attention which any or all of the parties to an adoption may require in this most delicate and emotionally charged experience. Various professional organizations (including the Legal Department of the American Medical Association, the American Academy of Pediatrics, the American Academy of General Practice, and the American College of Obstetricians and Gynecologists) have admonished physicians to confine their role in adoptions to medical care alone and avoid the “intermediary” function of finding an adoptive home, asserting that the licensed agency employing specialized caseworkers is the more appropriate medium for “placing” babies. Yet in spite of these admonitions by 411
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in California’s experience alone, independent adoption petitions have resulted in denial or dismissal of the petition in approximately 20 per cent of cases, whereas the overwhelming majority of petitions filed with the SUPport of licensed agencies are granted. The frustration, anxiety, and heartbreak of the natural parents and adoptive parents, and disadvantages to the adopted child which result from the breakdown of an adoption plan make the statistical comparison of independent and agency placements a real concern of the physician who is acting in the best interest of his patient. Attempts have been made to limit the intermediary role of physicians and others by restrictive legislation. For example, in 1953, the Attorney General of California interpreted the Welfare and Institutions Code as criminally forbidding all unlicensed adoption placements not made directly and personally by parents. For present purposes, the authors of this article are not concerned with the legal question of whether the physician’s activity is that of an intermediary or merely of an advisor. Whatever the legal role, many physicians do not readily consider referring their clients to an adoption agency whether consulted by prospective adoptive couples or natural parents regarding adoption. This is the focus of our concern. This article proposes to acquaint physicians with the proper role of the skilled caseworker and agency in adoptions. It is hoped that the illustrative case discussions will help the physician attain an awareness of the many variables which profoundly influence the important decisions about adoption, and the relevance of the social worker’s role in this complicated process. The case illustrations are taken from the records of a group of private and public adoption agencies in California and are intended as a description of the social worker’s services in some representative situations involving both natural and adoptive parents. In our discussions, a11 individuals’ names are fictitious.
February 1, 1967 Am. J. Obst. & Gynec.
The natural parents Separated woman. Pregnant by another manreconciliation, relinquishment, or both? Mrs. Larson came to the agency in her fourth month of pregnancy. She had been separated from her husband for the past year and their 5-year-old daughter had remained with her. She knew the father of her coming baby only slightly, and she realized their affair occurred because of her reaction to the breakup of her marriage. She understood that because her husband was presumed by law to be the father of the new child he must sign the relinquishment also. She described him as a bitter and revengeful person and she was terribly afraid that he might try to take their daughter from her if he knew of her pregnancy. She did not want to keep the baby and did not know any way out. In a series of interviews, Mrs. Hammond, the caseworker, led Mrs. Larson into a discussion of her specific fears about her husband, the events that led to their disagreements, and his irrational actions in the past. Mrs. Larson began to see that perhaps she had exaggerated her husband’s possible reaction to her pregnancy. Even in the heat of their quarrels, he never had any question about her care and devotion to her daughter, and he would probably not try to get custody from her. Then it became within the realm of a possibility to tell him about her pregnancy and secure his relinquishment. Gradually, Mrs. Larson began to see the way in which she had provoked her husband. Now she recalled the satisfying parts of her marriage, too, and even broached the subject of reconciliation. Shortly after, Mr. and Mrs. Larson did reconcile, but Mrs. Larson said she was not sure they would keep the baby. Could she have more time before deciding? Mrs. Hammond agreed but suggested a time limit of 2 months. Mrs. Larson felt this would not rush them and said it would be better for the baby’s sake to decide early. In contrast to an independent placement, in which the baby would go immediately to an adopted home, the agency could place her temporarily in a foster home to give the parents the time they needed. After reconciliation, Mrs. Larson said that earlier discussions at the agency about her part in the difficulties were helping her as they resumed their marriage. She soon said sadly that they felt it would make things harder between them if she kept the baby, and she decided to relinquish her. The baby went to her permanent
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home after both parents signed the relinquishment. Married couple. Reverse decision-in what circumstances? Mr. and Mrs. Jennings phoned the agency about a month before their first child was due. Mrs. Jennings had worked until the month before and the success of her husband’s newly established accounting firm depended on the financial underpinning of her continued salary after the baby was born. They just could not see it any other way. He had worked too hard to get his education for his plans to be set awry now with the responsibility of a baby. They felt they had sensitiviry to a baby’s needs and did not want a babysitter while Mrs. Jennings worked. Besides, this would be too expensive. They would not see the baby and planned to tell friends and relatives that there had been a stillbirth. Mrs. Ainsley’s attempts to touch on their feelings about this step were met with carefully worded explanations that they had mulled this over well together. They just wanted to be assured that the agency would take their relinquishmpnt and place the baby. Mrs. Ainsley agreed to this. She acknowledged their certainty about their decision and suggested only that thry think about the implications for the future as well as for the present. Following dclivery, the baby entered a temporary foster home. Therf was a different quality to the later inttarview, in which the relinquishment was to be signed. Mrs. Jennings now had some more detailed questions to ask about the adoption program. When Mrs. Ainsley commented that now Mrs. Jennings was speaking more specifically about the care her baby daughter would receive in an adoptive home, Mrs. Jennings looked surprised and shaken. Turning nervously to hrr husband who sensed this emotional turn, she fought back tears and said she just did not know now about giving up Ihe baby. She was afraid to tell him, did not want to spoil his plans, but now that they were aboul- to actually sign the relinquishment, she just could not do it. She remembered the remark Mrs. Ainsley had made the last time about the future and this had made her think again, Mr. Jennings was visibly upset and indicated that he, too, had some doubts, and said maybe they needed to talk this over again. Would the agency be willing to wait until they decided? Mrs. Ainsley assured them they could take the time they needed, When they met again, it was for the purpose
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of receiving the baby back from the agency’s temporary foster home. Mr. Jennings said they had so many good, practical reasons for giving the baby up, that they would not let themselves think of anything else. Now they realized they might always have regretted it. They have not forgotten how important his business is to both of them, but during the last few days, they have found some practical solutions to the dilemma of how to have both baby and business. The unmarried woman. Personal problems first; sound decision later. When Miss Costello first contacted the agency, she was 21, 5 months pregnant, unmarried and had just arrived from her out-of-town home. At home, she was a receptionist in a large industrial office and had had 2 years of junior college. She was certain adoption was the only recourse for her. Then, with hesitation, she wondered if she had to make a definite commitment about adoption now. The caseworker, Miss Berman, assured her that she did not and explained that the services of the agency include discussions to assist in this decision. Did she want this? She guessed so. She knew that she could not make a home for the baby, yet she was in a knot about the problem. In a few monrhs, living expenses and rhe cost of private medical care had almost depleted Miss Costello’s savings, and she received money for living costs from the agency. In a discussion of her indecision about adoption, Miss Costello continued to place responsibility for the decision on the baby’s father and his recent vacillation about divorcing his estranged wife and marrying her. By this time, Miss Berman had a better understanding of Miss Costello’s characteristically suhmissive way of relating to people and they also had had several conversations about thr frustrating relationship she had had with this man. Miss Berman acknowledged it was a very di%cult thing to begin to think differently ahnut surh an important relationship, but did she really want marriage to this unreliable man. Miss Costello said that perhaps he never really considered marriage to her at all, and that maybe she was trying to let him make the decision for her about the baby. As if in another effort to deny her own part in the decision, she wished that she could think she was relinquishing the baby in return for the money the agency gave to her. Then, it would not be her choice or responsibility. She finally wondered if she really wanted to place the decision anywhere
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but in herself. It had always been hard for her to make decisions. Finally, just after the baby’s birth, and after more discussion of her problem about decisions, Miss Costello said she had decided to relinquish for her own reasons. She said that of course she wanted the baby, but she knew she could not have him under the present circumstances. She did not want to marry the baby’s father and wanted her baby to have a complete home. She added, “And this is my own decision.” She signed the relinquishment the next day, and the baby, now legally free, went to his adoptive home directly from the hospital. As in this case, direct placement from the hospital is becoming more and more common in agency practice. Predictive tests relating to child development, used formerly by agencies, were found to be essentially invalid, so that babies are no longer kept in foster homes for this purpose. Although independent placements have been ahead of agency practice in this regard, it is also a fact that independent placements are made before the child is legally free and not until some time after placement do the adoptive parents have the assurance that the baby is legally free. The teen-agerand the silver cord. When Mrs. Hanford and her 17-year-old daughter, Barbara, first came to the agency they were told together of the agency’s services to both of them, that Barbara’s discussions would be confidential and the decision about adoption would be hers alone to make. Mrs. Hanford used her individual interviews to sound off on the strain of the experience for her and spoke gradually of her own feelings of guilt and inadequacy in relation to Barbara. She not only saw that all of the girls and boys in Barbara’s group were given too much freedom and encouragement at steady dating but that there had been long-standing problems in their own family that they had been avoiding. Barbara looked very much like everyone’s idea of a popular and vivacious high school girl. Her pregnancy seemed incongruously sad. Barbara spoke almost exclusively about her struggle with her mother. She felt that the pregnancy itself was due to her mother’s not setting limits for her. Almost in the same breath, she recalled many arguments when she fought against the restrictions her mother did set. Mrs. Mirras, the caseworker, believed that unless Barbara attked Some understanding of her strained rejationship with her mother, she was going to make a de-
February 1, 1967 Am. J. Obst. & Gynec.
cision about the baby just to make some gain in this struggle. In all of the discussions, Mrs. Mirras urged Barbara to see and understand her reactions a little more clearly so that she could make this very important decision as free of the entanglement as possible. Very soberly on one occasion Barbara said she had tried not to think about the baby as a real person, because then it would seem so unnatural to give it away. Mrs. Mirras said it was neither terrible nor dangerous to say she had strong feelings one way or another. It is just not possible to feel really good about whatever she decides, but a mother can feel love for her baby and talk about it, and still decide on relinquishment. By the time Barbara’s baby was born, she had definitely decided to relinquish. Both she and Mrs. Mirras felt this was more on the basis of what she wanted for herself rather than out of the fight with her mother. She saw the baby both at the hospital and at the agency office because, she said, “I want to know what I’m giving up.” Barbara said she felt more grown up as she signed the relinquishment, and seeing the baby had convinced her more than ever that she could not meet his needs. The fight with her mother was not all over, but at least her mother could see she could act like an adult in such an important decision. Then, a little more hesitantly, she guessed, “It’s not all my mother’s fault anyway.” In each of the situations described above, the trained caseworker provided a private, confidential service, focused on the social and psychological implications of plans for the coming baby. It is usual that the natural parents see the same caseworker throughout their contact with the agency. Because the agency can arrange temporary foster homes as needed and can assure the parents that the agency will have continuing responsibility for the child, an atmosphere exists for a calm, unpressured decision. The adoptive parents Before proceeding with illustrations of adoptive couples served by agencies, some general comments about the agency approach to adoptive applicants may serve to dispel misconceptions. First, there has been
much said about “red tape” and “investiga-
tion.” As a generalrule, currently,thehome
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couple, some jointly and some individually. The usual period of time from the original call to the agency to the date of placement is 6 months. The postplacement activity generally comprises 4 interviews at home over a period of 6 months to a year and many adoptions are finalized in 6 months. The procedure is individualized by the fact that the study worker ordinarily continues with the family through the placement and until the adoption is completed. What are the considerations made by both the couple and the agency worker during the study? Some couples have already had their own children when they apply, but the vast majority are childless. Most people who find they cannot achieve normal pregnancy react in some important emotional way. The range of reaction may be very wide indeed. For some people, this may be a shock to the foundations of their personalities, to their feelings about th.emselves as complete men and women. For others, it may mean just sincere disappointment. For most, time is needed for an adjustment to childlessness. Agencies are concerned with the way couples make peace with their childlessness, became if a couple still feels frustrated and angry about their infertility, they may feel that adoptive parenthood is a poor substitute for normal parenthood. This will place a great strain on them because they cannot act naturally, and the child’s reaction may very probably be that there is something very wrong with his situation and with him. Certainly the child’s emotional security and personal identity depend on his awareness that the facts of his birth and nurturing are nothing of which to be ashamed. The agencies believe that it is a disservice to be a party to an adoptive plan which will make a couple feel uneasy and may jeoparidze the child’s security. Often adoption can be helpfully delayed until a couple comes to accept their infertility with a reasonable degree of equanimity. Of course the adoption worker considers other factors too. She needs to be assured that the couple is reasonably mature, sensitive to children’s needs, flexible enough to
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meet new situations with a fairly good degree of adaptability. She will want to know that the marriage is a stable one, for this is the matrix in which the child will grow and a baby cannot be given the impossible assignment of “shoring up” a poor marriage. She needs to know that they can afford to care for a child, not that they have a great deal of money, but that they can manage what money they have in a fairly reasonable way. Social workers are not looking for perfect parents, any more than most adopting parents expect a perfect child. An adopting couple. Factors in their indecision-acceptance of infertility and of the natural parents. Though Mr. and Mrs. Patrick came to the agency for the purpose of applying for a child, they seemed to have many doubts about the whole matter of adoption. Among the many questions they raised was Mrs. Patrick’s request for assurance about the predictability of a baby’s intelligence. Told that adoptive applicants do assume some risks, though reasonable ones, Mrs. Patrick said she was not sure she was ready to take the risks. When the discussion turned to their attempts to have their own children, Mr. Patrick showed by his mannerisms that this was a difficult subject for him. Mrs. Patrick had completed her fertility study and knew it was unlikely she could conceive. He had not completed his study and felt there was no point to it. Mr. Patrick quickly added that they still have a lot of questions about adoption and needed to give it more thought. They would let the agency know if they wanted to go on and Miss Beringer, the caseworker, clearly left the door open for them. It was several months before the Patricks phoned the agency again. In his individual interview, Mr. Patrick said he had completed his fertility tests and learned that he also was infertile. He had been angry about the “loaded” questions in his first interview at the agency. Now he realized that he did not want to admit the possibility of his infertility even to himself, let alone talk about it with anyone. It was hard to admit, but maybe he wanted to think that it was only his wife’s responsibility. Knowing the truth, however, had made a change in their relationship. Outwardly he always felt he was understanding of her, but he may really have felt resentful that she could not become preg-
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nant. Now that he knew he was equally responsible, they have more compassion for one another. In a way, it made it easier for both of them to accept their condition. Both Mr. and Mrs. Patrick had some difficulty in their feelings about a child’s natural parents. Mrs. Patrick wondered if she would feel as if she were taking a child away from his mother. Miss Beringer assured her that this was a common feeling in adoptive mothers. She mentioned again the care with which the agency assisted each natural parent to decide about the baby. Mr. Patrick was finding it very hard to see how a mother could possibly give a child away. Later, he told of reading about juvenile delinquency and realized that many of these childrcn came from broken homes. It began to occur to him, then, that an unmarried mother, out of love for her child, might have chosen wisely in seeking a complete home for him. With Mr. Patrick’s greater acceptance of his infertility and both Mr. and Mrs. Patrick’s increased awareness of their attitudes toward natural parents, an awareness that would allow them later to help their adopted child with his questions about his natural background, both the couple and the agency felt more ready to proceed with the adoption. Couple returns child. They decide they will not adopt at all. Mrs. Ellender was very upset when she phoned the agency 3 days after an adoptive placement had been made. She wished to return the baby, because she thought the baby’s head misshapen. The caseworker knew from the physician that the baby’s head was not abnormal, but she recalled also that Mrs. Ellender had been unusually particular all along about the kind of baby she wanted. Mrs. Ellender seemed to show by her preferences that she was trying to think of the baby as biologically her own. Of course it is the normal wish of both couple and agency to match a child and his adopting parents as well as can be done so that he will have a real identity with the adopted family, but Mrs. Ellender’s request was so specific that it went beyond this. After Mrs. Ellender’s return of the baby, she came in for an interview. The worker’s task, enhanced by Mrs. Ellender’s basic sensitivity and intelligence, was to help her see that adoption may not be the answer for her. It had been a hard lesson for her, Mrs. Ellender said, but she realized that she could not bear the emotion
February 1, 1967 Am. J. Obst. & Gynec.
of raising another person’s child. She was assured the baby would be placed in another home and the natural mother need not be contacted. (In an independent plan the mother would, of course, have to be involved again.) The worker also pointed to the number of other accomplishments and satisfactions Mrs. Ellender had in her life that she hoped would, in time, soften this experience. With this understanding of her feelings, Mrs. Ellender would probably not subject herself to another such upsetting experience in the mistaken belief that the trouble was the shape of the baby’s head. Adopting mother’s pretense at pregnancy. Mrs. Ahearn did not know at first what to make of the facts which Mr. Hunt told her about his wife. She had already seen them jointly and talked with Mrs. Hunt privately the previous week. From all she knew about them, she thought they would enjoy being adoptive parents and could give a great deal to a child. Now Mr. Hunt said in a very hesitant way that Mrs. Ahearn should know his concern about his wife. Since her surgery last year when she had had a hysterectomy, they had talked of adoption and he felt she wanted this as did he. He thought she still wanted it, but then she began talking of pretending that this would be her own baby. She had told him she would stay in bed for several months, tehing friends and family that she was pregnant and that the doctor recommended bed rest. She had never been able to tell anyone the facts of her surgery. He knew she would be a good mother to a child, but he worried so about this plan. He felt they could not live this kind of lie. Mrs. Ahearn felt this behavior was different from all else about Mrs. Hunt, which had indicated a considerable degree of emotional maturity. She used consultation with the agency psychiatrist to confirm her thinking that this was an isolated reaction and not an all-pervasive personality disturbance. Mrs. Ahearn encouraged Mr. Hunt to tell his wife about his discussion, and after he did Mrs. Hunt seemed almost relieved to have it out. Then, in the ensuing interviews, her plans at pretension were understood as a reflection of her deep reaction to the hysterectomy and Mrs. Hunt decided to use psychiatric therapy to help in this adjustment. Mrs. Aheam assured them of the agency’s confidence in them as adopting parents at a later time, A year later, they were ready to adopt and the agency was ready to place a child with them.
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The facts of adopted life. Telling the child; a second adoption. The Linell’s came to the agency for their second child after having adopted a first one independently. Mrs. Irving, the worker, was impressed with their sensitivity to each other and to their son, Eric, who was then 7. However, they had never told Eric he was adopted, feeling that they would wait until he was a little older. For Mrs. Line& especially, this was a difficult subject to touch. She did understand fairly readily, however, Mrs. Irving’s concern that the placement of a ::econd child was going to provoke questions from Eric about his origins. This could lead to a lot of uneasiness in the family unless it was anricipated beforehand. Initially, Mrs. Line11 had had a terrible time accepting her infertility. She spoke of it as a “shock,” felt guilty about her condition, and was gravely upset that she could not have a child she and her husband wanted so much. When her husband spoke of: adoption, though she did not feel ready for this herself, she felt it was not fair to him to delay their family any longer. She told the lawyer she did not want to know anything about the natural mother, and her husband talked with the lawyer by himself about the baby’s background. Mrs. Line11 now realized that she had wanted to act as if Eric were the son she had really wanted to have herself. When Eric was about 4, and began to ask questions abour his birth, Mrs. Line11 found herself making general statements to him and, by default, leaving Eric with the impression that he was their own child. She was aware that the problem was not in saying that they chose him but in having to explain that he was born to another woman. He might want to know too much about his natural parents and it would be very hard to explain to him why his mother gave him up. ,She knew another family whose adopted girl was an adolescent and they lived in daily fear that she would learn of the facts of her adoption which they had kept from her. Hard as it was for her to face, she realized it needed to be done for Eric’s sake as well as for the new baby. She also said it was uncomfortable for her to face the fact that Eric was illegitimate. Mrs. Irving pointed out that this was a social problem for the parents and in no way affected Eric’s heredity, or character, and personality formed in his life with the Linell’s. After discussions of these and other feelings related to the problem, Mrs. Line11 made a beginning ef-
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fort to tell Eric about his adoption and then found it to be much easier than she had anticipated. Just before Eric’s adopted sister joined the family, Mrs. Line11 described a poignant incident when Eric told her he thought for a long time that Mrs. Line11 was not telling him something important and was worried that it might be “something really had.“ Comment The foregoing case examples illustrate the multiplicity of factors surrounding adoption decisions. They are presented in order to demonstrate, through a representative sampling of case situations, how the time, effort, and skill of the caseworker can be utilized to give those elements of attention to the parties to an adoption which the physician would have difficulty providing. In summary, two basic factors relevant to all the situations described should be stressed. In each instance the agency provided the program and the facilities in which decisions and plans could be made without pressure. The caseworkers offered the special service to foster full consideration of these plans. The natural parents were under no commitment to the agency to make a final choice either for or against relinquishment. The agency, on the other hand, made a commitment to them to accept the relinquishment if they decided on adoption, and to assume continuing responsibility for the child, if adoptable, including an interim plan of foster care if needed and another placement plan if the child were returned from the adoptive home. The adopting parents were offered services under similar conditions of choice, not only about the adoption itself but also in the selection of a child. True, the totality of these services require administrative personnel, supervisors, and various consultants such as pediatricians, obstetricians, psychiatrists, and geneticists in addition to the casework staff. We believe it is essential to have whatever professional consultation is needed in such momentous considerations as are involved in relinquishment and adoption, but we recognize that such procedures can give an institutional relevant to a referring image. However,
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physician’s concern for his patient’s privacy is the fact that these administrative procedures do not intrude upon the personalized, individual service which is provided. Natural parents and adopting couples in most instances see one caseworker privately throughout their contact with the agency. It is clearly understood that the agency resources depicted in these case reports may not exist in every community, and that in some instances the physician must of necessity “go it alone” in helping his patients to recognize all of the subtleties involved in adoption decisions. Nevertheless, the vast majority of adoptions occur today in urban settings. Here metropolitan physicians have ready access to the specialized services of adoption agencies if they would but think to regard them much as they would other specialized medical and social service resources, for consultation and referral. It is to these physicians that this article is addressed. It is further clearly understood by the authors that the quality and training of adoption casework personnel may vary from community to community and agency to agency. Indeed, there are good and bad social workers just as there are good and bad physicians. We deplore, however, the blanket indictment of all caseworkers by the physician who has had a disagreeable encounter with one, and submit that the image of the adoption caseworker is too often an inaccurate one. It has been suggested elsewhere that many physicians’ freely acknowledged “anger” with caseworkers (often expressed with considerable intensity of feeling) reflects the doctor’s own unconscious emotional investment in the adoption
February 1, 1967 Am. J. Obst. & Gynec.
situation in which the worker is perceived as a rival. Undoubtedly, related unconscious phenomena in the social worker account for similar hostile feelings expressed toward physicians. In those instances where the conduct of a caseworker or the practices of an agency seem genuinely open to criticism, the physician would benefit both his patients and the agency by seeking to correct that of which he disapproves rather than by despairing of cooperation with agencies in the future. This, of course, also applies to caseworkers who find certain physicians rigid, uninformed, or uncooperative. To this end the adoption committees of local medical societies, and the multidisciplined adoption committees in which physicians actively participate, serve a very useful purpose in assisting the physicians and social workers to understand the other’s language and customs, to recognize the other’s skills and limitations, and to work harmoniously in the best interests of the patient. It has been our experience that such committees can do a great deal to clear away the misunderstanding which often impedes the desired multidisciplined approach to adoptions which is endorsed by all of the professions concerned. Quite contrary to the stereotype envisaged by too many physicians, the field of adoption casework is a dynamic, scientific discipline, as well as an “art,” in which serious research and controlled experiments are under way to refine and perfect the adoption process. The seriousness of this exercise in delicate human relationships warrants all of the cooperation and support that the medical profession can offer.
OPINION
Pertinent comments
Dilemmas in adoption: Case studies of the adoptive process illustrating
the
role of the caseworker DONALD NAOMI Berkeley,
THE
HUMAN
H.
MINKLER,
STRESHINSKY,
M.D. M.S.W.
California
respected medical bodies, many physicians feel that their concern for the emotional as well as physical health of the patient, and a long tradition of counseling in intimate and family relationships places the intermediary role in adoptions within the scope of legitimate medical practice. Indeed many physicians assert with confidence that they feel better equipped than adoption caseworkers in making the necessary judgments involved in placing children. The avowed reasons for the physician’s reluctance to refer patients to adoption agencies range from this confidence in himself doing a better job, through personal encounters with individual caseworkers or agencies which have created a poor image of agency practices and personnel, to a general wariness of “institutionalizing” a process which the physician feels is better kept individual and personal. Whatever the reasons, the doctor or attorney who chooses to dispense with the participation of the licensed adoption agency in the conduct of adoption casesmust be prepared to face the fact that in recent years
RELATIONSHIPS~~-
volved in the adoption of a child are of a profound and lasting importance, and the medical profession is privileged to play a significant role in this process. The doctor’s responsibility in adoption may include the investigation and treatment of infertility, the obstetrical management of the natural parent, the immediate appraisal and subsequent pediatric care of the adoptee, and the psychiatric attention which any or all of the parties to an adoption may require in this most delicate and emotionally charged experience. Various professional organizations (including the Legal Department of the American Medical Association, the American Academy of Pediatrics, the American Academy of General Practice, and the American College of Obstetricians and Gynecologists) have admonished physicians to confine their role in adoptions to medical care alone and avoid the “intermediary” function of finding an adoptive home, asserting that the licensed agency employing specialized caseworkers is the more appropriate medium for “placing” babies. Yet in spite of these admonitions by 411
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in California’s experience alone, independent adoption petitions have resulted in denial or dismissal of the petition in approximately 20 per cent of cases, whereas the overwhelming majority of petitions filed with the SUPport of licensed agencies are granted. The frustration, anxiety, and heartbreak of the natural parents and adoptive parents, and disadvantages to the adopted child which result from the breakdown of an adoption plan make the statistical comparison of independent and agency placements a real concern of the physician who is acting in the best interest of his patient. Attempts have been made to limit the intermediary role of physicians and others by restrictive legislation. For example, in 1953, the Attorney General of California interpreted the Welfare and Institutions Code as criminally forbidding all unlicensed adoption placements not made directly and personally by parents. For present purposes, the authors of this article are not concerned with the legal question of whether the physician’s activity is that of an intermediary or merely of an advisor. Whatever the legal role, many physicians do not readily consider referring their clients to an adoption agency whether consulted by prospective adoptive couples or natural parents regarding adoption. This is the focus of our concern. This article proposes to acquaint physicians with the proper role of the skilled caseworker and agency in adoptions. It is hoped that the illustrative case discussions will help the physician attain an awareness of the many variables which profoundly influence the important decisions about adoption, and the relevance of the social worker’s role in this complicated process. The case illustrations are taken from the records of a group of private and public adoption agencies in California and are intended as a description of the social worker’s services in some representative situations involving both natural and adoptive parents. In our discussions, a11 individuals’ names are fictitious.
February 1, 1967 Am. J. Obst. & Gynec.
The natural parents Separated woman. Pregnant by another manreconciliation, relinquishment, or both? Mrs. Larson came to the agency in her fourth month of pregnancy. She had been separated from her husband for the past year and their 5-year-old daughter had remained with her. She knew the father of her coming baby only slightly, and she realized their affair occurred because of her reaction to the breakup of her marriage. She understood that because her husband was presumed by law to be the father of the new child he must sign the relinquishment also. She described him as a bitter and revengeful person and she was terribly afraid that he might try to take their daughter from her if he knew of her pregnancy. She did not want to keep the baby and did not know any way out. In a series of interviews, Mrs. Hammond, the caseworker, led Mrs. Larson into a discussion of her specific fears about her husband, the events that led to their disagreements, and his irrational actions in the past. Mrs. Larson began to see that perhaps she had exaggerated her husband’s possible reaction to her pregnancy. Even in the heat of their quarrels, he never had any question about her care and devotion to her daughter, and he would probably not try to get custody from her. Then it became within the realm of a possibility to tell him about her pregnancy and secure his relinquishment. Gradually, Mrs. Larson began to see the way in which she had provoked her husband. Now she recalled the satisfying parts of her marriage, too, and even broached the subject of reconciliation. Shortly after, Mr. and Mrs. Larson did reconcile, but Mrs. Larson said she was not sure they would keep the baby. Could she have more time before deciding? Mrs. Hammond agreed but suggested a time limit of 2 months. Mrs. Larson felt this would not rush them and said it would be better for the baby’s sake to decide early. In contrast to an independent placement, in which the baby would go immediately to an adopted home, the agency could place her temporarily in a foster home to give the parents the time they needed. After reconciliation, Mrs. Larson said that earlier discussions at the agency about her part in the difficulties were helping her as they resumed their marriage. She soon said sadly that they felt it would make things harder between them if she kept the baby, and she decided to relinquish her. The baby went to her permanent
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home after both parents signed the relinquishment. Married couple. Reverse decision-in what circumstances? Mr. and Mrs. Jennings phoned the agency about a month before their first child was due. Mrs. Jennings had worked until the month before and the success of her husband’s newly established accounting firm depended on the financial underpinning of her continued salary after the baby was born. They just could not see it any other way. He had worked too hard to get his education for his plans to be set awry now with the responsibility of a baby. They felt they had sensitiviry to a baby’s needs and did not want a babysitter while Mrs. Jennings worked. Besides, this would be too expensive. They would not see the baby and planned to tell friends and relatives that there had been a stillbirth. Mrs. Ainsley’s attempts to touch on their feelings about this step were met with carefully worded explanations that they had mulled this over well together. They just wanted to be assured that the agency would take their relinquishmpnt and place the baby. Mrs. Ainsley agreed to this. She acknowledged their certainty about their decision and suggested only that thry think about the implications for the future as well as for the present. Following dclivery, the baby entered a temporary foster home. Therf was a different quality to the later inttarview, in which the relinquishment was to be signed. Mrs. Jennings now had some more detailed questions to ask about the adoption program. When Mrs. Ainsley commented that now Mrs. Jennings was speaking more specifically about the care her baby daughter would receive in an adoptive home, Mrs. Jennings looked surprised and shaken. Turning nervously to hrr husband who sensed this emotional turn, she fought back tears and said she just did not know now about giving up Ihe baby. She was afraid to tell him, did not want to spoil his plans, but now that they were aboul- to actually sign the relinquishment, she just could not do it. She remembered the remark Mrs. Ainsley had made the last time about the future and this had made her think again, Mr. Jennings was visibly upset and indicated that he, too, had some doubts, and said maybe they needed to talk this over again. Would the agency be willing to wait until they decided? Mrs. Ainsley assured them they could take the time they needed, When they met again, it was for the purpose
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of receiving the baby back from the agency’s temporary foster home. Mr. Jennings said they had so many good, practical reasons for giving the baby up, that they would not let themselves think of anything else. Now they realized they might always have regretted it. They have not forgotten how important his business is to both of them, but during the last few days, they have found some practical solutions to the dilemma of how to have both baby and business. The unmarried woman. Personal problems first; sound decision later. When Miss Costello first contacted the agency, she was 21, 5 months pregnant, unmarried and had just arrived from her out-of-town home. At home, she was a receptionist in a large industrial office and had had 2 years of junior college. She was certain adoption was the only recourse for her. Then, with hesitation, she wondered if she had to make a definite commitment about adoption now. The caseworker, Miss Berman, assured her that she did not and explained that the services of the agency include discussions to assist in this decision. Did she want this? She guessed so. She knew that she could not make a home for the baby, yet she was in a knot about the problem. In a few monrhs, living expenses and rhe cost of private medical care had almost depleted Miss Costello’s savings, and she received money for living costs from the agency. In a discussion of her indecision about adoption, Miss Costello continued to place responsibility for the decision on the baby’s father and his recent vacillation about divorcing his estranged wife and marrying her. By this time, Miss Berman had a better understanding of Miss Costello’s characteristically suhmissive way of relating to people and they also had had several conversations about thr frustrating relationship she had had with this man. Miss Berman acknowledged it was a very di%cult thing to begin to think differently ahnut surh an important relationship, but did she really want marriage to this unreliable man. Miss Costello said that perhaps he never really considered marriage to her at all, and that maybe she was trying to let him make the decision for her about the baby. As if in another effort to deny her own part in the decision, she wished that she could think she was relinquishing the baby in return for the money the agency gave to her. Then, it would not be her choice or responsibility. She finally wondered if she really wanted to place the decision anywhere
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but in herself. It had always been hard for her to make decisions. Finally, just after the baby’s birth, and after more discussion of her problem about decisions, Miss Costello said she had decided to relinquish for her own reasons. She said that of course she wanted the baby, but she knew she could not have him under the present circumstances. She did not want to marry the baby’s father and wanted her baby to have a complete home. She added, “And this is my own decision.” She signed the relinquishment the next day, and the baby, now legally free, went to his adoptive home directly from the hospital. As in this case, direct placement from the hospital is becoming more and more common in agency practice. Predictive tests relating to child development, used formerly by agencies, were found to be essentially invalid, so that babies are no longer kept in foster homes for this purpose. Although independent placements have been ahead of agency practice in this regard, it is also a fact that independent placements are made before the child is legally free and not until some time after placement do the adoptive parents have the assurance that the baby is legally free. The teen-agerand the silver cord. When Mrs. Hanford and her 17-year-old daughter, Barbara, first came to the agency they were told together of the agency’s services to both of them, that Barbara’s discussions would be confidential and the decision about adoption would be hers alone to make. Mrs. Hanford used her individual interviews to sound off on the strain of the experience for her and spoke gradually of her own feelings of guilt and inadequacy in relation to Barbara. She not only saw that all of the girls and boys in Barbara’s group were given too much freedom and encouragement at steady dating but that there had been long-standing problems in their own family that they had been avoiding. Barbara looked very much like everyone’s idea of a popular and vivacious high school girl. Her pregnancy seemed incongruously sad. Barbara spoke almost exclusively about her struggle with her mother. She felt that the pregnancy itself was due to her mother’s not setting limits for her. Almost in the same breath, she recalled many arguments when she fought against the restrictions her mother did set. Mrs. Mirras, the caseworker, believed that unless Barbara attked Some understanding of her strained rejationship with her mother, she was going to make a de-
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cision about the baby just to make some gain in this struggle. In all of the discussions, Mrs. Mirras urged Barbara to see and understand her reactions a little more clearly so that she could make this very important decision as free of the entanglement as possible. Very soberly on one occasion Barbara said she had tried not to think about the baby as a real person, because then it would seem so unnatural to give it away. Mrs. Mirras said it was neither terrible nor dangerous to say she had strong feelings one way or another. It is just not possible to feel really good about whatever she decides, but a mother can feel love for her baby and talk about it, and still decide on relinquishment. By the time Barbara’s baby was born, she had definitely decided to relinquish. Both she and Mrs. Mirras felt this was more on the basis of what she wanted for herself rather than out of the fight with her mother. She saw the baby both at the hospital and at the agency office because, she said, “I want to know what I’m giving up.” Barbara said she felt more grown up as she signed the relinquishment, and seeing the baby had convinced her more than ever that she could not meet his needs. The fight with her mother was not all over, but at least her mother could see she could act like an adult in such an important decision. Then, a little more hesitantly, she guessed, “It’s not all my mother’s fault anyway.” In each of the situations described above, the trained caseworker provided a private, confidential service, focused on the social and psychological implications of plans for the coming baby. It is usual that the natural parents see the same caseworker throughout their contact with the agency. Because the agency can arrange temporary foster homes as needed and can assure the parents that the agency will have continuing responsibility for the child, an atmosphere exists for a calm, unpressured decision. The adoptive parents Before proceeding with illustrations of adoptive couples served by agencies, some general comments about the agency approach to adoptive applicants may serve to dispel misconceptions. First, there has been
much said about “red tape” and “investiga-
tion.” As a generalrule, currently,thehome
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couple, some jointly and some individually. The usual period of time from the original call to the agency to the date of placement is 6 months. The postplacement activity generally comprises 4 interviews at home over a period of 6 months to a year and many adoptions are finalized in 6 months. The procedure is individualized by the fact that the study worker ordinarily continues with the family through the placement and until the adoption is completed. What are the considerations made by both the couple and the agency worker during the study? Some couples have already had their own children when they apply, but the vast majority are childless. Most people who find they cannot achieve normal pregnancy react in some important emotional way. The range of reaction may be very wide indeed. For some people, this may be a shock to the foundations of their personalities, to their feelings about th.emselves as complete men and women. For others, it may mean just sincere disappointment. For most, time is needed for an adjustment to childlessness. Agencies are concerned with the way couples make peace with their childlessness, became if a couple still feels frustrated and angry about their infertility, they may feel that adoptive parenthood is a poor substitute for normal parenthood. This will place a great strain on them because they cannot act naturally, and the child’s reaction may very probably be that there is something very wrong with his situation and with him. Certainly the child’s emotional security and personal identity depend on his awareness that the facts of his birth and nurturing are nothing of which to be ashamed. The agencies believe that it is a disservice to be a party to an adoptive plan which will make a couple feel uneasy and may jeoparidze the child’s security. Often adoption can be helpfully delayed until a couple comes to accept their infertility with a reasonable degree of equanimity. Of course the adoption worker considers other factors too. She needs to be assured that the couple is reasonably mature, sensitive to children’s needs, flexible enough to
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meet new situations with a fairly good degree of adaptability. She will want to know that the marriage is a stable one, for this is the matrix in which the child will grow and a baby cannot be given the impossible assignment of “shoring up” a poor marriage. She needs to know that they can afford to care for a child, not that they have a great deal of money, but that they can manage what money they have in a fairly reasonable way. Social workers are not looking for perfect parents, any more than most adopting parents expect a perfect child. An adopting couple. Factors in their indecision-acceptance of infertility and of the natural parents. Though Mr. and Mrs. Patrick came to the agency for the purpose of applying for a child, they seemed to have many doubts about the whole matter of adoption. Among the many questions they raised was Mrs. Patrick’s request for assurance about the predictability of a baby’s intelligence. Told that adoptive applicants do assume some risks, though reasonable ones, Mrs. Patrick said she was not sure she was ready to take the risks. When the discussion turned to their attempts to have their own children, Mr. Patrick showed by his mannerisms that this was a difficult subject for him. Mrs. Patrick had completed her fertility study and knew it was unlikely she could conceive. He had not completed his study and felt there was no point to it. Mr. Patrick quickly added that they still have a lot of questions about adoption and needed to give it more thought. They would let the agency know if they wanted to go on and Miss Beringer, the caseworker, clearly left the door open for them. It was several months before the Patricks phoned the agency again. In his individual interview, Mr. Patrick said he had completed his fertility tests and learned that he also was infertile. He had been angry about the “loaded” questions in his first interview at the agency. Now he realized that he did not want to admit the possibility of his infertility even to himself, let alone talk about it with anyone. It was hard to admit, but maybe he wanted to think that it was only his wife’s responsibility. Knowing the truth, however, had made a change in their relationship. Outwardly he always felt he was understanding of her, but he may really have felt resentful that she could not become preg-
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nant. Now that he knew he was equally responsible, they have more compassion for one another. In a way, it made it easier for both of them to accept their condition. Both Mr. and Mrs. Patrick had some difficulty in their feelings about a child’s natural parents. Mrs. Patrick wondered if she would feel as if she were taking a child away from his mother. Miss Beringer assured her that this was a common feeling in adoptive mothers. She mentioned again the care with which the agency assisted each natural parent to decide about the baby. Mr. Patrick was finding it very hard to see how a mother could possibly give a child away. Later, he told of reading about juvenile delinquency and realized that many of these childrcn came from broken homes. It began to occur to him, then, that an unmarried mother, out of love for her child, might have chosen wisely in seeking a complete home for him. With Mr. Patrick’s greater acceptance of his infertility and both Mr. and Mrs. Patrick’s increased awareness of their attitudes toward natural parents, an awareness that would allow them later to help their adopted child with his questions about his natural background, both the couple and the agency felt more ready to proceed with the adoption. Couple returns child. They decide they will not adopt at all. Mrs. Ellender was very upset when she phoned the agency 3 days after an adoptive placement had been made. She wished to return the baby, because she thought the baby’s head misshapen. The caseworker knew from the physician that the baby’s head was not abnormal, but she recalled also that Mrs. Ellender had been unusually particular all along about the kind of baby she wanted. Mrs. Ellender seemed to show by her preferences that she was trying to think of the baby as biologically her own. Of course it is the normal wish of both couple and agency to match a child and his adopting parents as well as can be done so that he will have a real identity with the adopted family, but Mrs. Ellender’s request was so specific that it went beyond this. After Mrs. Ellender’s return of the baby, she came in for an interview. The worker’s task, enhanced by Mrs. Ellender’s basic sensitivity and intelligence, was to help her see that adoption may not be the answer for her. It had been a hard lesson for her, Mrs. Ellender said, but she realized that she could not bear the emotion
February 1, 1967 Am. J. Obst. & Gynec.
of raising another person’s child. She was assured the baby would be placed in another home and the natural mother need not be contacted. (In an independent plan the mother would, of course, have to be involved again.) The worker also pointed to the number of other accomplishments and satisfactions Mrs. Ellender had in her life that she hoped would, in time, soften this experience. With this understanding of her feelings, Mrs. Ellender would probably not subject herself to another such upsetting experience in the mistaken belief that the trouble was the shape of the baby’s head. Adopting mother’s pretense at pregnancy. Mrs. Ahearn did not know at first what to make of the facts which Mr. Hunt told her about his wife. She had already seen them jointly and talked with Mrs. Hunt privately the previous week. From all she knew about them, she thought they would enjoy being adoptive parents and could give a great deal to a child. Now Mr. Hunt said in a very hesitant way that Mrs. Ahearn should know his concern about his wife. Since her surgery last year when she had had a hysterectomy, they had talked of adoption and he felt she wanted this as did he. He thought she still wanted it, but then she began talking of pretending that this would be her own baby. She had told him she would stay in bed for several months, tehing friends and family that she was pregnant and that the doctor recommended bed rest. She had never been able to tell anyone the facts of her surgery. He knew she would be a good mother to a child, but he worried so about this plan. He felt they could not live this kind of lie. Mrs. Ahearn felt this behavior was different from all else about Mrs. Hunt, which had indicated a considerable degree of emotional maturity. She used consultation with the agency psychiatrist to confirm her thinking that this was an isolated reaction and not an all-pervasive personality disturbance. Mrs. Ahearn encouraged Mr. Hunt to tell his wife about his discussion, and after he did Mrs. Hunt seemed almost relieved to have it out. Then, in the ensuing interviews, her plans at pretension were understood as a reflection of her deep reaction to the hysterectomy and Mrs. Hunt decided to use psychiatric therapy to help in this adjustment. Mrs. Aheam assured them of the agency’s confidence in them as adopting parents at a later time, A year later, they were ready to adopt and the agency was ready to place a child with them.
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The facts of adopted life. Telling the child; a second adoption. The Linell’s came to the agency for their second child after having adopted a first one independently. Mrs. Irving, the worker, was impressed with their sensitivity to each other and to their son, Eric, who was then 7. However, they had never told Eric he was adopted, feeling that they would wait until he was a little older. For Mrs. Line& especially, this was a difficult subject to touch. She did understand fairly readily, however, Mrs. Irving’s concern that the placement of a ::econd child was going to provoke questions from Eric about his origins. This could lead to a lot of uneasiness in the family unless it was anricipated beforehand. Initially, Mrs. Line11 had had a terrible time accepting her infertility. She spoke of it as a “shock,” felt guilty about her condition, and was gravely upset that she could not have a child she and her husband wanted so much. When her husband spoke of: adoption, though she did not feel ready for this herself, she felt it was not fair to him to delay their family any longer. She told the lawyer she did not want to know anything about the natural mother, and her husband talked with the lawyer by himself about the baby’s background. Mrs. Line11 now realized that she had wanted to act as if Eric were the son she had really wanted to have herself. When Eric was about 4, and began to ask questions abour his birth, Mrs. Line11 found herself making general statements to him and, by default, leaving Eric with the impression that he was their own child. She was aware that the problem was not in saying that they chose him but in having to explain that he was born to another woman. He might want to know too much about his natural parents and it would be very hard to explain to him why his mother gave him up. ,She knew another family whose adopted girl was an adolescent and they lived in daily fear that she would learn of the facts of her adoption which they had kept from her. Hard as it was for her to face, she realized it needed to be done for Eric’s sake as well as for the new baby. She also said it was uncomfortable for her to face the fact that Eric was illegitimate. Mrs. Irving pointed out that this was a social problem for the parents and in no way affected Eric’s heredity, or character, and personality formed in his life with the Linell’s. After discussions of these and other feelings related to the problem, Mrs. Line11 made a beginning ef-
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fort to tell Eric about his adoption and then found it to be much easier than she had anticipated. Just before Eric’s adopted sister joined the family, Mrs. Line11 described a poignant incident when Eric told her he thought for a long time that Mrs. Line11 was not telling him something important and was worried that it might be “something really had.“ Comment The foregoing case examples illustrate the multiplicity of factors surrounding adoption decisions. They are presented in order to demonstrate, through a representative sampling of case situations, how the time, effort, and skill of the caseworker can be utilized to give those elements of attention to the parties to an adoption which the physician would have difficulty providing. In summary, two basic factors relevant to all the situations described should be stressed. In each instance the agency provided the program and the facilities in which decisions and plans could be made without pressure. The caseworkers offered the special service to foster full consideration of these plans. The natural parents were under no commitment to the agency to make a final choice either for or against relinquishment. The agency, on the other hand, made a commitment to them to accept the relinquishment if they decided on adoption, and to assume continuing responsibility for the child, if adoptable, including an interim plan of foster care if needed and another placement plan if the child were returned from the adoptive home. The adopting parents were offered services under similar conditions of choice, not only about the adoption itself but also in the selection of a child. True, the totality of these services require administrative personnel, supervisors, and various consultants such as pediatricians, obstetricians, psychiatrists, and geneticists in addition to the casework staff. We believe it is essential to have whatever professional consultation is needed in such momentous considerations as are involved in relinquishment and adoption, but we recognize that such procedures can give an institutional relevant to a referring image. However,
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physician’s concern for his patient’s privacy is the fact that these administrative procedures do not intrude upon the personalized, individual service which is provided. Natural parents and adopting couples in most instances see one caseworker privately throughout their contact with the agency. It is clearly understood that the agency resources depicted in these case reports may not exist in every community, and that in some instances the physician must of necessity “go it alone” in helping his patients to recognize all of the subtleties involved in adoption decisions. Nevertheless, the vast majority of adoptions occur today in urban settings. Here metropolitan physicians have ready access to the specialized services of adoption agencies if they would but think to regard them much as they would other specialized medical and social service resources, for consultation and referral. It is to these physicians that this article is addressed. It is further clearly understood by the authors that the quality and training of adoption casework personnel may vary from community to community and agency to agency. Indeed, there are good and bad social workers just as there are good and bad physicians. We deplore, however, the blanket indictment of all caseworkers by the physician who has had a disagreeable encounter with one, and submit that the image of the adoption caseworker is too often an inaccurate one. It has been suggested elsewhere that many physicians’ freely acknowledged “anger” with caseworkers (often expressed with considerable intensity of feeling) reflects the doctor’s own unconscious emotional investment in the adoption
February 1, 1967 Am. J. Obst. & Gynec.
situation in which the worker is perceived as a rival. Undoubtedly, related unconscious phenomena in the social worker account for similar hostile feelings expressed toward physicians. In those instances where the conduct of a caseworker or the practices of an agency seem genuinely open to criticism, the physician would benefit both his patients and the agency by seeking to correct that of which he disapproves rather than by despairing of cooperation with agencies in the future. This, of course, also applies to caseworkers who find certain physicians rigid, uninformed, or uncooperative. To this end the adoption committees of local medical societies, and the multidisciplined adoption committees in which physicians actively participate, serve a very useful purpose in assisting the physicians and social workers to understand the other’s language and customs, to recognize the other’s skills and limitations, and to work harmoniously in the best interests of the patient. It has been our experience that such committees can do a great deal to clear away the misunderstanding which often impedes the desired multidisciplined approach to adoptions which is endorsed by all of the professions concerned. Quite contrary to the stereotype envisaged by too many physicians, the field of adoption casework is a dynamic, scientific discipline, as well as an “art,” in which serious research and controlled experiments are under way to refine and perfect the adoption process. The seriousness of this exercise in delicate human relationships warrants all of the cooperation and support that the medical profession can offer.