This is a presentation specifically prepared for medical students to give an overview of the abortion recovery process and the types of help available so that medical students are prepared to make appropriate referrals for patients with unresolved abortion issues.
We know that many women experience adverse reactions to abortion. We know this from published studies and also through a grassroots movement of the women themselves who help each other through the abortion recovery process. Women on every continent are sharing their personal abortion stories through outreaches such as Operation Outcry (www.operationoutcry.org) and the Silent No More Awareness Campaign (www.silentnomoreawareness.org/index.aspx). Women are starting support groups and faith-based recovery programs that are multiplying, as those who are helped often desire to start new groups to help more women.
Rachel's Vineyard (www.rachelsvineyard.org), the largest abortion recovery ministry in the world, has a schedule of approximately one thousand weekend programs per year worldwide. Rachel's Vineyard has served more than 200,000 women since it began. Just looking at these numbers, we see that many women feel the need for help with abortion recovery issues. If no one were having any problems associated with their past abortions, why would 200,000 women give up a weekend to attend a Rachel's Vineyard program?
And Rachel's Vineyard is by no means the only abortion recovery program. The Abortion Recovery Care Directory has referred 200,000 people to abortion recovery programs operated by their affiliates since they started in 2007 (Abortion Recovery International, 2011). There are many programs, and they continue to grow and spread. This illustrates that many people desire help associated with their abortion experience.
The good news is, many women and men do recover after abortion, but for many it requires an intentional process. It doesn't always happen spontaneously with the passage of time. I've known grandmothers who were still grieving their abortion, decades later. The oldest woman I personally knew was 80 years old when she phoned me for help with a World War II era abortion.
It's important for medical professionals to understand the recovery process, and to be aware of resources for patients, and programs to which patients may be referred. Some physicians (men as well as women) may need help with their own abortion recovery, perhaps because of an abortion that took place during high school or during the pre-med years. Some physicians with a special interest may want to have in-depth training to be able to serve in abortion recovery programs, personally helping with the recovery process.
I want to start by giving a framework for thinking about abortion recovery. We'll consider the importance of faith-based recovery programs, and peer support programs, and the validity of referring to these kinds of programs. We'll look at some specific programs and resources which may be useful.
In 1987, I read an article by clinical social worker Sr. Paula Vandegaer, L.C.S.W. (founder of International Life Services), who taught that there are four relationships in which healing or reconciliation is needed after an abortion: the relationship with God, with the aborted child, with the other people involved, and with oneself (Vandegaer, 1987). Over the years, the more I've worked with post-abortive individuals, the more I've seen the truth and the usefulness of this framework for understanding the recovery process.
1. Reconciliation with God: Whether you personally are an atheist, a Baptist, a Catholic or a Hindu, in the United States, the majority of your patients have a Christian belief system whether or not they attend church. A Gallup poll showed that 7 out of 10 Americans self-identify as Christians (Gallup, 2001), and I saw this in my own private practice over many years. On a form that new patients completed, I asked patients to state their religious affiliation, and asked whether their religious beliefs helped them to cope with their stresses. The majority of my patients identified themselves as Christian. Some said their faith was a resource that helped them cope, while others said, "no, but I wish it did."
As we saw with Melody (during the previous presentation; see also Shuping, 2011), women of faith do have abortions. In Melody's case, her pastor had given her permission, and in fact had urged the abortion, but her own heart had not given permission, and she believed she had committed the unforgivable sin.
On a Rachel's Vineyard weekend, I met a grandmother in her sixties who had raised her grandchildren, sending them to Catholic school for their education. But at the time I met her, she had not been attending Sunday worship for decades, because she believed she was permanently excommunicated by the Catholic Church, and that she could not be forgiven - though that is a complete misunderstanding of the Catholic belief concerning abortion.
The lady in her 80's who phoned me wanted my help to connect with a Catholic priest who could help her to reconnect with God after fifty years.
Regardless of what we as professionals believe, many of the women who have had abortions have a deep need to reconcile with God and with their own faith community, and they will not fully recover until that need is met. There is also some evidence of this even in non-Christian cultures.
2. Reconciliation with the baby: In a qualitative study of English women at menopause (Dykes et al., 2010), all of the women reported that they continued to think about the child they had aborted many years previously.
Jenny said, "I've always thought of him … wondering how old he'd be, I do wonder about that child."
Elaine also thought about the baby and remembered the expected due date each year, thinking of what age the child would be.
Tina also reported "wondering what it would have been like now, how old would it have been."
Issues concerning the aborted child are often very persistent.
Women who experience the death of a child during infancy would normally have the comfort of a religious funeral and burial, with the prayers and support of family and friends. Donations might be made to a charity in memorial of the child, and there would be cards and special mementos. In the case of a stillborn, the mother would be able to see and hold her child, and say her good-byes. The loss of a child is devastating for most women, but at least there is a measure of support through funeral rituals and customs.
But with an abortion, there are rarely opportunities for social support from others. Typically, the abortion is done in secrecy, and those who know about it may have encouraged the abortion in order to keep the secret, as we saw with Donna (in the previous presentation; see also Shuping, 2011). In a study of women who participated in faith based abortion recovery programs, almost one half reported that only two or fewer people knew about their abortion (Layer, 2004).
With an abortion, there is "no body, no burial, no photos…" in addition to the lack of social support. (Layer, 2004, citing Harvath, 1990). The woman is typically alone with her grief, with no guidance or direction for processing her grief and coming to closure. Popular women's magazine have "how to" articles on for needs ranging from diet plans to parenting questions to breast cancer support, but never "Three things you can do to recover from abortion." A woman's OB/GYN can make a referral to a breastfeeding support group or a breast cancer support group on a moment's notice but may never have heard of abortion recovery groups, and may not even know about the abortion - out of shame, the woman may have gone to an anonymous clinic without telling her own physician.
McAll and Wilson in the Southern Medical Journal list twelve reasons that women may experience unresolved grief after abortion, including factors such as lack of a funeral, lack of recognition by others that a significant event has occurred, with caregivers, friends and family encouraging denial, "rarely encouraging the woman to cry, or talk about her loss…" (McAll and Wilson, 1987). They report a series of cases in which a private Memorial Service that included Christian Communion helped patients and their families to resolve grief and to improve psychiatric symptoms.
Women who find their way to various abortion recovery programs offered by faith based organizations typically have an opportunity to name their baby, and to participate in a Memorial Service. Through prayers, Scriptures, music, and actions, women are comforted by the belief that the child is at peace in the care of a loving God.
In the Rachel's Vineyard weekend, women are given a small fabric doll to use as a tool to help focus their grief. Women keep the doll overnight and are encouraged to express their feelings on paper. On Sunday, during the Memorial service, they will place the doll in a cradle or a basket at the altar, symbolically entrusting the child to God's care as they say good-bye. Women also receive a rose and other mementos that help them to maintain a positive memory of the child they have lost.
Nancy Buckles, while Acting Director of Counseling and Psychological Services within the Student Health Service of Indiana University, wrote in 1982 that there can be a need for saying goodbye while at the same time maintaining a "positive remembrance." (Buckles, 1982).
She wrote, "Women who need to say goodbye to a fetus need to let go of the affect still attached to it. Yet the existence of that fetus and its impact on their lives is something these women clearly do not want to forget. The second part of the process, then, becomes the establishing of positive remembrance of the significant meaning of its existence to the woman."
Buckles describes a secular approach appropriate to a state university, utilizing gestalt therapy to facilitate the woman's expression of "appreciations, resentments, and regrets," then creating something to memorialize the baby. She gives an example of Karen who was appreciative to "my baby" for giving her the "awareness that she could create life and had the potential for nurturing it." Karen made plans "to begin a window garden to which she made important additions on the anniversary of the abortion." Another woman, Ellen, chose to light a candle annually on the due date.
To see an artistic representation of something that many women experience during their abortion recovery: http://www.4life4family.org/sculpture.
3. Reconciliation with others: As we saw with Donna and Melody, parents or husbands may pressure for an abortion of a baby who is very much wanted by the mother. Donna was finally able to forgive her mother and experience freedom from anger when she attended an abortion recovery weekend. It is easy to see that a woman in Melody's situation might need marriage counseling.
Even in cases where the decision was not pressured, there may still be a need for healing within the marriage. Emma made the decision to have an abortion, but afterward felt that if her husband had really loved her, he would not have allowed her to abort their child. The husband on the other hand felt that it was expected that this was a woman's decision and it was his job to support her decision, though he wanted the baby. Decades later at a Rachel's Vineyard weekend, they shared their true feelings with each other for the first time and grieved together, experiencing healing in their relationships.
Abortion is a very isolating experience, and it's vitally important to help people to reconnect with others in their lives and to help family and friends to be supportive. The Rachel's Vineyard program allows participants to invite guests to the Memorial Service, which facilitates this reconnection. In one case, a young woman had gotten the abortion at the insistence of her father who could not understand why she was moping around instead of returning to college; after he heard a dozen women tearfully express their grief during the Memorial Service, he was able to acknowledge his daughter's loss and to begin to grieve his own loss of his grandchild.
4. Reconciliation with self: During the Rachel's Vineyard, we read a story from the Bible in which a woman has been caught in the act of committing adultery and the men of her village are going to stone her to death. Jesus stops the men and then tells the woman that he does not condemn her. I remember one woman saying, during the discussion about this story, "They should throw the rock at me. I deserve to die."
In the qualitative study of English women at menopause, all of the women said that the past abortion caused her to view herself in a negative way, which is clear from the quotations that were included in the report (Dykes, et al., 2010)
Ann said, "It's haunted me to be honest, I'm ashamed, I think it's just something else I have to hate myself about."
Elaine said, "It were wrong, I feel worse than a prostitute."
Claire said, "I'll probably have nightmares the rest of my life, I hate myself."
Freed and Salazar "found that the lack of self-forgiveness is a common obstacle" that can prevent resolution of post-abortion grief. (Layer, 2004, citing Freed and Salazar, 1993)
So, we see that women often experience shame, self-hatred and lack of self-forgiveness after abortion. Additionally, one of the symptoms of PTSD is that you have a sense of a "foreshortened future," meaning, you lose the ability to have hopes and dreams for your future. An effective recovery process must help women to forgive themselves, to replace shame with a healthy self-esteem, and to become able to look toward the future with hope.
To recap the four steps: There are a variety of formats in use for abortion recovery, but the common denominator is that the most effective programs will address four broad areas that include reconnection or healing in relationships with God, the baby, others, and self. These steps often can be completed most effectively within one program such as a twelve-week support group, or a weekend retreat, but aspects may be addressed separately, for example, when a woman seeks reconciliation with God with help from a priest or minister, participates in a Memorial service through a faith based organization, then goes to a marriage counselor to work on her marriage, while seeing an individual therapist to resolve self-esteem issues.
However, it's important to recognize that most therapists are not familiar with abortion recovery issues. Because the American Psychological Association maintains that women are not experiencing abortion related mental health problems, therapists are not being trained in these issues, and research into treatment has been limited. For similar reasons, many clergy are also limited in their ability to help, making it desirable that women be referred to a specific, established abortion recovery program staffed by trained personnel.
The book The Four Steps to Healing (Shuping, McDaniel, 2007) is a self-help book that can be used by patients needing help with abortion recovery issues, which also provides background that may be useful for medical students and health professionals. For those who are too fearful to participate in individual or group programs, the book facilitates women beginning their recovery on their own, while at the same time, the case examples provided can help women to understand what benefits they may experience from participating in a structured program. (Book is available on Amazon in both Catholic and non-denominational editions.)
There is a body of recent research showing that women respond to stress very differently than men. While for decades textbooks have repeated the "fight or flight" response to stress, that's a guy thing, and it's not what women do. Females "tend and befriend," that is, they tend their offspring and seek out companionship of other females (Azar, 2000). Unfortunately, in an abortion situation, their child is gone, and due to shame concerning the abortion, women typically don't feel free to seek support from friends and family, as we've already seen.
But evidence from rodent studies and studies in humans show that females, when stressed, "prefer being with others, especially other females... Indeed, in humans, women are much more likely than men to seek out and use social support in all types of stressful situations…"
This is an important feature of group programs. While a woman could go through the steps of abortion recovery individually or with the help of a therapist or minister, the group support women receive from other women is a vitally important coping mechanism, and one of our oldest biological systems. Research suggests the "tend and befriend" response may be mediated by oxytocin.
It's also important to remember that women have a long, accepted history of seeking support from other women in regard to health issues. At one time, when breast feeding was out of fashion, it was the women themselves who initiated support groups to teach and support each other in regard to the challenges they experienced in attempting to breast feed. Now, it's mainstream, and most OB's would have the phone number for breastfeeding support when that is desired. There are also groups for breast cancer support, and for women who have been raped or who have experienced domestic violence or childhood sexual abuse. Although most professionals today are not yet familiar with abortion recovery support groups, when considered in the context of other accepted support groups, and with an understanding of the research on how women cope with stress, it should be easy to recognize the appropriateness of such groups.
Some women prefer individual counseling when that is available due to shame and fear of self-disclosing to others in a group. However, most counselors very likely didn't learn anything about abortion recovery in their degree programs, and the specific type of therapy they learned may or may not be effective for abortion issues.
Some counselors who have had training and experience as facilitators in faith based abortion recovery group programs may understand the issues and bring what they have learned in group to the individual therapy setting. Similarly, therapists who are personally post-abortive who have gone through a faith-based abortion recovery program will also be well prepared to help others with the four steps to healing we've described.
But caution is needed in making a referral to a therapist, and I would recommend talking to a therapist about their approach to abortion recovery before making a referral.
One other consideration is that each state has their own licensing boards and there are separate licensing boards for various types of mental health counselors, such as marriage and family therapists, pastoral counselors, psychologists, clinical social workers, and licensed professional counselors. In some cases, there may be limitations or perceived limitations in regard to the extent to which an individual therapist is able to help patients with spiritual issues, aside from the fact that most therapists have not been professionally prepared for and are not comfortable with addressing spiritual issues. But in order to complete all four steps that we've identified, spiritual issues must be addressed. So, women referred only to a secular therapist for individual therapy may never fully complete their abortion recovery.
If your teaching hospital has a pastoral care department, or a chaplaincy department, or a chapel that was built by hospital founders or donors, that is institutional endorsement of the pastoral dimension as an appropriate part of medical care.
As a psychiatry resident in the 1980's, I was taught that within the field of psychiatry there were several different models to consider in our treatment of patients. These include:
We were told that none of us would become experts in all areas, but that we should be familiar with each area and skillful in at least one or two, understanding that we could refer to other professionals with greater expertise in other models. For example, I might provide medication monitoring for a patient with who had severe depression, but refer to a licensed marriage counselor to address marriage problems that were causing stress. A woman with severe depression after a stillbirth might require an antidepressant, and also be referred to a hospital chaplain for pastoral care regarding this perinatal loss.
In regard to many psychiatric illnesses, specific types of treatments are known to respond best to specific interventions, with behavioral treatment sometimes being offered as initial treatment for Attention Deficit Hyperactivity Disorder, while the pastoral approach has always been especially important any time there are bereavement issues.
For abortion recovery issues, it is my opinion that a pastoral model is the most appropriate model for helping. First of all, we are dealing here with grief as one of the issues, and there is professional literature supporting use of a Christian religious service to help resolve the grief issues and associated psychiatric symptoms (McAll and Wilson, 1987). We've also considered the four steps outlined above, two of which clearly are appropriately included in pastoral care. A woman who believes she has committed the unforgivable sin is not going to recover easily with Prozac alone. If she is in distress wondering whether God is caring for her baby, that is again a pastoral concern, though her insomnia, weight loss, and suicidal thoughts may represent a major depressive episode requiring medication.
Nevertheless, of the women experiencing distress associated with abortion, many will need a pastoral approach to help resolve their grief, and we should not feel embarrassed to recommend the most appropriate model for these women (or men). Just as we would refer to any appropriate community resource or support group for a range of needs, we can feel confident in noting that "patient was referred to a community support group for pregnancy loss issues" as well as to "domestic violence support group," or to the food stamp office.
Finally, in Layer's research 86% of women "reported that their religious beliefs played a strong to very strong role in the treatment process," with participants commenting on the importance of including the faith dimension, indicating it was important to them to "accept God's forgiveness" and indicating that Christian faith helped them to "forgive myself."
There are people for whom a faith based program may not be an appropriate resource, but many women are likely to benefit from such programs and for many, a faith based program is the most appropriate referral resource. (Layer's paper also gives further discussion of the appropriateness of faith-based programs).
Peer Support vs. Professional: A "peer support" group typically has a "peer counselor" as facilitator, someone who has personally experienced distress after abortion who has also been through a recovery process and who has then been trained in a particular support group model, often involving a Bible study related to abortion recovery. These programs are structured with written instructions to tell the leaders how to proceed, so that extensive training is not needed, and a graduate degree is not required. This type of faith-based group can be run by a professional but more often, is peer-led. However the workbooks used by such programs typically contain written exercises that lead women or men through the "four steps" regardless of the educational background of the facilitator. The majority of faith-based programs rely primarily on "peer counselors," though Rachel's Vineyard includes both professional therapists and peer counselors along with clergy on every team they establish.
The Rachel's Vineyard retreat was written by counseling psychologist Dr. Theresa Burke, Ph.D. The program originally used a once-a-week format. Later, the weekend format was developed which became more popular. This allows people to come from a distance and complete the program in one weekend, in cases where no support group is available in their area. Both options are still available.
Rachel's Vineyard Ministry is the largest abortion recovery ministry in the world. Their weekend programs are currently being offered about one thousand times per year. Rachel's Vineyard sites are located at throughout the U.S. and also at thirty-five international locations on six continents. Rachel's Vineyard materials are available in numerous languages including English, Spanish, Russian, Chinese, Korean, German, Vietnamese, and other languages.
There are several important reasons that medical professionals should consider Rachel's Vineyard for any patient who desires help with abortion issues.
Every Rachel's Vineyard weekend is conducted by a team that includes at least one mental health professional with at least a master's degree, as well as a team of volunteers and a minister or priest. So, when you make a referral to Rachel's Vineyard, you know that a professional will be involved in their care.
Every team is required to carry professional liability insurance of at least one million dollars. There has never been a lawsuit against Rachel's Vineyard, nor of any abortion recovery ministry that I know, but nevertheless, as a professional, you will be carrying professional liability insurance in that amount, and when you're in practice, you'll appreciate the importance of dealing with insured professionals.
Every team is required to go through a very thorough process of being trained, evaluated, and mentored, and every team is required to participate in a continuing education conference sponsored by Rachel's Vineyard at least every three years. There are also opportunities for ongoing consultation and mentoring so that each team can benefit from others with more experience. I know of no other program that provides a comparable process for training, evaluation and continuing education and support.
Rachel's Vineyard includes men and women on the weekend, though the program originally started with women only, and the greatest numbers are still women. This is different from some programs that will only accept women, and others that run groups for men or for women separately. Rachel's Vineyard can take husband and wife together if desired, which helps both parties to heal, and promotes healing within the marriage which is so often affected by abortion. Men can also attend a Rachel's Vineyard weekend on their own, for example, single or divorced men, or perhaps a married man grieving a past abortion that occurred before the marriage.
Rachel's Vineyard also allows family members to attend the weekend if desired, or to attend the activities on the Sunday afternoon, which helps the post-abortive individual to reconnect with family members and gain their support, if desired. But that is not required.
But the most important reason I love Rachel's Vineyard is: it works. People are helped; lives are changed.
I have personally conducted more than 50 Rachel's Vineyard weekend on three continents. In my experience, the Rachel's Vineyard retreat is both safe and effective way to help men and women who suffer from the effects of abortion.
To verify what I was seeing on the weekends, I conducted an "outcome study" regarding the Rachel's Vineyard retreat which I presented in 2004 at the Rachel's Vineyard international leader's conference. This study confirmed what I had observed, that the Rachel's Vineyard retreat it is a safe and effective way to help women and men to heal after abortion. (This study is also published in the book Sharing the Heart of Christ, by Kevin Burke, L.S.W., Theresa Burke, Ph.D., and Fr. Frank Pavone, 2009).
This study included 241 past participants of the weekend retreat from 22 different states. Participants were asked to rate their experience of Rachel's Vineyard on a number line indicating a negative number if Rachel's Vineyard harmed them, indicating zero if the retreat neither helped nor harmed, and indicating positive numbers 1 through 5 if the retreat helped them. The average rating was 4.75 with no negative numbers.
In the study, we also asked questions to find out to what degree these participants had originally been experiencing mental health problems prior to the weekend. The majority of responders, 70%, indicated a past history of mental health treatment, 48% reported a past history of alcohol or substance abuse, 65% reported a past history of suicidal thoughts, and 17% had made an actual suicide attempt - during the period after the abortion and before the retreat. So you can see that those surveyed had experienced much distress after their abortion, clearly a group of fragile individuals, many demonstrating suicidal thoughts or behaviors in the past, and yet no one from this group said that the Rachel's Vineyard harmed them in any way. Rather, 82.7% rated the retreat as "5," the highest rating possible, with the average rating being 4.75. Thus, in this group which had suffered greatly from their abortion, there was no harm from the weekend, but rather, tremendous healing.
Many experts who specialize in posttraumatic stress disorder have stated that "talk therapy" is typically not helpful in treating this disorder, and that sensory-based treatment is essential. This is because traumatic memories are stored in a non-verbal part of the brain. It is important to use non-verbal means to help integrate these traumatic memories into areas of the brain that can process information verbally.
The Christian Church has a very long history of sensory-based worship that includes music, candles, flowers, stained glass windows, oil for healing prayer, bread and wine for Communion, water for baptism-things that we can see, hear, touch, taste and smell, using all our senses. The Rachel's Vineyard retreat also integrates a sensory based element to each activity throughout the weekend, Using all the senses helps people integrate words, thought processes, emotions and memories so that people can come to closure. There is nothing mysterious about use of these types of resources, which have been very familiar to Christians for many centuries. It should not be surprising to find that these resources can be a means of facilitating emotional and spiritual healing as has been demonstrated in trauma research.
This is a structured, faith-based program with written exercises based on the Bible. Every exercise includes a Scripture reading and a meditation based on the Scripture reading, followed by prayer and discussion along with an activity that helps bring the meditation to life, which could be lighting a candle when blind Bartimeus is healed, or pouring of water after reading about the woman at the well.
The Rachel's Vineyard Catholic edition has received an Imprimatur, indicating full Catholic approval. The name comes from Rachel in the Bible, who wept for her children, linked to the image of the fruitful vineyard tended by the Lord. There is a separate interdenominational edition that is appropriate for Protestants and also non-denominational Christians.
People who know of Project Rachel may wonder if there is a relationship to Rachel's Vineyard. Project Rachel was founded by Vicki Thorn and has become the official Catholic outreach for abortion recovery sponsored by the United States Conference of Catholic Bishops. An important aspect of Project Rachel is that it has organized a referral network so that people in any part of the United States can make one phone call and learn how to contact a local abortion recovery ministry in their geographic area. People who call can receive a referral to a counselor or to a priest who has experience in helping with abortion recovery. Project Rachel national leadership has been known for a reliance on individual counseling rather than group programs. However, many local Project Rachel ministries typically offer a range of services that can include support groups and retreats or various programs.
In the official Project Rachel Manual, the Rachel's Vineyard retreat is listed as a "recommended resource" (http://hopeafterabortion.com/?portfolio=project-rachel-manual). In the United States, many Catholic diocesan Project Rachel teams use the Rachel's Vineyard weekend retreat as their main abortion recovery program.
Women Speaking Out: These groups provide post-abortive individuals opportunities to tell their stories publicly to create awareness of abortion recovery issues, and direct women to recovery programs.
Abortion Changes YouTM: This website offers "a confidential space is for those who are touched by abortion, whether the experience happened recently or years ago." There is a place to tell your story and to read about the experiences of others, as well as some helps to begin the recovery process. Not faith based. http://www.abortionchangesyou.com/ Associated with the webpage is a self help book: Changed: Making Sense of Your Own or a Loved One's Abortion Experience, by Michaelene Fredenburg. http://www.abortionchangesyou.com/node/963 , and a book for professionals who want to help: Grief and Abortion: Creating a Safe Place to Heal, by Michaelene Fredenburg.