Tag Archives: abortion

When post-abortion emotions need unpacking

By Bethany Bray April 3, 2018

Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon, has made it a habit to avoid using “must” phrases with clients. “It sends a message to the client about what they’ve experienced,” says Beckett, who specializes in grief counseling. “I don’t ever want to say, ‘Oh, you must feel so guilty,’ or ‘You must feel so isolated,’ because that may not be the case at all.”

A case in point: when clients reveal in counseling that they have had an abortion at some point in their past. Some clients consider that experience to be just another piece of their life story, free of any negative associations. For others, the experience can evoke a range of issues, from spiritual and familial turmoil to attachment difficulties and feelings of loss. When dealing with such a highly charged topic, counselors must be prepared to put their own personal views aside to support clients who fall into either camp — and those who present a range of emotions in between.

Research cited by an American Psychological Association task force found that the majority of women who elect to have an abortion will not experience mental health difficulties afterward (see apa.org/pi/women/programs/abortion/). In February 2017, JAMA Psychiatry published a study titled “Women’s mental health and well-being 5 years after receiving or being denied an abortion.” The study observed 956 women over the course of five years, including 231 who initially were turned away from abortion facilities. Among the authors’ conclusions: “In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women’s access to abortion on the basis that abortion harms women’s mental health.”

Even though most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or encounter other negative emotions caused by external factors such as culture or family. For certain clients, a past abortion experience, whether it took place one month ago or decades ago, can be at the root of a range of issues — low self-esteem, relationship problems, disenfranchised grief — that surface during counseling sessions.

Beckett notes that most of the women she works with aren’t questioning their decision to have an abortion but rather “struggling to process it and place it in the narrative of their own lives in a way that feels comfortable.”

“As a practitioner, you should know about [abortion] and understand that within the population you’re seeing, it’s probably in their story,” says Jennie Brightup, a licensed clinical marriage and family therapist in private practice outside of Wichita, Kansas. “You need to be prepared to know how to work with it.”

Counselors should approach the revelation of an abortion just like any other experience or issue that clients may have in their histories, Brightup says. “Have an open mind. Allow it to be something that can be a problem for your client. See that it could be an issue … [and] have some knowledge about how to treat it.”

‘You think you’re alone’

The Guttmacher Institute, a reproductive health research organization, estimates that in 2014 (the most recent data available), 926,200 abortions were performed among women between the ages of 15 and 44 in the United States. This comes out to a rate of 14.6 abortions per 1,000 women.

The institute notes that this marks America’s lowest abortion rate since the process was legalized nationwide by the Roe v. Wade Supreme Court decision in 1973. The U.S. abortion rate has seen a steady decline after peaking in 1980 and 1981 at close to 30 abortions per 1,000 women. Using the 2014 data, the Guttmacher Institute extrapolates that 5 percent of U.S. women will have an abortion by age 20; 19 percent will have an abortion by age 30; and 24 percent will have an abortion by age 45.

Abortion is more common than many people, including mental health practitioners, think, says Trudy Johnson, a licensed marriage and family therapist who presented on “Choice Processing and Resolution: Bringing Abortion After-Care Into the 21st Century” at ACA’s 2012 Conference & Expo in San Francisco. Johnson, who had an abortion in college, says that for many people, processing the abortion experience is “a slow burn. It doesn’t affect you until later on. [Many] women have had an abortion, but you think you’re alone. You don’t feel you get to grieve it. … It’s a gut-level thing, a tender place. Many have never told a soul,” says Johnson, who specializes in trauma resolution, including abortion-related issues.

Connecting issues

For clients who have yet to process and place a past abortion into their self-narrative, it can feel like a sadness that they can’t quite pinpoint or define. “It’s kind of like a phantom pain. It’s there, but you don’t know why,” Johnson says.

Clients with a variety of presenting issues may have unprocessed emotions surrounding a past abortion that could be compounding their struggles, Johnson says. These issues can include:

Depression and anxiety
Complicated grief
Anger
Shame and guilt (especially shame that is undefined or has no apparent cause)
Self-loathing and self-esteem issues
Relationship issues (including destructive relationships)
Destructive behaviors (including substance abuse)

For certain clients, their unprocessed emotions can feel like a weight they have carried and buried deep within themselves for a long time without sharing it with anyone, Johnson says.

Johnson recalls one client who initially came for couples counseling with her husband but eventually started seeing Johnson for individual counseling. During a session, Johnson recognized that the woman was becoming upset, so she handed her a blanket and pillow for comfort. The client put the blanket over her head, obscuring her face, and disclosed that she had had an abortion 18 years prior. Her family had shamed her for the decision, and her feelings of shame were still so overwhelming that putting the blanket over her head was the only way she could bring herself to talk about the experience, Johnson recounts.

“You just can’t imagine the shame that [some of] these clients carry,” says Johnson, a private practitioner who splits her time between Arizona and Tennessee. “They just have to talk about it. We, as professionals, can be that safe place.”

Clients who have had abortions sometimes question whether they have the right to grieve because there was a choice involved to terminate their pregnancies, says Beckett, who is an adjunct faculty member in the doctoral counseling program at Oregon State University. The concept of the experience of disenfranchised grief — those who are not supported in their grief because it is not culturally recognized or validated — applies in these instances, Beckett says. In fact, the disenfranchisement can be both external (a loss not recognized by the client’s culture) and internal (a loss that the client, individually, does not recognize).

“People do not have the same kind of support and validation [to grieve a loss] when they’re disenfranchised, and that is a huge part of abortion grief,” Beckett says. “The emotional aftermath is so impacted by spiritual, political and ethical values and beliefs. That will really color how they process it and how much they’re able to reach out and get support. This all needs to go into our assessment of a client. What was their experience, but also how are they talking to themselves about it? All of that should inform how we offer support.”

Broaching the subject

Practitioners might want to consider asking clients (female and male) about pregnancy loss, including abortion, on intake forms. Brightup asks clients about past pregnancy loss in a genogram exercise she does in the first few sessions of counseling. If the client mentions an abortion, she simply makes a note and keeps going. It is not a topic she feels a need to jump on immediately, she says, and she doesn’t want to risk retraumatizing clients or prompting them to talk about it if they are not ready. Some clients may not mention an abortion on an intake form or genogram because they don’t consider it a loss or associate it with trauma, Brightup says. Others have buried the issue so deep that they don’t think about it or feel that it is worth mentioning, she adds.

“When you’re hearing their story, you can find places to check in and ask questions. Most of the time, I allow them to come around and tell me. It’s a core secret. If you feel [judgmental] to them, they’ll never tell you and they’ll run [stop coming to therapy],” says Brightup, a certified eye movement desensitization and reprocessing (EMDR) therapist.

Practitioner language is also important, Beckett notes. “For some people, asking [if they have an abortion in their past] is giving them permission to talk about it. And the way we ask about it may give them clues about whether or not it is safe to talk to us about it,” she says. “For example, there’s a difference between, ‘Is this something you have experience with?’ and ‘Well, you haven’t had an abortion, have you?’”

Even the word “abortion” can provoke an intense reaction for some clients, Johnson says. In some cases, she will use the phrase “pregnancy termination” or even “the A word” with clients who feel triggered and begin to close themselves off.

“You might need to say it differently,” Johnson advises. “Abortion immediately turns it into a political, socially charged [issue]. Changing the terminology helps it to be safer.”

The key is to foster a safe, trusted bond so that clients will feel free to bring the topic up themselves when they are ready, Johnson says. “The most important thing is building a relationship of safety,” she emphasizes.

Different points on a path

Clients who disclose having an abortion in their past may vary widely on how they feel about the procedure and how much they have processed those feelings.

“There are clients who will come in and do not report having any mental health issues related to their abortion experience. Understand that they’re out there. But the other side is out there too,” Brightup says. Practitioners must be prepared to work with clients who express either sentiment — or a range of feelings in between.

Counselors should watch their clients’ body language and other cues, especially in cases in which a client is emphatic or even defensive when talking about an abortion. It is wise to unpack the client’s experience and associated feelings over time, Brightup says.

If counselors disagree with a client’s assertions concerning how she feels about the procedure, “you can lose the client because they won’t come back [to therapy],” she says. “Agree with their narrative. In little pieces, once they trust you, you can come back to the story and probe a little, ask a few questions as gently and carefully as you can.”

Some clients will have fit the abortion into their self-narrative and moved on, whereas others won’t be as far along in the journey. Still others will have worked through their feelings surrounding the procedure in a healthy way previously but may find themselves struggling with it again as they move into another life stage such as pregnancy or motherhood, Beckett says.

This was the case for one of Beckett’s clients who sought counseling because she was struggling with powerful emotions that had resurfaced. The client had undergone an abortion when she was 17. Later in her life, she had a daughter, and that daughter was now turning 17 herself. Even though her daughter wasn’t facing any type of decision regarding pregnancy or abortion, her age triggered feelings in the client that needed more therapeutic attention.

The client’s abortion had been illegal at the time where she lived, so she had felt compelled to keep it a secret, Beckett explains. The client realized her daughter was now the age she had been when she had an abortion. “The mother saw, for the first time, how young she [had been] and how desperately she had needed love and support at the time, and she didn’t get it,” Beckett says. The realization was “exquisitely painful” for the client, but at the same time, it brought “a new level of compassion for her 17-year-old self,” Beckett recounts.

“She took a great deal of comfort in knowing that if her daughter were to get pregnant, it would be an entirely different experience. Her daughter would have the support of her family and better care,” Beckett says.

The hard work of unpacking

Just as clients will differ in the work they have done — or haven’t done — to process the emotions surrounding an abortion, the support and interventions they might need from a counselor will also vary.

“People grieve very differently, and we need to be ready to support people however they are doing it,” Beckett says. “Some people are going to want to take action or give back somehow. Others will respond to more creative processes or ritual creation. Others will want a quiet, safe place to process.”

Normalizing a client’s experience can be a much-needed first step. Beckett says that talking about how common abortion is, and the fact that many people feel a need to process their feelings afterward, can bring relief to clients. Practitioners can also help clients reframe their thoughts to realize that feelings of relief after the procedure are common, as is a fear of judgment and a sense of isolation that can accompany that fear.

“Figure out what this particular client’s experience is and then, if appropriate, offer normalization of that,” Beckett says. “Support them to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

In Brightup’s experience, post-abortion work with clients often falls into four quadrants:

Reconciling how clients feel about themselves
Engaging in grief work around how clients perceive and feel about the loss (if they do indeed view it as a loss)
Working through clients’ spiritual issues or any inner tensions related to “rules” that were broken
Working on clients’ relationships and how they relate to people: Are there areas that need healing?

From there, practitioners should tailor their approaches to meet each client’s individual needs and pacing, Brightup says. She often uses sand tray therapy as a tool to help clients talk about post-abortion loss and find closure. Journaling, writing letters or poems, creating art and engaging in other creative outlets can also be helpful, she says. Certain clients may respond to creating some kind of physical memorial or taking time out of a counseling session to do a remembrance with just the two of you, Brightup adds.

Beckett agrees that counselors should collaborate with clients to find a ritual or activity that works for them. Although many clients will make progress through talk therapy or by connecting in group work to those who have had similar experiences, others will feel a need to take some kind of action, Beckett says. Creating memorials and rituals, writing letters or participating in other creative interventions can help these clients to process their emotions and experiences.

For one of Beckett’s clients, healing involved creating a special ritual on what would have been her child’s due date. Each year, the client would be intentional about spending time with a child — whether a niece or a nephew or the child of a friend — who was the same age that her child would have been.

“She came in pretty soon after her abortion, and she knew she needed help to process it,” Beckett says. “She wasn’t questioning the decision, but she was having trouble [with the fact] that her life would move forward but the life of the baby she had not had wouldn’t move forward. She wrote a letter to that baby expressing her caring and regret and explaining why she felt she couldn’t bring him or her into the world. Every year on her due date, she would find a way to connect with a child she knew that would be that age. She would spend time with that child and make it a good day for them.”

Whereas this intervention helped this particular client to find peace, “for other clients, the thought of that would seem hellish,” Beckett stresses. “There’s no prescription for this. It’s a process of figuring out what is still remaining and needs to be released. Talk with the
client to find creative ways to be able to do that.”

Counselors can help clients navigate areas in which they feel emotionally stuck, Beckett explains. For example, one of her clients was struggling even though she had worked through many of the emotions she had experienced after an abortion. The client had three children, and when she became pregnant with a fourth, she and her partner made the decision to terminate the pregnancy.

“There was one part that she couldn’t get OK with: ‘I see myself as someone who takes care of others,’” Beckett says. “That’s where we focused: How did she define ‘taking care’? How did this decision threaten her self-concept? We dove into that area and she eventually realized that terminating the pregnancy was taking care of her fourth child. That was the best way to take care of that child, instead of bringing the child into an already-overwhelmed system that wouldn’t have been able to provide what the child needed.”

Johnson finds narrative therapy a useful approach when focusing on post-abortion issues with clients. Giving them the freedom to tell the story of their abortion — how old they were, how it happened, who came with them that day — can be powerful, she says. Sometimes clients won’t remember the details about their abortion because they’ve blocked them out, Johnson says, but as they open up and talk about the experience in therapy, they often start to recall things.

“This has been in their head for years. When they finally start talking about it, they go on and on because that’s [often] what they need,” Johnson says. “You can see the layers coming off as they’re processing it verbally, the whole story. … Letting them talk about the details and tell their story is a starting point.”

When relevant, Johnson also helps clients identify all the points of grief connected to the abortion beyond the loss of a pregnancy. For example, clients might have experienced a breakup with their romantic partners or the breakdown of a relationship with their parents or other family members either leading up to or after the abortion. Giving clients permission to grieve and accept the loss of these things is an important step, Johnson says.

There are “so many layers to this. The main thing [for counselors] is being a safe place. The impact of a hidden abortion could really be affecting the outcome of your therapy if it’s not addressed. Be aware that there could be this issue under all of the other stuff [the presenting issues],” Johnson says.

“Treat this as a disenfranchised and complicated grief situation, and take out all the political mess and pros and cons,” she continues. “The client has already made a choice. Let’s forget about that and just work on the grief. They’re not the same person that they were when they made the choice. They’re a different person now, so they need to have permission to revisit that time in their life and be free of it. The therapist is kind of a vessel of freedom for that, and it’s a wonderful place. … You’re helping them overcome the bondage, pain and grief that’s been with them for so long.”

Putting personal feelings aside

Abortion remains one of the most politically and socially polarizing issues in modern-day America. Despite this — or, in some cases, because of this — certain clients are going to need to work through issues related to abortion in the counseling office. A practitioner’s role is to be a support through it all, regardless of his or her own personal views on the topic.

Brightup urges counselors to rely on their training, which includes setting personal opinions aside and being what the client needs.

Creating a neutral and welcoming space for clients to talk about such a sensitive topic is paramount, Johnson agrees. “If you don’t have any experience working in this area, you can do more damage without meaning to,” she says. “Or, for some people, there’s a hidden implication that if you help a client through feelings related to an abortion, you’re condoning abortion.” That is simply not true, she stresses.

Beckett agrees. “Clients need a safe and nonjudgmental space to share [about their abortion experience], and that’s hard for some counselors based on their own belief system. It’s not going to be easy for all counselors — that affirmation of [the client’s] right to grieve. [But] a client needs support to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

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Disclosing an innermost secret

As clients process post-abortion emotions, they may struggle with the decision to tell others, including a current or former partner. What should a counselor’s role be in that process? Read more in our online-exclusive article: wp.me/p2BxKN-54z

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Related resources

For more on the mandate for counselors to practice competent, nonjudgmental care, refer to the 2014 ACA Code of Ethics at counseling.org/knowledge-center/ethics/code-of-ethics-resources. ACA members with specific questions can schedule a free ethics consultation by calling 800-347-6647 ext. 321 or emailing ethics@counseling.org.
Interested in networking with other ACA members on this and other related issues? ACA has interest networks that focus on women’s issues, grief and bereavement, sexual wellness and other topics. Find out more at counseling.org/aca-community/aca-groups/interest-networks.

The Professional Counselor journal article, summer 2019 (page 100, Volume 9/Issue 2): “Supporting Women Coping With Emotional Distress After Abortion“

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Disclosing an innermost secret

By Bethany Bray March 26, 2018

Should I tell my partner about my abortion?

Fielding questions about sensitive and complicated topics is all in a day’s work for many professional counselors. This question, however, is one that counselors must handle with particular care.

Abortion is among an infinite number of scenarios that clients might want to work through with a counselor so they can fit it into their self-narrative. Telling others about their abortion, whether it occurred one month ago or decades ago, can be an action that some clients consider as they work through the feelings they may have related to the procedure.

Sharing their story — both in therapy and in other outlets — can be one of many potential ways that clients find release and closure, says Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon. Counselors can offer support as clients weigh their options and decide whether to disclose an abortion to a former or current romantic partner, family members or friends.

“Help the client assess the potential risks and benefits of sharing, with whom and when, and support them in a decision they feel good about,” says Beckett, an adjunct faculty member in the doctoral counseling program at Oregon State University. “Help them thoughtfully consider and think through what is going to be the most right for them, and perhaps introduce different options [to them as the counselor].”

Trudy Johnson, a licensed marriage and family therapist who splits her time between Arizona and Tennessee, notes that when clients feel ready to tell others about a past abortion, it can be a sign of progress. At the same time, counselors should remind and help prepare clients that their family members and friends may not feel the same way that the client is feeling.

“You can share with others, but you have to be strong enough not to worry about how they are going to respond. Remember, they are not in the same place as you,” says Johnson, who presented on abortion-related issues at ACA’s 2012 Conference & Expo in San Francisco. “You just have to realize that the person you’re telling might not respond the way you’re expecting, and you have to be OK with that. I often get the question, ‘Do I need to tell my children?’ That doesn’t necessarily need to happen. You have to be very careful and make sure that’s what you want to do. Will it serve a purpose? Will it help them to know? Do they need that information?”

It is a delicate “gray area” that has to be considered on a case-by-case basis, Johnson says.

Explore the reasons why the client is feeling a need to share, Beckett agrees. Counselors should help clients find release, whether it is through disclosure or other outlets.

Some clients may ultimately decide that the risks of disclosing their abortion to loved ones outweigh the benefits. Risks include the possibility of difficult feelings regarding the procedure — including grief and shame or stigma from culture or family — resurfacing. Clients who decide not to share might find release instead by posting their story anonymously on an internet message board or by writing a letter they never send, suggests Beckett, who specializes in grief counseling.

For those clients who do decide to disclose their abortion, it might be best to start small, tell just one person whom they trust and then go from there, Beckett says.

“For those who really feel the need to share, determine what is the safest place or who is the safest person to share it with. Then see how that feels: Did it help? Do they want to share further?,” she says. “I think, as counselors, that one of the most valuable ways we can support these women is to serve as someone to talk to about their options, who is not going to pressure or push them in any particular direction.”

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Although most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or other negative emotions caused by external factors such as culture or family. These feelings can surface in counseling sessions.

For more on this topic, see the feature “When post-abortion emotions need unpacking” in the April issue of Counseling Today.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling and Russian culture

By Anton Ivanov and Clifton Mitchell April 27, 2016

In Russia, counseling is often not considered a substantial profession. Unfortunately, the same is true for any country that used to be a part of the USSR. A very limited number of nonmedical-model counseling centers exist, particularly in rural parts of the country. The sad truth, however, is that most of the Russian population doesn’t even know about such services.

Anton Ivanov (this article’s first author) grew up in Russia. After five years in the United States, and as a second-year student in a counseling program, he has become acutely aware of the substantial contrasts between the two countries when it comes to their perspective and practice of counseling. He has a desire to educate American counselors about his country and people.

Historical context: Residue of the Soviet regime

To grasp fully the mentality of the Russian people regarding counseling, one needs to look deep into the country’s history. In the Soviet era (1922–1991), counseling and psychological services were either not available or were rejected by the government and people. Thus, such services were extremely rare. Lacking counseling services, Russians with mental health problems or drug and alcohol addictions were historically treated by medical doctors through the use of medications.

Sigmund Freud’s works were translated into Russian during the Soviet era and were one of the few sources of learning about psychotherapy for Soviet therapists. However, his works were soon forbidden, as were many works of other Western practitioners. For those seeking a more thorough review of the history and current development of counseling in Russia, we suggest reading Christine L. Currie, Marina V. Kuzmina and Ruslan I. Nadyuk’s article, “The Counseling Profession in Russia: Historical Roots, Current Trends and Future Perspectives,” in the October 2012 Journal of Counseling & Development.

Historically, people diagnosed with severe mental health issues in Russia were often sent to medically oriented psychiatric hospitals where confidentiality rights were not generally considered. When records were disclosed, citizens were often stigmatized and disgraced, which limited their opportunities for employment and minimized their chances of living a life without scrutiny. In many Russian communities, simply mentioning that parents were seeking mental health services for their children or themselves could have negative consequences. When such information became public knowledge, families’ reputations were jeopardized, and they were often stigmatized as “dysfunctional.” Unfortunately, these attitudes remain prevalent today.

Further compounding the stigma, the government used psychiatry as a tool to suppress ideas that were different from the accepted ideology by labeling rebels as “mentally unstable.” Because the specter of mental health problems were used to dissuade dissent, terms such as psychology, psychiatry and psychotherapy came to arouse fear among the population.

To complicate matters further, the idea that social or environmental factors could cause certain mental health issues was strictly rejected; the only allowed stance was that all psychiatric disorders had a biological cause. As a result, people suffering from psychological issues often minimized their symptoms in an effort not to see a doctor. When Russian people are sick, they often quip that “the issue will disappear by itself” or “it is already too late to treat the issue; it is incurable.”

Throughout Russian history, its people have commonly sought counseling and psychological help from “healers” who are believed to possess “good” energy, holy powers, skills to fix people’s issues and the ability to foresee events. Healers often prescribe herbs that are believed to be helpful. Russians also practice balneotherapy, take mud baths and schedule spa visits to reduce their stress levels and treat physiological issues. Most Russians rarely see a doctor about their mental health issues. Instead, many Russians prefer to talk about their problems with their friends in the kitchen while sharing a bottle of vodka.

Both historically and today, Russians respect and trust the army, the church and the national leader. In times of crisis, the Russian people have been inspired and united through the hope that they place in their leaders and the church. People still rely on the Russian Orthodox Church to “solve” their issues. People go to the church to have all their questions answered by priests and in hopes of magically ridding themselves of their mental health issues by either drinking holy water or attending public worship. Russians view priests as authority figures and trust them much more so than they do mental health therapists. Unfortunately, priests have little or no training in counseling and rely on their own knowledge to assist people who are dealing with mental health issues.

Counseling challenges and concerns

Russians’ mental health problems are similar to those found in other countries, but these problems are exacerbated by deeply ingrained political policies and social attitudes that are coupled with severe socioeconomic hardship. High rates of depression, anxiety, drug and alcohol use, eating disorders, divorce, suicide and unemployment are all present. Other lifestyle factors contribute to high rates of cancer and AIDS, leading to a decline in the average life expectancy. Racism, local and international wars, and religious discrimination further add to the stress. In a country where much of the population lives below the poverty level, it appears little might be done to thwart the high levels of depression and apathy. Recent economic sanctions have intensified these problems.

In Russian culture, many men view marriage as a loss of freedom, whereas women generally see marriage as a significant step toward a happy life. Women are often viewed as an inferior gender that prefers dependency and dreams only of having a family, whereas men conduct themselves assertively and prefer independence. Many male children are raised in Spartan conditions under which displays of emotion and the questioning of parents are rarely allowed. Unfortunately, acting in an aggressive manner is too often reinforced. These factors, in combination, have resulted in high rates of domestic violence and an overall hostile culture throughout Russia, making family counseling an urgent need.

Although sexuality is widely discussed among Russians, parents, teachers and priests are skeptical about sex education and hesitate to utilize it. Unplanned pregnancies have resulted in high abortion rates. In a 2001 article in the Canadian Medical Association Journal, Barbara Sibbald noted that Russian women had six abortions on average during their lifetimes. The prevalence of unplanned pregnancies has also resulted in overflowing orphanages that house abandoned children and those taken away from their parents because of drug and alcohol addiction. Understandably, a substantial need exists for access to birth control, sex education, family counseling services and drug and alcohol treatment.

Current status and foundational needs

Generally speaking, counseling in Russia is decades behind the United States in terms of acceptance, education and theoretical development. Yet, as Currie, Kuzmina and Nadyuk noted, counseling has been recognized as a branch of social work and is starting to gain a presence in Russia. Still, counselor education programs such as those commonly found in U.S. colleges are extremely rare in Russia. Counseling is still several steps away from becoming a viable profession in Russia, and various issues need to be addressed before it is viewed as a legitimate, functioning entity.

For instance, the requirements for training and certification vary across the country and are not established or consistently regulated by any governing body. Unfortunately, this has resulted in numerous charlatans and unqualified practitioners claiming to provide “counseling.” Currently, very few facilities consider offering practicums or internships to students. This leaves many beginning counselors poorly prepared for real-life practice. In addition, outstanding students with college degrees are offered no assurance of employment unless they have the aid of social and administrative connections. In addition, the low income of counselors does not attract many students to the field.

After an American Counseling Association delegation visited Russia in 2006, a Counseling Today article reported that Russian counselors were prone to learning one theory and using it exclusively. There appears to be a limited amount of training across theories. Thus, the idea of counselors adapting approaches to the client’s individual personality and problems is not commonly practiced. It is apparent that expanded training in a wider array of approaches is strongly needed.

In a country where corruption is too often the norm and where ethical codes are not viewed as essential, adherence to the strict ethical standards present in the United States is not emphasized. In her article, Sibbald noted that sexual relationships between medical practitioners and clients are common, and ethical standards regarding such relationships are not enforced. In particular because of Russians’ historical distrust of mental health services, it is essential that formal ethical guidelines be established, taught and monitored. Until the Russian public learns to trust that its counselors will protect confidentiality, mental health services will not gain a foothold in Russia.

Potential counseling needs of Russian immigrants

Many Russian immigrants would benefit from the counseling services offered in the United States, but counselors who underestimate the significance of cultural differences could inhibit the process. In a chapter in the 2004 book Culturally Competent Practice With Immigrant and Refugee Children and Families, Tamar Green described some of the primary psychological challenges that Russians encounter when coming to the United States. These challenges include cultural shock, which involves transitioning from a socialistic to a capitalistic society and from a nonreligious or Russian Orthodox atmosphere to the American spiritual environment. In addition, immigrants must manage language barriers, unemployment, basic shopping knowledge, navigation of the medical system, loneliness and isolation.

Although children adapt to the American environment faster, they still experience issues such as feeling neglected by parents, getting help with schoolwork and not feeling protected in a new environment. When going through the adjustment process, these youth can be psychologically traumatized. Green noted that they are searching for their new selves in an environment in which they have distinctly different names and accents. In addition, they are struggling to find new friends, striving to match American clothing styles and trying to develop new hobbies and interests, all of which are quite different from what they knew back home in Russia. At the same time, Russian parents adapting to this new environment are equally overwhelmed and cannot attend to children as much as they might wish. Yet, by virtue of possessing strong and persistent survival skills, Russians have learned to preserve their culture and identity while managing change and settling in other countries.

Russians usually view doctors as authority figures and readily hand their problems over to them. Similarly, if Russian clients decide to try counseling, they may expect the counselor to take responsibility for their problems and are likely to follow the counselor’s advice without question. Because of these characteristics, person-centered approaches to counseling are not likely to be suitable for these clients.

In addition, because of the harsh nature of Russian culture, empathy is not readily understood by most Russians. Olga Bondarenko, an associate professor of psychology at Nizhni Novgorod State University in Russia, points out in an article that Russians frequently mistake empathy in therapy for sympathy or pity, which is less acceptable to them (see bit.ly/23eZEZj). For this reason, directive techniques are much more suitable.

It might also be noted that Russian culture tends to be very philosophical, and Russians like to approach problems from philosophical perspectives. Existential approaches in counseling might best accommodate this cultural feature.

Another feature of Russian culture is a reluctance to wait. Hence, pacing in counseling can become a challenge because Russians expect immediate results. In addition, many immigrants simply cannot afford long-term treatment because of financial constraints. Likewise, the mindset of many Russians is that money should be invested in something tangible, such as electronics, clothes, cars or houses. Investing in counseling will likely seem foreign and even useless to them because of their inability to grasp its benefits and see the results immediately. Counselors will need to explain to Russian immigrants that counseling in the United States is a slower, more deliberate process.

Russian culture is communistic and collectivistic, and because a large percentage of the population lives in extended households, family is likely to be an integral part of these clients’ lives. In Russian schools and institutions, children are called by their last names, thus further promoting the ideology
that family comes first. In stark contrast to American culture, the familial emphasis of Russian culture strongly limits the idea of individuality, if not eliminating it altogether. Counselors should remain cognizant of this when attempting to construct problem solutions for Russian clients.

To better understand these clients, practitioners should bear in mind that Russians may appear to be grumpy, closed, secretive, suspicious, quiet, anxious and rather shy because they have often lived in a state of uncertainty. Many elders were traumatized by the division of the Soviet Union, which resulted in a loss of country, land, currency, political leaders and, most important, identity. It is not uncommon to encounter Russian elders who still hope and dream of one day again living in a socialistic society similar to the former USSR.

Because of a lack of experience with and understanding about counseling, counseling interventions remain novel to most Russian immigrants. If they were court ordered to attend counseling, they would likely find the process strange and present as exceptionally skeptical about its helpfulness. In addition, historical cultural attitudes toward mental health services may be ingrained in these clients, which might make them seem resistant to the process. Counselors should be aware of and prepared to manage this aspect of counseling Russians.

Similar to other cultures, Russians like to criticize and complain about the opposing mindsets and attitudes they encounter in other Russians and the Russian government. Incongruously, counselors may discover that some Russian immigrants are not close to or do not speak positively of other Russian immigrants. If such sentiments arise in counseling sessions, however, counselors should be careful in aligning with these perspectives in an effort to join with the client. Ironically, Russian immigrants might feel offended and disrespected by an American counselor who aligns with a negative attitude toward Russians and their motherland.

Overwhelming contrasts

To comprehend the essence of Russian culture and meet Russians’ counseling needs, one must understand the country’s history and the unique features of its people. This article was written to provide a glimpse into this often misunderstood world.

Being in the United States for five years has given me (Anton) an increased understanding of the usefulness of counseling and its eventual benefits for Russians. Being in a counseling program has intensified my desire to see the counseling field grow in Russia and be used by Russian immigrants. I believe that some information described in this article may also be applicable when working with immigrants from the countries of the former USSR or other Russian-speaking immigrants.

Yet counselors in the United States need to understand that counseling is foreign to most Russians. It is not something that meets the needs of those who come from or exist in a society in which the primary focus is survival, not personal growth. It is our hope that counseling services will progress in Russia and that through an understanding of Russian culture, counselors in this country will be better prepared to educate and counsel Russians.

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Anton Ivanov is from Orel, Russia, and is a second-year student in the clinical mental health counseling program at East Tennessee State University (ETSU). He hopes to seek residence in the United States, promote awareness of Russian culture among Americans and help Russian immigrants acclimate to American culture. Contact him at ivanova@goldmail.etsu.edu.

Clifton Mitchell is professor emeritus at ETSU and author of Effective Techniques for Dealing With Highly Resistant Clients. He travels the country giving seminars on the management of resistance in therapy and providing legal and ethical training in a game-show format. Contact him at cliftmitch@comcast.net, and visit his website at cliftonmitchell.com.

Letters to the editor: ct@counseling.org

The Hope Chest: Unpacking the hurt

By Kim Johancen-Walt August 19, 2014

When I first met Ally, 17, she surveyed the seating arrangement in my office and chose the chair closest to my door. Obviously guarded, she sat with both arms and legs crossed looking at me with green eyes slightly camouflaged by blond wispy bangs. Ally’s mother had been trying to get her to come to therapy in recent months because of Ally’s deepening depression. Her mother believed Ally’s depression was due to an abortion Ally had had several months prior to our first meeting. The mother had only insisted on therapy after reading a journal entry in which Ally had made it clear she was thinking about suicide.

As I began to ask Ally some questions during our initial visit, she stated that she did not need therapy and expressed anger at her mother for forcing her to come to my office. Although Ally knew I was aware of the journal entry and the abortion, I honored her resistance by staying in shallow waters, asking only about things such as hobbies, school and friends. I purposefully avoided the topic of loss. At first she answered questions but became increasingly quiet and then stopped talking all together. Counselors working with teens dread these moments, wondering how we will get through the hour when our young clients refuse to talk to us despite our best efforts to connect, create safety and begin the therapeutic process.

By the time many kids get to my office, they have come to believe that most of the adults in their lives cannot help them. They feel misunderstood, sometimes blamed, and tend to find their own emotion overshadowed by the emotion of others. They are also desperate for relief. I strive to educate these kids about the connections between unresolved grief, loss and suicidal behavior, about how therapy can help them manage pain differently and how to cultivate hope and resiliency along the way.

Sitting in silence, I explained to Ally that I actually did not need to know much about her to know that she was in incredible pain due to her suicidal thoughts. I told her that I knew I was looking at the tip of a very large iceberg. It is important to communicate to kids our knowledge of what may fuel suicide, that we take it seriously but are comfortable talking about it, and that we do not judge them for their thoughts and actions. I told Ally I knew she was doing the best she could to take care of herself as she dealt with unbearable pain.

Not believing that they can (or should) seek support and care from others, many kids come to believe that they must be fully self-reliant. Otherwise, they think they will risk more injury to themselves or become even more burdensome to those around them. Add to this the developmental (and oftentimes skewed) belief about the need to seek independence, and many teens retreat completely into themselves. Affected deeply by the things that happen in their lives, these teens believe they are mainly (if not solely) responsible for their losses, their pain and their inability to cope. Rather than asking for help, many of these teens become increasingly desperate as they find themselves drowning, with little or no ability to swim to the surface.

The overflow

When working with suicidal teens, I have found it useful to tell them about the invisible box that we each carry. It is a place where we store the painful events or losses in our lives, packaging them tightly to avoid the feelings associated with those events. Although this process of stuffing may work for a while, over time our boxes can begin to fill up, leaving us little room or tolerance for added stressors. I remember vividly the reaction of one of my 16-year-old male clients who, after I explained the box metaphor, stated, “If that is true, then I have a field of boxes buried in the ground.”

Once full, we find ourselves frantically trying to keep the lid on the box tightly sealed. But regardless of how hard we try, it is at this point of distress that painful content may begin to leak over the sides. When there is no room left in the box, many teens find themselves spilling over into what I term the “Overflow.” Desperate, they may turn to self-injury, substance abuse or suicidal behavior. After using this metaphor to explain the connections between my clients’ feelings and behaviors, most begin to understand the importance of making room so they can stay out of the Overflow. They become primed for therapy and ready to cautiously explore methods of healing and more effective ways of coping.

Although the unpacking is necessary, it is also a tender process. After a few sessions spent building both trust and safety, Ally started discussing the details of the abrupt and painful breakup with her boyfriend that occurred soon after her pregnancy. She cried quietly as she talked about his cruelty, along with how her mother had also abandoned her, “forcing” her to have an abortion and telling her she was irresponsible and an embarrassment to the family.

Ally believed she was fully to blame for the pregnancy, for having disappointed her parents through her reckless behavior and for her boyfriend leaving. Furthermore, she believed that her inability to cope and “just get over it” were signs of a flawed character. She believed she was weak and selfish for having aborted her baby. She continued talking about what happened, looking into the deep well of grief over having lost a child.

Throughout her process, I seized every opportunity to listen, understand and treat her with love and compassion. We discussed how her coping was outstripped trying to deal with complicated grief and that her suicidal feelings were the result of what had happened. In other words, I told her that her depression and increasing suicidal thoughts made sense.

Many of my clients have dealt with multiple losses and are unaware that each new wound can awaken others that are tucked away in dark corners. Overwhelmed with grief, most of these clients do not realize that the only way to make room is to unpack their losses one by one. And, sometimes, one explosion can be followed by several other mini blasts. For example, if our clients are not met with love, support or compassion after the initial bomb goes off, then their injuries can deepen, their framework distorted by multiple losses. They come to expect loss, perhaps blaming themselves and losing hope. Ally not only lost her child, but she also felt abandoned by some of the most important people in her life. She couldn’t stop the bleeding despite her best efforts to avoid stepping on additional land mines.

Handle contents with care

When I discuss the box metaphor with teens, I assure them that they are in charge of what content they choose to remove. Not wanting these young clients to feel further overwhelmed, it is critical to move forward at a gentle pace and to focus on the importance of making room rather than what is actually emptied. After explaining the therapeutic process in this way, many kids naturally begin looking at what is taking up the most space in their containers, knowing that the bigger objects are what contribute to their inability to handle added stressors.

We do not want our clients to empty everything at once, and each container must be handled with care. I want kids to know they are in control of their therapy, but I also want them to be aware that the unpacking is necessary if they are going to make room, build tolerance and effectively stay out of the Overflow. Throughout therapy, we assess safety and coping constantly, knowing that without careful attention to the process, speed and wounds touched, we may inadvertently push our young clients closer to the edge rather than away from it. We find ourselves dipping in and out of raw material.

Through our conversations, Ally slowly began building confidence in her ability to handle painful feelings. Gradually, we were ready to invite her mother into session to discuss what had happened. Both women cried together as Ally’s mother discussed feeling deep remorse for how she had handled the situation and for not considering Ally’s feelings surrounding the abortion. Through her own accountability, Ally’s mother opened the door to begin repairing the cherished relationship between mother and daughter. And in addition to cultivating compassion for herself, Ally was able to begin finding compassion for her mother. She came to realize that her mother had also done the best she could at the time and acted in what she believed to be the best interests of her daughter.

Through therapy, we help our young clients to uncover new pathways that were previously out of their view. We celebrate their victories and watch them gain confidence not only in their ability to cope but also in their ability to heal. And as we end therapy, we remain aware that they may have more work to do. Whether they collect new losses over time or whether older losses begin to reemerge, we know that future excavation may be needed — although that process may not happen with us.

We have done our job if we have given our young clients a new framework to work through the inevitable human experience of grief and loss, if we have taught them the importance of seeking help from caring others and if we have helped them learn how to effectively stay out of the Overflow. Through our work, these teens leave therapy with a new definition of healthy independence rather than one that finds them overwhelmed and in dependence. Through our connections with caring others, we are reminded that even in times when things are not OK, we will be OK.

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Kim Johancen-Walt writes “The Hope Chest” column exclusively for CT Online. She is a licensed professional counselor with almost 20 years of experience. Her clinical experience includes working as a therapist for La Plata County Human Services, where she helped develop a treatment model for adolescents in Durango, Colorado. She has presented her clinical work at mental health conferences nationally, including at the annual conference for the International Society for the Study of Self-Injury. Additional clinical experience includes a position as assistant training director and senior counselor in the Counseling Department at Fort Lewis College. She currently operates a full-time private practice in Durango. Contact her at johancenwaltks@gmail.com.

Read her previous column, “The Hope Chest: The GIFT of therapy,” here: ct.counseling.org/2014/06/the-hope-chest-the-gift-of-therapy

Bringing abortion aftercare into the 21st century

Trudy M. Johnson January 1, 2013

“The tipping point,” a concept presented by Malcolm Gladwell in a book by the same name in 2000, occurs when an idea, trend or social behavior crosses a threshold, tips and spreads like wildfire. I believe helping women process the grief they experience after an abortion choice is an idea whose time has come. Currently, very few venues exist in our culture where women have permission to grieve an abortion loss. It has been 40 years since abortion was legalized throughout the United States with the Supreme Court’s decision in Roe v. Wade (January 1973). Yet, in my opinion, most mental health professionals are not informed or equipped to serve an extensive population that is confused by and disenfranchised with their abortion grief.

Dr. Christiane Northrup, a noted author and gynecologist, speaks about the topic of grief after abortion in her newly revised edition of Women’s Bodies, Women’s Wisdom (2010). A former abortion doctor herself, Northrup takes the bold step of agreeing that women need a chance to grieve a voluntary pregnancy termination.

She writes, “Since the first edition of Women’s Bodies, Women’s Wisdom, many women have written to me expressing their gratitude that I have addressed this issue [processing abortion grief]. And they have written about how their willingness to tell the truth about their abortion experience has healed them.” She goes on to say that during the many years she performed abortions, she observed that “not having fully grieved a pregnancy termination can be a setup for pregnancy problems in the future” because of the unresolved feelings surrounding the choice.

Disenfranchised grief

Dorothy, we are not in Kansas anymore! We have spent decades arguing whether abortion “should be.” While we argue, we lose sight of the fact that abortion “is.” According to the Guttmacher Institute, the statistical gathering arm of Planned Parenthood (a good, reliable source of abortion statistics), around 1.36 million women have abortions each year in the United States alone.

Our culture views abortion as a political, moral and legal issue. In doing so, society does not acknowledge the natural grief that many times follows an abortion choice. One of my past clients said the following: “There is a conspiracy among the sisterhood not to tell each other about the sadness they feel about their abortion. We don’t discuss our grief after abortion because it can be so gut-wrenching. The depth of the grief goes to the core of our beings. Our society doesn’t talk about abortion because it is legal. We are not allowed to grieve our loss because there is an implication that we should buck up and get over it — it is legal, don’t complain, that is that.”

It is normal to assume that the abortion provides closure. This is a false sense of resolution, however. At some point after the procedure, most women are caught off guard with a sadness that is often unavoidable.

It is at this stage of the abortion experience that women need a safe place to talk about their decision. Many times, even the most well-meaning professional scrambles to help the client validate the abortion choice. Unfortunately, in doing this, the client’s grief is not acknowledged. Additionally, there will be no pause to consider the abortion as a loss.

The reality is that after an abortion, many women experience grief that is disenfranchised. As with any sort of grief that goes unacknowledged in cultural norms, this can be the deepest, most painful kind of grieving because the person is so alone in it.

In his book Disenfranchised Grief: New Directions, Challenges and Strategies for Practice, Kenneth J. Doka defines disenfranchised grief as a loss that cannot be openly acknowledged, socially validated or publicly mourned. Doka states, “The person experiences a loss, but the resulting grief is unrecognized by others. The person has no socially accorded right to grieve or to mourn it in that particular way. The grief is disenfranchised.”

Disenfranchised grief, whether connected to the loss of an ex-spouse, a gay partner, a pet or even an abortion, can have a profound effect on an individual. Forty years after the legalization of abortion choice in our nation, it is time that mental health professionals get onboard with learning how to respond to a woman experiencing grief after an abortion.

Abortion grief and fear of disclosure

According to a statistic provided by the Guttmacher Institute in 1998, it was expected that 43 percent of women would have an abortion by the time they were 45. Despite this large demographic, women very seldom admit a choice decision to another person. However, choice decisions affect every level of our culture, every race and every religion.

Professionals need to understand how hard it is to self-disclose an abortion choice. Because of the fear of judgment or disenfranchisement over the sadness they feel, women often walk alone in processing their grief after abortion. It is my experience in working with women in this area that it takes an average of nine hours of therapy before they will admit an abortion choice.

Northrup states, “A century and a half of rhetoric designed to make women feel guilt and shame surrounding abortion and the choice of self-development over motherhood (at least for a time) leaves little wonder that abortion is not an easy issue for women to talk about freely. Yet if every woman who ever had an abortion, or even one-third of them, were willing to speak out about her experience — not in shame, but with honesty about where she was then, what she learned and where she is now — this whole issue would heal a great deal faster.”

“Secrets kill” is a therapy concept I refer to often. What I am seeing from my clients is the existence of an intense loyalty to the abortion secret that is driven by an incredible sense of fear of disclosure. With decades of guilt and shame as an emotional backdrop, many women never adequately process the deep grief aspects of abortion. As long as the cloak of shame surrounds this issue in the hearts of women, they will stay loyal to their “dirty little secret.”

Being healthy in mind and spirit means all of us must work through the grief issues of our past. If our human souls do not take this journey into grief in all areas of our lives, we will spend our future days simply managing our sorrow. This can manifest itself as anger, depression, alcoholism, eating disorders and other serious emotional and behavioral problems.

In his writings, Doka says “disenfranchisement is an injury that blocks the possibility of mourning; self is turned inward, wishing repair, but instead it repeatedly attacks itself with its worthlessness.”

Disenfranchised grief should be an important consideration in the lives of our clients, even in cases of abortion. Counseling professionals should be knowledgeable of how to approach this topic with their clients. These clients need to know their grief matters to someone who will safely share in the pain of their loss.

Changing the labels

I believe the best way to create a paradigm shift in processing grief after abortion is to change the labels. Professional therapists can be the trailblazers in the area of abortion grief. We have an opportunity to be part of something bigger than we can ever imagine by bringing abortion aftercare into the 21st century for thousands of women sitting in silence about their grief.

Once you say the word abortion, the conversation gets polarized, paralyzed and/or politicized, inciting passionate emotions on every side. Doka says it best when he notes, “The ideological and political divide between those who accept abortion and those who do not complicate disenfranchisement.”

I began experimenting with changing the labels some years back in my own private practice. In assessing client history, I noticed clients would rarely self-disclose a past abortion. I remembered my own past experiences filling out forms in physician offices. I never checked the box that said “abortion.” One day, I began asking clients if they knew what the “A-word” meant. Surprisingly, most did. It was in simply changing the terminology to A-word that women began to self-disclose.

Eventually, I came across the term voluntary pregnancy termination as a possible way to talk about the A-word in session. After some time, I began using the shortened version, VPT. This process led me to the revelation that the terminology had been causing the glitch in disclosure. I now refer to the procedure as VPT in sessions with my clients and have found it to be a successful way of separating the politics from the issue of grief.

It is my opinion that professional therapists must lead the way in changing the terminology if we are to bring this therapy model into our culture. Given the guaranteed confidentiality processes we have in place, the professional therapist’s office should be the obvious place for women to go to process their grief after abortion.

The need is great

Given the number of women who need confidential dialogue about their abortion experience, I developed a new counseling model for professionals called Choice Processing and Resolution (CPR) therapy. I presented this model at a Learning Institute for the American Counseling Association Conference in San Francisco in March 2012.

Before adding CPR therapy to your counseling practice, however, there are several things to consider. First, make sure this is a subject that interests you. VPT aftercare, being so specialized in nature, is not for everyone. Also, therapist gender is not necessarily important. I believe both male and female counselors can lend support to clients processing abortion grief.

The main consideration should be whether you are a safe and nonjudgmental person for your clients when it comes to this controversial topic. Taking honest self-inventory, if you cannot separate the procedure from the issue of grief after abortion, then you should not get involved in this caring field. Additionally, if you have your own unprocessed abortion grief and hold your own judgment or are suffering your own pain, you have the potential of doing more harm than good for these clients.

On the other hand, you are the right person for this work if you have a natural heart to help clients who are suffering from secret shame and grief and can receive their stories with compassion and grace.

I once had a licensed professional counselor inform me that none of his clients had ever had an abortion. Looking at the statistics in place, this was an ignorant observation. I also had a pastor of a 3,000-member church tell me that no one in his congregation had ever chosen abortion. Realistically, considering the statistics, it is likely that at least 500 of the women in his congregation were secretly struggling with abortion grief.

As a professional counselor, please understand that if you assess for an abortion per se, your client will probably not self-disclose. However, if you note low levels of depression or unexplainable sadness in your clients, you can eventually introduce the possibility of a VPT in their history. Again, changing the labels is the way to assess. Asking clients to self-disclose an abortion will probably get you nowhere.

My journey of helping women in abortion aftercare spans almost two decades now. My own path to healing and helping other women has been my classroom for instruction. Because this is such a specialized topic, it is important to have a very clear understanding of the multifaceted aspects of processing grief after VPT. The combined elements of disenfranchisement, fear, shame and confusion make this a topic worth studying so that counselors will be informed.

Ways to help

Once you have determined that a client is experiencing disenfranchised grief about her choice decision, the best place to start is by offering a safe place to dialogue about her actual experience.

Begin safe dialogue: Just let the client do as much self-expressing as she wants about her entire experience — including before the decision, the procedure itself and after the decision. The mere fact that you are allowing her to share her deep dark secret in a place of safety and nonjudgment will help her release a lot of the grief. I can’t emphasize enough that changing the terminology from “abortion” to “VPT” will be a turning point for clients to share their stories.

Consider this grief therapy: Begin the grieving process by normalizing the grief your clients may feel. Instead of talking about the procedure and focusing on validating their choice to have a VPT, let your office serve as a place of validation for the natural grief that many times follows a VPT, even years later. Explain that attachment is very normal in a pregnancy. The process being interrupted by a VPT doesn’t necessarily stop the feelings of natural attachment that can occur. This simple paradigm shift gives your clients permission to label their experience as a loss. Validation and permission are what every client needs in a disenfranchised grief situation. Therefore, your main focus in therapy will be offering validation of the client’s grief and permission for the client to express needed pain over her loss.

Develop your companioning skills: Companioning is about honoring the spirit, not about focusing on the intellect. It is about respecting disorder and confusion, not about imposing order or logic. Companioning is about being present to another’s pain, not about taking that pain away. The person skilled in companioning will offer a safe place for women to share their secret of a VPT.

John Welshons, in his book Awakening From Grief, says it best: “You should think of yourself as a listening friend that teaches your clients the meaning of compassion. There are no experts in this line of work, only compassionate listeners. Since everyone truly does process their grief differently, it is important for you to let your client be as they walk the valley
of sadness.”

Process the emotions: I have found the best way to help women is to allow them to attach all the emotions to the event of a VPT. Going through the entire experience and letting women label the emotions can be very freeing for them. Supporting clients in writing letters to the people connected to the event and encouraging clients to give full expression to how they felt then and how they feel now can be very helpful in releasing hidden emotions.

If you are serious about adding help for VPT grief to your practice, I offer some free downloadable intake sheets on my website at missingpieces.org/professionals. The intake sheets can serve as a template to walk you through dialoguing about and processing VPT grief with your clients.

In summary, normalizing the grief and giving permission to label the experience as a loss are important components of this therapy. In addition, labeling the emotions will help bring resolution for your clients. Professional therapy offices should become the obvious venue for abortion aftercare in the 21st century.

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Trudy M. Johnson is an American Counseling Association member and a licensed marriage and family therapist. She is also the author of C.P.R.: Choice Processing and Resolution, a self-help workbook that professionals can use to assist clients in processing their grief after a voluntary pregnancy termination. In addition to her private practice, MissingPieces.Org, Johnson consults and educates professionals on the topic of grief after abortion. Contact her at missingpieces@gmail.com.

Letters to the editor:ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.