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EDUCATION

EDUCATION

Abortion is a controversial subject in any culture from moral, religious, personal beliefs and medical views of what is right, wrong and the rights of women. In this article I will try to show the approach taken from a psychotherapeutic point of view as to how a woman can be assisted in making decisions about her own well-being, the life of the unborn baby, the personal and social impact of that decision on her life, her family and her relationships. We will also cover briefly and in context the idea of termination, of having an unplanned miscarriage and sudden infant death including infanticide of children in a further paper to be published.The first evidence of an abortion goes back to an Egyptian Ebers Papyrus in 1550 BC that depicted the methods used for relieving the women of the unborn child. (1) Various accounts in history going back hundreds of years discussing abortion whether accepted or not and the penalties of killing an unborn child (often inflicted on the women for disobeying her husband in losing her baby) can be seen – this is not a modern medical choice but a historical phenomenon showing that abortion was an issue from the very beginning as controversial and difficult topic to discuss.In modern days the issue across cultures still rages on with particularly polarised religious and moralistic viewpoints as to what is right, what is allowed and what is seen as wrong (an offence) it is under this pressure and social umbrella that women have to come to terms with the decision of whether once they discover they are pregnant how to decide whether they should terminate of not.Psychotherapy itself makes no judgemental issue as to the rights and wrongs of abortion although individual therapists may have strong religious or moral views of the topic. Where the therapist does have a conflict of judgement they should clearly remove themselves from the situation of counselling a woman or couple of an abortion choice and should leave the matter to more professional therapists that stand by their non-judgemental stance in therapeutic situations. Any psychoanalyst who allows his or her personal prejudices into the therapy room should seriously consider a change of profession or at least declare that their professionalism is tainted by their own belief system. In saying this one should also declare their personal beliefs whether in the pro-life camp or the free to decide camp.In the start of a therapy session boundaries and objectivity should be set from the beginning with the client (patient) letting her or them know the limitations of your service and the difficulty in arriving at a any decision that feels emotionally completely right. In my own practice I usually set the boundary of who makes the decision to abort of not. I make it abundantly clear that the final say is in the hands of the pregnant woman only. That her partner, medical advisers, counsellors, family members are only secondary considerations to her own well-being and decision. This sense of responsibility is very important in the emotional recovery of deciding to go ahead with an abortion. Later she cannot look to anyone else as forcing her, influencing her or otherwise persuading her to go ahead when she was not sure. She must accept it is her decision and her final responsibility to go ahead or not. The reason this is important is that after the event she needs to be emotionally clear that she made the best decision for herself.In the first session it is best to establish the term of the pregnancy so far. (2) This gives you then a timetable for the decision process. Different countries and cultures have differing times limits for when an abortion is still possible medically. Around the world this can vary from eight to twelve weeks with variations from country to country. Therefore if the obstetrician has determined she is 6 weeks pregnant in a twelve week system you have at least five weeks to decide (although a decision to have the abortion should be made as soon as possible as procedures change on how the abortion is carried out medically). Once this timetable is set up it has two effects, one determines the amount of sessions the therapeutic process can be taken over, and two a certain pressure on the woman to come to an early resolution about what she wants to do.Once this is established the woman seeking counselling about an abortion should be encouraged to speak her mind about her fears, doubts and concerns about seeking an abortion in the first place. Once she has vented her view (which maybe quite confused at this point) you can reflect back to her what she stated where her feelings and reasons for the abortion. You should also establish why she is having doubts about the abortion, such as guilt, personal beliefs, practical considerations, fear of loss, inability to have a child in the future (real or not), the impact on her personal relationships with partner, husband, family and friends. It is always useful to have a whiteboard in a therapy office as this can help to list and clarify for the woman a visual cues to her dilemma. Later is can also act as a pros and cons list for her to again give clarity her reasons for an against having the abortion. This first session if very practical in setting the scene for further psychoanalytical discussions. It also helps the therapist to gain insight into the main issues the client maybe dealing with psychologically. At the end of the hour it is a good idea to give a homework assignment to be emailed back to the therapist before the next session. Usually this is a one page biography of her life with the first paragraph dealing with her own parents, family and upbringing, the second her developing years and any significant events and finally a short paragraph on the here and now situation. The reason of one page only is that it helps the client to focus only on the important issues. This biography can then be analysed by linguistic analysis and reflected back the clients at the second session. Why is it important to talk about her background and upbringing? From a psychoanalyst point of view her history can tell us a lot about her mental conflict over her decision for an abortion today. For example a highly religious upbringing, poor parenting, abuse in childhood, sibling relationships, previous personal relationships, prior abortions or sexual history. Any of these areas could be impacting on her current inability to see clearly what her own choices should be in the moment.In the second session it is best to ask the client what her thoughts had been about the clarification process of the first session, then if time, go through and reflect from her biography what issues arose when she wrote it, what thoughts had she about her past influencing the current situation? Also the therapist can reflect what they saw in the biography that struck them as significant and ask for the clients clarification and reflections. All this is to enable the client through psychoanalysis to have insight into their own character shaped by past events and help with a clearer understanding of the reasons for her emotional considerations in her decision making process now. By now a clear idea should emerge about her main thoughts and position of her decision to seek an abortion. She may not have made up her mind completely yet but is certainly getting a better idea of the choice that faces her.At the third session the beginning should establish clearly the current decision situation with the client, best established by asking the client out of 100 where do they see the percentage of for or against the abortion. This will help both client and therapist to establish how much more ground is there to cover before a firm decision can be made bearing in mind the original timetable of the pregnancy. Further sessions depending on the timetable should successfully bring the client to a firm decision of what they intend to do.What are the varying and common issues that arise from abortion counselling? The first issue is the fathers involvement, is he for or against, is he supportive and open or repressed and opposed? Is he in the decision making process or excluded? The state of the relationship itself, happy, strained, difficult or divisive. Is the father deserting the woman, is he unaware of the situation? What of her and his family issues and background has the father to contend with? Her wider family and social circle, judgementalism in the family, others views, pro life or free choice attitudes? Other siblings in the family, previous children and future pregnancy plans? All these issues are concerned with outside influences on the woman herself. In addition there maybe church, work and other components.Economic factors today play a big part in bringing up children, they are expensive, constant and long term. Women whose lifestyles may be free and uninhibited may see the idea of children as restrictive, socially damaging, prevent career advances or promotion, limiting their ambitions and freedom of choice in many areas. The family may simply already have too many children and an addition would tip the economic balance towards poverty. Country or even global economics can be an influence on choice, a downturn in fortunes could signal hard times ahead, not a good time to be bringing children into the world.Social factors in the idea of the future of the world state, terrorism, war, famine can be all wider influencing factors especially on the more intelligent mother to be, whose very education can be a factor in how she sees the future for her child. She may abort simply on the grounds of who would want a child to come into this world right now?Relationship factors, maybe an overriding issues of whether you have a stable environment to bring the child into abusive fathers or partners prone to domestic violence, constant disharmony with no guarantee of the relationship lasting or impending divorce. All this maybe an overriding decision making atmosphere in which abortion maybe to protect the future child from abuse or misery.Historical factors, her own history of abuse, an unhappy childhood, inability to be a good parents as she never experienced good parenting herself. Previous miscarriages, abortions and difficult pregnancies all may impact in her mental state. We are a product of our past and it is impossible to decide anything without that past tainting our present thinking and cognitions.The time factor, is a crucial element in the decision process. Brief focal therapy can help to focus only on the main issues of a quick decision when it is crucial to going ahead or missing the deadline. Longer sessions of two hours maybe a consideration where time is a factor.The fear issue, is when the actual fear of pain, birth and unable to cope with a new baby all give rise to the idea of an abortion as a better option. This fear element is best dealt with practically by asking new mothers to discuss their experiences and joy at the moment of birth. You may of course have to be selective here and of course not every new mother has a good time. Unfortunately movies and television always show birth as traumatic for the purpose of drama – so that the story line contains elements of over exaggeration – the real experience of most mothers is not like this at all and many mothers choose pain methods to help cope with a painful birth. The therapist should be familiar with current medical procedures both in pain relief and birthing methods.Medical issues are where the birth may cause the woman to die in childbirth. This is a purely a medical issue measured by possibilities, disease, DNA anomalies and birth defects.Abortion issues in what happens? Here the therapists should be aware of the methods and procedures of abortion available locally and have a working knowledge of best practice. The time factor makes a huge difference to procedures, early abortions are often half a day through two ingestions of an abortion pill, with a nurse to keep you comfortable and clean during the time. Later abortions require suction methods are more invasive and emotional.The rape issue! Of course of all the controversial issues pregnancies via a rape are the most emotional. The woman may feel forced into motherhood through a violent act. She may see the baby as a daily reminder of her assault and the child looking like the rapist.

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