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The psychological impact of abortion
The psychological impact of abortion Norman
D West, MD
Editor’s note: The Supreme Court decision January 22, 1973 established that during the first trimester of pregnancy “the abortion decision and its effectuation must be left to the medical judgment of the pregnant woman’s attending physician.” After the first 12 weeks the state may intervene only to the extent of protecting maternal health b y establishing requirements as to who can perform the abortion and where. During the lust 12 weeks, the state can make regulations to protect fetal life. The Court also struck down residency requirements. The luw in New York State meets the requirements of the new ruling. Other state laws appear not to conform. 0 In researching the literature for studies of the psychological impact of abortion, one is impressed by the lack of any good, valid study from which conclusions can be made. Most studies are heavily biased with an ~
Norman chiatry, Omaha, chiatric
132
D West, MD, i s assistant professor of psyUniversity of Nebraska Medical Center, and chief, liaison service, Nebraska psyinstitute.
obvious conclusion being desired by the researchers. Another glaring difficulty with these studies is the lack of good control groups for comparison. It is noteworthy, also, that the majority of studies have been done in urban areas, where the reaction to unwanted pregnancies is entirely different from that in rural areas. This is, in all probability, due to close community and family ties in rural areas, which tend to offer much more emotional support to the woman than could be obtained in an urban area. Cultural factors produce many additional variables in this area. This points out a need for a good, well-controlled study, which should include both urban and rural areas, and which should include a control group of women with similar problems who do not get an abortion but carry the pregnancy through to term. Another important key to make a study like this valid is the length of follow-up evaluation. Many of the psychiatric problems that confront the woman who has had an abortion may not show up for five to ten years after the abortion. At the time of the abortion, she may feel so relieved a t
&
t o 136
AORN Journal
the resolution of her crisis that any other feelings may be repressed. Later she may become guilt ridden and depressed because of her decision. On the other hand, the value in prolonged follow-up may also reveal the tendency of people to work through their feelings about an unwanted pregnancy which they decided to keep, and thus dispel some of the prevalent ideas that all unwanted pregnancies turn out badly, especially for the child. People on both sides of the controversy could benefit markedly from such a study. The psychological impact on women receiving an abortion for unwanted wegnancy varies as much as the psychological impact of any life crisis. Generally speaking, the initial impact is one of gross relief a t resolving the immediate stress. Very few, if any, women desiring abortion experience feelings of guilt or feel their value systems are being threatened a t this time. For some women this never apparently becomes a problem, as they successfully use denial and rationalization to alleviate any subsequent feelings of guilt or self incrimination. For others, however, the defense mechanisms may not work as well, and then they can experience depression and feelings of low selfesteem in varying degrees. This largely depends upon their religious and cultural beliefs and also is dependent largely on the amount of emotional support they have received. One fact has consistently come from the many studies on post-abortion feelings. Any woman who has a definite feeling that the fetus is a life from the moment of conception and therefore, feels that termination of this life constitutes murder, is a poor candidate to consider for abortion. These women have
136
repeatedly shown up later with severe depression, and even many have suffered psychotic breakdowns. It is paramount that anyone who does abortion counseling or screening honestly evaluates these feelings in the woman, and in her family members. Neglect in this area can lead to serious consequences if overlooked. Another important factor is the woman’s mental competency to make a decision during a gross stress reaction. It must be determined that she is making her decision in a rational, healthy, problem-solving manner. A frequent pitfall encountered in psychiatric screening involves the bias of people recommending abortion to the woman, including counselors, caseworkers and family members. These too should be thoroughly evaluated, and the decision should be the woman’s and her husband’s, if any, entirely, without outside influence being a major contributory factor. No discussion of the psychological impact of abortion is complete without considering the impact on people who are involved other than the pregnant woman. This includes the husband or father, the physician and the hospital personnel who will be caring for the patient. Frequently the man in the case is ignored if his involvement is not known, as so often happens in the unmarried woman’s pregnancy, or if there is no desire for the woman to include him in the picture. If, however, there is a husband or boyfriend who is emotionally involved in the pregnancy, his feelings must be considered. If the woman wants an abortion, but the male involved does not, serious legal implications could result. Here the problem (or fact) of equal rights comes into question. This cannot be ignored.
AORN Journal
The physician handles his problems in this area quite simply. He either is comfortable in doing the abortion, or he is slightly uncomfortable and refers the patient, or he is opposed and refuses to do it. He is in the “golden chair” and has very little chance of unintentionally becoming emotionally involved. The other hospital personnel represent a totally different story. Among these people many have strong feelings for or against abortion, and many continue to have mixed feelings. They are in a classic double bind. They are paid employees of an institution and generally are expected t o do their job regardless of moral issues. Occasionally physicians and administrators do take these things into consideration, but often as not the person will be expected t o function regardless. In this case the person may suffer severe guilt feelings a t even being a part of abortions. The ability of the caretaking person in the hospital to be comfortable in the work he does must be taken into consideration. If not, the person most likely to feel repercussions is the patient, as she may be looked upon as a “seedy” non-worthwhile person, and may be treated accordingly. It is interesting to observe the ploys that have been used on the wards of the hospital. Some insist that all abortion patients be put in private rooms, and then seen as little a s possible. On the other hand, one California hospital staff insisted that the abortion patients room with newly delivered mothers who were obviously happy with their babies. This in no way reflects on the ethical or professional competency of these people, but does indicate a mixture of rather strong feelings about this issue. The
138
solution to this problem is not to force them into working with it directly, but rather to involve them in working out their feelings prior to working with abortion patients. This is best done in a group setting. The people working with abortions deserve as much consideration as the patients, and if they cannot comfortably participate, they should be excused from this duty without penalty. It appears that while most people in the helping professions see a need for a change in the laws and attitudes regarding abortion, there are still some prominent stumbling blocks with which we must deal. The outstanding problem, however, is the need for more knowledge about the psychological impact of abortion, not only on the woman involved, but all people who are directly or indirectly involved. The moral and social issues are already under change, and time will undoubtedly bring about more changes. The issue of abortion on request is here t o stay, and now it is up to society in general, and medical personnel in particular, to deal with
0
it. REFERENCES
Aarons. ZA. “Therapeutic Abortion and the Psychiatrist,“ American Journal of Psychiatry, I24 ( December, I967), 745. Malmquist. A , e t al. “Psychiatric Aspects of Spontaneous Abortion,l. A Matched Control Study of Women With Living Children,” Journal of Prychosomatic Reseurch, vol 13, no 45, 1969. Patt, SL, RG Rappaport and P Barglow. “FollowU p of Therapeutic Abortion,” Archives of Gcnera/ Psychiahy, 20 (April, 1969), 408. Rodger, TF. “Attitudes Toward Abortion,” American Journal of Psychiatry, I25 (December, I968),
804. Simon, NM, et al. “Psychological Factors Related t o Spontaneous and Therapeutic Abortion,” American Journal of Obstetrics and Gynecology, I04 (July 15, 1969), 799.
AORN Journal
D West, MD
Editor’s note: The Supreme Court decision January 22, 1973 established that during the first trimester of pregnancy “the abortion decision and its effectuation must be left to the medical judgment of the pregnant woman’s attending physician.” After the first 12 weeks the state may intervene only to the extent of protecting maternal health b y establishing requirements as to who can perform the abortion and where. During the lust 12 weeks, the state can make regulations to protect fetal life. The Court also struck down residency requirements. The luw in New York State meets the requirements of the new ruling. Other state laws appear not to conform. 0 In researching the literature for studies of the psychological impact of abortion, one is impressed by the lack of any good, valid study from which conclusions can be made. Most studies are heavily biased with an ~
Norman chiatry, Omaha, chiatric
132
D West, MD, i s assistant professor of psyUniversity of Nebraska Medical Center, and chief, liaison service, Nebraska psyinstitute.
obvious conclusion being desired by the researchers. Another glaring difficulty with these studies is the lack of good control groups for comparison. It is noteworthy, also, that the majority of studies have been done in urban areas, where the reaction to unwanted pregnancies is entirely different from that in rural areas. This is, in all probability, due to close community and family ties in rural areas, which tend to offer much more emotional support to the woman than could be obtained in an urban area. Cultural factors produce many additional variables in this area. This points out a need for a good, well-controlled study, which should include both urban and rural areas, and which should include a control group of women with similar problems who do not get an abortion but carry the pregnancy through to term. Another important key to make a study like this valid is the length of follow-up evaluation. Many of the psychiatric problems that confront the woman who has had an abortion may not show up for five to ten years after the abortion. At the time of the abortion, she may feel so relieved a t
&
t o 136
AORN Journal
the resolution of her crisis that any other feelings may be repressed. Later she may become guilt ridden and depressed because of her decision. On the other hand, the value in prolonged follow-up may also reveal the tendency of people to work through their feelings about an unwanted pregnancy which they decided to keep, and thus dispel some of the prevalent ideas that all unwanted pregnancies turn out badly, especially for the child. People on both sides of the controversy could benefit markedly from such a study. The psychological impact on women receiving an abortion for unwanted wegnancy varies as much as the psychological impact of any life crisis. Generally speaking, the initial impact is one of gross relief a t resolving the immediate stress. Very few, if any, women desiring abortion experience feelings of guilt or feel their value systems are being threatened a t this time. For some women this never apparently becomes a problem, as they successfully use denial and rationalization to alleviate any subsequent feelings of guilt or self incrimination. For others, however, the defense mechanisms may not work as well, and then they can experience depression and feelings of low selfesteem in varying degrees. This largely depends upon their religious and cultural beliefs and also is dependent largely on the amount of emotional support they have received. One fact has consistently come from the many studies on post-abortion feelings. Any woman who has a definite feeling that the fetus is a life from the moment of conception and therefore, feels that termination of this life constitutes murder, is a poor candidate to consider for abortion. These women have
136
repeatedly shown up later with severe depression, and even many have suffered psychotic breakdowns. It is paramount that anyone who does abortion counseling or screening honestly evaluates these feelings in the woman, and in her family members. Neglect in this area can lead to serious consequences if overlooked. Another important factor is the woman’s mental competency to make a decision during a gross stress reaction. It must be determined that she is making her decision in a rational, healthy, problem-solving manner. A frequent pitfall encountered in psychiatric screening involves the bias of people recommending abortion to the woman, including counselors, caseworkers and family members. These too should be thoroughly evaluated, and the decision should be the woman’s and her husband’s, if any, entirely, without outside influence being a major contributory factor. No discussion of the psychological impact of abortion is complete without considering the impact on people who are involved other than the pregnant woman. This includes the husband or father, the physician and the hospital personnel who will be caring for the patient. Frequently the man in the case is ignored if his involvement is not known, as so often happens in the unmarried woman’s pregnancy, or if there is no desire for the woman to include him in the picture. If, however, there is a husband or boyfriend who is emotionally involved in the pregnancy, his feelings must be considered. If the woman wants an abortion, but the male involved does not, serious legal implications could result. Here the problem (or fact) of equal rights comes into question. This cannot be ignored.
AORN Journal
The physician handles his problems in this area quite simply. He either is comfortable in doing the abortion, or he is slightly uncomfortable and refers the patient, or he is opposed and refuses to do it. He is in the “golden chair” and has very little chance of unintentionally becoming emotionally involved. The other hospital personnel represent a totally different story. Among these people many have strong feelings for or against abortion, and many continue to have mixed feelings. They are in a classic double bind. They are paid employees of an institution and generally are expected t o do their job regardless of moral issues. Occasionally physicians and administrators do take these things into consideration, but often as not the person will be expected t o function regardless. In this case the person may suffer severe guilt feelings a t even being a part of abortions. The ability of the caretaking person in the hospital to be comfortable in the work he does must be taken into consideration. If not, the person most likely to feel repercussions is the patient, as she may be looked upon as a “seedy” non-worthwhile person, and may be treated accordingly. It is interesting to observe the ploys that have been used on the wards of the hospital. Some insist that all abortion patients be put in private rooms, and then seen as little a s possible. On the other hand, one California hospital staff insisted that the abortion patients room with newly delivered mothers who were obviously happy with their babies. This in no way reflects on the ethical or professional competency of these people, but does indicate a mixture of rather strong feelings about this issue. The
138
solution to this problem is not to force them into working with it directly, but rather to involve them in working out their feelings prior to working with abortion patients. This is best done in a group setting. The people working with abortions deserve as much consideration as the patients, and if they cannot comfortably participate, they should be excused from this duty without penalty. It appears that while most people in the helping professions see a need for a change in the laws and attitudes regarding abortion, there are still some prominent stumbling blocks with which we must deal. The outstanding problem, however, is the need for more knowledge about the psychological impact of abortion, not only on the woman involved, but all people who are directly or indirectly involved. The moral and social issues are already under change, and time will undoubtedly bring about more changes. The issue of abortion on request is here t o stay, and now it is up to society in general, and medical personnel in particular, to deal with
0
it. REFERENCES
Aarons. ZA. “Therapeutic Abortion and the Psychiatrist,“ American Journal of Psychiatry, I24 ( December, I967), 745. Malmquist. A , e t al. “Psychiatric Aspects of Spontaneous Abortion,l. A Matched Control Study of Women With Living Children,” Journal of Prychosomatic Reseurch, vol 13, no 45, 1969. Patt, SL, RG Rappaport and P Barglow. “FollowU p of Therapeutic Abortion,” Archives of Gcnera/ Psychiahy, 20 (April, 1969), 408. Rodger, TF. “Attitudes Toward Abortion,” American Journal of Psychiatry, I25 (December, I968),
804. Simon, NM, et al. “Psychological Factors Related t o Spontaneous and Therapeutic Abortion,” American Journal of Obstetrics and Gynecology, I04 (July 15, 1969), 799.
AORN Journal