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Effects of Abortion on Men
This comprehensive work was shared with me by the author, Michael Simon, M.S., M.A. If you would like to contact him for any reason about his work, here's his email address
Male Partners and the Psychological Sequelae of Abortion:
A Psychodynamic-Relational View
©1997 by Michael Y. Simon
We are caught in an inescapable network of mutuality,
tied in a single garment of destiny.
Martin Luther King, Jr.
Preface and Acknowledgments
Men and Abortion
Couple attitudes toward pregnancy and abortion
A Focus on Guilt and the Development of Pathogenic Beliefs
The Psychological Sequelae of Abortion
The Questions and Problems of "Psychological Sequelae"
Methodological Problems with Abortion Research
Psychological Sequelae of Abortion: Research Studies
A Note on Miscarriage and Infertility
Guilt, Psychopathology and Abortion
Freud's Contribution to the Study of Guilt
The Cognitive-Interpersonal Approach of Joseph Weiss, Harold Sampson & Lynn O'Connor: Work of the San Francisco Psychotherapy Research Group
A brief history of the Mt. Zion Psychotherapy Research Group
The cognitive-interpersonal approach of Control-Mastery theory
Trauma and the Development of Pathogenic Beliefs
A reformulation of trauma
Guilt, Shame and Pathogenesis: Negative Sequelae as Disorders of Engagement
Abortion, Guilt and Pathogenic Beliefs
Recent Advances in the Study of Guilt and Pathogenesis: Evolutionary Psychology, Relational Theory and Altruism
The assumptions of evolutionary psychology
Loss, Grief & the "Shut-Down" Male
Loss, Masculinity and Identification
Male Inexpressivity and Grieving
Oedipus Revised: New Psychodynamic-Relational Approaches to the Developmental Drama of Separation-Individuation
Discussion and Conclusions
Preface and Acknowledgments
When the idea for a project that examined the psychological consequences of abortion for male partners was first suggested to otherwise sympathetic colleagues in clinical practice, the modal response was telling: "what do you mean, men and abortion?"
The response was neither one of hostility, nor polite, cursory interest, but rather a curious mixture of disbelief and genuine confusion at just how men figured into the picture of the abortion experience. And while some found the topic intriguing, they warned against pursuing it, for reasons which make all too much sense and reflect themselves in the general dearth of literature on male responses to abortion. Some made an essentially political argument that discussion of psychological sequelae of abortion in male partners drew a necessary focus away from women's responses to the experience. Behind this response was an important, quiet fear that any attention given to men around the issue would be fuel for the fires of removing the essential elements of choice and privacy in abortion, codified on January 22, 1973 with the Supreme Court's landmark decision in Roe v. Wade. As Justice Blackmun wrote in the Majority Opinion of the Court:
The court has recognized that a right of personal privacy, or a guarantee of certain areas or zones of privacy, does exist under the Constitution. In varying contexts, the Court or individual Justices have, indeed, found at least the roots of that right in the First Amendment; in the Fourth and Fifth Amendments; in the penumbras of the Bill of Rights; or in the concept of liberty guaranteed by the first section of the Fourteen Amendment.... This right of privacy...is broad enough to encompass a woman's decision whether or not to terminate her pregnancy. (From the Majority Opinion of the Supreme Court, Jane Roe et al., Appellants, v. Henry Wade, Case No. 70-18 as quoted in Osofsky, 1973, p. 590.)
There is a kind of "zero-sum" thinking that warns us that an additional focus on male responses will be detrimental to women in any number of ways. For example, research on male partners that show negative psychological sequelae of abortion will be used by anti-abortion proponents to further their arguments, with all the attendant consequences of returning to a pre-1973 state of affairs; or it will be used by pro- and/or anti-abortion males to continue to wrest control over women's bodies around reproductive decisions and technology. Still others like Arthur Shostak (1996a; 1996b) argue that in a post-Roe world, the inclusion of research and family-planning perspectives that take fuller account of the male role is a win-win move with wide-ranging effects such as: sending a social message that both sex partners (whenever possible given the safety of both parties) are expected to share responsibility for the decision to terminate pregnancy; supporting spousal prenotification law while rejecting spousal consent laws which are inherently "male supremacist;" and supporting the view that abortion is fundamentally an interpersonal experience, and that questions of responsibility, intimacy, choice and healing are not the domain of one party, rooted in gender.
If research into the male response to abortion became more commonplace, no less crucial a question would arise as to just who did the research, under what socio-cultural conditions, and with what, if any, pre-figured limitations on the scope or applicability of such research. Government funding of any aspect of abortion research is often highly controversial and the subject of intense scrutiny by both pro- and anti-abortion supporters (United States Congress, 1989b). The call for a neutral or bias-free investigative position on abortion (or any subject, for that matter), while arguably fruitless, is nonetheless often used as a critical location from which to devalue the results of any study.
The highly politicized nature of the topic-which touches the deepest questions of value (e.g., Schnell, 1993). concretized in the interlocking spheres of personal and political autonomy, interpersonal relationship, parenting, sexuality, work and economics-should serve not as a warning against its exploration, but an urgent plea for it.
Shortly after Roe v. Wade was published by the Court, several researchers at the Temple University Hospital Health Sciences Center in Philadelphia produced an important edited volume entitled, The Abortion Experience: Psychological & Medical Impact (Osofsky & Osofsky, 1973). In a chapter in that volume on needed behavioral social research, Newman (1973, p. 560) was keen to point out that there were practically no studies of the "background, characteristics, psychodynamics and behavior of the male partners of females seeking and obtaining abortions" (Newman, p. 560). While he presumed that men played a significant role in concerns of sexual behavior, contraception and related matters, he noted that a consideration of men was virtually absent from the literature. This trend continued apace until Arthur Shostak and Gary McLouth's groundbreaking 1984 sociological study detailed in Men and Abortion: Lessons, Losses and Love. However, not much has been done since that work, and there are to date few theoretical or empirical researches either on the psychological sequelae of abortion or on intrapsychic dynamics of the abortion experience for male partners.
A computer search of over 3,500 documents which mentioned the terms "abortion," "psychological sequelae" and men revealed less than 100 studies, reports or theoretical pieces which dealt even marginally with the male partner's responses to abortion. Even fewer represented theoretically-based research on the psychological sequelae of abortion in men.
In the same volume with Newman's thoughtful analysis of much-needed abortion research, Osofsky, Osofsky and Rajan's (1973) meticulous review of U.S. studies on the psychological sequelae of abortion for women reported, with unsurprising cross-study consistency that, "for most women, abortion has had few, if any, psychological sequelae...[with] postabortal feelings of guilt and depression...[being] relatively uncommon" (p. 203). More recent studies which acknowledge negative psychological sequelae of abortion for women look at postabortion effects and resilience factors (Cozzarelli, Karrasch, Sumer & Major, 1994; Cozzarelli, 1993; Congleton & Calhoun, 1993; Speckhard & Rue, 1992, 1993; Major & Cozzarelli, 1992; Major, Cozzarelli, Tesa & Mueller, 1992; Wasielewski, 1992) or post-traumatic stress disorder and abortion (Bagarozzi, 1994; Clare & Tyrrell, 1994). And a relatively recent study by Posavac & Miller (1990) raised intriguing questions as to why earlier research seemed to show no significant negative psychological sequelae of abortion. While the absence of negative sequelae is part of a much larger political debate, played out within the historical context of feminism, the research results appear uniform to date. The majority of studies continue to support former US Surgeon General C. Evertt Koop's (1989) conclusion that the negative sequelae of abortion is "minuscule from a public health perspective."
Yet persistent anecdotal information-from colleagues in clinical practice doing individual, couples or family psychotherapy and from numerous friends who have experienced abortion-would suggest otherwise. The abortion experience-which 32.5 million women and over 16 million men experienced from 1973 to 1994 (The Alan Guttmacher Institute, 1995; Henshaw & Van Vort, 1994; Shostak, 1996b)-is a profound one, with long-lasting effects for many. It seems plausible that the discrepancy between research studies which report no significant negative sequelae of abortion and anecdotal reports from clinicians that the abortion experience is profound and often traumatic for the participants, can be understood from several vantage points.
The present work attempts to account for this discrepancy utilizing the insights of a relatively new cognitive-interpersonal psychodynamic theory of the mind and psychopathology called Control-Mastery theory, slowly developed over the last 30 years by Joseph Weiss, M.D., Harold Sampson, Ph.D. and more recently, Lynn O'Connor, Ph.D. of the San Francisco Psychotherapy Research Group (formerly the Mt. Zion Psychotherapy Research Group) (See Chapter 3 of the present work.)
Following Newman's (1973) call for a wide-ranging approach to the study of abortion, this project draws on multi-disciplinary resources and methods-from psychoanalytic and non-psychoanalytic theories; from attachment, developmental and evolutionary psychological perspectives and; from sociological and anthropological perspectives-to explore issues around the psychological sequelae of abortion for male partners. This exploration does not concentrate on psychological sequelae of abortion for women nor does it attempt to explain in sociological or anthropological terms the "causes" of the lack of material on the topic, although the present project refers to socio-cultural sanctions which mitigate against its exploration. Because these questions are so inexorably linked, and the social and psychological of such a piece, it is impossible to consider psychological consequences of abortion without the understanding, for example, that the sanction for the right of privacy contained in Roe v. Wade allowed women, "in the ultimate sense, the final privilege and responsibility for parenthood-a responsibility shared perforce with the medical profession" (Mudd, 1973, p. 542). The male intrapsychic response to abortion takes account of this fact, and both challenges and reinforces often intensely-held, culturally-reproduced gender roles for men (Walzer, 1994).
This last point illuminates the way to one of the central theses of this theoretical investigation and one which is contained in Martin Luther King's words which precede this volume. Namely, that if we are truly "caught in an inescapable web of mutuality," then perhaps it is with the lens of relationality that this subject must be approached.
It is one thesis of this project that there may be significant psychological sequelae of abortion for male partners (and indeed, for women), and that these effects are being missed because the theoretical underpinnings of most current researchers do not assume a relational view. This results in studies which only account for the presence of what I call "bounded effects:" effects localizable in the individual, exhibited in individual psychopathology, measurable by standard psychometric measures and relatively consistent over time. (See Chapter 2 of the present work.) However, current evolutionary psychological perspectives (Slavin & Kriegman, 1992), cognitive-interpersonal approaches which emphasize relatedness as a primary human motivation (Baumeister & Leary, 1995; Baumeister, Stillwell & Heatherton, 1994; Stolorow, Atwood & Brandchaft, 1994; Weiss, 1993; Weiss, Sampson & Members of the Mt. Zion Psychotherapy Research Group, 1986; Bowlby, 1980) or interpersonal experience as the seat of early developmental and ongoing personality structuration (Stern, 1985; Stolorow & Lachman, 1984/1985; Emde, 1988a; 1988b; 1989; Surrey, 1991) teach us that exploration of the interpersonal system is often key to understanding so-called normal as well as pathological developmental phenomena. Newman's (1973) call over 23 years ago for a broader focus in abortion studies illustrates the point when he urged researchers to look at:
dyadic relationships between married or unmarried sex partners; sexual emotions and activities of the involved sex partners; relationship to parental families; marital family relationships including effects on present and future children; educational activities and accomplishments; church and other religious activities; and social, economic and political activities and accomplishments (p. 562).
While it would not be difficult to broaden the above list, the salient point remains that current discrepancies between the literature on post-abortion effects for women and anecdotal reports might be accounted for by measures and methods which do not fully appreciate the highly interpersonal nature of the psychological sequelae of abortion.
Chapter 1 introduces the reader to some of literature on female responses as well as male partner's responses to abortion, exploring abortion as a deeply interpersonal experience for the man. While close to three-quarters of a million men each year accompany their female partners to abortion clinic waiting rooms (Shostak, 1993, 1996b), the bookshelf, as Art Shostak notes, is still barren. The heuristic promise of Shostak and McLouth's Men and Abortion (1984) has yet to be realized and the primary resources on men and abortion continue to be doctoral dissertations or master's theses (Lees, 1975; Smith, 1980; Rotter, 1981; Karesky, 1986; Ortega, 1987). Articles in the psychological literature are increasing, however, and this chapter reviews recent research on psychological effects of the abortion experience on male partners.
In Chapter 2 we move more directly to the issue of report short- and long-term sequelae of abortion. Prior to Roe v. Wade, traditional psychiatric approaches tended to emphasize the abortion decision as almost tantamount to a psychopathological response (Wallerstein & Bar-Din, 1972; Cavenar, Maltbie & Sullivan, 1978). For instance, abortion could be seen as an unsuccessful attempt to resolve the Oedipus complex, "as a rejection of the feminine role, overidentification with the father, [and] a conscious or unconscious desire to take revenge on either self or another" (Illsley & Hall, 1978, p. 13). Since 1973, however, psychosocial and behavioral approaches have widened that narrow frame and abortion could be understood as a response to economic factors, avoidance of stigma, adherence to deeply-held religious convictions or "just the desire not to have a baby at that time" (ibid.).
The legalization of abortion also made possible and necessary a proliferation of studies on the sociological, legal, psychological and medical effects of abortion. Most studies show only mild and transient negative sequelae of abortion, for both men and women. For studies that show significant post-abortion effects and those that show only mild and transient negative sequelae of abortion or brief reactive symptomatology, factors such as religious affiliation, ethnicity, culture and female partner attitudes (Black, 1991) are considered to help explain how men cope with and respond to their partner's abortion, as well as how men and women make abortion choices (Wetstein, 1996). In addition, the literature reveals important predictive links between body image (Terjestam, 1989), male self-attributions and life "ownership" attitudes and abortion responses (Ross & Kaplan, 1993-94).
But of those studies which indicate negative sequelae of abortion (in women or their male partners), conscious guilt is most often reported, however mild. Of course, guilt and psychopathology are not the same. The present work argues that unconscious, irrational guilt is at the base of psychopathological reactions to trauma and that an exploration of the forms and presentation of unconscious guilt is necessary in the case of abortion.
Specifically, in Chapter 3 we look at new researches designed to more deeply explore the complexities of measuring guilt and shame-related phenomena, and make important distinctions between various subtypes of guilt. Specifically we consider those measures designed to detect more interpersonally-oriented types of unconscious guilt as opposed to those measures which seem to measure more conscious, adaptive and less interpersonally-oriented forms of guilt. Unlike Freud's early view of guilt which was based on the idea that the affect arose in response to an unconscious wish to harm others, new researches like those of June Price Tangney and her colleagues (1990; 1991; 1995; Tangney and Fischer, 1995) and O'Connor, Berry and Weiss (1996) discuss the development of guilt as an "an interpersonally driven emotion, based on the need to maintain attachment to others" (O'Connor, Berry & Weiss, p. 6).
Chapter 3 also introduces several complementary psychological views of the concepts of guilt, shame, relationality and altruism. The perspectives of evolutionary psychology (Slavin and Kreigman, 1992) and the cognitive interpersonal theory developed by Joseph Weiss and Harold Sampson (Weiss, Sampson et al., 1986; Weiss, 1993) and researched and further advanced by Lynn O'Connor and her colleagues (O'Connor, Berry, Inaba, Weiss & Morrison, 1994; O'Connor, 1995; O'Connor, Berry & Weiss, 1996; O'Connor, Berry, Weiss & Schweitzer, 1996; O'Connor, Berry ,Weiss, Bush & Sampson, 1997) are viewed as providing a fruitful framework for understanding the relational aspects of the abortion experience.
In Chapter 4, "Loss, Grief and the 'Shut-Down' Male," we investigate barriers to male participation in the abortion process-social and psychic barriers which are often mutually reinforcing. According to current statistics (Shostak, 1996b), slightly over one-half of males accompany their sexual partners to the abortion clinic. But it must be noted that "participation" in the abortion experience is not reducible to male presence at abortion clinic waiting rooms. And emotional participation with a female partner is often tied to highly segregated gender roles and other social barriers to participation, including concerns that hard-fought battles around reproductive choice may be lost in giving attention to the male experience of abortion (Rosenwasser, Wright & Barber, 1987; Roberts, 1990; Shostak, 1996b).
Informed by Bowlby's (1969; 1980; 1982) work on attachment and loss, as well as the work of the Stone Center for Developmental Services and Studies at Wellesley College, this chapter explores interlocking social and intrapsychic sanctions against male grieving as well as the effects of deferred grief. We explore how the abortion experience may influence subsequent sexual behavior and male self-attribution. We also look at how the decision to terminate pregnancy may be experienced by some men as a "denial" or "refusal" of progeny. This chapter proposes that any consideration of male response to abortion must also consider male and female responses to pregnancy in general and issues of male envy of female creativity.
The psychoanalytic literature has often linked abortion and the Oedipal complex, focusing on (unconscious) pathogenic guilt and development of depressive symptomatology as consequences of abortion in women (Deutsch, 1945; Abraham, 1969; James and Benedek, 1970; Pines, 1982, 1990; Lester & Notman, 1986). These theoretical explorations have sometimes been dismissed, since psychiatric diagnosing (based on the medical model) often avoids etiological explanations that rely too heavily on reference to repressed material or material considered too conceptually abstract (like the Oedipus complex). However, the views of Peter Blos (1985), Jessica Benjamin (1994) and Janine Chasseguet-Smirgel (1994) are considered for their more reality-based reconstructions of the Oedipal complex, which view the Oedipal drama and its consequences as offering the individual a complex network of tasks around affect attunement and separation-individuation, thus setting a stage for subsequent responses to normal developmental strain and trauma.
The brief, final chapter offers a summary and some conclusions and suggestions for future directions.
When I first began this project, I was disheartened by the lack of material on the male response to abortion. I wish to thank Arthur Shostak, Ph.D. whose thoughtful, groundbreaking work Men and Abortion finally put this difficult subject in more of a public light, and whose generosity of spirit supported the effort of this project. Early on in my researches, I came across Art Shostak's work and decided to give him a call. I had no idea that I would be met with such abundant kindness. I owe much to his over 30-year commitment to understanding the abortion experience.
As a professional colleague and tireless researcher, Lynn O'Connor, Ph.D. has been a tremendous inspiration in my thinking about men and abortion. Her thoughtful and caring comments during the course of this project were invaluable. As well, the work of Joe Weiss, M.D., Harold Sampson, Ph.D. and members of the San Francisco Psychotherapy Research Group continue to stimulate my thinking on psychotherapy and psychopathology and continue to prove that as clinicians, empirical researchers and theoreticians we don't have to choose between psychoanalytic and non-analytic approaches in thinking about object relations.
I am deeply indebted to my advisor Ruth Goldman, Ph.D. for her unwavering support and grace in ways which always went well beyond even the most generous call of duty. This project, for reasons which she understands, had to be begun over and over again. It was to her that I turned when I felt like I couldn't begin one more time, and her quiet strength offered just the bolstering I needed to approach the work.
Harvey Peskin, Ph.D., stands as a quiet presence throughout this work and the clinical sensibilities that inform the project. As a mentor and friend, his unwavering dignity and commitment to acknowledging our fundamental relatedness as human beings stands as an enlivening inspiration to whatever may be helpful in this work.
Men and Abortion
We still know very little about men's psychological responses to their partner's abortion. To date, Arthur Shostak and Gary McLouth's (1984) groundbreaking study, Men and Abortion: Lessons, Losses, and Love stands as the most comprehensive work on men and abortion. It is important to note that the work is clearly in the domain of sociology, grounded in questionnaire research centering mainly on exploring men's reported attitudes and beliefs about abortion in general and the abortion experience. So while Shostak's work begins to raise many of the salient intrapsychic and interpersonal questions involved in the abortion experience for men, it does not provide a psychological, theoretical approach to the abortion experience. In Shostak's own abortion experience one sees many of the questions and needs approached by the present study:
Looking back on it now, I recognize I had been little prepared for the complex reality of an abortion. Deeply embarrassed by our contraceptive failure, and privately angry at my partner and myself (she had briefly gone off the pill to relieve headaches), I had confided in no one and had kept my own inadequate counsel. Because I was very upset by my partner's fright and bewilderment, I had rushed to assure her of my total support. But, in the process, I had rushed right past the task of gaining any insight into my own confused feelings and ideas (Shostak & McLouth, 1985, p. xii).
While the nation's abortion rate in 1997 dropped to a twenty-year all-time low, there have still been over 32 million abortions since the Centers for Disease Control and Prevention began tracking abortions (Henshaw & Van Vort, 1994; Henshaw & Kost, 1996; "U.S. Abortion Rate," 1997). Shostak (1996b) reports that about one-half of the women obtaining abortions are accompanied by their male partners to the abortion procedure. And for the estimated 16 million males who do accompany their partner to the procedure, their experience is predominately characterized by waiting and isolation:
Those who wish to offer comfort during the 15-minute abortion procedure (perhaps 70%) are generally barred from doing so. Those who wish to offer comfort during the hour-long recovery period (perhaps 90%) are generally told this is not permitted. And those many males who would profit from some instruction in birth-control options...must rely on booklets only available at the best of clinics (and often not ever there). Since over half of all pregnancies (56%) are unintended, giving a cold shoulder to these waiting-room males could not be more mistaken (Shostak, 1996b, p. 1).
It's important to note that the majority of women (55 percent) obtaining abortions are under the age of 25, with 21 percent under the age of 19 (Stone & Waszak, 1992). The highest abortion rate (by age) is among single women 18-19 years of age, and thus their male partners are, for the most part, still actively dealing with issues of separation and individuation from their own families of origin. Recent studies (Stone & Waszak, 1992; Marsiglio & Sheehan, 1993) reported in Family Planning Perspectives suggest that while adolescent males on the whole support a woman's right to choose, the majority (61 percent) of adolescent males surveyed felt that it was "not appropriate for a woman to have an abortion if her male partner objected" (Marsiglio & Sheehan, p. 166). This suggests that while adolescent and young adult males usually defer to their partner's decisions concerning the abortion-even though they have no legal rights to enforce their own decision preference-they have strong feelings about the pregnancy and decision to terminate, a finding borne out by other studies (e.g., Smith & Kronauge, 1990). Interestingly, Marsiglio and Sheehan (1993) also report that for men, religious affiliation was less of a predictor of unfavorable abortion attitude than were their views about relational factors such as feelings about premarital sexual intercourse and the possible pleasure of becoming a father (p. 167). On the whole, and contrary to the estimates of both pro-choice and pro-abortion women, men are overwhelmingly in favor of a woman's right to an abortion, with abortion attitude being determined by a variety of variables including gender role experience and religious affiliation for both men and women (Fleming, 1986; Adebayo, 1988, 1990; Curtis & Standing, 1992; Brown & Shuman, 1994; Walzer, 1994).
What of those studies that specifically examine the male experience of abortion? Many of the studies to date examine the male partner's role in postabortion adjustment for the woman (Major, Cozzarelli, Tesa & Mueller, 1992; Cozzarelli, Karrasch, Sumer & Major, 1994), although a few (mostly dissertation) researches specifically raise the issue of male response to abortion and the fundamentally relational nature of the experience for men (e.g., Lees, 1975; Smith, 1980; Rotter, 1981; Ortega, 1987).
We have known for some time that the male partner plays a significant role in determining positive postabortion outcome for his partner (Rothstein, 1977; Bracken, Hachamovitch & Grossman, 1974; Zimmerman, 1981). In an early review study on abortion decisions and psychological sequelae, Bracken, Hachamovitch and Grossman (1974) made a strong case for viewing relationship factors as correlated with pre- and post- abortion adjustment. In their study of 489 women aged 14-44, they investigated the level of support from significant others for the decision to abort. They utilized measures of 9 psychological, social and intrapsychic items and found that the woman's postabortion adjustment was significantly more favorable when she perceived partner support. For younger women, their postabortion adjustment was greatest when they perceived and anticipated parental support for the abortion. It should be noted that partner accompaniment alone was not a significant variable in postabortion adjustment, in this study or subsequent ones (e.g., Cozzarelli et al., 1994). Women's distress did not decline solely as a result of accompaniment by the male partner to the abortion clinic; the women had to experience their partners as supportive in order to have a beneficial effect postabortion. Women who experienced their male partners as emotionally supportive were found to be lower in state and trait anxiety, with married women (with supportive partners) showing the lowest levels of postabortion state and trait anxiety (Kalil, Gruber, Conley & Syntniac, 1993). And women who experienced their male partners as non-supportive during the abortion experience went through more stress, which the women traced not to the abortion itself but to the interpersonal conflict with their partner (Zimmerman, 1981). In contrast to the research noted above, no studies to date have assessed the effect of partner support on male coping and postabortion adjustment, and whether maintaining support for his partner necessitates, for the traditionally socialized male, the suppression and repression of his own psychological pain.
In Rita Black's (1991) study of women who underwent abortions or had spontaneous miscarriages, the women felt that their reactions to the abortion were very similar to their male partners, and overall felt very understood and supported by them. Interestingly, however, most women noted that their responses to loss were quite different from those of their male partners, and that the male partners tended towards being "strong" or putting their own needs aside in response to the miscarriage or abortion.
And in one study of the adolescent pregnancy and psychological sequelae of male partners, it was found that men were more psychologically distressed as young adults than those who did not have a girlfriend become pregnant (Buchanan & Robbins, 1990). Young men whose girlfriend's had abortions seemed to be as distressed as those men who abrogated the parental role and those who became fathers and stayed with their partners.
Major et al. (1992) examined the impact of men's attributions for pregnancy and anticipatory feelings about the abortion. Men overwhelmingly tended to blame the unwanted pregnancy more on their own character than did their partners, perhaps indicating something about the level of omnipotent responsibility they experienced for their partners and higher levels of internal locus of control, and thus guilt for causing the abortion to occur (Ortega, 1987). When something went wrong (the unplanned pregnancy) and the result was the decision to abort, these male partners more often felt that they had not done something wrong, per se, but that they were wrong, characterologically. Surprisingly, men's attributions about the pregnancy (positive or negative) were unrelated to their partner's postabortion adjustment expect in one case, raising the question of the degree to which men's attributions about pregnancy and abortion are made conscious to their partner. When the male's coping expectancy did affect women's adjustment, it was in cases where both the woman and her partner had expectations of not coping well after the abortion. Both partners showed depressive symptomatology as measured by the Beck Depression Inventory (BDI). According to the new framework of abortion response suggested here (See Chapter 3), such a result may suggest the use of compliance in one or both partners as a means of maintaining loyalty to someone perceived as suffering and undergoing loss (Lerner & Mathews, 1967; Rawlings, 1968; Miller, 1992a; O'Connor et al., 1997).
This last hypothesis is also supported by Lees' (1975) study of relational difficulties pre- and post-abortion in which he found stress levels in male partners (as compared to other less involved people in the woman's life) significantly higher pre- and post-abortion. Of this finding, Lees wonders "whether in fact high anxiety in the males reflects a high degree of empathy and thus leads to a strengthening of the relationship" (pp. 59-60). Lees argues, in effect, that the postabortion relationship between partners constituted a new relationship, and that jointly processing guilt, regret and anger was a key to whether or not stress levels declined and the relationship (postabortion) was maintained, ended or strengthened.
But while the abortion experience may be highly interpersonal for the male, it is one primarily processed alone (Rotter, 1981; Zelles, 1984). Indeed, Zelles (1984) found that it is this very concern for the welfare of their partner-often for the purposes of keeping what they perceive as the woman's secret-that leads most men not to discuss the abortion. The pledge of secrecy is one either inferred or directly requested by the partner where the male involved was usually a non-live-in boyfriend.
Couple attitudes toward pregnancy and abortion
Another noteworthy recent finding suggests that there are no significant differences in men's and women's abortion attitudes and their childbearing motivation (Miller, 1994). While for both men and women, acceptability of abortion increases with age, preference against childbearing for men and women appears to have a "psychological primacy," and to be set relatively early in life, "remain[ing] relatively unaffected by adult experiences" (p. 168). It makes intuitive sense and is borne out by this study that negative and ambivalent attitudes, beliefs and affects associated with childbearing (for both men and women) correlate highly with acceptance of abortion. Thus the abortion experience is one that occurs against a pre-existing background of conscious and nonconscious beliefs and affects, and is always already an interpersonal experience, since the response to abortion appears to be largely determined by earlier experience/interaction with significant others (Cozzarelli et al., 1994; Armsworth, 1991).
In a study of couple attitudes towards abortion, those couples who were higher in relationally-oriented personality traits thought to be associated with positive childbearing motivation ("nurturance" and "affiliation") were significantly more likely to hold anti-abortion attitudes than those couples who valued less relationally-oriented traits associated with negative childbearing motivation ("autonomy" and "achievement") (Miller, 1992b, p. 166).
One study that examined the effects of abortion on other than the women undergoing the procedure, showed negative sequelae among physicians, residents, students and nurses to include guilt, depression and anxiety (Kane, Feldman, Jain & Lipton, 1973). The abortion experience seems paradoxically among the most private and most public of experiences, the reach of which extends far beyond the women having the abortion.
The present study argues that male responses to abortion are determined by a complex web of factors. One important emergent factor is the degree to which the experience is perceived consciously and unconsciously as a relational experience, that is, as pertaining to one's partner, one's potential (or already existing) child(ren), one's family of origin and to the society and social values within which the abortion occurs. This should no longer surprise us since, as Winnicott (1970) observed nearly 30 years ago, the mother-infant (and today we might add, father-infant) experience is one of mutuality and it is thus through the interrelated psychic, biological and social frames of mutuality that all human development takes place (Cath, Gurwitt & Ross, 1982; Stern, 1985; Emde, 1989; Surrey, 1991).
It is the central thesis of this paper, then, that the relational, intersubjective context of abortion is the most overlooked and important factor in understanding the psychological sequelae of abortion for males.
Most men intuitively understand that their supportive presence in the abortion experience (and not just their physical presence in the waiting room) plays a significant ameliorative function, pre- and post-abortion. The conscious or unconscious decision-making process around their involvement after learning of the pregnancy is one in which the male is vulnerable to feelings of intense guilt over adequately supporting a significant other that he knows is undergoing a traumatic experience. This is not necessarily the only source of guilt, but it is an overlooked one, riding on the assumption that men, by virtue of their gender, have little capacity for empathy or other affiliative experience of pregnancy or its termination. As noted above, this is not supported by empirical research. (See for example, Chapter 4 on the work of Peter Blos and some of the new psychoanalytic thinking around pregnancy.)
As discussed in Chapter 4 of the present work, while anger is a socially sanctioned emotion in response to trauma, awareness of experiences of intense worry, concern and responsibility for the suffering of a close other are not socially supported for males, but may be a biologically-based response pattern nonetheless (Rawlings, 1968; Regan, 1971; Plutchik, 1987; Eisenberg & Strayer, 1990; Jones, Kugler & Adams, 1995). As such, the implications for the denial of such expressions ("inexpressivity") may show a positive link with pathogenesis. If the affect is experienced (see fn. 2 of the present work), there are often active pathogenic beliefs or scripts for responding in place that caution against the expression of these painful emotions, often in favor of another who is perceived as undergoing a greater suffering.
A Focus on Guilt and the Development of Pathogenic Beliefs
Rooted in a belief in the intersubjective context of abortion, the present study adopts a focus on abortion as traumatic largely because of the effects on engagement (both with oneself/affective world and with others, which are by no means separate processes).
In an intersubjective view of traumogenesis, painful affect becomes traumatic for a child when the requisite attuned responsiveness needed for tolerating, containing, modulating and alleviating that affect is not present (Stolorow & Atwood, 1992). Injurious childhood experiences of loss are not necessarily pathological, but in the absence of adequate attunement and responsiveness, they can become a source of traumatic states and psychopathology. The development of self-esteem and a "sense of being real" is thus dependent upon, from an intersubjective perspective, validating attunement of the caregiving environ to the child's emotional experiences. A child who is not met with an adequate response from the caregiving environ may conclude that, in fact, his own unmet needs and emotional pain are the result of self defects, and should be disavowed from conscious experience. The child can come to blame his own reactive states for the injuries that produce them and is warned off against experiencing painful affective states (for fear they will lead to similar traumas). By a similar process, the child can form organizing principles which preserve ties to the injurious caregiver (or caregiving environ) and (seemingly) protect him from further traumatization. It is important to stress the interpersonal nature of this process, because from an intersubjective psychological perspective, a person cannot autonomously regulate their own affective states; this regulation is always dependent upon another who attunes to you. Given the enormous difficult of parenting, it is not difficult to imagine the pervasiveness of organizing principles which predict malattunement.
In essence we have a descriptive process of the formation of pathogenic beliefs, as elucidated by Joseph Weiss, Harold Sampson and members of the San Francisco Psychotherapy Research Group (Weiss et al., 1986; Weiss, 1993; Sampson, 1992). A belief is termed pathogenic if it warns a person that pursuing highly adaptive and desirable goals (which are in each instance, person-specific) would be dangerous to oneself or destructive to others (Weiss, 1993, p. 3). Pathogenic beliefs are thus maladaptive, grim and fairly intransigent. We also have a closely analogous description of the formation of what Stolorow and Atwood (1992) have called "invariant organizing principles."
Once organizing principles or pathogenic beliefs are formed, they usually operate nonconsciously, although the person is usually testing these beliefs against reality and is exquisitely sensitive to the onset of experience which lends itself to being interpreted as an impending repetition of some original trauma. The efficiency and ubiquity of such a nonconscious assessment process makes intuitive sense and facilitates the mobilization of defensive activity directed against retraumatizaiton.
Retraumatization occurs, according to Stolorow and Atwood (1992) when: 1) a similar experience to an original trauma occurs or 2) when a sustaining bond is lost which had provided an alternative mode of organizing experience, and without which the old organizing principles are brought back to the fore.
In this context, abortion can be seen not as a primarily or somehow fundamentally (morally) traumatic experience but as a retraumatizing experience by virtue of the amount and intensity of earlier conflicts it can recapitulate around loss, affect attunement, threatened relational bonds (as in the resolution of the Oedipal complex), self-image, and the acceptability of complex affective states derived in relation to others. These earlier developmental challenges are once again stimulated in relation to the male partner's response to the woman, her pregnancy, the imagined loss of a child, the consideration and possible rejection of the father role, and numerous other relational dramas. The male's need to isolate his own affectivity in relation to earlier traumatic experience (see Chapter 4) while desiring connection with his partner, represents a complex network of (conscious and nonconscious) processes. It is thus difficult to pinpoint the specific impact of abortion on the male partner, in part because the effects may be subtle, may represent the stimulation of earlier pathogenic beliefs or may crystallize new ones that do not soon take shape in observable behavior post-abortion. One such result may be the stimulation of intense unconscious guilt, bolstered by earlier pathogenic beliefs, which warn the male partner against the pursuit of important normal developmental goals (Weiss, 1986). An inhibition of goals may be in relation to the female partner or any significant other (like the parents) for whom this inhibition may constitute a form of loyalty in the face of their perceived suffering. And unconscious guilt is a particularly powerful means for maintaining loyalty and attachment, and for restoring lost or threatened attachments (Weiss, 1986; Lewis, 1981; Baumeister et al., in press). For that matter, the withholding or walling off of affect can represent the resolution (albeit pathological) of a loyalty conflict between self and other. Modell, Weiss and Sampson (1983) put the point succinctly, and echo Stolorow and Atwood's (1992) emphasis on the traumatic nature of non-attunement:
The relationship between the self and the human environment is in part mediated through the sphere of affects; states of non-relatedness are one type of manifestation in response to disturbances in the holding environment. We are aware of whether someone is relating to us or not through the medium of affects. States of non-relatedness may be characterized by the non-communication of affects or the display of essentially false affects that serve not so much as a communication but as a manipulation of the affective response in the other (Modell, Weiss & Sampson, 1983, p. 2).
In Control-Mastery theory, varieties of guilt responses, especially those derived socially/interpersonally are often the precipitate of such struggles to balance the needs and wishes of significant others and our own perceived and unperceived needs. When negative sequelae of abortion are cited for male partners, conscious guilt is most often cited. The present study will address these findings, but concentrate on the phenomenon of unconscious guilt, and its role in the creation and maintenance of pathogenic beliefs and related psychopathology (e.g., Weiss, 1986).
The Psychological Sequelae of Abortion
The Questions and Problems of "Psychological Sequelae"
In what can be seen (as regards the current topic) as a somewhat ironic definition, The Oxford English Dictionary (OED) (1989) defines "sequel" in Feudal law, as "the offspring...and appurtenances of a villein [sic]." The term, which derives from the Latin, is used primarily in the area of estate law until its migration into literature and philosophy in the 16th century. By the late 17th- and early 18th-centuries, the term had come to denote something closer to our current general understand of a sequel as "something developed from or produced by something else...as a logical consequence" or the literary sense of "the ensuing narrative or remaining part of a narrative that...although complete in itself, forms a continuation of a preceding one." In medical terminology the Latin sequelae is picked up in the late 18th century as primarily related to pathology and disease, and understood as the consequence of an already-existing disease state or process. As quoted in the OED, the 1883 issue of The Spectator uses the term to refer to consequences which "interfere so deeply with human happiness," and as the outgrowth of some pathological social process.
Although the OED offers no such tracing of the importation of the term into psychological literature, it is arguable picked up no doubt because of its existing usage in medical parlance and psychology's strong early link with neurobiology.
What is important for our purposes is that we come to the present understanding of psychological sequelae as, by definition, secondary to some existing state of affairs, in much the same way that Freud originally defined the sense of guilt as secondary to the formation of the super-ego and conscience.
The term "psychological sequelae" has its own socio-cultural history, one that will not be traced here. But it is crucial to note that this term, like most terminology which appears to have a kind of "natural" existence, functions differently in different domains, and at different times (Eagleton, 1984; Williams, 1976). In the ethico-legal domain, the definition of psychological sequelae has important legal implications, and is influenced by legal considerations which value empirical, observable, repeatable criteria in the construction of definition. For purposes of quantification, then, it is preferable to define "psychological sequelae" as the: a) post-event occurrence of b) a diagnosable (that is, reliable and valid) psychological disorder; c) usually presented to a treating health profession; d) within a specified period of time post-event and; e) as consistent in observable symptomatology (or as showing a consistent developmental course). While no definition is only suggested based on current standard usage, and no definition is static over time, the denotation of the term "psychological sequelae" has been relatively consistent since Freud. This has important implications for the study of the psychological sequelae of abortion. It is one of the central theses of this paper that the blindspots produced by our current understanding of "psychological sequelae" have resulted in the under- and mis-representation of the effects of abortion on both males and females.
These misunderstandings, which are beginning to be corrected by research and thinking in a wide variety of disciplines, can be understood as representing two, still dominant 19th-century views of the "self" and "emotion," namely: 1) that affect should be understood as an individual phenomenon, subjectively experienced by a "bounded self," (a non-interactive, non-intersubjective, entity localizable within the somatic boundaries of an "individual" person whose interests are inimical to society at large) (in contrast, see Jordan, 1991) and; 2) that disease is a linear process, with effect following cause.
Item I: Affect and the view of the self
One's view of the self ultimately determines that person's view of psychic health. Heinz Kohut's (1982, 1984) definition of psychic health was one in which the generative process was dependent upon the selfobject; he composed a structural view of the self and inscribed what could be considered a "bounded" view of self development. However, it is not necessary to understand the generative process he described in this way. When Kohut spoke of "an uninterrupted tension arc" from basic ambitions and skills, towards basic ideals, he was describing a selfobject relationship, not primarily an intersubjective one rooted in more fluid, "real experience" with others. The question of the role of object loss and generativity was thus bypassed (Modell, 1993, p.61). However, Joseph Weiss, Harold Sampson, Lynn O'Connor and their colleagues in the San Francisco Psychotherapy Research Group hold a different view of the self than that proposed by Kohut. This view shares more features with some of the social scientific views of the self proposed by George Herbert Mead (1982), Erving Goffman (1956), and Berger and Luckmann (1966). This view of the self is supported by the infant research of Daniel Stern (1985) and Robert Emde (1988a; 1988b; 1989), as well as evolutionary psychological views (Slavin & Kreigman, 1992; Buss, 1995) and contemporary views on intersubjectivity such as those proposed by Sylvan Tomkins (1962-63) and Robert Stolorow and his colleagues (Stolorow & Lachmann, 1980; Stolorow & Atwood, 1992; Atwood & Stolorow, 1993; Stolorow, Atwood & Brandchaft, 1994) and the Stone Center theorists like Judith Jordan (1991). These views eschew the structural concept of the self and posit a more descriptive, fluid and adaptable construct. The "self" of these researchers and clinicians is a progressively multi-layered, complex, constantly interactive self-in-relation in which "real experience" of social relations constructs, maintains and reconstructs other mutually-influencing selves-in-relation. These selves-in-relation are not motivated by either competing or cooperative interests, but by both, in a tapestry of "shared and divergent interests" (Slavin & Kreigman, 1992, p. 282). Slavin and Kreigman are worth quoting at length here, for their heuristic description of the relational self, oriented towards resolution of conflict inherent in a relational world:
The "self" is...an inherently divided structure, divided along a fault line between two basic sets of affectively organized anticipations about reality, that is, narratives of reality as an essentially mutualistic world composed of individuals with essentially overlapping aims and goals (literally overlapping self interests) and narratives depicting a conflictual world fraught with divergent interests, hidden meanings, deceptions, and distortions. Thus, the child has an inborn dual vision, as it were, an expectation of and active search for both of the equally ancient, equally integral dimensions of our relational makeup (p. 282).
"Self" and "individuality" are no longer co-terminous, and, as in Stern's (1985) view, the experience of the self is an experience of activity, oriented towards organization/re-organization of experience, and often subjectively experienced as mastery. One sees in Stern's concept of "representations of interactions that have been generalized" or RIGs, the way in which the self establishes, as it were, a continuity of being through action (p. 97). And this "self-seeking" behavior is supported by-in the language of computers-a kind of affective hardwiring; that is, an innate readiness to respond to internal/external affective signals.
In a related matter, since the presence of psychological sequelae generally requires a diagnosable "disease" or disorder (following the medical model of diagnosis), there is an underlying understanding of affect as cognitive or biological, not usually both. The failure to understand the inherently psychophysiological nature of affective response results in the mis- or non-diagnosis of unconscious affect and its effects. The psychophysiological effects of affect play a central role in the creation, maintenance and relief of psychopathology (Modell, 1965, 1971; Lewicki, 1986; Weiss et al., 1986; Lewicki, Hill & Czyzewska, 1992; Nathanson, 1992; O'Connor, 1995; O'Connor, Berry & Weiss, 1996).
Stern (1985) has shown us that from birth, and most probably prenatally, we are never responding solely in a reflexive manner, and that this fundamental orientation of the infant towards engagement fuels the "initiation, maintenance, termination and avoidance of social contact" not only with the mother but with all others, and is prototypical of all human relatedness.
In defining the meaning of mutuality or mutual intersubjectivity, Judith Jordan (1991) notes that most relational theories still view autonomy, separation and independence as "hallmarks of maturing...[where the] individual is separated out from context, studied as a self-contained being" (p. 81). However, in Jordan and her colleagues view-adopted from the work of Roy Schafer (1959)-mutual intersubjectivity, as a definition of the entire lifespan trajectory is characterized by:
an interest in, attunement to, and responsiveness to the subjective inner experience of the other at both a cognitive and affective level. The primary channel for this kind of mutuality is empathic attunement, the capacity to share in and comprehend the momentary psychological state of another person.... (Jordan, 1991, p. 82.)
In a view based on the above notions of mutuality, psychopathology can only be understood in intersubjective terms, as the disruption in the various capacities and effects of engagement. It is in this way that the question of the negative psychological sequelae of abortion must be approached: as disruptions of engagement.
It is in this way that the question of psychological sequelae of abortion must be approached, in terms of disruptions of engagement.
Item 2: The Linearality of Psychopathology
Psychological sequelae is generally understood to be a result, a secondary process. The view proposed here sees the sequelae of abortion as describing a pre-existing, potential, dynamic orientation of a self geared towards others, triggered by a secondary process, as in the case of guilt in interpersonal relationships where the guilt phenomena are understood as related to altruistic, adaptive human motivation. As noted above, standard definitions of psychological sequelae operate on a series of largely unquestioned assumptions. Definitions of psychopathology are generally based on criteria codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). Disorders are understood as the pathology of the individual, not as system-wide disruptions or disorders of an interpersonal field maintained or triggered by prior, current or anticipation of future action (Stolorow & Atwood, 1994). This makes it difficult to understand the sequelae of abortion in terms of attachment and engagement capacity in forms other than the depressive or schizoid-type disorders. However, the concept of pathogenic beliefs developed by Weiss and his colleagues (see Chapter 3) allows for the detection and understanding of pathological processes that do not take the form of diagnosable syndromes which immediately follow upon traumatic events, but that nonetheless impair a person's functioning in the world.
The current definition of psychological sequelae appears to thus have serious, inherent limitations. Just as medical illness masks and reconfigures a variety of physiological functions, psychological conditions pre- and post-trauma often mask and reconfigure types of overt behavior, affective responding, emotional cognition, and conscious and unconscious processing functions (Lewicki, 1986; Van der Kolk, 1991; Lewicki, Hill & Czyzewska, 1992, 1994; Chu, 1996). Research on the psychobiology of traumatic memory suggests that traumatic memory is different from ordinary memory, and that memory is dynamic, affected by "attention, encoding, consolidation and retrieval" (Chu, 1996).
Research in this decade has also begun to reveal complex unconscious processing functions (Kunst-Wilson & Zajonc, 1980; Lewicki, 1986; Lewicki et al., 1992, 1994) that are in fact faster and more efficient than their conscious counterparts. While the research on trauma response is growing, we do not yet fully understand the ways in which traumatic experience reconfigures memory, crystallizes new structures of belief or modifies vulnerable organizing principles-all of which may result in new scripts for interpersonal interaction (LeDoux, 1994).
Emotions or feelings are conscious products of unconscious processes. It is crucial to remember that the subjective experiences we call feelings are not the primary business of the system that generates them. Emotional experiences are the result of triggering systems of behavioral adaptation that have been preserved by evolution (p. 57).
According to LeDoux (1994), the brain is able to "shape itself" through the creation of new neural pathways in response to traumatic events. The creation of what LeDoux calls "emotional memory" is thus a correlate of how Weiss describes the development of pathogenic beliefs. Emotional learning and memory is thought to operate outside of conscious awareness, and can cause the individual to become depressed or anxious, as the system is reactivated. LeDoux's research indicates that both emotional and declarative memories (viz., the memory of "bare facts") are mediated by different psychophysiological systems. The declarative systems keeps a record, so to speak, of the bare content of an experience, whereas the emotional memory system stores physiologic correlates. When a memory of an earlier traumatic even is retrieved, the declarative and emotional memories are interwoven in conscious experience. This is perhaps what Nathanson (1992) means when he describes emotion as the combination of affect (the physiologic correlate) and memory (associations to previous triggering of affect). It is not that we have access to the emotional memory, in LeDoux's terminology, but that we know the consequences of that memory: we know what we are now doing and the way our bodies feel. The result of this combining of emotional and declarative memory forms a new subjective experience which in turn influences other declarative memory and cognitive processes.
The distinction between declarative memory and emotional memory is an important one. ...We are unable to remember traumatic events that take place early in life because the hippocampus has not yet matured to the point of forming consciously accessible memories. The emotional memory system, which may develop earlier, clearly forms and stores its unconscious memories of these events. And for this reason, the trauma may affect mental and behavioral functions in later life, albeit through processes that remain inaccessible to consciousness (LeDoux, p. 57).
LeDoux's psychophysiological theory is consonant with Weiss's (1993) explanation of the creation, maintenance and relative tenacity of unconscious pathogenic beliefs formed in childhood. It also supports Nathanson's (1992) theory on the formation of emotion and response scripts.
These new adaptations or scripts may in time prove pathological, but may also be syntonic with an individual's current environment. For example, one need only think of the ways in which an individual's over-compliant behavior inside a rigidly hierarchical, dominating family system fulfills a stabilizing function as long as that individual remains entrenched in the system that requires his compliance. When that individual's environment begins to pull for independent thought, quick decision-making, tolerance for minimal feedback and greater self-differentiation, adherence to previously scripted behaviors and beliefs can produce social mis-attunement, failure in interpersonally-oriented tasks, and attendant psychological discomfort, all of which may or may not come to the attention of a mental health professional.
Additional difficulties with the concept of psychological sequelae
The notion of psychological sequelae also contains within it the idea of a consistent presentation of effects over time, or of an identifiable (and observable) developmental course. In a Control-Mastery view of pathogenic processes, there is the notion that pathogenic beliefs are not always easily picked up by standard psychodiagnostic measures, can develop at any time as a response to trauma, can crystallize pathogenic processes rather than create them or can mesh with past and future cognitive/affect processes of understanding or meaning-making (Weiss et al., 1986; Weiss, 1993). This last point speaks to the issue of linear causality in abortion research.
The type of pathogenic process stimulated by the trauma of abortion is not the kind investigated by research. In most research, there is an attempt to show that abortion is a causal factor in the creation of depressive illness. Research then becomes a matter of isolating variables and showing significant correlation (which is still not causation). The current volume argues that abortion predisposes one to psychopathological reactions because it is a disruption of engagement (with one's partner, with one's sense of self as a self-in-relation, with the potential child, with the potential role, with one's relation to pregnancy, fatherhood, etc.), and anything that disrupts engagement triggers the system to respond. It is not that disengagement is necessarily pathological but on a continuum, and if the view of the self is one of fundamentally oriented towards engagement, then important disruptions in that function could be seen as predictive of pathological processes (e.g., Baumeister & Leary, 1995).
Methodological Problems with Abortion Research
The psychological implications of induced abortion have been debated continuously over the last three decades in various scholarly publications. Reference to this literature is frequently made by both advocates and adversaries of abortion, sometimes to bolster with "hard data" a viewpoint inspired by philosophical and ethical considerations. Often such references are selective and make no attempt to consider the literature as a whole, acknowledging only articles with "favorable" conclusions. (Rogers, Stoms & Phifer, 1989, p. 347).
These authors observations, while seemingly commonplace, are nonetheless ignored in the design, research and publication of many abortion studies. It still remains all too easy to cite just those studies which support your particular position or hypothesis about abortion sequelae and many studies share important flaws in research methodology. Rogers, Stoms & Phifer's (1989) extremely thorough review of the literature on postabortion sequelae puts the point well:
Reference to the literature is frequently made by both advocates and adversaries of abortion, sometimes to bolster their "hard data" a view inspired by philosophical and ethical considerations. Often such references are selective and make no attempt to consider the literature as a whole, acknowledging only articles with "favorable" conclusions. ...In the current climate of controversy, policymakers and clinicians need a reliable method to decide how much confidence to place in statements seemingly supported by quantitative references from this literature (pp. 347, 370).
Most of the studies summarized by Rogers et al. defined positive postabortion experiences as the absence of negative effects. This, of course, rules out the possibility of repressed or suppressed painful affect. However, of the studies they considered, about 32 percent showed negative postabortion outcomes, mostly depression, moderate to severe guilt and anxiety (pp. 364-367). Outcome data was sometimes spotty or missing due to attrition or unwillingness to respond; there was an attrition rate of 25 percent or higher in about 34 percent of the studies reviewed by Rogers et al. (Ibid.).
In still other studies, ideological dimensions in research design and methodology often went largely unexplored and these methodological choices influenced the validity and generalizability of results (e.g., Zimmerman, 1981).
Until very recently there have been few solid longitudinal studies on the psychological sequelae of abortion, and prospective and retrospective within-subject comparisons are lacking. Posavac & Miller (1989) bemoan the lack of meta-analysis in the published studies, also raising questions about the validity and generalizability of the reported results. And most important for our purposes, there is still almost no research attention paid to the "male partner's reactions to the abortion experience, or to the impact of the male partner's conceptualizations of this experience on women's adjustment" (Major & Cozzarelli, 1992, p. 133).
Despite calls spanning 25 years for a thorough review of methodological problems in abortion research (e.g., Newman, 1973; Posavac & Miller, 1990), few studies of the psychological sequelae of abortion rely on a theoretical framework for understanding and investigating the effects of abortion, use adequate (or any) control groups to fit the objectives of the study, or account for the validity problems of using survey interviews as the main data source in the study.
Research based on questionnaire administration raises the issue of whether the mixed reactions reportedly common among post-abortion patients can be adequately picked up using this method (Lieberman & Zimmer, 1979; Neustatter, 1986; Rogers et al., 1989). Kent, Greenwood, Nicholls & Loeken (1978) argued that women who enter psychotherapy at any time post-abortion often exhibit feelings of pain and bereavement coupled with feelings of love for the potential child. The authors reason that these feelings are often unperceived and unrecorded in post-abortion questionnaire research due to repression or "numbness" following the abortion.
When Rogers et al. Reviewed over 280 articles that dealt specifically with psychological sequelae of abortion, they excluded 204 from their review study because the article did not report original empirical data. Of the remaining 76 articles which represented empirical outcome research done between 1966 and 1988, most were studies that utilized questionnaires to determine postabortion sequelae and thus mainly relied on self-report mechanisms for determining the presence of psychopathological states or processes.
More importantly, very few studies have adequately addressed the study of the long-term sequelae of abortion. Zolese and Blacker's (1992) through review of abortion studies to date cited only two studies that contained follow-up data for more than 2 years, and only one study (Adler, David, Major, Roth, Russo & Wyatt, 1990) looked at responses 24 months after the abortion. Needless to say, none of these studies directly address the long-term sequelae of abortion for men.
Clare and Tyrrell's (1994) recent review study of the psychiatric aspects of abortion echoes the view that abortion causes at most only mild and transient negative sequelae in women. They also note the large number of studies that show that when there is a previous psychiatric history of depression, the risk of post-abortion sequelae (like depression) is significantly greater than in women who have no known psychiatric history. In one study cited by the authors, moderate to severe guilt feelings were reported in 37 percent of the women, but this dropped to 7 percent by two years. While Clare & Tyrrell's review of abortion research echoed earlier studies, it did raise some important issues in relation to the debate over abortion research methodologies.
In several studies cited by the authors, negative sequelae were determined by psychiatric hospital admissions and/or treatment with psychiatric medications (Clark & Tyrrell, pp. 93-94). In the model proposed here for considering psychological sequelae (see Chapter 3), hospital admission and/or pharmacological treatment are insufficient criteria for determining negative sequelae proposed here. And Clark and Tyrrell note that most studies they reviewed "[could] only assess the post-abortion mental states of those women prepared to comply with the demands of research. Many women, on having their termination, are lost to follow-up" (p. 93). They are also keen to point out the fact that a primary pre- and post-abortion coping mechanism for women (and arguably for men) is through a process of denial.
Zolese and Blacker (1992) rightly point out that denial "can be an adaptive as well as a maladaptive response but either way follow-up interviews can threaten the stability of this psychological adjustment and thus prove unwelcome" (p. 748). And while we do not know how many women and men seek treatment for seemingly unrelated syndromes many years after the abortion, some research has suggested that only later developmental challenges (like pregnancy) will restimulate suppressed or repressed feelings from a prior abortion (Kumar & Robson, 1984). Kumar and Robson (1984) have also detailed the increased susceptibility to psychiatric and medical illness during pregnancy, perhaps as part of the normal strains of such a developmental milestone. We should therefore bear in mind that the male response to abortion is also a response to his partner's pregnancy and attendant increased psychiatric and physical health risks (e.g., Wilmoth, de Alteriis & Bussell, 1992). This will have important implications in our discussion of male partner guilt and omnipotent responsibility. (See Chapter 3.)
Finally, Peppers (1987-88) proposes the "bonding hypothesis" in discussing reasons why abortions affect or appear to affect women but does not show up as a significant effect in the literature. He argues that early bonding and anticipatory grief can result in the absence of noted sequelae if there is a sufficiently long time period between pretest and posttest measurements. Lindemann (1979) described "anticipatory grief" as a variant on normal separation reactions, in which the person is so concerned with their adjustment after the upcoming or potential object loss (and this could refer to the imagined loss of the child, loss of the parental role, loss of relationship to the partner, etc.), that they disengage with the surround prior to the loss, warding off feelings and thoughts that might connect him to the impending loss.
Once again, in viewing psychological sequelae in purely linear terms, one is confounded by grief reactions in which there appears to be no change in the male's attitude pre- and post-abortion, but where both pre- and post-abortion attitudes and emotions may already reflect the kind of anticipatory grief reaction of which Lindemann spoke.
It is, of course, not general research practice to interview someone prior to their having taken on the criteria for inclusion in study (Zabin, Hirsch & Emerson, 1989). Studies of the psychological sequelae of abortion would not normally include interviews or assessment with a male who hadn't yet learned his partner was going to have an abortion. There is little change to determine his attitudes and feelings about the "impending event" since he can only imagine his response and abstract from that; he cannot give us his actual response to the event with his partner. As we might imagine, interviewing someone about their partner attitudes after the abortion experience has ensued (whether pre-procedure or not), may produce a different result than if that same man had been tracked and interviewed/tested: 1) prior to hearing the news of the pregnancy; 2) after hearing the news (but pre-decision for abortion); 3) after learning of the pregnancy and having made a decision, but prior to the actual procedure or; 4) during and after the procedure (including short- and long-term follow-up of not days or weeks, but months and many years postabortion).
Psychological Sequelae of Abortion: Research Studies
Since the 1960s several important (national and international) review studies have investigated the impact of abortion on women (Simon & Senturia, 1966; Osofsky, Osofsky & Rajan, 1973; Shusterman, 1976; David, 1978; Kent, Greenwood, Nicholls & Loeken, 1978; Olson, 1980; Lemkau, 1988; Winter, 1988; Rogers, Stoms & Phifer, 1989; Ney & Wickett, 1989; Adler, David, Major, Roth, Russo & Wyatt, 1992; Posavac & Miller, 1990; Dagg, 1991; Wilmoth, de Alteriis & Bussell, 1992; Zolese & Blacker, 1992; Clare & Tyrrell, 1994), and these remain the most viable starting points for our purposes. However, it is important to bear in mind that the remaining sections of this work will argue that while men and women may have similar ways of responding, affectively and unconsciously to the abortion experience, they may have very different, gender-related ways of responding to their own responses. (See Chapter 4 of the present volume.)
It must be noted that the overwhelming majority of individual and review papers provide no satisfactory evidence for significant short- or long-term negative psychological sequelae of abortion in women (e.g., Ford, Castelnuovo-Tedesco & Long, 1971; David & Friedman, 1973; David, 1974; Adler, 1975; Cvejic, Lipper, Kinch & Benjamin, 1977; Illsley & Hall, 1978; David, 1978; Greenglass, 1981, Handy, 1982; Adler & Dolcini, 1986; United States Congress. 1989a; Dagg, 1991; Adler et al., 1992) and echo, to a degree, the findings of Osofsky, Osofsky & Rajan (1973) when they wrote:
For most women, abortion has had few, if any, psychological sequelae. In the limited number of cases where feelings of guilt or depression have been present, they have tended to be mild and transient in nature. On the whole, the experience has led to the further emotional maturation and resolution of conflict. In rare instances where psychiatric disturbances have been noted postabortion, they have appeared related to existence psychopathology rather than to the procedure.... Post abortal feelings of guilt and depression have been relatively uncommon. Relief and happiness have been the predominant moods [italics mine] (p. 203).
This chapter does not provide an in-depth review and critique of the studies cited above, since this kind of analysis is readily available, for example, in meta-analytic studies of abortion research (e.g., Rogers et al., 1989). However, the general trend appears to be that when negative sequelae are reported for women, guilt and depression (secondary to guilt) are most often cited as consequences of abortion (e.g., Zimmerman, 1981; Ney & Wickett, 1989; Cavenar, Maltbie & Sullivan, 1978).
It must be borne in mind, however, that Rogers et al. Report most empirical researches of postabortion sequelae contain numerous methodological limitations which in turn limit the generalizability of their findings. Their important articles offers a series of cautions and suggestions for further research and readers are encouraged to consult their study.
The present work's understanding of guilt as an interpersonally-driven emotion, related to concern for others, leads to a focus on those researches which either minimize or amplify guilt responses as part of the abortion experience. The researches glossed here show (in order of predominance: 1) studies indicated no serious negative sequelae (majority); 2) studies reporting long-term sequelae, including guilt and depression (minority) and; 3) studies which argue for the serious, long-term negative sequelae of abortion, like those that posit the existence of a "postabortion syndrome" (PAS), as a sub-type of posttraumatic stress disorder (least prevalent).
Osofsky, Osofsky & Rajan (1973) were among the first to conduct large-scale studies of the psychological effects of abortion, and as noted above, represent a large proportion of studies since then which demonstrated no significant negative psychological sequelae of abortion for women. Their study combined a retrospective review of abortion research (including data from private psychiatrists and other mental health practitioners and a large study from the New York State University Hospital in Syracuse, as well as an evaluation of the author's current work at the Temple University Health Sciences Center in Philadelphia).
During the Osofsky's association with the State University Hospital in Syracuse, 742 patients seen at the Obstetrics and Gynecology clinic (for general education, contraception and/or abortion services) participated in one or more parts of their study of abortion adjustment. Of the 580 cases evaluated psychologically through the use of interviews, most (70 percent) reported feeling either moderately or very happy, experiencing "much to moderate smiling" (76 percent), feeling positive relief as regards the abortion (56 percent) and overall "feeling happy about themselves" (63 percent). Eighty-give percent of those interviewed reported feeling no guilt and 56 percent of the patients report that their abortion decision was not a difficult one (Osofsky et al., pp. 195-196). Interestingly, 44 percent reported having moderate to considerable difficulty in making a decision to obtain an abortion, with most decisions centering around issues of finances and marital status, where being married positively influenced the decision towards having an abortion). Overall, if the patient was "older, married and better educated" they experienced less emotional difficulty with the procedure.
The authors also cite Kummer's (1963) survey of 32 Los Angeles psychiatrists who overwhelmingly (75 percent) reported that in an average of 12 years of clinical practice, "they had never seen a patient with any moderate or severe psychiatric sequelae from either illegal or therapeutic abortions" (as quoted in Osofsky et al., p. 189).
Follow-up interviews in the New York State University Hospital study were conducted, when possible, at 1 and 6 months postoperatively, and of those interviewed via telephone, 78 percent told the interviewer that they had resumed their normal activity level within 2 days postabortion. However, almost 60 percent of the total sample was not interviewed after the abortion due to various forms of patient unavailability; the authors do not quantify reasons for unavailability except to say the reasons included lack of accurate telephone contact information or a desire for anonymity.
While a 60 percent drop-out rate is not uncommon in psychological studies, the larger social context of the study must be considered in assessing the generalizability of findings. It must also be noted that these studies were conducted just after the legalization of abortion in July, 1970 and the sudden sanctioning of what had been (and continued to be) a highly controversial procedure could certainly increase the likelihood that negative responses would be denied or withheld from the interviewers. (See Chapter 3 on role guilt.)
Payne, Anderson, Kravitz & Notman (1973) (in their study of methodological issues in abortion research) looked at the change in affect level in women undergoing abortion. They administered questionnaires prior to the abortion, and at 24-hours, 6 weeks and 6 months postoperatively. Of the five affects they studied (anxiety, depression, guilt, shame and anger), they found levels of anxiety, depression, guilt and anger all decreased over time; levels of shame also generally decreased postabortion, but increased among a subgroup of women who had negative relationships with their mothers. These women did not demonstrate the "sense of release from the intense emotional distress experienced in the preabortion period" but instead showed significant increases in shame. Patterns of self-blame may have been activated in these women who inferred or were explicitly made to feel shameful for their decision to have an abortion.
Greer, Lal, Lewis, Belsey & Beard (1976) tracked 360 women who underwent abortion. Using structured interviews conducted at a mean of 18 months post-abortion, they found that adverse psychiatric and social sequelae were rare, and that in those who showed psychiatric symptoms (like guilt feelings) in marital and other interpersonal relationships prior to the abortion, there had been a significant improvement upon follow-up. However, Rogers et al. (1989) cites Greer et al. as a particularly noxious study for its:
incomplete information, poor or unknown interrater reliability, interviewer bias, an untested potential for mortality bias, a sample including histories of prior psychiatric illness and women who obtained abortions on psychiatric grounds, and a sample size too small to provide adequate statistical power (Rogers et al., p. 356).
Greenglass (1977) studied women who had abortions and asked about their childbearing attitudes. Those who wanted children in the future exhibited more neurotic symptoms post-abortion than those who did not plan on having children, suggesting, as in other studies, that pathogenesis is related to a fear of or perception of harming others.
David (1978) conducted a major international research review study which emphasized the social control aspects of guilt responses in women seeking and having abortions. He examined transnational trends in abortion research and argued that guilt was utilized as an effective social control mechanism in most societies. He considered it "superfluous to ask whether patients experience guilt-it is axiomatic that they will." Thus one acts in the world and guilt is physio-psychological means by which social values are reproduced: guilt is the policing-function emotion. We are taught to feel guilty when we do something that is not socially sanctioned (by caregivers, through existing values concretized in a variety of socio-cultural forms such as codified and non-codified law, art (and all forms of popular art like film and television), literature and the like.
How have the guilt phenomena been typically understood to interact with the abortion experience?
Successful contraception requires the coordination of three distinct human forces: the drive to have sexual intercourse, the wish to have or not have a child, and the will to regulate the fertility consequences of sexual behavior. While these forces may be logically linked, they are not psychologically related; coordinating them requires a considerable and ever-vigilant effort. Abortion does not. Abortion obviates the need for advance planning, and for frequent action with no immediate reward, or long-term reward that appears only in the guise of the absence of an event.... Where guilt is associated with abortion, it is often also associated with modern contraception; the latter requires continual violation of the code whereas abortion does not. (David, Friedman, van der Tak and Sevilla, 1978, p. 5).
As noted above, David (1978) seems to understand only one aspect of conscious guilt, that is, its social-control function, and appears to repeat the then-current understanding of abortion as a violation of the nature of woman as childbearer.
Included in the studies edited and compiled by David, Friedman, van der Tak & Sevilla (1978), Illsley & Hall (1978) look at selected psychosocial issues in abortion research. Their review showed guilt and depression as significant negative psychological sequelae to abortion in women if the pregnancy was ended because fetal malformation was suspected. (See also Kolker & Burke, 1993.) The authors recommend that research focus on providing more emotional support to this small minority.
Overall, they reported a discrepancy in reports of psychiatric sequelae of abortion in women citing early studies (Bolter, 1962) showing guilt feelings in each case of abortion to early 1970s studies (Osofsky et al., 1973; David & Friedman, 1973; Ewing & Rouse, 1973; Monsour & Stewart, 1973; Adler, 1975) which described "relief" as the predominant sequel to abortion. Illsley and Hall account for this discrepancy in opinions by arguing that studies like Bolter (1962) which demonstrated significant postabortion guilt feelings failed to account for: a) guilt caused by pre-abortion psychiatric functioning; b) the stigma of "illegitimate" pregnancy; c) relationship conflicts due to the abortion; d) the physical trauma of surgery; e) possible aftereffects of sterilization (sometimes combined with abortion in the 1960s and 1970s); f) conflict with hospital personnel and other ward patients relative to the abortion (see also Lasker et al., 1994); g) trauma related to the administrative difficulties of abortion and; h) ignorance about the physical sequelae of the procedure. However, Illsley and Hall's implicit suggestion that one can separate out these important relational experiences from some kind of "pure" abortion experience seems misguided. The experience of abortion, for the woman, includes all of the above elements.
Again, in the same volume (David et al., 1978)-in a study of abortion-seeking in Switzerland-Kellerhals, Pasini & Wirth (1978) found that a strong relationship existed between guilt feelings and women's perceptions of the fetus, which they categorized as showing either "fundamentalist," "relational" or "positivist." views. The fundamentalist view holds that the fetus becomes a person-to-be from conception whose life must be protected. The relational viewpoint asserts that the threshold of personhood is reached at the moment when the biological parents recognize the fetus as a human being, and give identity to the fetus as an individual human being. The positivist view states that the fetus becomes a human being based on its embryogenetic stage, for example, "at three months," or "when it has a brain." In the study, 20 percent held a fundamentalist view, 43 percent a relational view and 25 percent held a positivist view, with the remaining 12 percent as "unclassifiable."
The authors showed that 93 percent of those holding a fundamentalist outlook felt a sense of guilt about their abortion decision, which continued post-abortion, while only about 60 percent felt guilt who held the relational or positivist views. The salient factor here seems to be whether or not the fetus is determined to be an autonomous entity. The predominant viewpoint however was the relational perception of the child as determining its viability: if the fetus was seen as an identity dependent upon the mother-child relationship, it was more likely to be viewed as a person, and thus, more likely to generate a sense of guilt at decision to terminate the pregnancy.
Among single women, the study showed that the "nature of the relationship with the partner correlates with the sense of guilt towards abortion." The authors propose that this is based on the symbolic meaning of the child as a bond between them, and as the abortion decision as representing a rupture in that bond. "Negative moral judgment of abortion occurs among 81 percent of the women with steady relationships with their respective partners," but drops to 61 percent among those who became pregnant in "occasional" relationships.
If the women is married, her sense of guilt is stronger if she already has children, while only 57 percent expressed negative judgments about abortion. When the number of children in the family increases, one sees what the authors term "an unexpected result:" the more children in the family, the more guilt about the abortion. The authors conclude that "the presence of children, which does not influence the perception of the fetus, makes the women more sensitive towards the possible moral aspects of abortion."
However, it must be noted that this early study confounds "negative moral judgment of abortion" with the "sense of guilt" and does not adequately explain what is meant by either. The interviews in this study were conducted after awareness of the pregnancy and first visit to a physician, but before the visit with an advisor to discuss abortion and the authorization for abortion that was then required in Switzerland (even though abortion availability was considered very liberal there in 1970-71.
In the year following the publication of David et al.'s (1978) volume on abortion in psychosocial perspective, Liebman & Zimmer (1979) studied calls to a free, 24-hour telephone hotline for people who had problems or questions following abortion, miscarriage or adoption placement. Of the women who called about abortion-related questions or concerns, the majority were calling to express significant feelings of conscious guilt, anxiety and depression (with "guilt" being the most common emotional reaction). Interestingly enough, most of the calls came from women who had experienced an abortion over 10 months previous to the call, with several callers reporting having had an abortion up to 25 years prior.
The authors also reported receiving calls from significant others relative to the abortion. When boyfriends called, they tended to call and identify guilt feelings towards their partner for having to undergo what they perceived as the loss and trauma of abortion. As might be predicted by the theory adopted here (see Chapter 3), all callers (boyfriends, friends, parents or siblings) reported feeling excessive "concern" or guilt as the main reason for their call to the hotline, with some reporting that the abortion had stimulated feelings of guilt about other incidences involving their inability or failure to save someone or alleviate their suffering.
Abortion research continued apace into the 1980s, and studies began to grow increasingly sophisticated, focusing more on the kinds of factors outlined by Illsley & Hall (1987) as confounding the question of negative sequelae. Lemkau (1988) for example, examined pre-abortion psychiatric status, socio-cultural support around the abortion, characteristics of the medical environment and abortion procedure and postabortion events and their relation to postabortion conflict. She also began to address implications for psychotherapy for women having experienced abortion. Her literature review suggested that ambivalence is often present pre- and post-abortion (e.g., Allanson & Astbury, 1995), and that an exploration of the abortion decision and aftermath may be a crucial focus for the psychotherapy.
The clinician should remember that even women who report negative post-abortion sequelae overwhelmingly report that they feel the decision was the right one for them. Having ambivalent feelings to resolve does not necessarily mean that one has made a wrong choice, only that one has made an emotionally significant choice with far-reaching personal implications, in a sociocultural environment that reinforces the ambivalence inherent in such decisions (Lemkau, 1988, p. 469).
Zolese & Blacker's (1992) review of other abortion studies found negative sequelae (mostly depression and anxiety) on average in approximately 10 percent of the women studied. Factors determined to increase risk of negative sequelae included past psychiatric history, younger age, poor social support and belonging to sociocultural groups antagonistic to abortion.
The authors cite a study (Mueller & Major, 1989) which showed pessimistic attributional styles as casually linked to negative postabortion adjustment. Those women who engaged in higher amounts of self-blame were significantly less well adjusted shortly after the abortion. This was especially true of those whose self-blaming attributional style appeared characterological. In addition, those who were other-blaming expected their postabortion adjustment to be worse than those who blamed themselves. In that study, the authors predicted that women who received counseling designed to lessen characterological blame (or what might be seen as "self-hate guilt"; see Chapter 3) prior to the abortion showed significantly better postabortion adjustment. Since men have been shown to be higher than women in characterological self-blame as regards the pregnancy, this finding may be another important argument for the provision of counseling services to men prior to the abortion.
In a presentation to the 143rd Annual Meeting of the American Psychiatric Association, Dagg (1991) reviewed the available literature on the psychological sequelae of abortion in women and reported that of the 225 original research papers consulted, most reported that adverse sequelae in women were rare, and usually the result of the existence of pre-procedure pathology. As with many other studies, Dagg's review of the literature noted that adverse sequelae result much more frequently in the cases of denied abortion, with intrapsychic and interpersonal complications occurring in parents and children of the denied abortions.
Major and Cozzarelli's (1991) much quoted review article adopts a kind of "risk and resiliency" model for understanding adjustment to abortion and looks at psychosocial factors as predictors of abortion sequelae. Among the factors they identified as predictive of post-abortion adjustment were: 1) personal conflict; 2) attributions for the pregnancy; 3) coping expectancies and styles; 4) perceived social support, especially from the male partner; 5) social conflict; 6) pre-pregnancy psychologically functioning and; 7) post-abortion events. For purposes of the current paper, I want to focus specifically on male partner responses and self-attributions surrounding the pregnancy and its termination.
In assessing whether women's postabortion adjust was better if they were accompanied by their male partner, Major and Cozzarelli reviewed an earlier study (Major et al., 1985). They reported tracking 247 women, 34 percent of which were accompanied by their male partner. These women were significantly more depressed and showed more physical complaints than their unaccompanied counterparts. The authors attribute this surprising finding to the fact that perhaps these women were accompanied by their partners because they were showing higher pre-procedure distress levels, and thus warranted or needed accompaniment. According to Control-Mastery theory, it is more likely that these women in fact felt safer to experience depressive affect and have greater awareness of their somatic complaints and distress because of the presence of a close, supportive partner.
Weiss and Sampson's (Weiss et al., 1986; Sampson, 1989; Weiss, 1993) studies of the psychotherapeutic process indicate that patients experience painful affect and bring forth deeper material only when they (consciously or nonconsciously) judge it safe to do so. If the woman was excessively worried about her male partner's response to demonstrated distress, it is more likely that she would have masked or hidden that distress.
Evidence for this masking pattern of response was found in Major's (Major & Cozzarelli, p. 134) follow-up study when she found that depression among women was associated with low coping expectancies in their male partners. Specifically, women who expected to cope poorly after the abortion were found to be more depressed if their partner also thought they would cope poorly. When the woman expected to cope well, her partner's low coping expectation had only a minimal effect. These findings support the view in Control-Mastery theory that people who are higher in proneness towards negative self-assessment (O'Connor, 1995), tendency to make negative causal attributions about difficult life events (Menaker, 1995; O'Connor, Berry & Weiss, 1996), and submission (O'Connor et al., 1996) are also higher in survivor guilt (O'Connor, 1995) and would tend to match their responses to someone close to them that they perceive is suffering. These individuals also tend to suffer from both conscious and unconscious pathogenic beliefs-often presented in the form of negative self-attribution)-which leads to exaggerated fears of harming others (O'Connor, Berry & Weiss, 1996; O'Connor et al., 1996). This is discussed further in Chapter 3 in considering the role of survivor guilt in the maintenance of depression; it is also considered in Chapter 4 which addresses the role of altruism in empathic attunement and affective expressivity.
In a more recent review, Miller (1996) argues for the underrepresentation of concerns related to abortion for women, and asserts that women's concerns are often invisible to medical health professionals and medical research. In exploring the psychological effects of growing, limited access to abortion services within a tense political climate, as well as the introduction of RU-486, an alternative to surgical abortion, she rightly points out important links between socio-legal processes around abortion and changing women's views about the process. As noted throughout this work, men's responses to the changing socio-legal climate continue to go largely unexplored in considerations of abortion sequelae.
Finally, Butler (1996) confirms the predominant view that pregnancy termination is not usually associated with negative sequelae, but seems to echo other results which indicate that for the small groups of women who experience negative sequelae the consequences are often profound and long-lasting. These consequences include depression and guilt associated with self-destructive or self-reproachful negative attributions which the woman may or may connect to the abortion experience.
Several studies either raise the question of a distinct postabortion syndrome (Stotland, 1991; Minden & Notman, 1991), specifically argue for its existence (Ney, 1989; Speckhard & Rue, 1992, 1993; Rue, 1994; Doherty, 1995) or assume its existence and offer treatment models (Bagarozzi, 1994). Ann Speckhard and Vincent Rue are two of the most vocal proponents of significant adverse psychological sequelae of abortion, arguing for the creation of a new clinical diagnostic category called postabortion syndrome (PAS), as a specific type of posttraumatic stress disorder (PTSD). (See National Center for Post-Traumatic Stress Disorder, 1990.) They argue that male partners (as well as children, extended family members and health care providers) can and do exhibit PAS, where the trauma of abortion is repressed, patients show impacted or significantly delayed grief and complicated mourning ensues.
In related research, Ney and his colleagues (Ney, 1993; Ney & Wickett, 1989), vehement advocates for the existence of a postabortion syndrome, utilize case studies from clinical practice to outline eight types of occurrences of the syndrome, focusing on the issue of survivor guilt. They note that postabortion syndrome occurs in children and adults with accompanying sense of "existential guilt, a sense of worthlessness, and a feeling of impending disaster." Ney notes that children especially feel guilty because they are "wanted" as opposed to a potential sibling. Its interesting to note that among the eight subtypes of postabortion syndrome, Ney (unlike Speckhard and Rue) does not refer to male partners of women who undergo abortion.
Wasielewski (1992) attempts to bridge the chasm between those psychologists like Speckhard & Rue (1992) who argue for the existence of postabortion syndrome, and those whose studies (e.g., Koop, 1989) show little or no evidence to support the inclusion of PAS as a clinical diagnosis. She argues that women's experiences of abortion are primarily one of mixed emotions, and that women demonstrate those emotions deemed acceptable by close others, and the wider ideological context in which the abortion occurs. She notes that the emotional reaction to abortion is thus one already circumscribed by relational and cultural contexts, and effects both those affects which are brought to awareness (viz., experienced as emotion), and those emotions which are displayed.
Much of what a woman feels with respect to pregnancy depends on the face-to-face interactions she encounters from her sexual partners, family, friends, and medical practitioners. The degree to which these individuals have incorporated the social ideals about pregnancy inevitably determine their reactions when a woman becomes pregnant outside of these social boundaries (Wasielewski, 1992, p. 107).
Wasielewski also notes that women do not often describe negative affective experiences involving shame or guilt until they begin to talk about securing a service provider and negotiating the abortion (p. 111). Thus, Wasielewiski reminds us that responses to abortion exceed responses to the procedure: it is about both ideological and interactional level acceptance of abortion. For men, no less than for women, the abortion experience involves responses to others about how one is treated (as someone considering/having/having gone through an abortion) and how one perceives significant others and the larger community's attitudes about abortion (to what degree is the decision and experience seen as a "deviation" from social expectations?). And existing theories of the emotional sequelae of abortion, from a sociological perspective, do not adequately explain responses to abortion because they fail to account for the view that abortion engenders competing social definitions of the act of abortion and thus produce mixed emotions (e.g., Scott, 1989).
The question becomes: How do women who have abortions respond to the traditional message that they have failed to practice self control (and thus should feel guilt, shame, and embarrassment) and the supportive message that they have, indeed, experienced control of their bodies and should feel positive, powerful and relieved. The competing social definitions of the act set up a situation in which mixed emotions are inevitable (Wasielewski, p. 119).
As noted above, while many studies cite relief as the primary emotional sequelae of abortion, a significant number cite the presence of mixed emotional responses, many of which are understood to resolve relatively quickly (e.g., Francke, 1978; Neustatter, 1986; Allanson & Astbury, 1995). Wasielewski posits that women do not feel either relief or guilt but relief and guilt. She goes on to consider existing theories of how mixed emotions are resolved and cites what Wiegert (1991) argues is a rare alternative: the strategy of resolving complex emotional dissonance by stoically facing ambivalence and still acting. However, Wesielewski takes issue with Wiegert to contend that this is in fact what she believes many women do, that is, overcome ambivalence by a kind of compliance through ideological acceptance. On the one hand, the woman can show the "appropriate" emotions for the social situation of abortion, but it is not clear just what is appropriate or to which social situation one is responding. Thus, she argues, women are held in "emotional limbo" by the continuing debate of issues in the public sphere. For men, the situation is much clearer because there is not the same premium placed on the display of any emotion, and stoic acceptance in the face of ambivalence (in any psychologically stressful situation) is the culturally reinforced method for the resolution of painful experience.
Indeed, Smith's (1975) study seems to support the view that for men, too, the effect of abortion is often mixed, arguing for "longitudinal studies which accurately assess the changes foreshadowed" (Smith, p. 162). But in the same study, Smith found that 66 percent of the men in his sample felt that the "abortion put no special strain on the relationship." And in Finley's (1978) study, 78 percent of those who took part in the study felt that the abortion would "either make difference in their relationship, or would bring them closer together" (Finley, p. 3). How is one to make sense of the apparent findings that men report no significant self- or relationship-effects of the abortion, yet when privately asked about behavioral changes or assessed for pre- and post-abortion anxiety levels, are found to indeed be experiencing significant effects?
Wasielewski's work forces us to consider the hypothesis that men are not held in the same emotional limbo around abortion because there are a fewer variety of processes used for emotional management available to men. If a male consciously experiences strong relief and guilt (a mixed emotional reaction) there is perhaps a greater chance, based on gender, that he will display imperturbability, rather than distress. Allanson & Astbury (1995) rightly point out that abortion studies seldom operationally define the concept of "ambivalence." Most studies use the term "conflict" rather than "ambivalence," and the authors argue that the researchers' choice of method "does not allow women to indicate both happy and unhappy, or both glad and sad about being pregnant or about the ultimate choice" (p. 124).
And we are once again challenged with the notion that by and large, men may unconsciously understand the need for certain role-based responses to abortion which include constellations of behavioral/affective response scripts around what gets felt (what emotion is acceptable to self and what gets warded off) and what of these emotions gets displayed and/or is allowed to inform behavioral expressions (what emotion is acceptable to others given relational concerns and how these can be acted upon). (See Chapter Four of the present paper.)
A Note on Miscarriage and Infertility
Because it is beyond the scope of the present work, I will not fully deal with the relationship between loss issues relating miscarriage, infertility and abortion. However, it is important to consider that there may be lessons to learn from linking a thorough review of the literature on the psychological sequelae of miscarriage and infertility, with a study of male responses to abortion. Studies detailing male partner or couple responses to miscarriage and infertility are more readily available, more often show gender-based differences in grieving (e.g., Hunfeld, Wladimiroff & Passchier, 1994; Hunfeld, Mourik, Passchier & Tibboel, 1996), and could be productively considered alongside male responses to abortion.
For example, Frost & Condon (1996) reviewed 123 articles published between 1917 and 1993 on the psychological sequelae of miscarriage. High levels of guilt were found not only in the mother but in partners, other family members and surviving children. In addition, adverse sequelae were found in a significant number including depression, anxiety and posttraumatic stress disorder (PTSD). Conway's (1995) pilot study in Australia also showed the presence of protracted bereavement processes following miscarriage and noted that adjustment post-miscarriage was related to the degree of community and health professional support received following the miscarriage. The long-term negative psychological sequelae of miscarriage were also noted in Slade (1994) and Garel, Blondel, Lelong, Bonenfant et al. (1994) who specifically focused on the increase in depressive disorders following the terminated pregnancy. These studies indicate that expression of conscious survivor guilt and presence of depressive symptomatology is more apparent in women and men who experience spontaneous abortion, where it seems psychologically safer to bring the issue of responsibility into consciousness.
Contrary to expectations, men and women experience the same levels of emotional strain around infertility, despite expectations that it is more traumatic for women. As with abortion, men and women experience infertility difficulties differently, related to sex-role identification, not gender. Masculinity is associated with decreased emotional strain and greater marital adjustment than is femininity, where femininity includes personality traits more associated with relational factors (Berg, Wilson & Weingartner, 1991).
A comparison of the literature on the sequelae of infertility, miscarriage and abortion might reveal homologously structured issues of bereavement and grief responses. It would be fruitful to compare cases where grieving is more socially sanctioned and recognized (as in the case of miscarriage and infertility) versus the case of induced abortion where there are strong social and intrapsychic barriers to grief (especially for male partners). (See Chapter 4 of the present work.)
Guilt, Psychopathology and Abortion
Freud's Contribution to the Study of Guilt
[It is] my intention to represent the sense of guilt as the most important problem in the development of civilization and to show that the price we pay for our advance in civilization is a loss of happiness through the heightening of the sense of guilt (Freud, 1930, p. 91).
Because of the necessity of guilt's controlling function, Freud adds to this quote, "conscience does make cowards of us all." Until recently, contemporary understandings of guilt have not proceeded much beyond the classical Freudian view outlined above. The understanding ushers forth from two of Freud's organizing principles, one which took the form of the dictum homo homini lupus-man is to man a wolf-a statement about human nature, motivation and value-and the other seen both in Civilization and Its Discontents (1930) and in the introduction to The Future of an Illusion (1928), that the individual and society were by their nature in conflict. Freud's view of guilt, then, passes by way of his interpretation of Darwin, Lamarck and 19th century evolutionary theory, and is rooted in beliefs about the primacy of aggressive motivation-carried with us as a kind of biological inheritance-"in the evolutionary events in our development as a species" (Slavin and Kriegman, 1992, p. 296)
In Freud's understanding, guilt was related to the conscience phenomena and represented the internalization of a harsh, relentless critical agency, introjected from the parents and immune to change through "real experience." Parents or other social authorities could induce guilt, and was understood as a means of using the emotion as a painful warning device against which behavior could be checked.
In this view, Civilization and guilt are related, homologous and continuous functions:
Civilization, therefore, obtains mastery over the individual's dangerous desire for aggression by weakening and disarming it and by setting up an agency within him to watch over it, like a garrison in a conquered city (Freud, 1930, p. 79).
Freud cautioned that one should not speak of conscience or a sense of guilt (terms that seemed to lack adequate distinction in his writings) proper until one is already speaking of the guilt phenomenon as it arises through the internalization of authority established psychically as the super-ego. In this developmental stage in children, the super-ego takes up a position relative to the ego that "civilization" takes up relative to the individual:
The super-ego torments the sinful ego with the same feeling of anxiety and is on the watch for opportunities of getting it punished by the external world. ...Thus we know of two origins of the sense of guilt: one arising from fear of an authority, and the other, later on, arising from fear of the super-ego. The first insists upon a renunciation of instinctual satisfactions; the second, as well as doing this, presses for punishment, since the continuance of the forbidden wishes cannot be concealed from the super-ego" (Freud, 1930, pp. 81, 83).
In Freud's economic model of guilt development, there is a progression from natural aggressive instinct to renunciation of instinct for fear of loss of love (the "protection against this punitive [external] authority"). The origins of the Oedipus complex are thus, for Freud, the origins of the first sense of guilt.
Since, as Freud believed, "man is to man a wolf," our social arrangements must take account of this natural inclination towards violence, and does so in the function of civilization (socialization); at the familial level, the Oedipus complex reproduces this "natural inclination" towards violence and domination, in the form of aggressivity towards the father. This renunciation is accomplished by a complex process in which the child identifies with the external authority in order to master it and reduce its unlimited power to inflict pain. The parent (civilization at the familial level) is taken into the child as the superego, but as superego maintains the same aggressive, threatening stance toward the child's destructive impulses. And whatever measure of control is gained by internalization, it is effectively lost as the child's ego now has to "content itself with the unhappy role of the authority-the father-who has been thus degraded" (Freud, 1930, p. 85).
Freud goes on to say that the question of the severity of conscience (or the strength of the guilt feelings) seems unrelated to real experience, since severity of conscience is observed in children who are treated leniently by their fathers. But in a move that re-opens the question of the malleability of the drives and their determining role in the development of pathology, he reasons that perhaps it is wrong to consider treatment (reality) and conscience development as independent. He now proposes that super-ego formation, and thus the development of conscience (the sense of guilt) is dependent upon a combination of the givenness of the aggressive drives, "innate constitutional factors and influences of the real environment" (Freud, 1930, p. 97). He adds that this should not surprise us, since it represents "a universal aetiological condition for all such processes."
As was so often the case with Freud, the end of his quiltwork in Civilization left a dangling thread in understanding the guilt phenomena. It was this loose thread that is picked up by contemporary clinicians and researchers in understanding the relational aspects of the guilt phenomena that exceed questions of innate aggressivity as a primary factor in human motivation.
In the final chapter of Civilization and Its Discontents, Freud seems to reverse his developmental progression of guilt when he argued that in fact the sense of guilt and experience of remorse preceded the development of the superego and conscience. He tells us that remorse takes the form of anxiety, and is itself a punishment already and "can include the need for punishment." How does he resolve this apparent contradiction? He wonders whether or not the sense of remorse (the ego's reaction to an aggressive act) is always conscious whereas the sense of guilt that arises from the perception of an aggressive impulse can remain unconscious. He also raises the question of whether the sense of guilt is endemic to human being, and fundamentally prior to super-ego formation, since it is the result of the conflict between the two primal instincts (between the erotic and the aggressive drives, Eros and Thanatos) and the "exigencies of reality" (1930, p. 97). The human task is to take ourselves-separate, aggressive, selfish individuals-and bind ourselves together into one community by libidinal ties.
Conscious guilt is thus remorse, and unconscious guilt is to be understood as a need or wish for punishment. But conscious and unconscious guilt are related.
To put it in other words, the development of the individual seems to us to be a product of the interaction between two urges, the urge towards happiness, which we usually call 'egoistic," and the urge towards union with others in the community, which we call 'altruistic.'
Individual development, for Freud, focuses on egoistic concerns, while the development of society (civilization) requires engagement in the community, a process in which the individual must renounce (or at least "push into the background") his urges towards happiness in service of the whole. The altruistic urges and the egoistic urges are thus forever in tension, and individual and cultural development remain "in hostile opposition to each other," in each individual.
But Freud has introduced the idea of an altruistic urge, grounded in a movement towards community, which exceeds the aggressive impulses. The individual moves towards others not solely in order to eliminate them, as his theory would have us believe, but as an attempt to suppress one's own interests (happiness) in the service of the group. It is in this light that we turn to Control-Mastery theory and the work of the San Francisco Psychotherapy Research Group, whose contribution to the study of guilt was to ground the guilt phenomena in the interpersonal sphere.
The Cognitive-Interpersonal Approach of Joseph Weiss, Harold Sampson & Lynn O'Connor: Work of the San Francisco Psychotherapy Research Group
Much of the central work presented below is an outgrowth of initial empirical research into the psychoanalytic process begun in the mid-1960s by Joseph Weiss, M.D. and then followed by a longtime collaboration at Mt. Zion Hospital in San Francisco with psychologist Harold Sampson, Ph.D. The interpersonal-cognitive theory they developed as an outgrowth of this research has come to be known as Control-Mastery theory.
A brief history of the Mt. Zion Psychotherapy Research Group
In the late 1950s Weiss, a physician who completed his psychoanalytic training at the San Francisco Psychoanalytic Institute, began to investigate just how patients made progress in treatment. He spent hundreds of hours studying transcripts of audio-recorded analyses and slowly developed a series of new hypotheses about the therapeutic process. He observed through careful study of the transcripts that analysands changed their worldviews, acquired new insights and remembered long repressed events without explicit interpretation on the part of the analyst. This flew in the face of the more classical analytic stance that explicit interpretation of the resistance (work with the transference through interpretation) formed a if not the central part of the working through of analysis enabling growth and change.
By 1965, Weiss had teamed up with colleague Dr. Harold Sampson in order to clarify a set of hypotheses about pathogenesis and mental functioning. Beginning in 1966, they met weekly to discuss their common work, and after six years of pilot studies, hypothesis clarification, research designing, development of measures and controls and recruitment of additional colleagues, they published their first research paper, "Defense analysis and the emergence of warded-off mental contents: An empirical study" (1972). It was in this year that the Mt. Zion Psychotherapy Research Group (MZPRG) was formed, consisting of those interested in joining what was by then a broadly conceptualized, rigorous empirical research program. The work of the Mt. Zion group continued apace with the publication in 1986 of The Psychoanalytic Process: Theory, Clinical Observations, and Empirical Research-a collection of the empirical research in support of Weiss and Sampson's theories of mental functioning, psychopathology and psychotherapy. In 1989, the nonprofit San Francisco Psychotherapy Research Group was formed, and with the growth in new members came new research on emotion and psychopathology.
The cognitive-interpersonal approach of Control-Mastery theory
Control-Mastery theory speaks to a certain conception of human motivation which differs from the classical Freudian view of the relationship between motivation and unconscious processes. The term "control" refers to Weiss's theoretical axiom that unconscious mental functioning is accessible to regulation, often by the criteria of danger and safety. Our unconscious does not completely rule us, as a cauldron of aggressive and sexual forces and defenses against their eruption into consciousness, but we assert a degree of control over all unconscious content (cognitions, affects, fantasies, behaviors, etc.) (Weiss, 1990). An individual can and does regulate their unconscious mental life in order to seek safe engagement with others. If a particular cognition, affect or other mental content is nonconsciously assessed to be too dangerous (for example, if it is judged to be a threat to maintaining a tie to a significant relationship), those cognitions, affects or other mental contents can be warded off in service of maintaining that tie, at least until the person judges that it is safe to experience the warded-off contents (e.g., Sampson, Weiss, Mlodnosky & Hause, 1972; Gassner, Sampson, Weiss & Brumer, 1981; Sampson, 1990; Weiss, 1993; LeDoux, 1994). This has important implications for the ways in which men do or do not experience the full range of their affective responses to the abortion experience. (See Chapter 4.)
Weiss (1993, p. 191) argues that Freud's theory assumed an "automatic functioning hypothesis" (AFH), whereby the unconscious forces of the mind (impulses and defenses) were regulated automatically by the pleasure principle, and were not accessible to modification through interaction with the environment ("testing"). In contrast, Weiss saw in Freud's (1940) later work, evidence for what he calls the "higher mental functioning hypothesis" (HMFH). This hypothesis asserts (consonant with parts of Freud's later ego psychology) that individuals are capable of many unconscious functions which bear close resemblance to their conscious counterparts, i.e., judgment, memory, planning. In An Outline of Psycho-Analysis (1940) Freud suggested that the ego may unconsciously regulate behavior by thought, not just by automatic processes. Because, as Freud wrote, the ego is "governed by considerations of safety," a person is powerfully motivated to unconsciously assess their reality, considering the present and comparing it with the past in order to make decisions about what will or will not be brought to consciousness in safety.
The term "mastery" refers to the individual's strong, fundamental motivation to master trauma, conflict and other non-traumatic developmental challenges. Weiss again picks up from Freud's later work (in Beyond the Pleasure Principle (1920) and in An Outline of Psycho-Analysis (1940) ) to argue that there is an unconscious wish and drive towards mastery of trauma:
Freud suggested that a patient may unconsciously repeat traumatic experiences not for gratification, but in order to master them.... In Analysis Terminable and Interminable (1937) Freud developed this concept further by strongly implying that the patient works unconsciously with the analyst to solve his problems. (Weiss, 1993, p. 194).
For our purposes, it is important to note that Weiss's theory assumes, also in contrast to the AFH, that unconscious identification is crucial in ego and superego development. Since identification requires "real experience" with others in the development of motivational tendencies, the process of identification cannot be governed solely by impulses impervious to reality, seeking immediate gratification.
For example, behavior that arises in the superego may be conceptualized not as expressing the pursuit of gratification, but as expressing a wish to atone, to sacrifice, or to be punished. Thus a patient's sexual attachment to a love object, which in Freud's early theory is seen as the expression of a primary impulse seeking gratification, may be understood according to the late theory as motivated by a wish to restore the love object. For example, a patient who suffers from an exaggerated sense of responsibility for the therapist and who believes he has hurt him may attempt by loving him to restore him. Such a patient is seeking not gratification but relief of guilt (Weiss, 1993, p. 195).
Here we have the genesis of the idea that superego development and thus the development of the guilt phenomena may be related not to aggressive or sexual concerns but to some kind of altruistic motivation and orientation to the world. This is an idea that the Research Group, under the auspices of chief researcher Lynn O'Connor would later explore in their studies of the self-conscious emotions such as shame and guilt, and the development of psychopathology. What should also be clear is that Control-Mastery theory is a relationally-based theory of trauma and pathogenesis. Control-Mastery theory offers an important window, therefore, on male (and female) responses (both positive and negative) to abortion.
Trauma and the Development of Pathogenic Beliefs
The work of Weiss, Sampson, O'Connor and members of the San Francisco Psychotherapy Research Group occupies a unique place in our understanding of psychopathology in its emphasis on the what they call the development of pathogenic beliefs, and the importance of guilt and shame in pathogenesis.
As noted above, according to Weiss's theory, a person is powerfully motivated to adapt to one's environment. These efforts at adaptation include the acquisition of beliefs about oneself and one's relational world. A belief is termed pathogenic if it warns a person that pursuing highly adaptive and desirable goals (which are in each instance, person-specific) would be dangerous to oneself or destructive to others (Weiss, 1993, p. 3). Pathogenic beliefs are thus maladaptive, grim and fairly intransigent.
Thus, powerful maladaptive impulses may be maintained by pathogenic beliefs that are developed in infancy or early childhood in an attempt at adaptation. An infant or child may develop such beliefs in order to maintain his ties to his parents. For example...a patient may become maladaptively "bad" if he infers that by being so he pleases a parent by giving the parent an opportunity to feel morally superior to him. Moreover, he may generalize this belief, and so may continue for years to behave provocatively with parent surrogates in an unconscious attempt to maintain his ties to them (Weiss, 1993, p. 35).
While pathogenic beliefs, as attempts at adaptation to one's relational world, are understood as largely developing in childhood, they are by no means only developed in childhood (Shilkret, 1995). A person may develop new pathogenic beliefs at any time in the developmental life cycle, and in the same manner as children do, by direct treatment by close others or by inference from relational events, especially traumatic ones. In addition, a person may have an old pathogenic belief structure that is restimulated or crystallized in response to a new traumatic event or maintained by current realities and interactions. Indeed, both Weiss and Sampson, see abortion as a traumatic event which is capable of creating, maintaining or restimulating pathogenic belief structures (Weiss & Sampson, personal communication, September 20, 1997).
A reformulation of trauma
In Object Relations in Severe Trauma Stephen Prior (1996) utilizes Freud's (1920, 1923, 1926) conception of trauma to note that trauma points to an overwhelming of the psyche, object loss and the fear of annihilation. But he is keen to point out that Freud's conception of trauma is neither fully developed nor sufficiently relational. Prior cautions about the difficulty of delineating a univocal concept of trauma:
What happens to the psyche when it is overwhelmed is what theories of trauma need to explain. Each theory characterizes the traumatic event, the damage to the psyche, the defensive mobilization, and the long-term consequences in different terms. Because all the theories contain the term trauma, one might think they are all talking about the same thing. Surely, one might say, they are all about trauma. But each theory of trauma gives new or different significance to the concept. ...In the theory I devise, trauma is understood as damaging the capacity to relate to others, producing specific relational dynamics, and evoking annihilation anxiety. Because the theory defines the concept, we must allow the initial definition to be imprecise [italics mine] (Prior, 1995, p. 14).
Prior's caution is wise, because it points to the difficulty (but not impossibility) in operationalizing such an intersubjective experience. For Judith Herman (1992), psychological trauma "is an affliction of the powerless...[where] the victim is rendered helpless by overwhelming forces...[and where] the common denominator of psychological trauma is a feeling of 'intense fear, helplessness, loss of control, and threat of annihilation'" (p. 33). On its face, the abortion experience for men and women is not primarily described in Herman's elaboration of the traumatic event.
In Greenacre's (1967/1971) usage of the term trauma, he spoke of any condition "definitely unfavorable, noxious, or drastically injurious to the development of the young individual" (p. 277). Greenacre's definition reminds us that theories of trauma are often discussed in terms of injuries to self and as occurrences of childhood. However, when Niederland (1961) introduced the phenomenon of survivor guilt into the psychoanalytic literature, it represented a reconceptualization of the concepts of both guilt and trauma.
Niederland's (1961, 1981) studies of Holocaust survivors led him to conclude that his patients were not suffering because of unconscious, ambivalent, hostile wishes toward their friends and family members, but because of these patients' unconscious beliefs that their having survived represented a betrayal of their loved ones.
Drawing on his traditional psychoanalytic background, Lindemann (1979), one of the pioneers in the study of crisis and trauma, defined traumatic experience in relation to the arrested development of the sexual and aggressive drives, and trauma as revealed as arising "on the occasion of a crisis or at a time when the legitimate expression of these drives is expected:"
If the sex drive is the one that has been repressed, varying degrees of impairment of the capacity for sexual enjoyment may ensue. Such arrested development of drives toward sex or aggression often results from overstimulation-excessive provocation of the drives at a time when the person is too young, too inexperienced to understand or handle them-in which case we speak of a traumatic experience (Lindemann, 1979, p. 104).
In a Control-Mastery approach to trauma, while self and childhood experience play a central role in their view of trauma development, there is a strong recognition-rooted in the empirical study of how irrational unconscious guilt produces psychopathology-of the link between symptomatology and the process of identification in the witnessing of suffering. Marshall Bush (1989b) writes of the link between survivor guilt and symptomatology:
Traumas that befall other family members tend to produce intense unconscious survivor guilt. Traumas that befall oneself, especially those stemming from parental mistreatment and rejection, often produce a deep-seated unconscious belief that one is unworthy and deserves punishment. Massive trauma can exert a pathogenic influence and create masochistic symptomatology at any point in the life cycle. Weiss has suggested that most inhibitions and symptoms represent either compliances to or identifications with other family members toward whom one unconsciously feels guilty. Symptoms may also represent mixtures of compliance and identification. The unconscious purpose of these compliances and identifications is to reduce guilt through a self-sacrificial restoration of or a display of loyalty to the injured party (Bush, 1989, p. 102).
The Control-Mastery approach to trauma, guilt and psychopathology is thus more akin to the altruistic-adaptive hypothesis of human motivation proposed by sociologist W. Trotter (1919) that Freud considered and rejected in Group Psychology and the Analysis of the Ego (1921). It takes account of the interpersonal nature of trauma and psychopathology as the result of the conflict between one's own needs and the perceived needs of others. This hypothesis assumes an altruistic motive system and set of biologically-based prosocial instincts, like those proposed by Bowlby (1982) and Hoffman (1981), which Freud's theory of motivation reduced to sublimation or "a defense against egoistic motivation" (Friedman, 1985, p. 504).
Michael Friedman's (1985) excellent article "Toward a Reconceptualization of Guilt," outlines this new view of guilt, altruism and psychopathology in arguing that both Freud and Trotter were correct: that we are aggressive animals concerned with our own survival and "herd" animals, concerned with the perceived needs of others, not because we choose to be, but because we must be.
The conceptualization of trauma in the present paper draws upon features of the above theories but draws special attention to the interpersonal aspects of traumogenesis and points to the issue of a continuum of severity. It is thus possible to speak of a relatively severe traumatic event, grounded in altruistic concern, occasioned by object loss, engendering feelings of helplessness and loss of control in relation to the witnessed or imagined suffering of another in which pathogenic beliefs are created, maintained or strengthened.
It is somewhat unfortunate that Weiss chose the term "belief" because it seems to make his theory a purely cognitive one. Since publication of the 1986 volume, Weiss has clarified his use of term "belief" and suggested that pathogenic beliefs are more structurally complex since they always include affects (and thus, predictable physiological correlates), emotions (or in the language of Donald Nathanson (1992), memory plus affect), and schemas of likely behavioral responses, as well as beliefs about these responses and the entire relational environment (people, places and things). Thus, Weiss (1996, personal communication) has made clear that by "pathogenic belief" he implies something closer to what Bowlby (1969) discussed in terms of internal "working models" and dominant and sub-systems of internal working models or what Donald Nathanson-in expanding on Sylvan Tomkins (1962-63) script theory-discusses in terms of the development of "affect scripts," that is, means of organizing and managing affective experience (Nathanson, 1992, p. 245).
Nathanson links Stern's (1985) idea of a RIG with what Tomkins called scenes, or linked sequences of affective responses. Affect-based scenes thus link together to form scripts, which in turn generate additional affect. But scenes do not necessarily form pathological scripts just because the affect triggered by the scene is particularly strong. In simple terms, affective pain is not pathology. In fact, according to Weiss, the affective resonance of a particular experience may be very low or nonconscious in relation to a particularly strong pathogenic belief. This is seen in the case of unconscious survivor guilt (e.g., Modell, Weiss & Sampson, 1983; Bush, 1989b).
In Control-Mastery theory, the development of a pathogenic belief (or families of related pathogenic beliefs) inhibits normal developmental goals (and their attendant affective and emotional correlates, behavioral vectors and the like) and influences the ability and desirability for interpersonal relatedness and engagement. Pathogenic beliefs, often held in place and created by intense shame and guilt, affect one's ability to maintain safe psychological distance or intimacy, the ability to maintain self-esteem, and the ability to know one's desires and aspirations (Nergaard, 1985; Nergaard & Silberschatz, 1989; Nichols, 1989; Lowenstein, 1996). Factors affecting the morbidity (severity, course, intransigence) of the pathogenic beliefs include age at development of the belief structures, individual temperament, current life circumstances (including interpersonal resiliency factors), and psycho-physiological status of the organism (how is affect processed? What level of cognition is the individual capable of?). Thus, pathogenic beliefs acquired earlier in life may be more dominated by affective experience, whereas in other pathogenic beliefs one may be more or less conscious of attendant affect, and have greater access to the cognition surrounding the beliefs. Anxiety, shame, guilt, envy, sadness (and thus, depression), may all accompany pathogenic beliefs (Lowenstein, 1996).
In summary, Control-Mastery theory places a special focus on the role of unconscious guilt in the formation of psychopathology. While Freud emphasized guilt in the development of psychopathology, his understanding of the nature of guilt was quite different from that of Weiss and his colleagues. In his early theorizing, Freud saw guilt pathology as stemming from repressed impulses/wishes seeking gratification without regard to reality (chiefly, as rooted in the Oedipus complex). Yet Weiss took up Freud's later work, most notably in An Outline for a Psycho-Analysis, and argued that Freud had indeed opened the door for a view of guilt rooted in ego-based, altruistic concerns for the welfare of the other. Following from this belief, Control-Mastery theory holds that guilt does not arise primarily in the development of the superego and resolution of the Oedipal drama (as the result of aggressive impulses), but can arise at any time in the developmental life cycle and develops based on the fundamental orientation of the individual to the other, and our tendency to blame ourselves for the traumatic (or traumatically perceived) experiences of close others.
While the work of Weiss and his colleagues may still yet appear as tangential to a study of responses to abortion, it will hopefully soon become clearer that the theoretical axioms of Control-Mastery theory and the empirical research supporting the theory offers considerable descriptive and explanatory power not only for male responses to their partner's abortion, but for why pervasive, negative psychological sequelae do not readily show up in the literature on abortion research.
Guilt, Shame and Pathogenesis: Negative Sequelae as Disorders of Engagement
Part of the contribution of Weiss's early work was to confirm a classical psychoanalytic maxim about the work of psychotherapy. In early studies of the therapeutic process (Weiss, 1971; Horowitz, Sampson, Siegelman, Wolfson & Weiss, 1975), Weiss and his colleagues demonstrated that successful treatment included the emergence of warded-off mental contents (cognitions, feelings, impulses). In showing not only the criteria by which mental contents were warded off through defensive activity, but also the conditions under which these contents were brought to greater awareness, Weiss and his colleagues demonstrated empirically what Freud took as a given about pathogenesis, namely that there is an intimate link between the themes which are warded off and subsequent symptom formation, but not necessarily between the affective resonance of a warded off content and related behaviors.
Along these lines, then, Weiss and his colleagues identified certain types of unconscious guilt as fundamental in the development of pathogenic processes including depression (Fretter, 1995; O'Connor, 1995; O'Connor, Berry & Weiss, 1996), the inappropriate sexualization of relationships (Weatherford (Gassner), 1989), anorexia nervosa (Friedman, 1985), self-punitive patterns of interpersonal interaction (masochism) (Weiss, 1986; Weiss et al., 1986), and interpersonal interactions rooted in irrational beliefs about how one already has or may in the future harm significant others (Weiss et al., 1986; Dulay, 1987; Bush, 1989a, 1989b; Weatherford (Gassner), 1989).
While Weiss did not originate the concepts related below, he developed a program of empirical research with his colleagues that would eventually come to emphasize the importance of certain forms of unconscious, interpersonally-driven guilt. Some of these subtypes of guilt were often already identified in the literature as survivor guilt (worry about being better off than others/the belief that being alive is at the expense of a loved one/the belief that there is a limited amount of the good things in life to go around, and that experiencing the good things in life will harm someone else) (Freud, 1896; Neiderland, 1961, 1981; Modell, 1965, 1971); separation/disloyalty guilt (worry that being separate/different from loved ones will harm them and constitute an act of disloyalty) (Modell, 1965, 1971; Loewald, 1979); omnipotent responsibility guilt (the exaggerated sense that one is responsible for the happiness and well-being of others) (Modell, 1965, 1971; O'Connor, 1995); role guilt (the guilt that people experience consciously and unconsciously when they believe they have violated or are going to violate the socially sanctioned rules and regulations accepted for their sex/gender, class or ethnic group) (O'Connor, 1997) and; self-hate guilt (which refers to a general sense of badness indirectly related to interpersonal guilt) (O'Connor et al., 1997).
The elaborations on interpersonal guilt proposed by Control-Mastery theory also follow upon earlier psychoanalytic work of Kris (1976) and Loewenstein (1972/1982) which posited "signal guilt" as "an anticipatory warning reaction to an unconscious perception that one is in danger of hurting someone else, and it initiates defensive and restitutional activity to avoid that danger" (Bush, 1989b). The first four forms of guilt are all deemed interpersonal because they are deeply connected to the fear of harming others. The last form, self-hate guilt, may occur in relation to extremely punitive parents or caregivers, and is theoretically akin to the other forms of guilt insofar as people are trying to preserve a connection to significant others by maintaining themselves as bad (in order to see the other as good). O'Connor et al. (1997) notes that people may experience self-hate guilt in an effort to ward-off survivor guilt. For example, if one feels always at fault when something goes wrong, then one is not outdoing one's loved one in being at fault and undeserving.
It is this last point that bears closer scrutiny for it points to the ways in which affect-laden beliefs (which must be warded off in the service of maintaining close ties to others) and behaviors associated with those unconscious beliefs are linked with the development of psychopathology. For males, social and cultural prohibitions against emotional responsivity (the linking of affect and memory), forms one part of a complex chain of events which may predispose them to developing pathogenic beliefs around the experience of abortion, but not necessarily to exhibiting dense, negative emotion immediately subsequent to the abortion experience, which might constitute an observable mood or mood disorder.
The idea that guilt is associated with psychopathology is, as noted above in the discussion of Freud, not a new idea. Guilt has often been the emotion most associated with pathological processes (Freud, 1923, 1926, 1940; Klein, 1948; Modell, 1965, 1971).
To a lesser extent, shame had been seen as a contributor to psychopathology. But since the work of Helen Block Lewis (1971) and Heinz Kohut (1971), researchers and theoreticians began to focus on shame as the more problematic of the human emotions (Miller, 1985; Morrison, 1989; Retzinger, 1991; Nathanson, 1984, 1992; Lansky, 1992; Lewis, 1992). This might be seen to coincide with other advances in psychological theory along object relations lines which focused on attachment and stressed the interpersonal experiential sources of pathogenesis (Mahler, Pine & Bergman, 1975; Bowlby, 1969, 1973). The debate over "shame" versus "guilt" as the most potentially problematic emotion now occupies a significant portion of the literature, with some beginning to agree that-as Lynn O'Connor and her colleague Jack Berry assert in an ongoing online conversation with Don Nathanson and his colleagues-that both shame and guilt (which often arise together), powerfully organize our social lives and when linked to pathogenic beliefs can lead to severe inhibitions and potential pathology (O'Connor & Berry, 1996). Lewis (1981) herself argued that both shame and guilt were socially derived emotions, oriented towards restoring lost or threatened attachments. The present work adopts a focus on irrational, unconscious guilt as a powerful contributor to psychopathology, though, in agreement with O'Connor, Berry & Weiss's (1996) views that may often be a defense against unconscious guilt.
O'Connor (1995, O'Connor et al., 1997) and others rightly argue, I believe, that the debate over the relative importance of shame versus guilt hinges on the traditional Freudian psychoanalytic view of guilt as a primarily selfish emotion, motivated by individualistic concerns and an underlying wish to harm others, as exemplified and shaped by the resolution of the Oedipus complex (Modell, 1971; Friedman, 1985). Freud, Darwin and other 19th-century thinkers held a predominately self-oriented view of social phenomena in which the "self" was deemed the most salient focus of investigation:
If one beliefs that the "self" is the main unit...of the social group, then emotions focused on the self-or threats to the self-become primary. However, if one considers that groups may be an equally significant unit of organization and of selection, then an emotion related to the group, such as guilt, may be primary. Weiss's theory...incorporates an understanding of man as a group-based social animal, with empathy and the need to belong as primary motivations (O'Connor, Berry & Weiss, 1996, p. 2).
O'Connor points to a certain lack of understanding of how evolutionary processes may have developed which support not only "purely" competitive (Hamilton, 1964, 1969), but fundamentally cooperative, mutual ties to others, beginning with family members, close kin, friends and significant others in the environment (Trivers, 1971, 1985; Axelrod & Hamilton, 1981; Trower & Gilbert, 1989; Boehm, 1993; Jones & Burdette, 1994; Baumeister, Stillwell & Heatherton, 1994; Jones, Kugler & Adams, 1995). (See below "Recent advances in the study of guilt and pathogenesis".)
Advances in evolutionary biology, psychology and psychoanalysis (Hamilton, 1964, Greenberg & Mitchell, 1983; Trivers, 1985; Stolorow, Brandchaft & Atwood, 1987; Slavin & Kriegman, 1992; Wright, 1994;) support a more inclusive view of both shame and guilt as playing dual roles. In this more recent view, shame and guilt are emotions in the service of what is beginning to be understood as a fundamental human motivation, that is, to belong and to maintain attachment to significant others not as a consequence of aggressive, anti-social impulses and ensuing guilty feelings, but as the result of a human organism "hardwired" for empathy and altruism (Hoffman, 1981; Plutchik, 1987; Baumeister & Tice, 1990; Eisenberg & Strayer, 1990; Jones & Burdette, 1994; Baumeister & Leary, 1995; Jones, Kugler & Adams, 1995; Baumeister, Stillwell & Heatherton, 1994, 1996). Thus, guilt and shame are now understood to be related to socially-valued traits and behaviors (Tangney, 1990, 1991, 1995; Tangney & Fischer, 1995; Tangney, Wagner & Gramzow, 1992), and to psychological maladjustment and psychopathology (Modell, 1965, 1971; Kugler & Jones, 1992). What, then, makes a particular form of guilt or shame maladaptive and how are these traits measurable?
It was just these questions that Control-Mastery oriented researchers Lynn O'Connor, Jack Berry, Joseph Weiss and their colleagues sought to answer in the early 1990s, through a program of studies on emotion and pathogenesis.
They began their series of studies using a measure developed by June Price Tangney which defined guilt in a widely accepted formulation as "a self-conscious emotion related to the sense that one has done some specific wrong for which one can make reparation" (O'Connor, 1995). Tangney had defined shame as the feeling that something was globally wrong with them. In other words, in guilt, I did something wrong, whereas in shame, I am wrong.
However, O'Connor and her colleagues found that Tangney's measure-the Test of Self-Conscious Affect (TOSCA, a revised version of the Self-Conscious Affect and Attribution Inventory, the SCAAI)-did not specifically measure the types of interpersonal guilt (for example, survivor guilt, separation guilt, omnipotent responsibility guilt) they felt were associated with the development of pathogenic beliefs and psychopathology like major depression. In response, they sought to develop a theoretically-based and clinically relevant measure of guilt (now called the Interpersonal Guilt Questionnaire or IGQ-67) which not only assessed the types of guilt emphasized by Control-Mastery theory but attempted to control for effects of shame. The results of their studies were published in 1997 and suggested that when controlling for shame, survivor guilt continued to be significantly correlated with the development of symptoms, whereas shame (when controlling for survivor guilt) did not lead to the development of pathology. Tangney's studies using the TOSCA, O'Connor argues, were studying forms of adaptive guilt that were not always correlated with the presence of symptoms.
The present study therefore focuses more exclusively on interpersonal guilt in the formation of pathogenic beliefs as negative sequelae of abortion for male partners.
In each study, O'Connor and her colleagues found that interpersonal guilt was significantly correlated with psychological problems (Menaker, 1995; O'Connor, 1995; O'Connor, Berry & Weiss, 1996, Webster, 1996; Herbold, 1996) and that survivor guilt and shame were highly correlated. The studies also suggested that some types of unconscious guilt are more highly correlated with pathology than shame, and that some types of guilt are more maladaptive than others. In particular, omnipotent responsibility guilt can be held in place by extreme feelings of shame and a pervasive self-attribution system in which guilt over specific negative incidents is multiplied and linked, the replay of these scenes creates global moods, depressive affect and tendencies to interpret upcoming and past life events as fatefully negative (this relates to the pervasiveness of pessimistic explanatory styles). In the case of pathological guilt, one indeed functions with the belief described by Modell (1971) that "one does not have the right to a life." High proneness to shame may be an indication of unconscious survivor guilt (O'Connor, 1995a).
In reviewing Menaker's results, however, O'Connor found that not all types of guilt are associated with the emergence of psychological problems:
in regards to negative events, it was found that the Shame subscale of the TOSCA, the Guilt subscale of the TOSCA, and the Omnipotent Responsibility Guilt subscale of the ICG-67 were significantly positively correlated with a pessimistic style for negative events. The study suggests that a depressive explanatory style and the associated tendency for depression is thus highly associated with guilt, and particularly when one focuses on explanatory style for positive events. Shame on the other hand appears in this study to be more related to explanatory style for negative events [italics mine] (O'Connor, 1995b, p. 12).
O'Connor (1995) argues that Tangney's measure (the TOSCA) assesses for adaptive types of guilt (those most often negatively associated with symptomatology), and not the kinds of maladaptive dimensions of guilt assessed by the IGQ-67 such as survivor guilt, rooted in altruistic concerns for others.
It is important to bear in mind with the studies cited above that correlation is not causation. But perhaps we can understand guilt as such a potentially maladaptive emotion because its function in orienting us towards others is so crucial. We might conceive of shame and guilt as issuing forth from the same system whose basic function is engagement and attachment.
In this sense, shame could be understood as the "face" of a guilt-system oriented towards maintaining attachment to objects, roles and ideals perceived (consciously or nonconsciously) necessary for an organism whose fundamental orientation is to the other(s), viz., significant others and groups, not only for its individual survival but for the continuation of the group. By "face" I mean that shame is what is displayed (literally, on the face), when unconscious guilt is being held in place by a family of pathogenic beliefs (see fn. 4 of the present work).
This is related to Buss's (1980) view that guilt is the private aspect of the self-conscious emotional response, while shame is public. For Buss, shame implies an observer, although one wonders whether this observer could just as well be an internal observer, as in the case of a harsh, internalized super-ego. And Jones and his colleagues research (Jones, Kugler & Adams, 1995, p. 306) does not support such a clear distinction, however, between shame as public and guilt as a private emotion. It seems more promising to consider that shame and guilt can be related in that a person who appears ashamed and deficient is seeing himself as worse off than others. But in compliance with his pathogenic beliefs, he puts himself down and sees himself as deficient and shameful, not for purposes of pity or pride, but in order not to feel better off than others close to him (O'Connor et al., 1996).
Nathanson (1992) and Sylvan Tomkins (1962-63) before him understood the shame response not as a primary affect, but as ancillary, as the impediment to the primary affect pair Tomkins termed "excitement-joy." This matches well with the understanding from Control-Mastery theory that the development of pathogenic beliefs in response to traumatic experience results in the inhibition of certain otherwise desirable life goals and/or the capacity to experience joy. In this case, "failure" or holding oneself back evident in survivor guilt, would be syntonic with self views, and not necessarily show up in all measures of depression. However, as noted above, these feelings, beliefs, attitudes and self-attributions do seem to be picked up by measures of interpersonal guilt which are correlated with the presence of symptoms.
The standard argument is that if an experience is "bad" it produces observable, "bad" effects. Thus, in the case of abortion, if clinical interviews or psychometric measures such as the Beck Depression Inventory (BDI) do not show significant post-abortion depressive symptomatology (or other psychological disorders) for a significant number of people, it is argued that abortion produces no significant negative psychological sequelae. However, the development or restimulation of particular pathogenic beliefs in response to the abortion experience must be understood as more outstripping the phenomenon of negative psychological sequelae as we currently conceive of it.
Theorists and clinicians at the Stone Center (see below) have proposed the construction relationship-differentiation as a revision of the separation-individuation model. This reformulation is an important effort to help correct the errors inherent in previous understandings of autonomy and relatedness as in opposition.
By differentiation, I do not mean to suggest as a developmental goal the assertion of difference and separateness; rather I mean a dynamic process that encompasses increasing levels of complexity, structure, and articulation within the context of human bonds and attachments. Such a process needs to be traced from the origins in early childhood relationships through its extensions into all later growth and development (Surrey, 1991, p. 36).
For Surrey (1991), it is not that this new model of self-development implies a lack of individual agency. It is, however, a reassertion of the relational context in which all self-development takes place. This model puts connectedness to others and a more fluid capacity for identifications at the core of human developmental "progress." As such, disruptions in the capacity to empathize, in short, disruptions in the capacity to engage with others and one's own relational world can be understood, by definition, to be at the very heart of pathogenesis.
Abortion, Guilt and Pathogenic Beliefs
In some ways, we are still not far from Freud's discussion of loss in Mourning and Melancholia (1917). Since Freud spoke of depression (melancholia) as occasioned by loss (which need not be object loss, but the loss of an ideal), it is worth considering that what is lost for men (in the case of abortion) is not only something that can be variously interpreted as a potential child, but also the socially sanctioned roles of parent (father) and progenitor. In the case of abortion, the male may unconsciously experience the abortion as the rejection of the role of father, and develop significant pathogenic beliefs in response to this rejection. This can be seen as occasioned by a form of role guilt, which O'Connor (1997) defines as "the guilt that people experience consciously and unconsciously when they believe they have violated or are going to violate the socially sanctioned rules and regulations accepted for their sex/gender, class or ethnic group." O'Connor (1997) writes:
This type of guilt may constitute the internal psychological mechanism that leads to what is often regarded as "internalized oppression". Because it is learned in the family of origin and then reinforced in a continuous manner by most social interactions in a person's ordinary life, role guilt is often a major source of inhibitions and the pursuit of normal developmental goals and it may be most difficult to change in the course of a therapy.
The formation of pathogenic beliefs as regards role guilt is not dependent upon how the male views the status of the fetus. In other words, the male does not have to view the abortion as having ended a child's life in order to experience a loss, since the lost "object" is related to a socially-sanctioned gender role, not the human being. One is responding to the "it-could-have-been" of the experience (i.e., the lost social role of parent/father) where the focus is not on a potentially valued and then rejected child but to a socially valued and then rejected interpersonal role and individual ideal.
Deven's (1976) study on the social-psychological aspects of inducted abortion support a consideration of role guilt in the case of women. Deven argues that the social context of abortion in Brussels was one in which the intervention of abortion was generally viewed as traumatic because it was against a backdrop where motherhood was considered in the "true nature" of women. A rejection of this role was thus, if not tantamount to psychopathological, at least risking the production of serious adverse psychological reactions. While Deven's study did not bear out this hypothesis, viz., that abortion produces significant negative sequelae, it did illustrate significant methodological flaws in abortion research to date and indicate the persistence of valued social roles such as motherhood as a backdrop of abortion decision-making.
In addition, role guilt may come into play related to feelings about participating in the abortion procedure to begin with. While the procedure remains morally controversial, participation in abortion when it goes against a large proportion of the public can engender this kind of guilt. As previously noted (see Chapter Two on "Methodological Problems with Abortion Research"), the presence of this type of guilt, as Posavac and Miller (1989) note, "might well be hidden by the effects of relief and dissimulation in the pre/posttest designs. It would be compatible with a negative effect size in comparison group designs" (p. 21).
In the related cases of omnipotent responsibility, separation and survivor guilt, there is not only a relation to the fantasied (potential) life of a child, but an ongoing relationship to the female partner, with whom (according to the theory adopted here) one is always already altruistically and empathically linked. In the case of survivor guilt, the male partner may feel uncomfortable at not undergoing the same perceived trauma as his partner, and appearing to get the "easy end of the deal" as regards the experience, especially if his partner appears to be having a difficult time surrounding the abortion decision and experience. This is especially difficult when women are not often aware of their own survivor guilt, as in the related case of miscarriage reported by clinical psychologist and researcher Lynn O'Connor:
One of the most painful examples of survivor guilt that I have witnessed in the past year was in the case of a school counselor who miscarried in about the third month of her pregnancy. She became extremely depressed, dysfunctional almost. She came to see me to talk about her dissertation and how she couldn't work. I told her about survivor guilt. She said that that wasn't the problem, that she understood about survivor guilt, and that she didn't feel responsible for what happened, even though she felt sad. Then about three weeks later she called me and said she'd been in the kitchen cooking and found herself sobbing. She suddenly became conscious of a thought: "How can I enjoy eating when my baby is dead?" While it seemed to her later to be a normal part of the grieving process, she realized how she been feeling not only that she didn't have a right to go on in the face of her child's absence, but that she was partly responsible for the loss, and thus was not entitled to go on (Lynn O'Connor, personal communication, October 20, 1996).
It's important to note that these senses of guilt may be particularly complicated if the male considers abortion the termination of a human life (Harris, 1986). In this case, the situation in abortion goes beyond ordinary survivor guilt in that there may be a pathogenic belief formed that the one is to blame, quite literally, for another person's death or misery. This is a case where one may believe one has sacrificed one's child, and while there is a long history of the sacrifice of one's child in human history (for example in the selling of sons or daughter due to economic conditions), there is little said about the psychosocial significance of such practices on the development of beliefs about oneself and one's relational world.
According to Weiss (Modell, Weiss & Sampson, 1983), most forms of guilt, including Oedipal guilt, are based on pathogenic beliefs. Weiss discusses Oedipal guilt but does not consider it a separate category of guilt, since he understands it in relation to both separation and survivor guilt. Underlying separation guilt is the childhood belief acquired through inference that if a child becomes stronger than a parent, it will hurt that parent (or parents). A person suffering from survivor guilt assumes that his normal developmental strivings are at the expense of close others. A variety of masochistic and narcissistic symptoms may be associated with intense survivor guilt, and may present as their opposite, namely, that the individual does not care about others, or he may unconsciously arrange for losses in order to compensate for the imagined crimes against parents, siblings or close others who he believes have fared worse than he (Modell et al., p. 17). Both Modell (1965, 1971) and Weiss (Weiss et al., 1986; Weiss, 1993) emphasize that the sense of guilt can arise from any traumatic experience, and that the child or adult is likely to not only feel responsible for the trauma (unconsciously experiencing it as a punishment), but also develop new pathogenic beliefs about how he caused it or deserved it. These strong often irrational guilt affects, including Oedipal guilt are most often unconscious: the individual does not know he feels guilty; he may know he feels ill or unsettled, but the guilt does not announce itself as such. And since the individual is likely to link almost any impulse or goal to the trauma (in an effort to master that trauma), it is not always possible to predict just what pathogenic beliefs may be formed in the process of trauma response (Modell et al., p. 28).
It is thus crucial to consider that a patient, especially a male patient, may not present in therapy with issues of guilt. As noted above, survivor guilt and the pathogenic beliefs associated with this guilt does not often present in the clinical setting because it is often unconscious. A patient, according to Weiss (1996, personal communication, September 15, 1996) may describe himself as "deficient" (which is highly correlated with self-hate and shame), but can be unconsciously struggling with survivor guilt. The shame may function to reduce or mask the underlying guilt. O'Connor and her colleagues' (O'Connor, Berry & Weiss, 1986) studies on survivor guilt suggest that as patients increase their understanding of survivor guilt and the pathogenic beliefs associated with that guilt, the shame and self-hate accompanying their feelings of deficiency can be reduced.
But while the male partner in an abortion may not present with significant psychological sequelae (that is, distinct syndromes), it does not therefore follow that there are no traumatic effects of abortion. If the abortion experience for the male concretizes a family of pathogenic beliefs/inhibitions, and acts as the precursor to the formation of new scripts of responding ("My sexual feelings and desires are dangerous since they can result in the abortion of an unwanted child"), there may be negative effects which are noticeable only to the male and his partner (or subsequent partner) or not traceable to the abortion experience (Finley, 1978). In the example cited above, the male may be experiencing a change in sexual desire or dysfunction in erection which warns against a certain type of experience ("I will inhibit my sexual impulses because they may harm another") and not necessarily connect it to the abortion experience or report it to a professional for treatment. Recent estimates indicate that close to 60 percent of those men experiencing erectile dysfunction or lack of libido do not seek treatment due to the perceived negative view of being "impotent" (The National Institutes of Health, 1992) and the social value placed on men's readiness and willingness to engage in sex at any time (Nozick, 1989; Kimmel, 1987).
Yet, not all sequelae of abortion for men need be unconscious. In an unpublished study of male responses to abortion, Finley (1978) reported that most (94 percent) of the men in his study consciously linked post-abortion behavioral changes such as "less interest in sex" "enjoying work or school less," "socializing less," "sleeping less," and "drinking more" and their abortion experience. These behaviors often continued long after the abortion.
Control-Mastery theory suggests that people who are experiencing survivor guilt may present in a variety of ways including wanting to put others ahead of themselves or hold themselves back in order to "even the score." They may also present with mild "feelings of depression, obsessive thinking, compulsive behaviors or frightening thoughts common to phobic conditions and somatization" (O'Connor, 1995b; see also Zisook & DeVaul, 1976). Men especially might present not with feelings of depression but of anger and hostility, secondary to feelings of guilt related to the fear of harming others (anger as a defense against guilt).
Control-Mastery theory would also predict that men who were already higher in proneness to guilt and shame would demonstrate more negative self-attributions, more pessimistic explanatory styles and show a more external locus of control after the abortion experience than their counterparts who were lower in proneness to guilt and shame (e.g., Major & Cozzarelli, 1992; O'Connor & Weiss, 1993; O'Connor, 1995). One would also expect to see positive correlations between religious affiliation and practice, and proneness to guilt and shame. But the most salient point continues to be that when patients suffering from intense survivor guilt present in therapy it is not often with a conscious sense of feeling guilt, and being depressed about it. Patients do present, however, with concerns about perfectionism, chronic jealousy and pessimistic ways of explaining events and experiences. Each of these have been empirically demonstrated to be linked with survivor guilt (Menaker, 1995; O'Connor, Berry & Weiss, 1996; Herbold, 1996; Webster, 1996), and may warn a therapist to the presence of some trauma underlying the inhibitions and problems presented for therapy.
The above section does not argue that irrational guilt and defenses against it are the sole or even primary causes of psychopathology, merely that they are overlooked causes in pathogenesis, especially in the male experience of abortion. The experience of abortion for men is indeed a complex one, and unconscious guilt may be produced not only in relation to what is perceived as the traumatic experience of abortion, but in relation to earlier dramas and their effects. Men may experience unconscious guilt not only because of their partner's experience, but because of what is provoked around earlier unresolved Oedipal issues, or as stimulating unconscious feelings of envy over the pregnancy and the woman's generative capacities. Thus, unconscious guilt over an abortion may be responses to a deeply-buried wish to terminate the pregnancy and ward off painful feelings of envy. This is discussed in more detail in Chapter 4 and argues for an understanding of guilt as rooted in both competitive as well as cooperative impulses, as a reflection of not only hostile, but of concern.
Because of the highly political nature of the abortion debate (e.g., Tribe, 1992; Schnell, 1993), it is charged to argue that abortion constitutes a traumatic experience for women and men. It should be clear, however, that while not arguing for or against abortion, the present study takes as a starting point that abortion constitutes a traumatic experience for both women and their male partners, not only because it potentially constitutes a disruption of engagement and threatens real and imagined relational bonds, but because it can be seen as a re-traumatization. (See Chapter 1.)
Recent Advances in the Study of Guilt and Pathogenesis: Evolutionary Psychology, Relational Theory and Altruism
As noted earlier in this work, both Freud's theory of guilt and Control-Mastery theory are trauma response theories. And as trauma response theories they offer important insights into relational dilemmas involved in abortion.
Control-Mastery theory also shared insights with a number of other contemporary psychoanalytic and non-analytic theories of the mind and psychopathology, most notably those that take as their starting point-to borrow from the title of Malcolm Slavin and Daniel Kriegman's (1992) excellent volume-the adaptive design of the human psyche. The theoretical insights advanced by Weiss, Sampson, O'Connor and members of the San Francisco Psychotherapy Research Group are consonant with the work of the early interpersonal theorists like Harry Stack Sullivan (1940), the attachment theory of John Bowlby (1969), parts of Heinz Kohut's (1971) self psychology, the intersubjectivity theory of Robert Stolorow, George Atwood, Bernard Brandchaft and Frank Lachmann (Stolorow & Lachmann, 1980; Stolorow & Atwood, 1992; Atwood & Stolorow, 1993; Stolorow, Atwood & Brandchaft, 1994), contemporary infant and child developmental theorists and researchers like Daniel Stern (1985) and Robert Emde (1989), as well as other contemporary theorists of the mind like the group of researchers and clinicians at the Stone Center in Wellesley (Jordan, Kaplan, Miller, Stiver & Surrey, 1991).
Control-Mastery theory assumes a fundamental human capacity for practical understanding of relationships, "hardwired" if you will, from birth. It receives confirmation in the researches of Stern who has demonstrated that infants have both the motivation and capacity to acquire knowledge about their relational world, and demonstrate this by an almost constant monitoring of their caregiver's reactions, often revising their behavior very quickly in response to extremely subtle interpersonal cues. Infants only a few weeks after birth are already making hypotheses (non-cognitively) about how their caregivers will respond, in an attempt to form secure attachments to them. This behavior does not require language or even conscious processing. Recent work in psychoneurology (Lewicki, 1986; Lewicki, Hill & Czyzewska, 1992, 1994) and developmental linguistics (Pinker, 1994) suggests that unconscious processing is faster, more efficient and often more accurate than conscious processing of information.
When Bowlby (1969) spoke of attachment relations and the development of internal working models of the caregiving environ (see also Bretherton, 1987) or Stolorow et al. (1993) wrote about invariant organizing principles, they were pointing to relational phenomena akin to Weiss's notion of an internal framework of experience and interpretation from which pathogenic beliefs are formed. From birth, then, barring any significant interruption of the psychophysiological mechanisms necessary for interpersonal relatedness, we are continually scanning our environment, testing hypotheses about interactions (especially in new situations), and revising our hypotheses or internal working models about how the world functions. Much of this "experimental" work goes on nonconsciously, and continues throughout our lives with others.
Lewicki and his colleagues (Lewicki, 1986; Lewicki, Hill & Czyzewska, 1992, 1994) argue that unconscious processing is much more like conscious processing than we imagine, and that scanning, assessment, judgment and planning, for example, can be and are carried out without conscious thought. This highly developed attunement system is most likely closely allied to the affect system, as described by Nathanson (1992) and LeDoux (1994). This kind of nonconscious processing allows infants to develop crucial impressions of others, as well as adults to determine whether their current relational field is being threatened (Weiss, 1995a). While a person may become conscious of the results of their nonconscious processing, they are not aware of the nonconscious "thinking" that led to a chosen action.
Thus, in Weiss's theory, people are powerfully motivated towards adaptation to reality, and are supplied with a kind of inborn hardwiring geared towards this adaptation with others. This has great survival value and appears to be a part of our human evolutionary inheritance (Slavin & Kriegman, 1992). In Freud's early theorizing (1911-1915), there was a view of the mind advanced which was relatively inadequately at adaptational tasks. This is because his theory postulated a psyche structured and in many ways developmentally bound by (sexual and aggressive) impulses over which the mind had little control. "We are lived by our unconscious" Freud believed, and postulated a schema of consciousness as epiphenomenal-the result not of planful, unconscious processing, but of powerful, fluid and often destructive psychic forces.
In contrast, newer evolutionary psychological theories seem to share in common a set of views about human relatedness, belonging and attachment which posits a fundamentally adaptational orientation to behavior, cognition and biology.
Researcher Roy Baumeister, one of the most productive writers on attachment and interpersonal affective phenomenon, understands guilt as serving an adaptive function, oriented towards maintaining close ties, by providing affective signals for the initiation of relationship-enhancing action. But while the guilt phenomena are understood to be linked to anxiety, as Freud understood them to be, many contemporary theorists understand this anxiety to be linked not to aggressive impulses but to empathic impulses, as a response to perceived threats to interpersonal relationships (Bowlby, 1969, 1973; Hoffman, 1982; Baumeister & Tice, 1990; Tangney, 1992).
So, ironically, at the end of the current century, the return to evolutionary psychology is revealing what psychoanalysis promised in its infancy with Freud's Project for a Scientific Psychology (1896), and has ambivalently resisted since: the link between psychoanalysis and neurobiology (Reiser, 1985).
The growing body of literature in evolutionary psychology has already begun to link up the study of affect, motivation and human adaptation. While the question of the possible adaptive function of affect was raised by Freud and then discarded (see Friedman, 1985), modern evolutionary psychology reopens the question again, fueled by investigation in fields such as psychotherapy process research, psychosocial research on motivation, psychoneurobiological research on human unconscious processing and ethographic studies of higher primates (e.g., de Waal, 1996). The new picture beginning to emerge challenges predominant 19th- and 20th-century views of human behavior and biology as solely self-oriented, competitive and rooted in the sexual and aggressive instincts.
The assumptions of evolutionary psychology
Evolutionary psychology rests on several important assumptions. First, the mind is seen as a set of adaptable interlocking systems, which are much more efficient than that predicted by Freud's view of human development.
Evolutionary psychology approaches the mind from a functional perspective to ask "what are the mechanisms of the mind 'designed' to do?" (Buss, 1995, p.1) Conscious and nonconscious functioning are much more interwoven and the barriers and distinctions between consciousness and unconsciousness are not discrete in the way Freud's early theory seemed to suggest.
Secondly, human evolution through natural selection is seen as relative static since the Pleistocene era, and as the only presently known causal process capable of producing the kinds of complex psychophysiological mechanisms under investigation.
Thirdly, complex, adaptable information processing systems evolved as a result of universal problems of survival and propagation of the species associated with Pleistocene conditions (a "hunter-gatherer" environment), and therefore these systems are context bound and content specific, generating many aspects of human culture. (Buss, 1995).
Most importantly, when evolutionary psychology studies a particular human phenomenon, it asks: 1) What problem was solved which shows itself in (and as) the phenomenon under investigation and how is this a nonarbitrary solution?; 2) How was that earlier problem an adaptation to environmental conditions and how does it interact with the current environment and; 3) What physiological resources and capabilities would be necessary to have solved this problem (or set of problems?). Evolutionary psychologists would thus ask about the adaptive function of different types of guilt, altruistic behaviors or depressive affect. In the wider sense, evolutionary psychology opens a door to the investigation of the adaptive function of affect that Freud had tried to close.
In Chapter 3 of the present work, it was argued in contradistinction to Freud's view, that guilt could be considered related to an altruistic motive system and the maintenance of prosocial behavior. Evolutionists since Darwin had noticed an array of highly mutual, cooperative, even self-sacrificing behaviors in a wide range of species. Some of these self-sacrificing behaviors appeared difficult to explain because they did not promote the survival of the altruistic individual member of the species. How could a trait or trait-system be the result of evolutionary processes which were thought to select for individual members of the species that were more successful at replicating themselves, when these "altruists" sacrificed themselves more often than their more "selfish" competitors? In addition, the "altruists" were easily taken advantage of by less self-sacrificing members of the species. If these altruistic behaviors (and their underlying genotype) were selected for their contribution to the greater social good, why would nature create a type of individual member whose genotype would more easily be removed from the gene pool, thus removing the supposedly altruistic or self-sacrificing behavior (the phenotypic expression)?
As noted above, in Freud's still widely-accepted view, empathy and altruism are acknowledged, but considered to be forms of egoism and selfishness, driven by instinctual forces. In this view, we help others and respond affectively and behaviorally to them in order to preserve ourselves. While it is difficult to dismiss survival as a primary motivating factor in human life, it may not be the only story.
However, there is a current of thought in evolutionary psychology that supports Freud's view in positing two types of altruism, both of which are egocentric. The first type is related to kin selection and inclusive fitness as described in the work of W.D. Hamilton (1964, 1969) and R.L. Trivers (1971, 1985).
Inclusive fitness is based on the recognition that survival of copies of an organism's genes in other individuals, and in the resultant future gene pool for the species, is the only measure of evolutionary success or ultimate fitness. The success and survival of the individual is not the ultimate focus of selective pressures. Natural selection has shaped organisms that maximize their inclusive fitness, not their personal fitness (Slavin & Kriegman, 1992, p. 86).
In this view ("kin altruism"), the primary goal for the individual is the replication of the gene. And so acts of altruism (which require empathic attunement to the other and oneself) are viewed as providing the continuity and survival for the those related to us (kin), for those that share similar genes. According to Trivers (1971), kin altruism seemed to account for the abundance of unselfish acts found in nature.
Trivers proposed the second concept of "reciprocal altruism" to explain why it might be adaptive to relate altruistically not only to those who can carry on related genes (as in kin), but to unrelated others who do not share anywhere near as high a proportion of related genes. If one can, at some point, "pay back" the other, then temporary costs to personal fitness (through altruistic acts) might be equalized through the eventual (future) return of an equally seemingly altruistic act. This model of "tit-for-tat" or negotiated exchange seemed to account for the range of seemingly unmotivated altruistic acts towards unrelated others. This has also been applied in game theory to show that reciprocal, mutually cooperative problem-solving strategies outcompete selfish ones (Axelrod & Hamilton, 1981).
Trivers concept of reciprocal altruism, while shifting the focus to the adaptive function of relatedness, still appears to operate with an understanding of human motivation as primarily selfish. However, the concept takes the individual (genotypically and phenotypically) as its starting point, and as the focus of investigation.
A new trend in evolutionary biology, however, focuses more on the group as the salient unit of study, and argues for a primary social altruism, that is a motive system rooted in a fundamental need to help others, not solely to reproduce our genes or "get paid back" at some future time. Control-Mastery theory (Weiss, 1993), consonant with the attachment theory of Bowlby (1982, p. 133) and empirical research on altruism (Hoffman, 1981; Zahn-Waxler, Radke-Yarrow & King) assumes a motive system oriented towards belonging and care-giving, not only because it benefits the individual gene and person, but others in related and nonrelated groups. (In this regard, see also Batson, 1991.)
And what of the maintenance of psychological health? In agreement with Control-Mastery theory, researchers Baumeister and Leary (1995), following Bowlby (1969, 1973) posit the existence of the need to belong and maintain close interpersonal bonds as a fundamental human motivation. In Baumeister and Leary's view, there is a persistent drive to form and maintain "at least a minimum quantity of lasting, positive, and significant interpersonal relationships."
Satisfying this drive involves two criteria: First, there is a need for frequent, affectively pleasant interactions with a few other people, and second these interactions must take place in the context of a temporally stable and enduring framework of affective concern for each other's welfare (Baumeister & Leary, p. 497).
Baumeister and Leary have taken a bold move in positing the need to belong as a fundamental human motivation, and have thus raised the status of their claim to the metapsychological level. In exploring their hypothesis, they suggest nine litmus tests for determining whether or not the "belongingness hypothesis" fits the criteria for a metatheory. While I will not explore their researches in detail, it is important to note that among the criteria they suggest is the idea that "failure to satisfy a fundamental motivation should produce ill effects that go beyond temporary affective distress" (p. 498). They argue that if belongingness is a fundamental human need (as opposed to a want or wish), unsatisfied belongingness needs should lead to medical, psychological or other behavioral psychopathologies.
In this regard, the authors offer a thoughtful review of the consequences of the deprivation of belongingness needs, which are extremely germane to the study of relatedness of males to their partners in the abortion experience. They review: 1) general consequences of deprivation and two forms of partial deprivation: 2) relatedness without interaction; and 3) interaction without a bond of caring.
What they find in common between the various forms of disruptions in capacity for engagement is a need for greater frequency of contact, without which the need to belong is only partially satisfied and results in a variety of medical and psychological consequences and; a base of positive mutuality in contact (that is, mutual caring, concern and affection). Their evidence, which bears close scrutiny, suggests that there is a basic desire to form and maintain close social attachments, and that deficits in belonging and engagement lead to a variety of ill effects (correlationally, not causally). In addition, their research also shows how the need to connect to others shapes emotional responsivity and patterns of cognitive processing.
Along these same lines, Friedman (1985) incorporates this evolutionary psychological view in discussing the origins of guilt:
Guilt refers, I believe, to a distress that derives from our being herd animals. It reflects a biological sensitivity to and concern for the needs of significant others, and arises when one believes one has injured or failed to help these others. The phenomenon of guilt derives from what evolutionary biologists are now calling the altruistic line of motivation in human life (p. 508).
Guilt, particularly survivor guilt, may serve the adaptive function of group cohesion (O'Connor, Berry, Weiss & Schweitzer, 1996). O'Connor and her colleagues argue that survivor guilt helps "equalize the playing field," in cases where inequality creates anxiety. Survivor guilt may thus function to improve group fitness, if it prompts altruistic acts of sharing. O'Connor notes that submissive behavior/submissive individuals tend to be much higher in proneness to survivor guilt. This tendency may in fact function to maintain a group's organization in a peaceful manner (ibid., p. 12).
In this view, male inexpressivity and the predominant self-reported experience of relief consequent to abortion, while on the one hand a potential source of discomfort and anxiety for the female partner, may also be serving the function of "evening the playing field" where an other is perceived as undergoing greater suffering. Thus guilt is understood as derived from empathy, as a capacity for interpersonal sensitivity to transgressions against valued partners in close relationships (Hoffman, 1981; Baumeister, Stillwell & Heatherton, 1994, in press, 1996).
A series of studies conducting by Aron, Aron, Tudor and Nelson (1991) demonstrated that close relationship partners in fact experience cognitive effects similar to those of the self. Interpersonal cognitive processes between close partners tend to thus blur boundaries between self and other, more than between self and distant others. These cognitive patterns seem to involve different neural pathways and forms of processing, suggesting a kind of innate readiness to perceive something of the internality of others. One must consider the affective system as a primary pathway by which we assess the maintenance and status of the interpersonal bond.
The function of guilt as a primary, positive motivational factor in interpersonal relationships has, as noted above, been demonstrated through Baumeister and his colleagues critical work (Baumeister, Stillwell & Heatherton, 1994, in press (1996)). Their research supports the view that guilt (like survivor guilt) serves important interpersonal functions like relationship enhancement, increasing lesson-learning rate, changing subsequent behavior and assessment of differences in self- and other-expectations. Their research also demonstrates the high priority that individuals give to the welfare of close others, sometimes to the detriment of their own needs and interests.
This chapter thus invites the reader to reconsider the question of the psychological sequelae of abortion for men (especially of unconscious guilt) against a new background. This backdrop assumes the biological givenness of an altruistic motive system for humans, comprised of a natural propensity for empathy, cooperation and reciprocity alongside competitive, hostile aims, and a constantly shifting assessment process of "balancing" the needs of others (close and distant), with our own perceived needs and the needs of the wider culture. Temporary acts of altruism may be returned later or repaid to other individuals in a wider, reciprocal network (viz., I can pay you back by paying back someone of value to you), all of which may reduce individual personal fitness while increasing long-term inclusive fitness benefits.
Slavin & Kriegman (1992) describe our psychological structuration as highly relational and adaptable, containing deep capacities for attunement to connections between self and other. These capacities are psychobiologically based and often involve nonconscious processing. They include capacities for quickly distinguishing who may have competing and/or cooperative aims; a capacity for fluid reassessment and reinterpretation of types of relatedness (such as between kin and non kin); an intuitive drive to understand the "hidden dimensions of relatedness," that is, to distinguish between boundaries that predict apparent conflictual aims (between "self" and "other") and to understand and act on the longer-term prospects of overlapping interests (p. 106).
What does evolutionary psychology, then, have to teach us about male partner's responses to abortion? In situations like abortion where there may be competing interests and conflictual aims between partners, the solution to an unwanted or ambivalently wanted pregnancy (the abortion) or the solution of sequelae (that is, how does each individual respond affectively and emotionally to the experience) is a problem of mutuality. The expression of symptoms (whether by self-report, psychometric measure or interview) is the result of a complex series of psychophysiologically-based weighing acts occurring at conscious and nonconscious levels, rooted in the constant assessment/scanning of one's relational world.
These weighing processes are not only in regard for the other(s) involved-at individual and social levels-but processes requiring components/capacities that evolved through the same complex network of relatedness and reciprocity described by researchers like Stern (1985) and Emde (1989) as necessary for human development. The social comparisons made in order to determine the appropriateness and adaptability-(in a narrow sense) of affective attunement to oneself and other-of emotionality in any particular situation (linking of emotion and memory and its expression to an other) are also rooted in earlier experiences of these same balancing acts. Pathogenesis is, in a Control-Mastery understanding, not simply biological, but a relational problem of adaptation to reality:
Adaptation to reality is a central psychic concern, and a central organizer of mental life, from birth. ...As part of this effort, [one] seeks to acquire reliable knowledge (i.e. beliefs) about [one's] interpersonal world. These beliefs are central to a person's conscious and unconscious mental life. They organize personality and psychopathology (Sampson, 1990, p. 690).
"Real" experience with others (as opposed to the workings of the drives in accord with the pleasure principle) is thus thought to play a central role in the formation, maintenance and resolution of psychopathology (Sampson, 1992).
In this light, the next chapter discusses how male inexpressivity represents not only the results of complex socialization processes but also a type of altruistic behavior, in loyalty to one's own father who was more often than not socialized in ways that delimit possibilities for mutuality, attunement and engagement with others. If the affect system is one of the primary systems by which attunement, belongingness needs and other forms of relationality are nonconsciously assessed, then disruption in the ability to attune to one's affect must necessarily result in (degrees of) disruptions in engagement.
Loss, Grief & the "Shut-Down" Male
Loss, Masculinity and Identification
It is arguably a commonplace that males in American society do not and should not grieve their losses. Sex differences have been demonstrated in response to loss, as well as in the expression of emotionality (Allen & Markiewicz, 1976; Black, 1991; Hunfeld et al., 1995). Further, some have argued that the perception of what constitutes a loss is oriented by gender role (Hartley, 1959; Mischel, 1966; Bowlby, 1974; Steinberg, 1993). Yet the clinical literature is abundant with case reports of intense male guilt responses in relation to death and other losses of role, status and relationship (e.g., Epston, 1991).
In exploring the barriers to male expressivity, this chapter is informed by the important work of a group of women clinicians, theorists and researchers at the Stone Center for Developmental Services and Studies at Wellesley College. Based on a paper presented at the dedication of the Stone Center, the publication of Women's Growth in Connection (Writings from the Stone Center) (Jordan, Kaplan, Miller, Stiver & Surrey, 1991), represented a progressive synthesis of previous literature on empathy and attachment, and added fresh new perspectives on thinking about women's and men's development.
Masculinity is traditionally defined in terms of instrumentality/activity, aggressivity, male-male competition, power-over, individuality and control of affect (Mussen, 1961; Ellis & Bentler, 1973; Pleck, 1975; David & Brannon, 1976; Bem & Lenny, 1976; Bem, Martyna & Watson, 1976; Komarovsky, 1976; Chodorow, 1978; Silverberg, 1986, p. 71; Jordan et al., 1991; Steinberg, 1993, p. 208). In accord with the traditional views of masculinity, boys, from infancy, are generally socialized to avoid becoming or exhibiting roles or behaviors associated with femininity (Thompson & Pleck, 1987). The Stone Center theorists assert, in general, strong, observable differences between men and women in capacity for empathic response. And among those behaviors traditionally associated with femininity-passivity, loss of objectivity and loss of control-are the very components of both self- and other-empathy (Jones, Surrey & Kaplan, 1991, p. 30). The association of these abilities with femininity thus not only leads to the contraction of the male's ability to perceive the suffering of others, but to perceive his own suffering. And since empathy, "can lead to the other always coming first at the expense of valuing one's own experience" (Jordan, Surrey & Kaplan, ibid.), an increase in conscious empathy may be associated with a decrease in unconscious survivor guilt. Of course, of all the capacities most associated with femininity and female gender identity are childbearing and pregnancy (Notman & Lester, 1988).
According to social learning theory, children learn about gender roles primary through direct observation and tutelage (Mischel, 1966). And psychoanalytic perspectives have long maintained that learning about gender roles is primarily a process of identification, not of imitation (Jung, 1953-59; Freud, 1905, 1933).
For Jung, identification with the father was a process of adaptation to reality in the face of conflictual demands from the environment. Identification with the father was thus a question of regression. But for Freud, identification was defensive, a way of minimizing the intense anxiety associated with aggression, guilt and loss. The process of male gender role development then, according to Freud, comes about as a result of: 1) the reality of bisexuality; 2) the resolution of the Oedipus complex; 3) the role of anatomy and; 4) through the mechanism of identification.
Once again we are left with the dominant view, based on Freud's early theorizing, that identification is not rooted primarily in love and attachment, but in the fear of loss and retaliation for crimes real and imagined. In distinction to the then-current Victorian view of males as innately more aggressive and independent, Freud posited a psychobiological bisexuality, and argued that the observed male gender behaviors were due to strong social influences (nurture), not biological givens (nature). In both Freud and Jung's view, the process of identification was a negative one in which the boy's individuality is compromised, and the process of identification is always in relation to the father, and not, as in argued in contemporary revisions of the Oedipal situation as "shifting identifications with the mother and father" (Ross, 1994). Both the traditional psychoanalytic and social-learning models of male gender-role development ignore the question of purposefulness and positive adaptability of identification in the formation of masculinity. The male child's ability to grieve is thus shaped not only by the Oedipal complex and in relation to the father (Chodorow, 1978), but in capacities for self-attunement to painful affect, developed or retarded in relation to all significant caregivers (Stiver, 1991). And understanding of the fear of parental retaliation must move beyond notions of castration anxiety to focus on the child (and later adult's) fear of harming significant others through individuation (the pursuit of normal developmental goals of separation-individuation). One can imagine how the abortion experience for the young male recapitulates a wide array of relational issues surrounding individuation.
In this light, newer researches have added a more complete picture to include the important roles played by learning through inference, somatic and psychoneurological processes such as affect development (Nathanson, 1992), language acquisition and development (Pinker, 1994), genetic predisposition, and "hardwired" orientations/needs for attachment and belonging, which are thought to underlie all learning processes, conscious and unconscious (Stern, 1985; Baumeister & Tice, 1990; Slavin & Kriegman, 1992; Baumeister & Leary, 1995). Some like psychologist and researcher Donald Nathanson argue that there is no learning without an attendant affective state (since consciousness requires affectivity), and we would do well to stop thinking that physiology, affect and emotion, learning and the development of complex environmentally-based response scripts are not inexorably interrelated.
Male Inexpressivity and Grieving
Much of the literature on grief responses take up the concept of phases or stages of grief (Bowlby, 1980; Parkes, 1972, 1975). While these stages or phases may be conceptualized as overlapping or sequential, it is generally understood that one must complete certain tasks in order to mourn, that is, go through a post-loss healing process. In this view, mourning requires time and creates tasks that need accomplishing. The tasks of mourning can be difficult based on relational factors such as the degree of dependency in the relationship. And we must remember that loss is occasioned not only by death but by the loss of a self- or other-ideal. And a person who has a highly dependent relationship and then loses the connection to the other, also loses a sense of their own efficacy and self-image (Horowitz, Wilner, Marmar & Krupnick, 1980).
Thus, the loss occasioned by an abortion may be a perceived loss in self- or other-strength and invulnerability to trauma or a (temporary) loss of ego boundaries which some argue is at the core of the "affective, intuitive process" we call empathy (Schafer, 1959; Jordan, Surrey & Kaplan, 1991, p. 27). For men, however, the experience and expression of their own vulnerability is often avoided, consciously and unconsciously (Jordan, Surrey & Kaplan, ibid.).
One particularly crucial aspect of traditional masculine roles is the notion (and reality) of male inexpressiveness (Mishkind, Rodin, Silberstein & Striegel-Moore, 1987; Jordan, Surrey & Kaplan, 1991). Hartley's (1959) early study on sex-role identification showed that with consistent, early enforcement of male role behaviors such as physical risk-taking, toughness, competitiveness and aggressivity, the male kindergarten child will "feel virtual panic at being caught doing anything traditionally defined as feminine" (as quoted in Steinberg, p. 53). Steinberg puts the point quite nicely that inexpressivity is considered a "positive sign of masculinity," unless the emotion being expressed is anger (modulated as resentment or unmodulated as rage).
We are all familiar with experiences, either our own or observed, of grown-ups admonishing a young boy who has been hurt and is crying that boys are not supposed to express such emotions. Sometimes there is even the more shaming pejorative "sissy" thrown at the boy, or he is told that only girls cry and he should be a man. By attaching shame and humiliation to the expression of emotions, parents solidify the idea in their son that a real man does not show his emotions and that outward expressions of emotion are feminine and undesirable in a man (Steinberg, p. 54).
As Steinberg notes, "being inexpressive is not even considered a role, it is an assumed reality-men really are this way, it is the nature of masculinity [italics mine]" (ibid.). This intense expectation, coupled with what may be an underlying altruism towards his female partner, can result in the self-expectation that it is both desirable and necessary to put aside (or not even feel) anything negative in relation to the partner or the abortion experience. If the need for attachment and dependence is thus triggered by the abortion experience, it would generally be considered a sign of weakness to exhibit these emotional needs (Silverberg, 1986; Scher, Stevens, Good & Eichenfield, 1987; Horrocks, 1994). But the situation is more complex, for the walling-off of affective awareness does not merely serve to protect the male from experiencing painful feeling or from himself as weak. Since boys are socially supported in forming a primary identification to the father as soon as possible ("curtailing the primary identification with the mother") (Mahler et al., 1975; Chodorow, 1978), a young male's disconnectedness from feeling can also be seen as a way of maintaining loyalty (attachment ties) to the real and imagined father. It is one of a series of compromises that the male child must make (in the general case) to balance his shifting identifications between mother (as more affectively responsive) and father (as the model of mastery through the containment of affect) (Jordan, Surrey & Kaplan, p. 31).
With boys, the process of understanding on the mother's part may be more "intellectual" and less immediate. Further, the experience of looking to the mother for mirroring and confirming becomes questionable at some point for the boy, as he recognizes and often ultimately devalues her differentness. It is likely that these differences in the experience of being mirrored may give the boy a diminished sense of being in contact with and understanding another person in a directly affective way (Jordan, Surrey & Kaplan, p. 32).
The effect of all this, as the Stone Center theorists assert, is to "amplify disconnection and lessen empathic responsiveness" (ibid.). The processes of attachment, as a "lessening of the boundary between self and world" (Levinson, Darrow, Klein, Levinson & McKee, 1978, p. 323) is one in which a loss of self is occasioned. This does not mean, however, that the male's needs for attachment cease to exist, but, according to Steinberg, that men simply "do not develop a conscious relationship to them; either they do not recognize their needs or they are too humiliated to state them and ask for their satisfaction" (Steinberg, p. 55). But there is a crucial point to be made here.
The present work does not argue that men, for example in the experience of abortion, cannot empathize with their partner or with themselves (in having an empathic response towards oneself). It does assert, however, that men do not as readily develop a conscious relationship to their own natural empathic attunement to the other, and often feel guilty not only because of their apparent lack of engagement in traumatic situations, but because of their own inability to respond to themselves. If the male child comes to believe that too much responsive attunement to others goes against (and outdoes) the father's ability to be affectively responsive, it can engender feelings of unconscious survivor guilt towards his own father, as well as increase feelings of omnipotent responsibility guilt, insofar as he fails to respond to his partner.
One important implication for this sex-role socialization against expressivity is that when we are looking for male responses to significant life events (or even consciously understood trauma), we cannot rely on self-report or interview techniques as effective means of determining the presence of pathogenic processes. And thus, the methodology employed in the research will expand or limit the scope of the findings. In addition, the effects of social and psychological pressures on men not to experience or articulate emotional reactions involving grief, anger, fear or shame may also call for different models of therapy for men and women in relation to the abortion experience (Dore, 1994).
As noted previously, the majority of studies on abortion report that relief is the most commonly experienced post-abortion emotional response (Osofsky, Osofsky & Rajan, 1973; David & Friedman, 1973; Illsey and Hall, 1978; Dagg, 1991). Sociological studies like those of Art Shostak and his colleagues (Shostak, 1984, 1987; Shostak & McClouth, 1984; Shostak, McClouth & Seng, 1987)) also indicate that men feel relieved after the abortion. But this can be also be understood in the light of male sex-role socialization and what Steinberg noted as the "two basic types of inexpressive male common in the media...the cowboy and the playboy":
An example of the cowboy is the strong, silent John Wayne type of hero. While he likes females and has feelings toward them, he does not express his feelings. The James Bond playboy type is similar to the cowboy in his detachment and inexpressiveness. He differs in that he is non-feeling toward women and treats them more as objects to be used (Steinberg, p. 54).
What is the legacy of contemporary male gender-role socialization? Researcher and psychotherapist Carol Staudacher (1991) argues that men often do not show their grief responses and appear to "work through" their response to trauma and loss much more quickly than women, although this may not be the case. Male gender-role socialization leads to what amounts to a "socially endorsed lack of empathy...sometimes even to the point of glorifying the repression of feeling" (Staudacher, p. 145).
Staudacher describes the three major phases of "normal" grief as: 1) Psychological retreat; 2) Working through and; 3) Resolving. She understands these phases as fluid and overlapping, nor as sequential. The general progression, however, is towards integration of the loss.
In psychological retreat, the first phase of so-called normal or "successful" grief responses, one experiences numbness, pain, anxiety, shock and disbelief. Any significant emotional responses to the loss may be absent, delayed or suppressed.
In the phase of working through, one enters a period of emotional, social and physical disorganization in which sadness, confusion, despair, feelings of powerlessness, abandonment, loss of control, specific fears of additional loss, anger (at self, others and God), guilt (e.g., survivor guilt, separation guilt), hallucinations, impeded concentration and memory are common. Working through refers to the bringing to light of painful emotions, resolving conscious and unconscious inhibitions to their expression and dealing with the myriad of physiologic and psychological correlates of the loss response.
In the last phase termed resolving-which bears some resemblance to Freud's notion of the recathexis of libido-the person begins reorganizing and restructuring their life and life goals. One must "make a new world" for oneself, with others, reorienting oneself in new roles (e.g., no longer as a husband, father, etc.).
If any of these phases is incomplete, Staudacher argues, the result may include delayed grief, absent grief, chronic grief, or addictive/destructive behaviors. What is striking, however, is not that the grief process can become impacted, but that there is a correlation between gender and pathological grief responses. Her research indicates that for men who are strongly socialized in traditional male roles, their grief experiences are significantly different from those of women, including the following:
1. Experience of a shorter Working Through phase.
2. Appearance of passing through only the first (Retreating) and third (Resolving) phases.
3. Evidence of less help- and support-seeking.
4. Evidence repression and suppression grief responses, with five primary coping styles:
A. Remaining silent.
B. Engaging in solitary mourning or "secret" grief.
C. Taking physical or legal action.
D. Becoming immersed in activity.
E. Exhibiting addictive behavior(s).
In remaining silent, the male wards off his sense of vulnerability in the face of loss. And common social responses to loss often reinforce cultural expectations that men's feelings should be unsolicited; that they are not important or less important in comparison to a significant female in their life (how is your wife doing? How is your mom taking it?); that one should "take it like a man" and be in control and detached enough to assess and respond to others' emotions and; that interpersonal relatedness around loss for a man can center on instrumental functions/task completion but not around the experience of emotion.
In what might be seen as a particularly complicated form of survivor guilt and identification, Zisook and DeVaul (1976) coined the term "facsimile illnesses" to describe cases where physical symptoms experienced by grieving parties were similar to those suffered by the significant other lost in the original trauma. Somatic symptoms similar to the suffering party can develop, with physical pain representing the symbol for suppressed grief. Zisook and DeVaul (1976) also noted the presence of later unexplained depressions and also point to acting out or otherwise maladaptive behaviors as a sign of masked grief.
In Worden's (1991) discussion of the diagnosis of complicated grief, he gives 12 clues to presence of an impacted grief process. Several clues are particularly germane for a consideration of how males may present with grief reactions in therapy, notably the tendency of minor events to trigger off intense grief reactions. The author presents the case of a woman who had a profound grief response to a friend who lost a baby in utero, and only later did they uncover an ungrieved abortion in this woman's past. Persistence of subclinical depression and presence of lowered self-esteem may indicate unresolved grief. This is complicated since, as the author points out, the absence of such symptoms and experience of a kind of false euphoria and relief subsequent to a loss can also indicate the presence of unresolved grief (p. 76).
Many men report never being asked about their abortion experience, never talking about it until the research interview, and feeling that no one would have understood or cared about their responses(Shostak, 1984). One male in my clinical practice reported having "kept my feelings about the abortion a secret...only to realize that later setbacks and losses which made me think about killing myself were actually related to guilt over an abortion that happened over 17 years ago."
Staudacher (p. 22) reports on a sensory deprivation experiment involving men and women as subjects in which both were put into difficult environments (soundproofed rooms with no lights and a monotonous background hum, or no noise at all), and the men, overall persisted in "denying that they had difficulty coping with the torment of sensory deprivation, even though they had been observed during the course of the experiment to be moaning and writhing."
Staudacher's description seems consonant with Lindemann's (1979) observations that acute grief was a definite syndrome, which could be delayed, absent or exaggerated, and was normally resolved over time, which could vary in intensity and duration. Lindemann characterized somatic distress, preoccupation with the image of the deceased, guilt, hostile reactions and loss of normal patterns of conduct as pathognomic for the grief syndrome, but he did not study gender differences in successful and unsuccessful resolution of grief responses to traumatic experience. However, for our purposes, Lindemann did delineate an "anticipatory grief reaction" as a variant on normal separation reactions, in which the person is so concerned with their adjustment after the upcoming or potential object loss (and this could refer to the imagined loss of the child, loss of the parental role, loss of the relationship to the partner, etc.) that they disengage with the surround prior to the loss, warding off feelings and thoughts that might connect him to the impending loss.
As previously noted (see Chapter Two on "Methodological Problems with Abortion Research"), Peppers (1987-88) proposed the "bonding hypothesis" to explain how abortions affect or appear to affect women but do not show up as significant negative effects in the literature. He argues that early bonding and anticipatory grief can result in the absence of noted sequelae if there is sufficiently long time period between pretest and posttest measurements. The present work proposes that men would be even more susceptible to anticipatory grief reactions and would thus be less likely to show posttest effects. This is of course a hypothesis of the present work and not confirmed by empirical research.
The salient point, however, is that the apparent absence of negative sequelae may in part be due to methodological errors which do not have an adequate conceptualization of specific types of guilt, or how they have different presentations by time, subtype, gender and race (e.g., Wilcox, 1990; Lynxwiler & Gay, 1994)
Male grief responses in general offer an important perspective on why significant negative sequelae of abortion in male partners is not being picked up in the literature. First of all, we would expect that men's grief responses would be delayed, suppressed or would not present to observation in easily understandable forms. A man's throwing himself into activity following an abortion, while indicative by some measures as the absence of pathological response, may be viewed by other measures as potentially pathological. Related to the delay or "masking" of grief responses, we might expect the male to be highly encouraged to go through the process alone, in secret, either in deference to someone he perceives as more deserving of attention, or in deference to a culture which equates the silence response for men, as strength in the face of trauma. Self-reported based measures such as the MMPI or BDI may fail to pick up links to interpersonally-driven shame, depression or guilt, especially if those responses are exhibited more in changes in interpersonal behaviors, coping styles, and life goals. We would do well to look at achievement in interpersonal relationships, successes in other areas as indicators of the emotional sequelae of abortion, rather than the presence of elevated levels of depression. (See Chapter 3.)
Oedipus Revised: New Psychodynamic-Relational Approaches to the Developmental Drama of Separation-Individuation
[t]he Oedipus complex is the nuclear complex of the neuroses, and constitutes the essential part of their content. It represents the peak of infantile sexuality, which thought its after-effects, exercises a decisive influence on the sexuality of adults. Every new arrival on this planet is faced by the task of mastering the Oedipus complex; anyone who fails to do so falls victim to neurosis (Freud, 1905, p. 226).
This idea, that oedipal dynamics reflect the phase-specific workings of sexual and destructive impulses, has become the litmus test of theoretical orthodoxy; it is the new shibboleth. More important for the conceptual development of psychoanalysis, a particular explanation of the Oedipus complex has become the Oedipus complex. (Greenberg, 1991, p. 15).
Freud often said that his psychoanalytic vision was simultaneously directed inward, toward peoples' impulses, and outward, toward what has happened to them in their lives. Everybody wants to know whether neuroses are "the inevitable result of a particular constitution or the product of certain detrimental (traumatic) experiences in life." But we might as well ask, "Does a baby come about through being begotten by its father or conceived by its mother?" (1916-17, pp. 346-347). In fact, neither the neurosis nor the baby is possible without some contribution from both sides. (Greenberg, 1991, p. 93).
The above three quotations represent something of the shift in understandings of the Oedipal drama and its relation to psychopathology. According to Freud's view of the Oedipal complex, aggressive and sexual impulses are at the heart of human motivation. And thus, they also form the centerpoint for any exploration of psychoneuroses. As noted earlier, the origins of the Oedipus complex are thus, for Freud, the origins of the first sense of guilt. Since, as Freud believed, "man is to man a wolf," our social arrangements must take account of this natural inclination towards violence, and does so in the function of civilization (socialization); at the familial level, the Oedipus complex reproduces this "natural inclination" towards violence and domination, in the form of aggressivity towards the father. This renunciation is accomplished by a complex process in which the child identifies with the external authority (the father) in order to master it and reduce its unlimited power to inflict pain.
But perhaps, as Jay Greenberg wonders, it is time to move beyond the Oedipus of Freud and ask what the challenges of the so-called Oedipal period have to teach us in a fresh way about masculinity, loss and trauma response. As noted above, theorists at the Stone Center propose a new view of human development described as relationship-differentiation, in part, as an effort to understand autonomy and relatedness in non-oppositional ways (Surrey, 1991). While theorists like Jay Greenberg (1991) do not adopt this new terminology for discussing the Oedipal drama, there is a clear move in his own work towards the kind of thinking about selves-in-relation that characterizes the Stone Center author's reassessment of the separation-individuation paradigm.
Following on the work of Mahler et al. (1975), Greenberg revisions the Oedipus complex as a developmental drama of separation-individuation; it is the "gateway to permissible relationships with available objects" (Greenberg, p. 11). While I will not trace out Greenberg's theory here, it will suffice to note the major components of his reformulation involve three propositions in the developmental events of separation-individuation: the role of agency, the role of fantasy and the role of conflict.
In Greenberg's view, the child of 3-4 must negotiate the establishment and resolution of very intense, sometimes threatening feelings for both parents. Unlike the developmental crisis envisioned by Freud, the child identifies not only with the father, but has to negotiate shifting and complex identifications with both parents. In this revisioning of the Oedipus complex, the child (and the later adult) is assumed to be the agent of his own actions, in a drama that is mutually influencing.
The role of fantasy in the resolution and structuration of the Oedipus complex is maintained because the developmental task of separation-individuation occurs at a time when the child has sophisticated cognitive structures in place, including a considerable imaginative capacity. This is a particularly important time for the development of pathogenic beliefs, since the child at this stage often assumes (as is developmentally appropriate) omnipotent responsibility for the people and events around them, and comes to treat himself the way he is treated (Weiss, 1993; 1995b). There is a kind of moral certainty to his cognitions, and this early rigidity of belief affords a sense of control over events and people that may be experienced as traumatic (not attuned to his affective needs). In Greenberg's terminology,
as the vicissitudes of the original crisis continue to influence psychic experience throughout life, the effect is exerted through the persistence of early fantasies. The oedipal fantasies-both those that contributed to the original domestic drama and their elaborations in later life-are substantially shaped by the individual's endogenously generated need. These needs grow out of the child's normal developmental requirements (p. 12).
Finally, the role of conflict is stressed because in the separation-individuation process, there are always powerfully ambivalent conflicts in which one's caregiver can be the object of contradictory feelings, where there are loyalties to balance between caregivers, and loyalties to balance between one's own real and perceived needs and the real and perceived needs of the caregiver(s). Guilt, shame and jealousy are seen as the primary "negative" precipitates to the resolution of these shifting identifications and their affective "balance sheet." Greenberg is keen to point out that positive affect, while neglected in the study of separation-individuation as Freud conceived of the Oedipus complex, is also present, with the child feeling pride in newly developed capacities, ambition to express these new relational capacities and excitement about how these capacities may influence others and one's own developmental trajectory. Note that there is the suggestion, following Greenberg, that guilt may be the result of the child reacting to "his new motives and their attendant object relations," but they are not the result of endogenous aggressive or sexual (parricidal or incestual) impulses, rather they can be seen as the result of an altruistically-rooted wish to maintain a kind of whole relatedness to significant others, not only for the child's individual survival but to care for the parents in their own right, as expressions of love, loyalty and concern.
In Freud's view, the child wishes to possess the mother in her entirety (through the impulse towards incestuous sexual intercourse), but in Greenberg's relational view, the child's conflicting feelings towards both parents emerge as the result of separation and survivor guilt, that is, in trying to balance his own needs with the needs of his parents, and coming to understand the new internal representations of these caregivers as perhaps weak. In the experience of outdoing a valued other, one can come to feel intense guilt at the imagined (or real) harm inflicted on the other and be warned off against pursuing normal developmental goals that might separate one from one's significant others. Future events that restimulate questions of conflicting loyalties, ambivalent feelings, fears of outdoing and the like, especially those centered around relational themes such as pregnancy, childbirth, death, illness and the like, are likely to call us the same fantasies (or pathogenic beliefs) developed in Oedipal period, along with defenses against the awareness of those beliefs. Weiss (1983) reminds us that Freud noted in some of his late writings that psychopathology was often held in place by guilt, and that psychopathology is always to some degree masochistic.
Control-Mastery theory does not eliminate the importance of the Oedipal period or of conflictual emotions, but instead places a priority on the ego's tasks of "preventing and mastering psychic trauma, of protecting itself from unbearable and dangerous affects...and of preserving vital object ties" (Bush, 1989, p. 131). The Oedipus complex is thus descriptive of the child's (and later adult's) processes of pursuing normal developmental, object-relational and self-needs.
As argued elsewhere in this work, the male response to abortion is at one and the same time a response to pregnancy and the imago of the mother, and thus, "womanhood" in general; with that goes attendant emotions of envy and rejection (Notman & Lester, 1988). Hostile sibling emotions as well as envy toward the pregnant partner are possible backdrops for the male's experience of pregnancy. In this light, Oedipal issues can arise via the experience (or imagined experience) of impending fatherhood, even if the pregnancy is terminated. Ambivalent feelings on the part of the potential father towards his imagined child may be occasioned by his own parents' ambivalent feelings about him, his siblings (if he has any), the pregnancy or childbirth in general. We must remember that one's views and beliefs as well as their attendant affective resonance are always the product an interaction with others (Jordan, 1991). And so what we allow ourselves to think and feel is thus partially conditioned by the same conscious and nonconscious "balancing acts" negotiated in early childhood.
The degree to which we can experience affect and display emotion, as well as negotiate conflicting demands of those affective needs, rests upon the resolution of earlier attempts at separation-individuation (or according to the Stone Center theorists, relationship-differentiation). When developmental crises are not sufficiently negotiated, pathogenic beliefs can be formed or restimulated. Blos (1985) presented the case of a 40-year-old man who entered analysis around the time of the birth of a wanted son:
However, the "joyous" event of pregnancy and birth aroused in him recurrent waves of depression. An overpowering jealousy started to rise in him when his wife's body changed shape during pregnancy; the near presence of a rival had suddenly become real. The rival was her child, boy or girl. Nursing became the baby's theft of the breasts.... All through the first year of the baby's life the father was periodically tortured by envy and resentment. Pleasurable fantasies about a motherless household shared by father and son rushed through his mind engendering momentary feelings of bliss. The ego dystonicity of his negative emotions reached a chronic state of dysphoria due to guilt and self-blame. Whenever the baby preferred his mother to his father, he felt rejected and abandoned (Blos, 1985, p. 29).
This patient's fear of a "castrating mother" took shape in a variety of pathogenic beliefs about the trustworthiness of women. And rather than reinforce with pride a sense of the patient's own masculine identity as a father, the pregnancy and birth experience served to stimulate intense feelings of envy at his wife's capacity "to create a perfect organism that lives" (Blos, p. 30). When this patient felt the envy and powerlessness of his position, he experienced a rage towards his own father, whom he began to see as weak, selfish and falsely generous. This is not to say that the case presented above is prototypical, only that, as Blos writes, "fatherhood arouses emotions from the father's own sonship experience-dyadic and triadic-which has to be brought into intergenerational harmony with the actuality of having become a partner-the senior male partner...in a new family (p. 30). One must imagine that the experience of pregnancy and the decision to terminate that pregnancy stimulates many of the same developmental conflicts of parenthood, and calls on abilities or deficits of the mutually formative experiences between the male partner's father and himself as an infant son.
Often neglected in past treatments of the Oedipus complex are the father's envious feelings toward the mother due to the very fact of her procreative ability. Janine Chasseguet-Smirgel (1994), a French psychoanalyst, explores just these feelings in trying to understand why prevailing maternal representations tend to either devalue or overidealize women. And we see the same idea in Sophie Freud's review of John Munder Ross's What Men Want (1994)-a reformulation of the Oedipus complex centered around male envy of the woman.
Ross leans here, at least partially, on his own clinical research with over 60 boys aged three to ten years old. He presents us with transcriptions that show the importance of "womb envy" in the development of male children. This version of the Oedipus complex becomes resolved when the boy's identification with an available father holds out the promise for his own future fatherhood and its nurturing and caretaking aspects. We can appreciate the author's ironic twist of Freud's original theory: Freud's girls reluctantly accept the promise of a baby as a penis substitute while Ross's boys resignedly give up their wish for a baby and make do with a mere penis (Freud, p. 226).
In the same volume in which Smirgel's work appears-Representations of Motherhood (1994)-several writers and psychoanalysts struggle with envisioning a new account of the oedipal crisis, away from its classical understanding in which the father plays the all-powerful savior role, to a vision not unlike Greenberg's (1991) where the child has agency and capacity to recognize the mother in her own right and be recognizing by her. This is clearly an intersubjective take on the developmental challenge of the oedipal period. The various contributors to this fine volume all argue, in a fashion, that there are no natural views of motherhood and mothering, but working models (in Bowlby's sense), representations of motherhood. As such, both women and men's views of motherhood are conditioned, can be the result (and cause) of pathogenic beliefs about motherhood, pregnancy and the like. Benjamin (1994) speaks of both the maternal and paternal imago as akin to the result of a family of beliefs (often pathogenic), and it is to this level men respond in considering and (at least temporarily) refusing in the decision to abort.
Benjamin's reversal of the Oedipus complex provides an interesting turn of focus onto the father-son relationship. In her view, the oedipal phase marks the elimination of the possibility of establishing "mutuality through identification." "The Oedipus complex," argues Benjamin, "does not dissolve narcissism; it displaces it" (p. 140). The boy displaces the mother's "all-consuming" power onto the father, and then attempts to mourn the loss through identification with the father. In Benjamin's reconstruction of the Oedipal drama, we see not a solution but a translation of the problem by the child's shift in omnipotence to the father away from the mother:
Thus the theory of phallic monism reflects the contempt for mother's organs and her value in general that is essential to the oedipal boy's move to deal with envy and difference: Everything I can't have is (worth) nothing. Traditional oedipal theorizing states that the boy realizes he cannot have mother, accepts the limit that father sets, and so gives up omnipotent control over the primary object. But at another level, omnipotence is restored through the repudiation of the mother, whereby that which he gives up is turned into nothing, and indeed, father now has "everything," the phallus. (ibid.)
According to this view of the oedipal drama, the pregnancy and decision to terminate the pregnancy can be seen as a recapitulation of the early situation of intense envy. Mothering/motherhood becomes worth nothing: abortion is not a problem for me, it is a relief. Benjamin's recasting of the oedipal situation raises once again the question of male envy of women's procreative capacities as well as the possibility that a decision to eliminate a potential rival may engender unconscious guilt.
When a patient in therapy happily announces that they have no ill feelings towards a loved one, or protests, on the contrary that they only harbor hateful feelings towards one rejected, we recognize in this surface ease of presentation the workings of denial, and the warding-off of painful and/or ambivalent underlying affect. For example, in the Oedipal situation of adulthood, the degree to which the male can see the whole mother and father-that is, to the degree he moves beyond the illusory dichotomy of an all good or all bad father-psychoanalysis understands this as an integration, as a movement to a higher developmental level in the resolution of the oedipal conflict. One rarely takes the patient's pronouncements as a final word, but as the starting point for empathic inquiry. But research studies on abortion which utilize self-report, interviews or questionnaire methods do just this: they take the subject at his or her word, and take pronouncements of relief at their face value? What is it that we do not wish to hear in positing the first word of relief as the last?
Discussion and Conclusions
Of all the far-reaching, mutually-reinforcing consequences of the lack of research on male partner responses to abortion, perhaps none is more problematic than the view that since there are presumably no significant psychological sequelae of abortion for male partners, there is no reason to consider abortion as a traumatic or significant event for the male partner. For complex reasons, men too have come to believe (despite their experiences) that abortion, like pregnancy, is primarily a woman's experience, and the ceiling of their participation is described by the "support" role.
This paper has argued that abortion constitutes a traumatic (though not necessarily pathogenic) event for men and women, and calls for the examination of the long-term psychological sequelae in male partners. This understanding of the effects of abortion is based on the hypothesis-supported by a growing body of literature in relational and attachment theory, evolutionary theory, psychoneurology and emotion research-that the event powerfully (consciously, but more often unconsciously) forces the reexamination and realignment of one's beliefs, structures of engagement and ways of comprehending the subsequent normal interpersonal dramas of living.
In this view, trauma is not co-terminous with psychopathology, nor is there a "hidden" agenda here that would suggest that anything that produces trauma is perforce morally wrong or a priori reprehensible at an ontological level. Trauma calls for a response, not a judgment. This paper adopts a view of trauma as falling upon a continuum of threats of engagement with others. One can imagine, for example, developmentally appropriate separation as (relatively) traumatic, as calling for responses from the caregiving environ, and as (potentially) creating both developmental crises and opportunities.
I have purposefully avoided making a causal link between abortion and psychopathology because doing so places this work squarely within those debates about whether or not one can prove that abortion causes significant psychopathological reactions in men (or women). This study does suggest, though, that because the abortion experience for men (and women) contains such strong challenges and strains to one's developmental integrity (as a relational self), we should expect the psychological sequelae of abortion, especially for males, to be more subtle, unconscious and complex than those delineated or refuted by current means. Since the abortion experience-for better or worse-raises questions, consciously and unconsciously about our fundamental notions of relatedness, empathy and generativity, it is a situation, par excellence, of developmental strain, and worthy of our attention.
As documented in the literature, the lack of response to men through the abortion experience has constituted and continues to constitute a significant problem in mental health care (Gordon, 1978; Shostak, 1983, 1984, 1987; Shostak, McClouth & Seng, 1987). Shostak (1987) puts the point succinctly:
Unfortunately, emotion-constricting attributes of the male role and the neglect of the male by abortion clinics combine to discourage attendees from using clinic counseling services to explore their various motivations. Unless and until the clinics sensitively reach out to help the waiting room men get beyond their "bottled-up" macho posturing, nearly a half million men every year will make far less of their three-hour clinic wait than may be possible (p. 196).
One might say that this work is centered around two related themes: engagement and responsivity. In our discussions throughout, we have touched upon issues of self- and other-attunement, focusing on the male partner in the abortion experience.
A more thorough treatment of the topic would have to consider mental health professional responses to the male client. Our review of the psychoanalytic and non-analytic literature revealed interlocking social and intrapsychic barriers to mourning, and we explored the function of the suppression and repression by the male of painful affect associated with abortion. Psychotherapists and other mental health professionals-trained to listen as much to what is not said, as what is said-can demonstrate their own empathic self- and other-attunement by working to more fully understand their male clients responses to abortion. Control-Mastery theory, rooted in empirical research, offers us a rich understanding of the therapeutic process, with specific attention to facilitating the safe emergence of warded-off contents in therapy.
Of no less consequence are the significant countertransferential aspects of working with male partners having gone through or about to go through the abortion experience. This is a vital area of concern for male and female therapists alike. A challenge is issued to psychotherapists to explore their own attitudes toward abortion, grieving, and male gender role expectations as a precursor to their work with male partners.
Despite very real concerns that we not take away needed attention from women in the continuing research and compassionate responsiveness around abortion, there are ways of expanding our responsivity for the mutual benefit of men and women. If we allow our individual and collective moral beliefs about abortion to interfere with our ability to respond to the fact of abortion, we abrogate the very roots of altruistic concern that lead us to adopt the positions to which we hold fast, whether for or against abortion. This would be similar to arguing that because we do not cherish war, we will not respond to those who fight, the families that lose loved ones, our own grief at the pain inflicted upon a nation struggling with questions of the necessity and trauma of war. Yet, it would not be difficult to argue that the legacy of war includes this very legacy of turning away. We have choices about the legacy of abortion in this country in relation to those for whom it has already become a reality and those for whom it will be, someday.
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