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Clinical Case Conference   |    
Abortion: Social Context, Psychodynamic Implications
Nada L. Stotland, M.D.
Am J Psychiatry 1998;155:964-967.
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In the following case presentation, the patient's name and other identifying information have been changed to protect confidentiality. She has given permission for publication.

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Initial Complaint

Julia Osborne was a 24-year-old graduate student when she applied for treatment at the psychoanalytic institute. She gave as her reason for seeking psychoanalysis her fear that she would never be able, psychologically, to marry and have children. She was intensely focused on her demanding and competitive academic work, and she could not reconcile the mind-set she had adopted with her vision of marriage and motherhood. An intense relationship had recently come to a bitter and very painful end. She was reluctant to chance another such experience, but at the same time she feared she would have an isolated future. She appeared to be motivated, highly intelligent, and insightful; psychoanalysis appealed to her as a treatment because it was intellectually interesting and offered the prospect of self-exploration and self-understanding leading to the resolution of psychic conflict. She was referred as a "control," or training, case to a psychiatrist studying at the institute. The following description begins with the complaints and history as presented at the initial diagnostic evaluation and continues with a discussion of the therapeutic process, the history that emerged as therapy progressed, the events that brought the patient's history of abortion to the fore, and a discussion of the issues raised by this patient's experience of abortion.

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Childhood and Early Adulthood

Julia was born to a couple in their very early 20s, the older by 2 years of two sisters. Her mother was called by an androgynous nickname, having disappointed her father by being female, and always complained that her own mother, the patient's grandmother, had not been at all maternal. Less was known about the patient's father's family. He had grown up in rather straitened, rural circumstances. His mother was somewhat warmer to the patient than her maternal grandmother; she helped Julia to learn some domestic crafts. The patient's mother was overwhelmed by the responsibility of caring for two young children and was probably depressed throughout the patient's early childhood. She did work at motherhood, however, practicing the domestic arts, sewing, and baking for her girls.

During this period the patient's father was both working to support the family and studying for a professional degree. He was seldom at home during his children's waking hours, and he was preoccupied and exhausted when he did see his wife and children. When the patient was 5 years old, her parents hired a babysitter to care for her and her sister so that her mother could work alongside her father in his new professional practice. The patient remembers the baby~sitter as a forbidding, angry, cruel person. Her mother ceased nearly all domestic activities, leaving the patient in her early school years to prepare lunches for herself and her sister to take to school and to do her own laundry in order to have something presentable to wear. Julia became an expert seamstress, first sewing wardrobes for her dolls and later making many of her own clothes. She frequently came to psychoanalytic hours in attractive and tasteful clothes she had made. She was also a superb self-taught cook and earned money by catering high-level university events.

Both her father and her mother experienced Julia as an overly demanding, difficult child. Her requests for items of cloth~ing were not only refused but criticized as greedy and selfish. She frequently challenged her father's authority, precipitating fits of rage on his part. He seemed to enjoy and appreciate her formidable intellect at times but to find it inappropriate and unnerving in a female child. Her father, a very bright man, taught her to play chess. She was skilled enough to offer him a genuine game, but then he relished every opportunity to beat her at it savagely. Her sister, in contrast, was less capable but more tractable and traditionally feminine. Using manipulation rather than confrontation, she managed to get what she wanted from their parents.

Julia's mother was very impressed with the women's movement during the 1970s. The only time the patient recalled her mother's ever having come to her school or taking an interest in her schoolwork was when the patient was in sixth grade. When her mother learned that the class had been divided, with the girls assigned to cooking classes while the boys learned carpentry, she interceded with the school administration to demand an end to this enactment of traditional gender roles. The patient was rather proud of her mother's advocacy. Having left college to get married, the mother returned to school. She stopped working in her husband's increasingly successful practice and sought independent employment. In fact, she became increasingly dissatisfied with him and with her marriage. When Julia was in junior high school, her mother insisted on a divorce.

Julia was torn between her parents; she sympathized with her mother's resentment of her father's sexism and rages, but she felt sorry for her father, who was lonely and, she felt, quite unable to provide for his own domestic needs. She lived with him and did his cooking and housekeeping for a time. He, however, focused on his feeling that his wife and daughters had rejected and abandoned him. Although he had become quite affluent, he retaliated by withholding various kinds of support. With great anticipation, Julia brought him to the college fair at her high school. His enthusiasm faded the moment he learned the costs of the private colleges for which Julia's talents and academic achievements qualified her. He announced that he would pay no more than the cost of the state university. Stung, Julia determined she would choose a private college on the other side of the country and manage somehow. Her parents bought a beautiful wardrobe for her sister's college entrance, but her sister never attended college. She took a lovely trip to Europe, a place Julia had never been, drifted for some years, and eventually joined the Church of Scientology.

Julia's allotted funds were soon exhausted. Julia worked, borrowed money, and moved in with the family of a sympathetic professor. After graduating from an academically competitive college, Julia earned a master's degree. She discovered an interest in a highly intellectual field and ultimately decided to pursue doctoral studies in it, although she had little formal background and was therefore at something of a disadvantage academically. She was bitterly jealous of her fellow graduate students, who were better prepared and whose meager stipends were generously supplemented with parental funds. She was struggling to attain a large body of basic knowledge essential to the field.

Julia's social development was complicated by several factors. The family moved several times—first, across the country when she was in her early school years, later from a diverse neighborhood where Julia felt comfortable to a highly affluent, homogeneous neighborhood characterized by right-wing and materialistic values. The contrast was accentuated by the fact that her father angrily refused to provide the designer clothing and other possessions considered de rigueur in her peer group. Not long after the divorce, each of her parents remarried and acquired stepchildren. Each was wealthy enough to buy elegant household furnishings, to travel abroad, and to provide lavishly for the stepchildren. Neither parent's home had a designated room for Julia. If she chose to go "home" for holidays, she was expected to pay her own way and, often, to prepare gourmet meals for one family or the other. Each parent resented the time she spent with the other. Although they lived in the same city, it was difficult to get from one house to the other without a car.

As she was growing up, Julia received contradictory messages about sexuality from her parents. Her father was quite puritanical, especially in regard to his daughters. Her mother's expressed attitudes derived from the women's movement, and as Julia was coming of age, the sexual revolution was raging. She felt that most people now understood that sex was a normal human function, free of the old guilts and taboos. She became sexually active in her mid-teens, with a wealthy and snobbish schoolmate who ultimately treated her unkindly. What was most upsetting to her, however, was an incident at high school. A talented poet, short story writer, and painter, she had a leading role in the school newspaper, with attendant frequent and friendly contact with its faculty advisor. When the advisor learned of Julia's sexual relationship with her boyfriend, which she had felt no particular reason to hide, he condemned her and virtually blacklisted her. Her investment and grades in school fell. She was admitted to college on the basis of her previous record, test scores, and artistic accomplishments.

The sexual atmosphere at college was quite open. Students were sexually involved not only with each other, but also with some faculty members. The friendly family with whom Julia came to live included a son about her own age. Unlike her previous boyfriend, he was loving and respectful of Julia. They became close friends and lovers. After a time, she became pregnant. The Supreme Court's decision in Roe v. Wade, which legalized early abortions, had been handed down just a few years before; Julia understood that it guaranteed her right to control and enjoy her reproductive life. She knew she was ready neither to make a permanent commitment to her young boyfriend nor to provide properly for a child. She was grateful and proud that, in her era and in her social context, motherhood was not imposed on women as a punishment for their sexuality and that childbearing was not an unintended consequence of intercourse but a free choice, enabling women to bring children into the world only when they were assured of appropriate emotional and physical support. Abortion was free of the stigma, the terror, the danger, the clandestine arrangements of the unenlightened past; it was safe, convenient, accessible, painless. Women had abortions, openly, every day. Julia had an abortion and went on with her life.

As she completed her college education, Julia felt that her boyfriend was too immature for a lasting relationship; they grew apart. She came to see the small university community as rather incestuous and to resent the faculty's using students, who were so dependent on them for intellectual approbation, for sexual relationships. She decided to try a different style of education and sought a master's degree at a very different sort of institution far away from the first. There she had an intense affair with a very bright, highly intellectual, cold, and ungiving man who denigrated her academic achievements and expected her to keep house and entertain his friends. She was in awe of his knowledge, stimulated by the intellectual atmosphere, but emotionally trampled by his critical, even cruel, relationship with her. She decided to study for a doctorate at a university where some of the professors had close ties to her master's program, but in a somewhat different field. In fact, there was considerable mutual criticism between the two departments. She also wrenched herself painfully away from the destructive relationship. It was shortly after moving to a new city and a new graduate program that Julia had sought analysis.

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Therapeutic Process

Julia came to analysis lonely and unhappy. She was still grieving over the relationship she had left. She was struggling to bring her skills in her new field up to the high level of her classmates and to compete for the attention and favor of faculty members, with whom many of her fellow students had existing scholarly collaborations. She had very little money; she had to hold down jobs while other students could devote all their time to study, and every expenditure had to be carefully thought out. She was loath to allow herself any time to express her other talents: poetry, drawing, sewing. She felt excluded, put down, disadvantaged. But Julia was an excellent analytic patient. She was committed, hardworking, and insightful. Her associations and dreams were plentiful and were full of rich material for analysis. She had a largely positive transference to her analyst but was able to express frustration and anger toward her, to question interpretations when they did not seem apt, and to recognize transference projections and distortions, especially as related to her feelings about the analyst as a professional woman and academic. Did the analyst have a husband and children, or had she had to forgo those attachments in order to attain her position? At times she thought that must be the case, and at other times she assumed that the analyst had been able to "have it all." The conflicts uncovered and addressed in the analytic process were related more to narcissistic than to Oedipal injury. The patient consciously experienced the pain she had suffered, and continued to suffer, as a result of her parents' failure to appreciate, nurture, and reward her and her particular gifts and her parents' denigration and rejection of her feelings as overblown and unjustified.

During the initial period of the analysis, Julia's friendships and intimate relationships were painful. Female friends were demanding of her without reciprocating when Julia needed understanding or support. Men were unreliable and disrespectful. Julia's mother, who, like her father, rarely called Julia to see how she was doing, was able to commiserate when Julia was upset, but Julia came to realize that her mother had virtually no understanding of or interest in Julia's interests, activities, and successes. Julia's father was somewhat awed by her enrollment in a prestigious graduate program, but his general competitiveness and discomfort with female achievement in particular made it impossible for him to show any pride except in teasing terms. No one else in the nuclear, extended, or stepfamilies had reached this academic level.

Julia was also distressed that neither parent seemed concerned about her sister's membership in Scientology. As a Scientologist, Julia's sister was posted to various jobs in changing locations. She was twice married to men she hardly knew and then sent to work in places at major geographic removes from her husbands. Julia's mother, especially, was more impressed with her daughter's descriptions of glamorous events and expensive evening wear than with the fundamental beliefs and activities of the organization and their implications for her daughter's future. It was particularly poignant that Julia should be invested in psychoanalysis while her sister belonged to a group with an avowedly antipsychiatric agenda.

In psychoanalysis, Julia continued to bring in dreams and associations that revealed her sense of not being acknowledged, her sense that her energy and talents were threatening to her family, and her wish for a home and family. In her early dreams, she rode as a passenger in a car driven by her father as the car sped out of control. She wandered, bereft, through houses of many rooms, none of them hers, with vanishing walls that failed to protect her from marauding ogres. Her thesis advisor appeared in her dreams, rageful and destructive. Her analyst appeared first as a critical figure and later, more often, as a mother with a welcoming, nurturing home. The analyst was able to help Julia not only recognize, but experience, the connections between the events of her childhood, the events of her ongoing life, and her dreams and associations. Julia used her analyst as a reliable, benign figure, invested but not intrusive in her life. And Julia was increasingly able to make her own interpretations.

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Adult Developments

After arriving in the new city for her doctoral work, Julia had dated a couple of men briefly and then entered a relationship that was initially exciting and romantic. But soon the man was hellishly trying to control her and then harassing and threatening her. That was the last straw for Julia. She recognized the relationship as a reenactment of her punitive relationship with her father, as suffering she had felt she had to bear because of her own intellectual and material greediness. She recognized that the problem had been her father's, not hers. She resolved that her talents and accomplishments were legitimate and that her feelings were valid. It was extremely difficult to convince this man that nothing would induce her to continue the relationship, but at last he left her alone. Not long afterward, she met a bright graduate student who seemed to be on the same wavelength. They had animated debates about intellectual issues, but each respected the intellect and interests of the other. They treated each other with respect and affection. They became seriously involved and then moved in together, became engaged, and married. There were the inevitable, universal in-law issues, the challenges of finding career options in the same location, and minor misunderstandings and disappointments, but the relationship was gratifying and solid. It was clear that academic and romantic success were not mutually exclusive.

In parallel fashion, Julia conquered her academic obstacles. She mastered the "tools of the trade" and passed her examinations. She identified a research topic that brought together her core academic field, her artistic interests, and her social values. She wrestled with the competitiveness, personal quirks, and exacting demands of her primary thesis advisor, after blaming them at first on her own deficits, poor planning, and bad fortune. She was able to strike a balance; she did what was necessary to please the advisor without feeling that her own intentions were being subverted. She was able to consider the crushingly competitive academic marketplace and focus her work so as to position herself advantageously in it. She no longer felt a stepchild in her department. She was given the coveted opportunity to teach some undergraduate courses and found herself both invested and appreciated.

As she and her husband neared the completion of their graduate studies, they became increasingly interested in parenthood. Although Julia had some trepidation about her own attempt to "have it all," Julia's husband was optimistic about their ability to manage and felt strongly that he should share equally in caring for their future children. Julia was nearing the age of 30 and facing the prospect of naturally decreasing fertility. She wanted to have a baby. It was 6 anxious months of trying before Julia conceived. She was quite ill with nausea, prompting fear that she would not be able to complete her thesis as planned. Again, it seemed, she was the unlucky one. Contemporaries either breezed through pregnancy without a symptom or had few responsibilities and doting husbands. Julia could barely function. Was this a manifestation of still-latent, unconscious conflict over motherhood? Julia certainly felt ambivalent about pregnancy at this point.

Unfortunately, Julia's sense of being unlucky was not inaccurate this time. Routine ultrasound revealed that, rather than a normal pregnancy, she was suffering a hydatidiform mole, an aberration of pregnancy in which a disorganized conglomeration of tissues, rather than an embryo, develops. The "mole" must be removed. Julia underwent the procedure and was reassured to learn that her condition had not been malignant and did not preclude the possibility of ensuing successful pregnancies. She would have to be monitored closely for several months, however, to make sure that the condition did not recur. Julia's husband was tearful about the loss, but he had difficulty caring empathically for Julia after this event and protecting her, as she wished, from the thoughtless comments of their more reproductively successful colleagues. Notably, Julia's analyst made an error in scheduling and missed the appointment following Julia's surgical procedure. Julia was justifiably angry. It was painful, but therapeutic, for the analyst to acknowledge that she had been so disappointed by the loss of the pregnancy that she had unconsciously avoided seeing Julia. While this lapse was unfortunate, Julia and the analyst were able to make therapeutic use of it. It embodied two important things for Julia: the fact that the analyst did care about her and the fact that the analyst was vulnerable to human failings.

As Julia was recovering from treatment for the hydatidiform mole and waiting out the prescribed observation period, memories of her abortion 10 years earlier began to appear for the first time in her associations. The following story emerged.

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Memories of Abortion

Julia had had passing, fond thoughts about having a baby and quickly suppressed sadness that that potential could not be realized. She understood that the potential baby was still just a tiny mass of cells. She felt that having an abortion was the obvious, logical thing to do, that it was the enactment of her rights and her obligations. She called her mother to tell her of her decision. Her mother was reasonably supportive and suggested that Julia let her father know so as to have his support as well. Knowing her father's attitudes and temperament, Julia was dubious, but she also wanted paternal encouragement. Unfortunately, her own, not her mother's, instincts proved correct. Her father did not try to prevent the abortion, but he was deeply disappointed and angry. Julia was hurt but not surprised. She felt that her mother should have realized how her father would react and should have protected her against his negative reaction. She thought she had been dragged into her parents' conflicts again, as a pawn used between them. As an independent young woman, and perhaps out of unacknowledged feelings of guilt for having been so negligent as to allow conception to take place, Julia refused her boyfriend's offer to accompany her to the abortion. She went to the local abortion clinic alone. The procedure itself went smoothly, without complications. The abortion clinic staff were matter-of-fact. She lost no time from school or her after-school job and saw no reason why she should have, much less express, further feelings about the abortion. She had been 19 years old.

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Subsequent Emotional and Reproductive Events

Julia's grief about the recent loss of her pregnancy melded with her grief over her earlier abortion. Given the meager resources available to her at the time and her need to muster each to the fullest in order to make a life for herself and a future family, she did not doubt the wisdom of her decision. But the fact that a decision is advisable does not mean that it is devoid of meaning and feeling. Her pregnancy underscored her vulnerability and her aloneness. There had been no one to help her adolescent self face and work through the loss. Her boyfriend had been kind but overwhelmed. His parents had been too removed. Her own parents had used the occasion to embroil her in their own unresolved conflicts. Finally, the likelihood of emotional support had been so remote that she had not exposed herself to disappointment by looking for any. The context of the sexual revolution and the women's liberation movement, at that time, similarly sacrificed emotional complexity to justice and freedom. In the safety of the analytic relationship, Julia was able to experience and express her sadness for the first time.

After being given a clean bill of health from the gyne-oncologist, Julia became pregnant again. Far away from home on a scholarly assignment, she miscarried again. Although this spontaneous abortion was uncomplicated, for a time it exacerbated Julia's sense that she was particularly, somehow, cursed. She was able to struggle with the feeling that it was all useless and to throw herself into her academic work with redoubled rigor. Thus she completed her graduate work, put her dossier and recommendations together, and, in a field in which any sort of academic employment was considered a boon, was offered and accepted a tenure-track position in a major university. The termination of the analysis had been planned, by mutual agreement, to coincide with the completion of her studies. Julia had also hoped to offer a baby as embodiment of her success, but as she completed her treatment and moved to another city, she was again hopeful on that score.

Soon after beginning her faculty career, she gave birth to a healthy child. Managing career and parenthood was more daunting than she had expected, but she adored her baby, she was both happy and successful in her research and teaching, and she was anxious to have another child. She received thinly veiled threats about the academic failures of mothers of two children from the departmental leadership. At this juncture, she wrote to her former analyst to ask for a consultation when she was back in town. The consultation was a combination of pep talk and revisited insight. Julia had a second baby. According to her Christmas cards, she is about to earn tenure and she is happy with her children, her husband, her work, and herself.

This is a case with a textbook proc~ess and a 1990s storybook ending. It is presented not to illustrate the untangling of a diagnostic knot or the mastery of a therapeutic dilemma. The treatment was psychoanalytic, led in a self-psychological direction by the nature of the analytic material, but was not confined to any particular analytic orthodoxy. This patient's reproductive symptoms—her excessive nausea, her miscarriages—might at one time have been considered "psychosomatic." Psychotherapeutic harm might have been added to somatic injury. While the connections between psychodynamics and reproductive functions are rich and intricate, they are not as simple as that.

It is not clear whether the abortion 10 years before would have become an issue had the patient not suffered the loss of two pregnancies during the analysis. It was not presented as a problem at the outset, nor would the analyst necessarily have identified it as a potential problem. It was not a focus of the analysis, nor was it found to be an etiologic factor in the patient's presenting symptoms. The unintended pregnancy and abortion themselves were more likely symptomatic of the patient's sense of abandonment. It is possible that the analyst's own focus on the importance of reproductive choice for women meshed with the patient's need to suppress the feelings associated with her abortion—until both were shaken by the trauma of the subsequent reproductive loss. No analyst and no treatment is free of values, nor should they be, but unacknowledged values, whether they clash with or echo those of a patient, can interfere with treatment.

Another historical note: the circumstances under which this treatment was undertaken did not require DSM diagnosis. Axis I disorders susceptible to treatment with psychoactive medication were largely ruled out; it is possible that the patient's initial dysthy~mia would have responded to an antidepressant, but the patient was not disabled by her mood nor interested in this approach. Because of the training situation, the patient was paying out of pocket, just the little she could afford, and no other payers or authorities were involved. Perhaps now, over 10 years after this treatment began, and in a setting other than an analytic institute, there would be pressure to identify an axis I diagnosis and to treat the diagnosed condition with medication or manual-based, brief psychotherapy. Perhaps the patient would have fared as well. It is hard to argue for a less specific diagnosis and an infinitely more time-intensive treatment, but it is also hard to argue with a very gratifying outcome, an outcome compassing much more than symptomatic relief.

For the purposes of this paper, this case is a vehicle to illustrate the psychological complexities of induced abortion. In the rancorous debates about reproductive rights, the life-and-death questions—the termination of real or potential human life, the septic abortions, domestic violence, loss of subsistence, the blighted futures that threaten pregnant women, the substantial contributions of racial and gender justice and of faith, and the need to make black-and-white legal and medical decisions (whether a pregnancy is aborted or not)—the complicated, sometimes heart-wrenching realities of each pregnant woman's life and of her feelings can get lost. Antiabortion forces focus on the primacy, the sanctity, of the embryo's right to life and see the mother's subsequent emotional health as a reaction to providing or depriving it of that life. However the embryo may have been conceived, it is, as a human embryo, a creation that God needs its mother to protect.

Pro-choice forces focus on the choice rather than on the destruction of real or potential life. Termination of pregnancy is viewed as the least destructive alternative in a bad situation. Despite the rhetoric of the right-to-life movement, no one is actually "pro-abortion." Pro-choice movements stress the real-life vulnerability of women to unplanned and untenable conception and to unsafe abortions undergone out of desperation. They see the right to abortion as crucial to women's health and to the realization of our talents and dreams as equal (not identical) partners in society.

Whichever of these irreconcilable perspectives the reader, or a woman facing a choice about a pregnancy, subscribes to, an abortion is experienced by that woman as both the mastery of a difficult life situation and as the loss of a potential life. There is the danger that the political, sociological context can overshadow a woman's authentic, multilayered emotional experience. Had this patient's abortion occurred now, rather than nearly 20 years ago, she might have been faced with abortion protesters accusing her of murder rather than with peers who considered abortion a trivial event. As with any other significant life decision, the inability to acknowledge and share one or the other facet of that experience leaves the person vulnerable to reminders and reenactments, to difficulties that may surface in life and in subsequent psychotherapy.

Received Jan. 13, 1998; revision received March 23, 1998; accepted April 8, 1998. From the Department of Psychiatry and Substance Abuse Services, Illinois Masonic Medical Center. Address reprint requests to Dr. Stotland, Department of Psychiatry and Substance Abuse Services, Illinois Masonic Medical Center, 836 West Wellington Ave., Chicago, IL 60657-5193.

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