- Email: [email protected]
Therapeutic abortion
CURRENT
OPINION
Therapeutic abortion A social work FRANCES Boston,
view
ADDELSON,
M.S..
A.C.S.W
Massachusetts
The consciously unwanted pregnancy is a complex medical-psychological-social condition. Benefits from early and continuing social work involvement have been demonstrated by an examination of social work performance at Beth Isreal Hospital, Boston. During a nine-month period, a systematic classification of all women with problem pregnancies known to the Social Service Department showed an increasing number of such pregnancies as well as a significantly increasing percentage of requests for abortion. The latter exceeded the treatment potential of our hospital, resulting in an overflow group of women whose needs could not be met by existing medical and community resources. Our observations lead us to recommend that social work be regarded as an integral approach to all obstetric-gynecologic care in facilities where therapeutic abortions are evaluated or performed and that private obstetrician-gynecologists consider utilizing social work more extensively in treating the therapeutic abortion-applicant patient.
A T T H I s T I M E when abortion laws are rapidly being liberalized throughout the nation and women with unwanted pregnancies learn of alternatives long denied and long felt to be taboo, there is need for greater community clinical resources where women may be helped to make an early decision required by an unwanted pregnancy entailing minimum emotional sequelae. Under existing conditions, the personal dilemma for most women is compounded by the confusion society presents in its varying laws, attitudes, and resources, thereby diminishing the chances of a healthy resolution of the individual’s problem. It is the purpose of this paper to demonstrate the unique potential of social work to assist constructively such women by examining the social work role both as part of the obstetric-gynecologic From Work
Beth Israel Department.
Hospital,
team treating the therapeutic abortion patient and in its experience with therapeutic, abortion applicants who could not be aecommodated by the hospital. Hospitd
setting
At Beth Israel Hospital, a general teaching hospital of 372 beds, obstetric-gynecologic patients comprised 43 per cent of all admissions, and 3,211 women were delivered during the year ending September 26, 1970. Our hospital as well as other Massachusetts hospitals was deluged at that time by direct calls for help from women with unwanted pregnancies as well as referrals on their behalf by physicians, agencies, and individuals far beyond the capacity of the hospital to respond. The Social Work Department, in addition to its traditional function of working collaboratively with the medical staff on behalf of patients, was also pressured by its
Social
984
Volume 111 Number
Therapeutic
abortion
985
”
own professional commitment into counseling numer’ous would-be patients, limited by few guidelines from customary hospital social work practice and inadequate practical referral resources. Composition
of the
applicant
Table I. Problem pregnancies known to social work. Comparison of No. of women requesting therapeutic abortion with No. of unmarried women carrying to term
group
With therapeutic abortion now providing a new dimension in meeting the age-old problem of unwanted pregnancy, our Social Work Department decided to conduct a study, descriptively analyzing all consecutive applications for service from women with any problem pregnancy between December 1, 1969, and August 30, 1970. Our clinical experience supports our continuing to characterize the out-of-wedlock pregnancy as a problem, even when described by the patient as “wanted” and despite society’s recent relaxation of sexual mores. The unmarried pregnamt woman we see almost invariably describes conception as “unexpected,” implying an essential ambivalence on her part. In addition, we find that illegitimate pregnancy compounds the pre-existing social, economic, and emotional problems of mother, child, and children already born. Our study is confined to hospital clinic patients only. The total obstetric-gynecologic hospital population includes women from 3 satellite clinics and private patients in addition to the hospital clinic patients studied. We chose to omit the satellite clinic patients because their social work records were not conveniently available for incorporation and the private patients as well because their doctors did not consistently refer to the Social Work Department. By December 1, 1969, we had noted that the number of women requesting abortion had exceeded the number of unmarried women who planned to carry to term. Under the all-inclusive term of problem pregnancy, we offered all these women social work and divided them into two mutually exclusive categories: ( 1) all women who requested therapeutic abortion or presumably sought abortion, (2) all unmarried women-single, separated, or divorced-who planned to carry the out-of-wedlock pregnancy to term.
Dec., 1969 to Feb., 1970 March, 1970 to May, 1970 June 1970 to Aug., 1970 Totals
75
55
130
79
65
144
97
88
185
251
208
459
Table II. Requests for therapeutic abortion for girls under 18 (known to the Department of Social Work)
Date Of contnct ~;gjij; Dec., 1969 to Feb., 1970 March, 1970 to May, 1970 June, 1970 to Aug., 1970 Totals
Ytjgd~7tJ;?f
2
9
11
6
3
9
8
11
19
23
39
16
Our study, then, is concerned with social work as it was offered to 208 unmarried women who carried their pregnancies to term, 109 patients who received therapeutic abortion, and 142 other women whose requests for this procedure were not granted in our hospital. Analysis
of applicant
group
Table I shows a steady rise in all problem pregnancies as well as therapeutic abortion requests. Although the total prenatal clinic population rose only 26 per cent during the period studied, the percentage of increase in women with problem pregnancies rose 42 per cent. We note also that during a 15 per cent increase in gynecologic patients there was a simultaneous 29 per cent increase in women requesting abortion. Table II shows that there was a signifi-
986
Addelson
Table III. Requests Social -~
for therapeutic
abortion
by race (known
__________._-.-
_____~___._.._ --.. White
Date
Therapeutic abortion requests
of contact
Dec., 1969 to Feb., 1970 March, 1970 to May, 1970 June,
to the IUepartl~mlt.
oi
Work)
1970
to Aug.,
Totals ‘Totals
1970
65 67 - 66
198 by race
___-.-~-.-.---.~---.__~-~ I!nmarried *omen Therapeutics carrying abortion to term requests 28 25 06
9 I” 131 *
89
i?
287
_---_
- -.
Black llu,r,arried iuomen carrying to term 17 39 jz* 118 170
Total ; problem / pregnancies
129 14.1 18.5 .-. 457) 457f
* These figures may have been affected by a local redistribution of patients due to the temporary closing of a Beth Israel Hospital satellite clinic in Roxbury. tDisparity of this total with that shown in Table I is dw to the fact that ? member of another race arr not included here.
cant percentage of increase in requests for therapeutic abortion in girls under 18. Table 111 demonstrates that 69 per cent of white women requested therapeutic abortion contrasted with 31 per cent of black women. However, black women showed a 12 per cent increase in such requests during our study period. This shift in the pattern of coping with unwanted pregnancy by black women was predicted in previous social work research. These studies examined “Negro cultural apathy toward illegitimacy,” invalidating that simplistic explanation for the greater percentage of black unmarried mothers over white and for the reported tendency of black women to carry to term and keep their babies.l Most social workers who have shared the black unmarried mother’s experience are sensitive to her feelings of rejection in the unmarried status and her ambivalent acceptance of a life predicament where premature motherhood may offer an escape from social competitiveness. One observes the general unavailability of desirable adoption and therapeutic abortion resources as well as economically stable marriage opportunities for her. One may reasonably expect that with the current upward mobility of black people consideration of the timing and values of motherhood will be weighed by them against available economic, educational, and social realities just as it has always been done by nonminority-group mothers. Increased social advantages will not obliterate for the present the general tendency of the
black unmarried mother to raise her own out-of-wedlock child or to keep him within the extended family.’ Each decision made under such improved circumstances will, one hopes, be a truer reflection of individual choice and enhance the opportunity for a healthy mother-child relationship. Our statistics covering June through August, 1970, indicate the following significant characteristics of women with problem pregnancies served by our Department. Almost twice as many women over age 35 considered resorting to abortion rather than carrying to term. Religious differences revealed that among the 80 per cent of our sample who offered this information 52 per cent of the Catholic and 63 per cent of the Protestant women requested therapeutic abortion. Of the small number of Jewish women who use the clinic, 75 per cent of those with problem pregnancies requested abortion. Casework
dynamics
Effective service to women struggling with resolving feelings as well as realistic plannin? for a problem pregnancy draws on the entire range of the professional social worker’s skills. The timing and manner of the pregnant woman’s initial approach to the hospital suggest much about her motivation, her personality dynamics, and her ego strengths as well as her general sophistication. This material is used by the social worker to clarify the meaning of the patient’s request for abortion. For those who have been accepted for
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Therapeutic
medical care, the social worker provides supportive casework complementary to the doctor’s m.anagement of his patient, coordinating her skills with medical and other hospital services. For those women who are excluded from the clinic because of logistic considerations, the social worker may still provide various helping services. With all women, her work must be based on an understanding of the dynamics leading to conception and the meaning of the request for termination as well a,s the social and economic relevancies in the environment. Helping
women
clarify
their
needs
Ambivalence toward abortion as a solution to an unwanted pregnancy is present to some degree in almost all women we see. A complex interaction of many overwhelming forces--cultural, developmental, and social -undlerlies the crisis which confronts the pregnant woman. The urge of biological continuity; the positive elements leading to conception, and the frustration and sadness of electing to terminate life, in whatever stage or manner, may usefully and skillfully be explored with such women, whenever pertinent, in the early weeks and measured agains,t the proposed termination. At present, a wom.an recognizes that where the laws are still restrictive she must present a desperate and unequivocal stand to most helping authorities, often exhibiting displaced emotion, to effect her request. What she needs at this point :is the help of a nonjudgmental, professional person in order to assist in clarifying her own thinking and anticipating the consequences of a solution which she might otherwise make in panic or under the immense pressures of immediacy and wellmeaning friends or family. Women arrive at the condition of unwanted pregnancy in varying stages of emotional maturity, but the crisis situation intensifies their vulnerability and may easily lead to disequilibrium.3 The basic casework approa.ch is to meet such women at their individual levels and help them face their individ.ual realities with a clear understanding of their own strengths and long-term
abortion
987
needs. It must include exploring with them the underlying motivation of their decision to abort in order to appraise realistically their reaction to the internal threat of selfdestructive forces whether they defend with an intrapsychic mechanism, such as depression, or extrapsychically, as with projection. This calls for establishing a therapeutic as well as a trust relationship within a critically short period of time. 4 It assumes the client’s right to choose the direction of her own life.5 Such service should be offered to all women with unwanted pregnancies. It may be maintained through a brief or relatively prolonged relationship or may, of course, be rejected. Helping
women
wait
In the more familiar role as a member of the obstetric-gynecologic team, the social worker receives referrals primarily from the resident physician on that service. Social work offers support during a difficult waiting period for those patients who in the doctor’s judgment appear eligible for the procedure under Massachusetts law.6 Interpreted diversely by individual gynecologists, the law allows abortion to prevent serious impairment of the patient’s physical or mental health providing such judgment corresponds with that of the prevailing medical community. Alternatively, during the review period by the medical personnel whose function is to determine final eligibility, those patients initially recommended may be exposed to further uncertainty while already in a highly anxious state. To offset the tendency to regression often found in any critical waiting process, the social worker supports and maintains the patient’s autonomy. Emphasis is placed on the maturity of waiting for a hospital decision as against the impulsivity of self-destructive or manipulative behavior, such as might result in illegal abortion or forced marriage. Alternate plans are considered for the rare eventuality of hospital rejection. Most important, this time is used for the patient to work on more insightful resolution of feelings around the course she is pursuing, which includes the circumstances
988
Addelson
of impregnation as well as the decision to request abortion. With hospital admission finally arranged, it has been our experience that many women continue to need emotional support. Many institutional innovations have been introduced to neutralize the emotional impact on the patient resulting from the physical setting of the procedure. Patients admitted for abortion are now housed whenever possible at the opposite end of the hospital from the maternity ward. Constant communication by means of conferences and consultation among nursing, medical, and social services encourages positive personnel attitudes and reflects the educational aims of the hospital. Obstetricians advise that certain therapeutic abortion procedures require more supportive nursing time and may be more painful and prolonged than labors at term.? Psychiatrists regard the emotionally supportive roles played by all the caretaking people during hospitalization as significant preventive therapy.8 Casework techniques that support the worthiness of the individual in this stressful situation, which usually evokes self-devaluating feelings, may help to lay the groundwork for prevention of sexual acting out in the future. Emphasis on the therapeutic aspect of the abortion procedure as sanctioned by the hospital enables the patient to integrate this whole conflictual experience into a constructive perspective, an egosyntonic process essential for her mental health and further maturation. If indicated, the prospect of postabortion counseling and/or psychiatric treatment may be introduced at this time. Need for support and clarification in extreme ambivalence Social work involvement with patients referred during the abortion evaluation process begins with social evaluation and may continue to casework support or treatment according to the need of the individual patient. Social work evaluation is not part of the medical decision either recommending or rejecting abortion, but it is one of the considerations which may be used by the deci-
December 1, 1971 Am. J. Obstet. Gynecol.
sion-making physicians. In the interdisciplinary approach, the doctor has the primary relationship with his patient, but, in those instances where social and emotional factors threaten to interfere with medical management, the social worker’s contribution of special skills may illuminate patient ambivalence and lead to better total care. Such an instance may occur when patients are extremely ambivalent while proceeding with the abortion they had so desperately requested. Case report Miss B., an 18-year-old unmarried primigravida, presented herself in the clinic as depressed and essentially nonverbal. She stated that she had taken various measures to abort and threatened to continue these if the doctor would not help her. In the social work interview she revealed many ego strengths as manifested by her obvious ability to make difficult and constructive life choices in the past. She had left her southern rural home to acquire training in the Job Corps and now lived in a girls’ residence and worked in a factory. She found it difficult to talk about the alleged father or about her family, both of whom she seemed to keep emotionally isolated from the fact of pregnancy. During the hospital processing period, casework with the patient focused on the following: her own feelings about the pregnancy; her anxieties about the reactions of her family and peers; the meaning of her goals for self-advancement; the realistic means available to assist her in reaching these goals; and the effect upon her goals of continuing the pregnancy. Her suspicion of authority figures and her difficulty in communicating were sufficiently eased in the casework relationship to allow her to express anxiety concerning her deeply rooted equation of aborShe wanted the social tion with “murder.” worker to make the decision to abort for her. It took much work on her part and support and clarification from social work, for her to manage her conflicting needs. Only minutes before surgical intervention was she able to articulate with positive feeling the moral conviction that could not tolerate abortion, which took, she felt, precedence over her other needs. We assume that helping this young woman express her deepest convictions, uncomfortably submerged by more immediate concerns, contributed to greater emo-
Volume 111 Number 7
Therapeutic
tional integrity and ego strength. Without the opportunity provided by casework, she would no doubt have allowed the abortion and probably experienced serious emotional sequelae. Efforts
to offset
recidivism
A patient such as the above required continuing support as she prematurely assumed the maternal role. She was followed in our prenatal clinic and was helped with child care education and family planning as well as in obtaining living arrangements after hospital discharge. Community agencies and a maternal neighborhood figure whom the social worker interested in her behalf provided lsupport for positive emotional involvement with the infant. This particular patient is indeed, almost three years later, using our Gynecology and Child Care facilities, is employed, and appears to be adequately combining the stressful dual role of young adult and mother. Should she encounter serious problems, one may assume she would more readily turn to social work since she had used the relationship prenatally so effectively. In a study of illegitimacy among Aid to Families of Dependent Children clients,9 it was fo’und that the crucial period in the emotional development of the unmarried multipara occurred during and after her first illegitimate pregnancy. Repeated outof-wedlock pregnancies have been psychoanalytically interpreted as symptomatic of complex unconscious disturbance, especially the acting out of a negative identity.lO Psychiatric consultation revealed that an intelligen t, self-supporting, unmarried young woman, pregnant for the third time and demanding a second abortion, was overdeterm&d in her identification with a promiscuous, unloving mother and hence psychologically incapable of living up to her good potential without psychotherapy. Our clinical experience confirms that the optimal time for working with such clients is during and after the first problem pregnancy. It is then that aggressive reaching out by referral to social and psychiatric agencies is required if the ‘client is unable to maintain a useful casework relationship.
Septic
abortion
989
abortions
Other types of social work collaboration with the Obstetric-Gynecologic Service involve the alarming number of women who are admitted to the hospital with a diagnosis of septic or incomplete abortion, where there is history or evidence of attempts to obtain or self-induce an abortion. Three women hospitalized for septic abortion had previously approached the Department of Social Work requesting help with abortion. One, too impulsive to wait out the process of obtaining a hospital abortion, had received psychiatric treatment in our hospital and would, we believe, have been considered favorably for the procedure. The other two women, with fairly stable life histories and college ambitions, were able to use the social worker to assess that they would probably not be eligible for abortion under Massachusetts Law. Both students’ high scholastic performances and educational opportunities primarily motivated their determination to abort and both concluded that they would go to another state where an unrestrictive abortion law was in effect. Later, upon admission to our hospital, one stated that she had aborted spontaneously. She expressed much guilt about these circumstances and about the second unwanted child she had carried. In the social work interviews, she was prepared for long-term psychotherapy. The other patient was helped to express feelings concerning the loss of pregnancy as well as that of the alleged father, a meaningful but inaccessible partner. She continued to use the social worker regularly after hospital discharge while following a previously neglected program of sustained gynecologic treatment for infection and contraception. For those patients who suffer from septic conditions after having obtained a legal abortion elsewhere, the social worker provides an opportunity for expression of feelings about the abortion and the subsequent need for hospitalization for infection. In egosupportive casework, shaken defenses are restored and the patient’s usual ego strength is regained. Those women who are admitted after an illegal abortion often resist social
990
December 1, 1971 Am. J. Obstet. Gynecol.
Add&on
work interviews. Nevertheless, a social worker’s interest in such areas as family relationships or improved work or living arrangements may be expressed. Such inititative from a social worker may become an incentive to healthier adaptive patterns after hospital discharge. As a minimum, someone in a therapeutic setting has introduced the possibility of alternative life goals and the availability of casework when the patient is ready. Social work for overflow
responsibility requests
Service to this group evokes ethical and philosophical considerations. Similar to the doctor, unable to meet the needs of all women requesting abortion within the legal and functional limits of his hospital, the social worker is at the interface of a divergent value system, that of the hospital and the profession. Optimal patient care may require that social workers engage in “forms of expression and action . . . that are often considered controversial.“11 The question of whether these numerous and pressing requests for abortion are the concern of the individual hospital or of other community representatives evokes emotion-laden disagreements. During this period of rapidly changing public opinion and awareness of the abortion problem, our Social Work Department attempted to offer guidance to all women with unwanted pregnancies who requested assistance, but we were soon overwhelmed by the sheer number of applicants. By September, 1970, we found it necessary to offer service only to those women with some prior hospital relationship and to those who requested assistance in person, redirecting other inquiries to available community resources. The women who approached the hospital in such numbers, often coming from considerable distance, seemed to envision Beth Israel as a liberal hospital concerned exclusively with the individual patient’s need. Confused by the suddenness of the unplanned pregnancy, some wanted merely an opportunity to explore possible choices with an experienced professional person either for themselves or a member of their family. Oth-
ers telephoned, sounding confused and mistrustful, disconnecting precipitously for fear of being identified. There were other telephone conversations with women, seemingly stable and controlled, who wished specific iriformation about medical procedures, legal requirements, and reliable resources for obtaining therapeutic abortion but who did not know where to turn. The majority presented themselves as desperately wanting termination of pregnancy. Some of these women needed care in addition to a response to their initial request for abortion. They were advised to come to the hospital for evaluation. One 23-year-old mother of 5 children called too late in the pregnancy for any consideration of termination, and another 38-year-old woman, separated from her husband, expressed fear that LSD taken at the time of conception had damaged the fetus. A prolonged telephone conversation with each seemed to allay anxiety and to initiate a course of useful action. Both women are currently attending our prenatal clinic, and the social worker, in collaboration with the obstetric team, is helping them carry to term. The social worker is offering casework aimed at assisting these women maintain their ego strengths during and after the crisis of an unwanted pregnancy. In urgent cases, the social worker arranged a personal interview and offered brief, crisisoriented casework followed by referral to appropriate resources when indicated. The limitation of time provided a structure encouraging immediate problem solving rather than the expression of subjective preoccupations. “A little help, rationally directed and purposefully focused at a strategic time, is more effective than more extensive help given at a period of less emotional accessibility.“l’ The woman with a healthy ego under stress may often require protective guidance. This is offered in the form of the casework relationship which enhances the clarity of available choices and assists in anticipating emotional reactions to various POSsible decisions. Two mature women overwhelmed by ambivalence decompensated un-
Volume Number
Therapeutic
111 7
der t.he stress of an unwanted pregnancy to such an extent that they did not turn to those safe and logical resources which were easily obtainable. One social work interview with a 41-year-old married school teacher, mother of two young children, who had suffered a postpartum depression after her last delivery, helped her see that her gynecologist was the appropriate person for her to turn to for help. Another client, a 38-year-old, self-supporting divorcee with 3 grown children, employed in a responsible hospital posifon, found it difficult to believe that her good standing as an employee entitled her to th.e same confidential care in her own hospital as is offered to all other patients. Transitional
aspects
of the
problem
Since the period of excessive demand described earlier, we have seen a change in the number and social background of those wome:n who turn to our hospital for abortion. This we believe is a reflection of increased community involvement, less restrictive abortion laws, renewed confidence in the Pill, and patient awareness. It is our impression that those now seen are fewer in number and more likely to be disturbed, dependent and pressured by excessive reality demands and more disadvantaged than those women seen in our study.With the reduction of the heavy, indiscriminate demand upon our hospital resources, its facilities may more appropriately be utilized by these unstable and deprived patients, for whom social work has traditionally had much to offer. More mature women with financial and social resources quickly utilize facilities made available by new laws, new agencies, new policies of existing institutions, and a more accepting attitude toward abortion on the part of the public and the medical profession. Such women will turn increasingly to obstetriciangynecologists of their own choosing or travel to areas where therapeutic abortion is more readily available. As a result, we see a rising tide of therapeutic abortions performed ever more skillfully and efficiently but with lessened consideration for the individual’s emotional health.
Relevance
for
the
abortion
991
physician
In view of this increasing demand for therapeutic abortion on the private practitioner who may not be part of a team including social work or psychiatry, consideration of the approach and techniques described in this study may be useful. A psychiatric view of abortion dispels the concept that there are any unequivocal indications available to a therapist, be he psychiatrist,13 social worker, or gynecologist, which predict the amount or quality of the emotional damage that will ensue from enforced continuance of an unwanted pregnancy. Since psychodynamic considerations often conflict and vague legal criteria further invalidate any consistency in decision making, a physician will tend to support the side of the ambivalence that identifies with his own personal thinking. By assuming a nonjudgmental approach and viewing the unwanted pregnancy not as an isolated circumstance but as part of a woman’s ongoing needs and drives, the gynecologist could be most effective in helping an applicant for therapeutic abortion determine whether she is reacting to self-destructive or essentially healthy forces in her personality. In her search for realistic choices, he could help her separate sexual and procreative functions and sort out priorities so that her ego functioning is strengthened and not threatened by responsibilities masochistically undertaken and involving emotional demands with which she cannot cope. This period of self-determination arrived at with the aid of professional understanding could be an insightful time, culminating in a truly therapeutic experience with redirections toward more positive ego-fulfilling behavior. Where prior professional commitments make it impossible for a physician to provide the exploration and long-term support that may be required or when he identifies psychosocial disturbance, it would be hoped that he would use social work in a mutual endeavor to meet the patient’s total needs. Recommendations
Until society resolves the issues of family planning, sex education, and acceptance of
992
Addelson
legal termination of pregnancy according to individual wishI and offers equal services to all, disregarding racial, ethnic, or economic factors, we may not expect the woman with an unwanted pregnancy to find her way to a healthy resolution of her problem unaided. Our clinical experience teaches us that most women facing the problem of unwanted pregnancy can utilize crisis-oriented, shortterm casework or guidance depending on individual need. This professional intervention not only helps a woman make the crucial decision-whether to keep or place her child for adoption or to seek a medical abortionin accordance with her most basic needs but also supports her self-esteem during and, when useful, after the crisis of unwanted pregnancy. The immaturity of many who have emancipated themselves from the familiar influences of family, church, and school and who face an unwanted pregnancy a10ne,15 the confusion in locating helping resources, and our experience with the emotional and social instability in most women during this critical
REFERENCES Shapiro, D.: In Unmarried ParenthoodClues to Agency and Community Action, New York, 1967, National Council on Illegitimacy, p. 58. H. J., Jones, W. C., Borgatta, E. F.: 2. Meyer, J. Sot. Work. 1: 103, 1956. 3. Caplan, G.: Principles of Preventive Psychiatry, New York, 1964, chap. 6, Basic Books, Inc. 4. Rapoport, L.: Sot. Service Rev. 1: 31, 1967. 5. Report of the Task Force on Family Law and Policy: Citizens Advisory Council on the Status of Women. Washinaton. D. C.. Auril, 1968, p. 31. ’ ’ 6. Massachusetts Law originally prohibiting abortion (G.L., Chapter 272. Sec. 19) is currently interpreted according to the most recent Supreme Judicial Court’s decision in Comm. vs. Wheeler (1944). 315 Mass., pp. 394-395. 7. Goodlin, R. C., McLannan, C. E., Choyce, J. M., et al.: Obstet. Gynecol. 34: 5, 1969. 1.
Decembel 1, 1971 .4m. J. Obstet. Gynecol.
period all suggest the need for the availability of professional social work. For greater effectiveness, such casework should be offered in those public health facilities providing early pregnancy detectionI in all facilities which offer the range of obstetricgynecologic care, and to private patients of obstetrician-gynecologists. This service should be offered in a manner that permits and encourages potential clients to use it. Social workers, we believe, are uniquely qualified by their training to play an essential and ongoing role in helping women with unwanted pregnancies meet this crisis. They are already strategically placed in many hospitals, agencies, and community units where people in trouble turn for confidential help with personal problems. With their routine presence in the medical facilities where women with problem pregnancies turn and their greater utilization by private physicians, social work, we believe, will ensure the optimal emotional benefits from the quality obstetric and gynecologic care now being given.
8. 9.
10.
11.
12. 13.
14.
15. 16.
Caplan, G.: Med. Sot. Work 4: 153, 1955. Griswald, B. B., Wiltse, K. T., and Roberts, R. W.: Illegitimacy Recidivism among AFDC Clients,, 1 pp. 20-21. Erickson, E. H.: Psychological Issues, ed. 1, New York, 1959, Vol 1, International Universities Press, pp. 129-146. Committee on the Study of Competence: Guidelines for the Assessment of Professional Practice in Social Work, New York, 1968, National Association of Social Workers, p. 16. Rapoport, L.: Sot. Work Rev. 2: 217, 1962. Group for the Advancement of Psychiatry, ed. 7, New York, 1969, No. 75, pp. 215, 219. Deutch, H.: Psychology of Women, New York, 1945, vol. 1, Grune & Stratton, Inc., pp. 179-188. At seventeen the road to abortion is lonely, The New York Times, October 18, 1970. Pion, R. J.: Obstet. Gynecol. 34: 300, 1969.
OPINION
Therapeutic abortion A social work FRANCES Boston,
view
ADDELSON,
M.S..
A.C.S.W
Massachusetts
The consciously unwanted pregnancy is a complex medical-psychological-social condition. Benefits from early and continuing social work involvement have been demonstrated by an examination of social work performance at Beth Isreal Hospital, Boston. During a nine-month period, a systematic classification of all women with problem pregnancies known to the Social Service Department showed an increasing number of such pregnancies as well as a significantly increasing percentage of requests for abortion. The latter exceeded the treatment potential of our hospital, resulting in an overflow group of women whose needs could not be met by existing medical and community resources. Our observations lead us to recommend that social work be regarded as an integral approach to all obstetric-gynecologic care in facilities where therapeutic abortions are evaluated or performed and that private obstetrician-gynecologists consider utilizing social work more extensively in treating the therapeutic abortion-applicant patient.
A T T H I s T I M E when abortion laws are rapidly being liberalized throughout the nation and women with unwanted pregnancies learn of alternatives long denied and long felt to be taboo, there is need for greater community clinical resources where women may be helped to make an early decision required by an unwanted pregnancy entailing minimum emotional sequelae. Under existing conditions, the personal dilemma for most women is compounded by the confusion society presents in its varying laws, attitudes, and resources, thereby diminishing the chances of a healthy resolution of the individual’s problem. It is the purpose of this paper to demonstrate the unique potential of social work to assist constructively such women by examining the social work role both as part of the obstetric-gynecologic From Work
Beth Israel Department.
Hospital,
team treating the therapeutic abortion patient and in its experience with therapeutic, abortion applicants who could not be aecommodated by the hospital. Hospitd
setting
At Beth Israel Hospital, a general teaching hospital of 372 beds, obstetric-gynecologic patients comprised 43 per cent of all admissions, and 3,211 women were delivered during the year ending September 26, 1970. Our hospital as well as other Massachusetts hospitals was deluged at that time by direct calls for help from women with unwanted pregnancies as well as referrals on their behalf by physicians, agencies, and individuals far beyond the capacity of the hospital to respond. The Social Work Department, in addition to its traditional function of working collaboratively with the medical staff on behalf of patients, was also pressured by its
Social
984
Volume 111 Number
Therapeutic
abortion
985
”
own professional commitment into counseling numer’ous would-be patients, limited by few guidelines from customary hospital social work practice and inadequate practical referral resources. Composition
of the
applicant
Table I. Problem pregnancies known to social work. Comparison of No. of women requesting therapeutic abortion with No. of unmarried women carrying to term
group
With therapeutic abortion now providing a new dimension in meeting the age-old problem of unwanted pregnancy, our Social Work Department decided to conduct a study, descriptively analyzing all consecutive applications for service from women with any problem pregnancy between December 1, 1969, and August 30, 1970. Our clinical experience supports our continuing to characterize the out-of-wedlock pregnancy as a problem, even when described by the patient as “wanted” and despite society’s recent relaxation of sexual mores. The unmarried pregnamt woman we see almost invariably describes conception as “unexpected,” implying an essential ambivalence on her part. In addition, we find that illegitimate pregnancy compounds the pre-existing social, economic, and emotional problems of mother, child, and children already born. Our study is confined to hospital clinic patients only. The total obstetric-gynecologic hospital population includes women from 3 satellite clinics and private patients in addition to the hospital clinic patients studied. We chose to omit the satellite clinic patients because their social work records were not conveniently available for incorporation and the private patients as well because their doctors did not consistently refer to the Social Work Department. By December 1, 1969, we had noted that the number of women requesting abortion had exceeded the number of unmarried women who planned to carry to term. Under the all-inclusive term of problem pregnancy, we offered all these women social work and divided them into two mutually exclusive categories: ( 1) all women who requested therapeutic abortion or presumably sought abortion, (2) all unmarried women-single, separated, or divorced-who planned to carry the out-of-wedlock pregnancy to term.
Dec., 1969 to Feb., 1970 March, 1970 to May, 1970 June 1970 to Aug., 1970 Totals
75
55
130
79
65
144
97
88
185
251
208
459
Table II. Requests for therapeutic abortion for girls under 18 (known to the Department of Social Work)
Date Of contnct ~;gjij; Dec., 1969 to Feb., 1970 March, 1970 to May, 1970 June, 1970 to Aug., 1970 Totals
Ytjgd~7tJ;?f
2
9
11
6
3
9
8
11
19
23
39
16
Our study, then, is concerned with social work as it was offered to 208 unmarried women who carried their pregnancies to term, 109 patients who received therapeutic abortion, and 142 other women whose requests for this procedure were not granted in our hospital. Analysis
of applicant
group
Table I shows a steady rise in all problem pregnancies as well as therapeutic abortion requests. Although the total prenatal clinic population rose only 26 per cent during the period studied, the percentage of increase in women with problem pregnancies rose 42 per cent. We note also that during a 15 per cent increase in gynecologic patients there was a simultaneous 29 per cent increase in women requesting abortion. Table II shows that there was a signifi-
986
Addelson
Table III. Requests Social -~
for therapeutic
abortion
by race (known
__________._-.-
_____~___._.._ --.. White
Date
Therapeutic abortion requests
of contact
Dec., 1969 to Feb., 1970 March, 1970 to May, 1970 June,
to the IUepartl~mlt.
oi
Work)
1970
to Aug.,
Totals ‘Totals
1970
65 67 - 66
198 by race
___-.-~-.-.---.~---.__~-~ I!nmarried *omen Therapeutics carrying abortion to term requests 28 25 06
9 I” 131 *
89
i?
287
_---_
- -.
Black llu,r,arried iuomen carrying to term 17 39 jz* 118 170
Total ; problem / pregnancies
129 14.1 18.5 .-. 457) 457f
* These figures may have been affected by a local redistribution of patients due to the temporary closing of a Beth Israel Hospital satellite clinic in Roxbury. tDisparity of this total with that shown in Table I is dw to the fact that ? member of another race arr not included here.
cant percentage of increase in requests for therapeutic abortion in girls under 18. Table 111 demonstrates that 69 per cent of white women requested therapeutic abortion contrasted with 31 per cent of black women. However, black women showed a 12 per cent increase in such requests during our study period. This shift in the pattern of coping with unwanted pregnancy by black women was predicted in previous social work research. These studies examined “Negro cultural apathy toward illegitimacy,” invalidating that simplistic explanation for the greater percentage of black unmarried mothers over white and for the reported tendency of black women to carry to term and keep their babies.l Most social workers who have shared the black unmarried mother’s experience are sensitive to her feelings of rejection in the unmarried status and her ambivalent acceptance of a life predicament where premature motherhood may offer an escape from social competitiveness. One observes the general unavailability of desirable adoption and therapeutic abortion resources as well as economically stable marriage opportunities for her. One may reasonably expect that with the current upward mobility of black people consideration of the timing and values of motherhood will be weighed by them against available economic, educational, and social realities just as it has always been done by nonminority-group mothers. Increased social advantages will not obliterate for the present the general tendency of the
black unmarried mother to raise her own out-of-wedlock child or to keep him within the extended family.’ Each decision made under such improved circumstances will, one hopes, be a truer reflection of individual choice and enhance the opportunity for a healthy mother-child relationship. Our statistics covering June through August, 1970, indicate the following significant characteristics of women with problem pregnancies served by our Department. Almost twice as many women over age 35 considered resorting to abortion rather than carrying to term. Religious differences revealed that among the 80 per cent of our sample who offered this information 52 per cent of the Catholic and 63 per cent of the Protestant women requested therapeutic abortion. Of the small number of Jewish women who use the clinic, 75 per cent of those with problem pregnancies requested abortion. Casework
dynamics
Effective service to women struggling with resolving feelings as well as realistic plannin? for a problem pregnancy draws on the entire range of the professional social worker’s skills. The timing and manner of the pregnant woman’s initial approach to the hospital suggest much about her motivation, her personality dynamics, and her ego strengths as well as her general sophistication. This material is used by the social worker to clarify the meaning of the patient’s request for abortion. For those who have been accepted for
Volume 1.11 Number ‘1
Therapeutic
medical care, the social worker provides supportive casework complementary to the doctor’s m.anagement of his patient, coordinating her skills with medical and other hospital services. For those women who are excluded from the clinic because of logistic considerations, the social worker may still provide various helping services. With all women, her work must be based on an understanding of the dynamics leading to conception and the meaning of the request for termination as well a,s the social and economic relevancies in the environment. Helping
women
clarify
their
needs
Ambivalence toward abortion as a solution to an unwanted pregnancy is present to some degree in almost all women we see. A complex interaction of many overwhelming forces--cultural, developmental, and social -undlerlies the crisis which confronts the pregnant woman. The urge of biological continuity; the positive elements leading to conception, and the frustration and sadness of electing to terminate life, in whatever stage or manner, may usefully and skillfully be explored with such women, whenever pertinent, in the early weeks and measured agains,t the proposed termination. At present, a wom.an recognizes that where the laws are still restrictive she must present a desperate and unequivocal stand to most helping authorities, often exhibiting displaced emotion, to effect her request. What she needs at this point :is the help of a nonjudgmental, professional person in order to assist in clarifying her own thinking and anticipating the consequences of a solution which she might otherwise make in panic or under the immense pressures of immediacy and wellmeaning friends or family. Women arrive at the condition of unwanted pregnancy in varying stages of emotional maturity, but the crisis situation intensifies their vulnerability and may easily lead to disequilibrium.3 The basic casework approa.ch is to meet such women at their individual levels and help them face their individ.ual realities with a clear understanding of their own strengths and long-term
abortion
987
needs. It must include exploring with them the underlying motivation of their decision to abort in order to appraise realistically their reaction to the internal threat of selfdestructive forces whether they defend with an intrapsychic mechanism, such as depression, or extrapsychically, as with projection. This calls for establishing a therapeutic as well as a trust relationship within a critically short period of time. 4 It assumes the client’s right to choose the direction of her own life.5 Such service should be offered to all women with unwanted pregnancies. It may be maintained through a brief or relatively prolonged relationship or may, of course, be rejected. Helping
women
wait
In the more familiar role as a member of the obstetric-gynecologic team, the social worker receives referrals primarily from the resident physician on that service. Social work offers support during a difficult waiting period for those patients who in the doctor’s judgment appear eligible for the procedure under Massachusetts law.6 Interpreted diversely by individual gynecologists, the law allows abortion to prevent serious impairment of the patient’s physical or mental health providing such judgment corresponds with that of the prevailing medical community. Alternatively, during the review period by the medical personnel whose function is to determine final eligibility, those patients initially recommended may be exposed to further uncertainty while already in a highly anxious state. To offset the tendency to regression often found in any critical waiting process, the social worker supports and maintains the patient’s autonomy. Emphasis is placed on the maturity of waiting for a hospital decision as against the impulsivity of self-destructive or manipulative behavior, such as might result in illegal abortion or forced marriage. Alternate plans are considered for the rare eventuality of hospital rejection. Most important, this time is used for the patient to work on more insightful resolution of feelings around the course she is pursuing, which includes the circumstances
988
Addelson
of impregnation as well as the decision to request abortion. With hospital admission finally arranged, it has been our experience that many women continue to need emotional support. Many institutional innovations have been introduced to neutralize the emotional impact on the patient resulting from the physical setting of the procedure. Patients admitted for abortion are now housed whenever possible at the opposite end of the hospital from the maternity ward. Constant communication by means of conferences and consultation among nursing, medical, and social services encourages positive personnel attitudes and reflects the educational aims of the hospital. Obstetricians advise that certain therapeutic abortion procedures require more supportive nursing time and may be more painful and prolonged than labors at term.? Psychiatrists regard the emotionally supportive roles played by all the caretaking people during hospitalization as significant preventive therapy.8 Casework techniques that support the worthiness of the individual in this stressful situation, which usually evokes self-devaluating feelings, may help to lay the groundwork for prevention of sexual acting out in the future. Emphasis on the therapeutic aspect of the abortion procedure as sanctioned by the hospital enables the patient to integrate this whole conflictual experience into a constructive perspective, an egosyntonic process essential for her mental health and further maturation. If indicated, the prospect of postabortion counseling and/or psychiatric treatment may be introduced at this time. Need for support and clarification in extreme ambivalence Social work involvement with patients referred during the abortion evaluation process begins with social evaluation and may continue to casework support or treatment according to the need of the individual patient. Social work evaluation is not part of the medical decision either recommending or rejecting abortion, but it is one of the considerations which may be used by the deci-
December 1, 1971 Am. J. Obstet. Gynecol.
sion-making physicians. In the interdisciplinary approach, the doctor has the primary relationship with his patient, but, in those instances where social and emotional factors threaten to interfere with medical management, the social worker’s contribution of special skills may illuminate patient ambivalence and lead to better total care. Such an instance may occur when patients are extremely ambivalent while proceeding with the abortion they had so desperately requested. Case report Miss B., an 18-year-old unmarried primigravida, presented herself in the clinic as depressed and essentially nonverbal. She stated that she had taken various measures to abort and threatened to continue these if the doctor would not help her. In the social work interview she revealed many ego strengths as manifested by her obvious ability to make difficult and constructive life choices in the past. She had left her southern rural home to acquire training in the Job Corps and now lived in a girls’ residence and worked in a factory. She found it difficult to talk about the alleged father or about her family, both of whom she seemed to keep emotionally isolated from the fact of pregnancy. During the hospital processing period, casework with the patient focused on the following: her own feelings about the pregnancy; her anxieties about the reactions of her family and peers; the meaning of her goals for self-advancement; the realistic means available to assist her in reaching these goals; and the effect upon her goals of continuing the pregnancy. Her suspicion of authority figures and her difficulty in communicating were sufficiently eased in the casework relationship to allow her to express anxiety concerning her deeply rooted equation of aborShe wanted the social tion with “murder.” worker to make the decision to abort for her. It took much work on her part and support and clarification from social work, for her to manage her conflicting needs. Only minutes before surgical intervention was she able to articulate with positive feeling the moral conviction that could not tolerate abortion, which took, she felt, precedence over her other needs. We assume that helping this young woman express her deepest convictions, uncomfortably submerged by more immediate concerns, contributed to greater emo-
Volume 111 Number 7
Therapeutic
tional integrity and ego strength. Without the opportunity provided by casework, she would no doubt have allowed the abortion and probably experienced serious emotional sequelae. Efforts
to offset
recidivism
A patient such as the above required continuing support as she prematurely assumed the maternal role. She was followed in our prenatal clinic and was helped with child care education and family planning as well as in obtaining living arrangements after hospital discharge. Community agencies and a maternal neighborhood figure whom the social worker interested in her behalf provided lsupport for positive emotional involvement with the infant. This particular patient is indeed, almost three years later, using our Gynecology and Child Care facilities, is employed, and appears to be adequately combining the stressful dual role of young adult and mother. Should she encounter serious problems, one may assume she would more readily turn to social work since she had used the relationship prenatally so effectively. In a study of illegitimacy among Aid to Families of Dependent Children clients,9 it was fo’und that the crucial period in the emotional development of the unmarried multipara occurred during and after her first illegitimate pregnancy. Repeated outof-wedlock pregnancies have been psychoanalytically interpreted as symptomatic of complex unconscious disturbance, especially the acting out of a negative identity.lO Psychiatric consultation revealed that an intelligen t, self-supporting, unmarried young woman, pregnant for the third time and demanding a second abortion, was overdeterm&d in her identification with a promiscuous, unloving mother and hence psychologically incapable of living up to her good potential without psychotherapy. Our clinical experience confirms that the optimal time for working with such clients is during and after the first problem pregnancy. It is then that aggressive reaching out by referral to social and psychiatric agencies is required if the ‘client is unable to maintain a useful casework relationship.
Septic
abortion
989
abortions
Other types of social work collaboration with the Obstetric-Gynecologic Service involve the alarming number of women who are admitted to the hospital with a diagnosis of septic or incomplete abortion, where there is history or evidence of attempts to obtain or self-induce an abortion. Three women hospitalized for septic abortion had previously approached the Department of Social Work requesting help with abortion. One, too impulsive to wait out the process of obtaining a hospital abortion, had received psychiatric treatment in our hospital and would, we believe, have been considered favorably for the procedure. The other two women, with fairly stable life histories and college ambitions, were able to use the social worker to assess that they would probably not be eligible for abortion under Massachusetts Law. Both students’ high scholastic performances and educational opportunities primarily motivated their determination to abort and both concluded that they would go to another state where an unrestrictive abortion law was in effect. Later, upon admission to our hospital, one stated that she had aborted spontaneously. She expressed much guilt about these circumstances and about the second unwanted child she had carried. In the social work interviews, she was prepared for long-term psychotherapy. The other patient was helped to express feelings concerning the loss of pregnancy as well as that of the alleged father, a meaningful but inaccessible partner. She continued to use the social worker regularly after hospital discharge while following a previously neglected program of sustained gynecologic treatment for infection and contraception. For those patients who suffer from septic conditions after having obtained a legal abortion elsewhere, the social worker provides an opportunity for expression of feelings about the abortion and the subsequent need for hospitalization for infection. In egosupportive casework, shaken defenses are restored and the patient’s usual ego strength is regained. Those women who are admitted after an illegal abortion often resist social
990
December 1, 1971 Am. J. Obstet. Gynecol.
Add&on
work interviews. Nevertheless, a social worker’s interest in such areas as family relationships or improved work or living arrangements may be expressed. Such inititative from a social worker may become an incentive to healthier adaptive patterns after hospital discharge. As a minimum, someone in a therapeutic setting has introduced the possibility of alternative life goals and the availability of casework when the patient is ready. Social work for overflow
responsibility requests
Service to this group evokes ethical and philosophical considerations. Similar to the doctor, unable to meet the needs of all women requesting abortion within the legal and functional limits of his hospital, the social worker is at the interface of a divergent value system, that of the hospital and the profession. Optimal patient care may require that social workers engage in “forms of expression and action . . . that are often considered controversial.“11 The question of whether these numerous and pressing requests for abortion are the concern of the individual hospital or of other community representatives evokes emotion-laden disagreements. During this period of rapidly changing public opinion and awareness of the abortion problem, our Social Work Department attempted to offer guidance to all women with unwanted pregnancies who requested assistance, but we were soon overwhelmed by the sheer number of applicants. By September, 1970, we found it necessary to offer service only to those women with some prior hospital relationship and to those who requested assistance in person, redirecting other inquiries to available community resources. The women who approached the hospital in such numbers, often coming from considerable distance, seemed to envision Beth Israel as a liberal hospital concerned exclusively with the individual patient’s need. Confused by the suddenness of the unplanned pregnancy, some wanted merely an opportunity to explore possible choices with an experienced professional person either for themselves or a member of their family. Oth-
ers telephoned, sounding confused and mistrustful, disconnecting precipitously for fear of being identified. There were other telephone conversations with women, seemingly stable and controlled, who wished specific iriformation about medical procedures, legal requirements, and reliable resources for obtaining therapeutic abortion but who did not know where to turn. The majority presented themselves as desperately wanting termination of pregnancy. Some of these women needed care in addition to a response to their initial request for abortion. They were advised to come to the hospital for evaluation. One 23-year-old mother of 5 children called too late in the pregnancy for any consideration of termination, and another 38-year-old woman, separated from her husband, expressed fear that LSD taken at the time of conception had damaged the fetus. A prolonged telephone conversation with each seemed to allay anxiety and to initiate a course of useful action. Both women are currently attending our prenatal clinic, and the social worker, in collaboration with the obstetric team, is helping them carry to term. The social worker is offering casework aimed at assisting these women maintain their ego strengths during and after the crisis of an unwanted pregnancy. In urgent cases, the social worker arranged a personal interview and offered brief, crisisoriented casework followed by referral to appropriate resources when indicated. The limitation of time provided a structure encouraging immediate problem solving rather than the expression of subjective preoccupations. “A little help, rationally directed and purposefully focused at a strategic time, is more effective than more extensive help given at a period of less emotional accessibility.“l’ The woman with a healthy ego under stress may often require protective guidance. This is offered in the form of the casework relationship which enhances the clarity of available choices and assists in anticipating emotional reactions to various POSsible decisions. Two mature women overwhelmed by ambivalence decompensated un-
Volume Number
Therapeutic
111 7
der t.he stress of an unwanted pregnancy to such an extent that they did not turn to those safe and logical resources which were easily obtainable. One social work interview with a 41-year-old married school teacher, mother of two young children, who had suffered a postpartum depression after her last delivery, helped her see that her gynecologist was the appropriate person for her to turn to for help. Another client, a 38-year-old, self-supporting divorcee with 3 grown children, employed in a responsible hospital posifon, found it difficult to believe that her good standing as an employee entitled her to th.e same confidential care in her own hospital as is offered to all other patients. Transitional
aspects
of the
problem
Since the period of excessive demand described earlier, we have seen a change in the number and social background of those wome:n who turn to our hospital for abortion. This we believe is a reflection of increased community involvement, less restrictive abortion laws, renewed confidence in the Pill, and patient awareness. It is our impression that those now seen are fewer in number and more likely to be disturbed, dependent and pressured by excessive reality demands and more disadvantaged than those women seen in our study.With the reduction of the heavy, indiscriminate demand upon our hospital resources, its facilities may more appropriately be utilized by these unstable and deprived patients, for whom social work has traditionally had much to offer. More mature women with financial and social resources quickly utilize facilities made available by new laws, new agencies, new policies of existing institutions, and a more accepting attitude toward abortion on the part of the public and the medical profession. Such women will turn increasingly to obstetriciangynecologists of their own choosing or travel to areas where therapeutic abortion is more readily available. As a result, we see a rising tide of therapeutic abortions performed ever more skillfully and efficiently but with lessened consideration for the individual’s emotional health.
Relevance
for
the
abortion
991
physician
In view of this increasing demand for therapeutic abortion on the private practitioner who may not be part of a team including social work or psychiatry, consideration of the approach and techniques described in this study may be useful. A psychiatric view of abortion dispels the concept that there are any unequivocal indications available to a therapist, be he psychiatrist,13 social worker, or gynecologist, which predict the amount or quality of the emotional damage that will ensue from enforced continuance of an unwanted pregnancy. Since psychodynamic considerations often conflict and vague legal criteria further invalidate any consistency in decision making, a physician will tend to support the side of the ambivalence that identifies with his own personal thinking. By assuming a nonjudgmental approach and viewing the unwanted pregnancy not as an isolated circumstance but as part of a woman’s ongoing needs and drives, the gynecologist could be most effective in helping an applicant for therapeutic abortion determine whether she is reacting to self-destructive or essentially healthy forces in her personality. In her search for realistic choices, he could help her separate sexual and procreative functions and sort out priorities so that her ego functioning is strengthened and not threatened by responsibilities masochistically undertaken and involving emotional demands with which she cannot cope. This period of self-determination arrived at with the aid of professional understanding could be an insightful time, culminating in a truly therapeutic experience with redirections toward more positive ego-fulfilling behavior. Where prior professional commitments make it impossible for a physician to provide the exploration and long-term support that may be required or when he identifies psychosocial disturbance, it would be hoped that he would use social work in a mutual endeavor to meet the patient’s total needs. Recommendations
Until society resolves the issues of family planning, sex education, and acceptance of
992
Addelson
legal termination of pregnancy according to individual wishI and offers equal services to all, disregarding racial, ethnic, or economic factors, we may not expect the woman with an unwanted pregnancy to find her way to a healthy resolution of her problem unaided. Our clinical experience teaches us that most women facing the problem of unwanted pregnancy can utilize crisis-oriented, shortterm casework or guidance depending on individual need. This professional intervention not only helps a woman make the crucial decision-whether to keep or place her child for adoption or to seek a medical abortionin accordance with her most basic needs but also supports her self-esteem during and, when useful, after the crisis of unwanted pregnancy. The immaturity of many who have emancipated themselves from the familiar influences of family, church, and school and who face an unwanted pregnancy a10ne,15 the confusion in locating helping resources, and our experience with the emotional and social instability in most women during this critical
REFERENCES Shapiro, D.: In Unmarried ParenthoodClues to Agency and Community Action, New York, 1967, National Council on Illegitimacy, p. 58. H. J., Jones, W. C., Borgatta, E. F.: 2. Meyer, J. Sot. Work. 1: 103, 1956. 3. Caplan, G.: Principles of Preventive Psychiatry, New York, 1964, chap. 6, Basic Books, Inc. 4. Rapoport, L.: Sot. Service Rev. 1: 31, 1967. 5. Report of the Task Force on Family Law and Policy: Citizens Advisory Council on the Status of Women. Washinaton. D. C.. Auril, 1968, p. 31. ’ ’ 6. Massachusetts Law originally prohibiting abortion (G.L., Chapter 272. Sec. 19) is currently interpreted according to the most recent Supreme Judicial Court’s decision in Comm. vs. Wheeler (1944). 315 Mass., pp. 394-395. 7. Goodlin, R. C., McLannan, C. E., Choyce, J. M., et al.: Obstet. Gynecol. 34: 5, 1969. 1.
Decembel 1, 1971 .4m. J. Obstet. Gynecol.
period all suggest the need for the availability of professional social work. For greater effectiveness, such casework should be offered in those public health facilities providing early pregnancy detectionI in all facilities which offer the range of obstetricgynecologic care, and to private patients of obstetrician-gynecologists. This service should be offered in a manner that permits and encourages potential clients to use it. Social workers, we believe, are uniquely qualified by their training to play an essential and ongoing role in helping women with unwanted pregnancies meet this crisis. They are already strategically placed in many hospitals, agencies, and community units where people in trouble turn for confidential help with personal problems. With their routine presence in the medical facilities where women with problem pregnancies turn and their greater utilization by private physicians, social work, we believe, will ensure the optimal emotional benefits from the quality obstetric and gynecologic care now being given.
8. 9.
10.
11.
12. 13.
14.
15. 16.
Caplan, G.: Med. Sot. Work 4: 153, 1955. Griswald, B. B., Wiltse, K. T., and Roberts, R. W.: Illegitimacy Recidivism among AFDC Clients,, 1 pp. 20-21. Erickson, E. H.: Psychological Issues, ed. 1, New York, 1959, Vol 1, International Universities Press, pp. 129-146. Committee on the Study of Competence: Guidelines for the Assessment of Professional Practice in Social Work, New York, 1968, National Association of Social Workers, p. 16. Rapoport, L.: Sot. Work Rev. 2: 217, 1962. Group for the Advancement of Psychiatry, ed. 7, New York, 1969, No. 75, pp. 215, 219. Deutch, H.: Psychology of Women, New York, 1945, vol. 1, Grune & Stratton, Inc., pp. 179-188. At seventeen the road to abortion is lonely, The New York Times, October 18, 1970. Pion, R. J.: Obstet. Gynecol. 34: 300, 1969.