This paper questions the apparent lack of interest on the part of psychoanalytic psychotherapists in thinking about induced abortion. There is a dearth of analytic literature on this topic, despite the fact that almost 200,000 abortions take place in this country per annum (DOH, 2009). This statistic suggests that the issue is potentially in the room but possibly ignored, perhaps owing to the psychotherapist’s reluctance to engage with the topic.
This is not a clinical paper illustrating work in the consulting-room with a particular patient. It is rather a paper that has emerged from practitioner-research done as part of a doctoral project on the topic of post-abortion experience and psychotherapeutic input; it examines something of the relationship between induced abortion – a procedure performed to end a pregnanacy – and psychotherapy, playing with ideas about why this area attracts so little attention within the profession. Even a cursory glance through back numbers of psychotherapy journals reveals a lack of psychoanalytic papers on the topic. Moreover, when I attempted to elicit the views of psychotherapists in three different contexts by means of a questionnaire, I received only eight responses out of a total of one hundred and thirty questionnaires and, of the eight, at least half were from people known to me who might well have had a sense of personal loyalty. Certainly my own training at Arbours was silent about the issue. It is thus with a modicum of trepidation that I set forth any thoughts on the subject, despite the fact that a third of women in this country have had at least one termination of pregnancy (Weyman, 2004) and hence it seems almost inevitable that the issue would regularly enter the psychoanalytic space in some respect.
I question my own reticence in the expectation that to do so might shed light on the wider picture. Possibly I fear being a lone voice and attracting derision for raising a non-concern – a topic that others do not feel the need to consider. I possibly do not wish to come across as a zealot: to be viewed as a person with a cause to evangelise, given the value-laden nature of the topic in hand. There is the challenge of desiring to raise the issue for consideration, questioning the neglect it appears to elicit, whilst at the same time not wishing to give any hint of adding undue import to the topic, in particular without equally stressing a consideration of its wider context. I wonder if therapists remain largely silent on this issue because they fear coming across as opinionated. It is hard not to have a personal view on the issue of abortion, and the debate quickly becomes polarised into a pro-/anti-abortion view. If anti-, there is ensuing fear that one will be viewed as judgmental, and if pro-, that one might be perceived either to have a sense of callous disregard, or alternatively, a possible allegiance to a politically-correct, partisan cause.
In addition to not wishing to be aligned with a particular stance, I suggest the possibility that a number of therapists have been affected by the experience of abortion in their own lives and have not experienced sufficient closure to be able to feel safe with open discussion and potential exposure of these private parts of self. There is a ripple effect of the lack of opportunity for processing within psychotherapy training and via clinical papers, and the ensuing limitation on the next generation of training therapists, and hence the veil over the issue continues to be held in place. I liken this to the issue of racism. I believe that a couple of decades ago, a white therapist seeing a black patient would not have felt that any issue related to their respective skin colours was there to be addressed in the room. There might have been a self-congratulatory pride in being able to think about pre-conscious notions of blackness to darkness, fear and dirt, and an overriding idea of dealing with difference, but the issue in the room would have been completely unspoken through the therapist’s fear of exposure of their own unaddressed racism. Clearly, given the large body of work done on racism awareness in relatively recent times, this is no longer the case. I wonder if abortion now occupies a similar unspoken space.
Much has been published in other disciplines about the effects of abortion: whether and in what circumstances it might predispose to mental health issues, or whether the psychopathology precedes and predetermines the abortion experience; its morality, both from a religious and a neuro-biological viewpoint in which personhood is attributed at different stages of a pregnancy; the political implications of where power resides in the decision-making process, in which currently the putative father has no say at all. These issues are important, but they are not for primary consideration in this paper. I think it fair to say that most people would find it barbaric even to think about a situation where abortion was made illegal and women had to resort to often dangerous back-street practices, as happened prior to the Abortion Act 1967. Beyond the mental health, moral, political and legal arenas, are we really able to stay with the issue in a fully reflexive and reflective capacity? The care offered in this domain is often linked to context and determined by the same, be it the abortion provider sector and a market driven economy, or that offered by Careconfidential, a Christian charity, and hence influenced by subtext and belief that abortion contravenes God’s law and that it is always better to keep the baby than to have a termination. Before starting this research, I had worked in both these sectors for over twenty years and felt that I was offering an objective service based on years of expertise. It is only through the birthing of this project, that I have come to realise the ways in which unacknowledged aspects of my stance on abortion undoubtedly influenced the therapy I was offering. But what is it that is important to consider in thinking about abortion outside the anti-/pro-abortion debate? The abortion narratives I collected for the research, and my own experience in the field, show that there are as many different abortion stories as there are people. Hence any number of psychoanalytic theories can be applied to thinking about the meaning of the experience.
Some aspects are important in different guises: for example, the role of the putative father and other key relationships, beliefs held around abortion prior to the crisis pregnancy and the patient’s life history prior to the abortion. It feels extraneous to pick out particular theoretical constructs. One might speculate on early psychological damage that interferes with thinking and linking (Bion, 1993) having its enactment in the process of abortion, at times carried out without a space for reflection. This might be part of a pattern of repeated abortion, as portrayed by Gee (2005) in her paper on the re-enactment in the consulting-room. This same pattern could be thought about using theory related to bulimia (Woodman, 1980) and the compulsion to fill and void, or to self-harm and somatisation (McDougall, 1989).
Other theories of note relate to the internal representation of the foetus and the relationship between this construct, the pregnant woman and her own mother (Pines, 1993). Fisher (1984) has developed this to think about the pregnancy that ends in abortion as a maturational rite-de-passage that has little to do with a baby at the end of the process, but is rather a space in which the child-woman plays at growing up whilst retaining the safety-net of adolescence. Interestingly, she mentions the idea of the abortion ritual as being a place for reparative work in which the child-woman can experience good enough mothering and holding by the doctors and nurses to enable a change to occur through action being done to her, as opposed to a purely psychic process. This seems particularly sad to me, in that the reality of the experience is likely to be that the abortion is speedily, albeit safely, executed, in a situation where the woman has almost no personal identity but is on a conveyor belt of rapid, almost statistical, intervention. In our modern world of virtual reality and airbrushed celebrity, even the opportunity to be narcissistically queen of her own drama for the day is shockingly negated.
So how does psychotherapy relate to abortion? In America, the psychological care around abortion is more readily perceived to be the domain of the nursing profession (Hess, 2004). But those I interviewed for my project had had their abortion experience a minimum of five years in the past, and one as long ago as thirty years. The nurses would have been long gone, and thus it falls to the psychotherapists, potentially, to be the key point of processing after the event. One of the ways in which we perceive the value of our role is in helping to make the unconscious conscious, and hence we use our analytic minds, drawing on embedded theory, to help facilitate this process. And yet there is a sense in which it is important to retain the awareness that in the context of abortion, there is always a bigger picture. I have heard mention of the notion of the choice for abortion being made on the basis of the least destructive path in a difficult and less-than-ideal situation. Whilst superficially this sounds all right, one quickly realises that it is simply not possible for any therapist to really judge the significance of such an action in the life of a patient. We are not able to say what it would have meant for a particular pregnancy to proceed to a birth rather than a termination, for the patient, the child, and for significant others in the wider sphere. The picture goes beyond a constructive/destructive lens, to a sense of fatalism and reality that cannot be judged. Zoja (1997) writes convincingly of this realm of the abortion as taboo, ritualistic, beyond the ordinary language of psychotherapy.
I wonder if it is this unfamiliar domain that keeps the subject of abortion as taboo and relatively unspoken within the psychotherapeutic profession. As the traditional mid-wife (with woman) dealt in the mysterious, murky realm of bringing forth life, I wonder if the psychotherapist needs to be able to set aside the usual notions of illumination of repressed emotional baggage, and simply stay with the confusion and inchoate darkness. The midwife was just as much present in bringing forth the stillborn child, the deformed infant, even possibly being instrumental in choosing not to aid the passage of life, and certainly in some cultures very obviously administering medicine that actually aborted rather than preserved life. I question whether, as psychotherapists, it is at the peril of our patients that we choose to form judgments that prevent us from engaging in genuine reflexivity, reflection and dialogue, that move us along a continuum away from the pole of abortion as the premature ending of life to a place of safety in theoretical construction. As we grapple with what this means for us individually, only then might we move to a place of being able simply to be with, fully present and alongside, the patient and her abortion. This can be an uncomfortable, paradoxical, confusing space: a place where potency and helplessness sit side by side, where death and life co-exist. It is also the place where the psychoanalytic bedrock of theory might actually veil something of the reality of the particular abortion experience as a unique and fatalistic fact for the patient in the room.
Anne Atkinson trained as a psychoanalytic psychotherapist at Arbours and has since completed the Doctorate in Psychotherapy at Metanoia Institute/Middlesex University. She has held a number of NHS posts but now works in private practice in London.
Bion, W. (1993) Second Thoughts London: Karnac
Department of Health (2009) Abortion Statistics, England and Wales: 2008
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_099285 retrieved 7 March 2010
Fisher, S. (1984) Reflections on abortion as acting-out BAP Bulletin, 15, pp. 20-30
Gee, E. (2005) The Psychology of Multiple Abortions, unpublished paper given at the Society of Analytical Psychology on 16 April 2005
Hess, R. (2004) Dimensions of women’s long-term post-abortion experience, American Journal of Maternal/Child Nursing, 29(3), pp. 193-8
McDougall, J. (1989) Theatres of the Body: a psychoanalytical approach to psychosomatic illness London: Free Association Books
Pines, D. (1993) A Woman’s Unconscious Use of Her Body London: Virago
Weyman, A. (2004) Abortion http://news.bbc.co.uk/1/hi/health/3894245.stm retrieved 19 March 2010
Woodman, M. (1980) The Owl was a Baker’s Daughter: Obesity, Anorexia Nervosa and the Repressed Feminine Toronto: Inner City Books.
Zoja, E. (1997) Abortion: loss and renewal in the search for Identity London: Routledge