Nursing the disenfranchised: women who haverelinquished an infant for adoptionJ . A . A L O I , m s r n c n e

Assistant Professor of Nursing, School of Nursing, University of Medicine and Dentistry of New Jersey, Newark,NJ, USA, and doctoral student in Medical Humanities at Drew University, Madison, NJ, USA

ALOI J. A. (2009) Journal of Psychiatric and Mental Health Nursing 16, 27–31Nursing the disenfranchised: women who have relinquished an infantfor adoption

Grief that occurs as a result of relinquishing an infant for adoption is explored. Traditionalgrief models are cited as ineffectual for the satisfactory resolution of grief resulting from therelinquishment of a child for adoption. The reasons for disenfranchised grief are describedand narratives of personal interviews provide insight into the grief process of birthmothersand evidence of their disenfranchisement. The role of psychiatric-mental health nurse isdiscussed and interventions aimed at assisting the birthmother to grieve are suggested.

Keywords: adoption, disenfranchised, grief, mothers, relinquishment

Accepted for publication: 2 July 2008

Correspondence:

J. A. Aloi

35 Crestview Drive

Clinton NJ 08809

USA

E-mail: aloija@umdnj.edu

Introduction

Adoption has many life-long consequences, one of which isthe intense, overwhelming grief on the part of the birth-mother. The decision to place a child for adoption is almostalways a heart-wrenching one; and, with it, some of themost significant losses that one can face. The bond formedwith an unborn child during pregnancy, sharing a long-term relationship with the child, guiding the child throughthe formative years, and being an integral part of the child’slife are losses expressed by women who have relinquishedchildren (Lauderdale & Boyle 1994, Lenhardt 1997,Robinson 2001, Fessler 2006, Roles 2007). The role thatnurses play can be critical in determining the emotionalaftermath of this life-altering experience. That role existsfar beyond administering prenatal care, physical care in thedelivery room, and the immediate postpartum period,which often takes place on a medical-surgical floor. Thechallenges faced by these women in their effort to movetowards resolution are immense. They are denied expres-sion of the emotional response to loss, resulting in feelingsassociated with grief that persist for a very long time, and,for some, a lifetime. Doka (1989) defines disenfranchisedgrief as ‘grief that is not openly acknowledged, socially

accepted or publicly mourned’. For the most part, thebirthmother experience has been unheard and unacknowl-edged by the healthcare delivery system and by society, aswell, even though the effects are life-long and profound.The attitude, acknowledgement, support and interventionsutilized within the context of the nurse–patient relationshipare key ingredients for effective resolution. Unfortunately,many nurses do not even recognize the birthmother’s needto grieve, do not approve of the birthmother’s decision, orare at a loss of what to say, thus contributing to herdisenfranchisement. Lauderdale & Boyle (1994) describedthe experiences of birthmothers who relinquished infantsand sited comments from nurses such as ‘Pretend the adop-tion is a miscarriage’, or ‘Oh, you’ll get over it. Why you’llforget all about it when you have another baby’. Thepsychiatric nurse specialist can be instrumental in explain-ing the reasons for this disenfranchisement in an attempt toprovide greater understanding of the depth and power ofthe loss.

Grief and mourning

Most birthmothers are advised to ‘move on’ as quickly aspossible, resulting in the inability to move through the

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stages of grief, which many know as denial, anger, bargain-ing, depression and acceptance (Kubler-Ross 1969).

Kubler-Ross (1969) outlines five stages of grief that onemust pass through on the road to healing. Briefly, these are:Stage One – Denial: ‘No, this can’t be happening to me’.The loss is not accepted or, perhaps, not even recognized.Stage Two – Anger: ‘Why me?’ Feelings of persecution andanger towards others are felt.Stage Three – Bargaining: ‘I promise I will . . .’ Begging,wishing and attempts to make a deal are made.Stage Four – Depression: ‘I don’t want to live anymore . . .’Feelings of hopelessness, frustration, bitterness and self-pity are experienced.Stage Five – Acceptance: ‘I have to go on . . .’ Painfulfeelings are less frequent and less intense. Comfort andhealing occur.

Kubler-Ross (1969) suggests that true healing can onlyoccur when these five stages are experienced by the griever.She further states that problems arise when the emotions offear, anger, sadness, jealousy and love, are distorted and,therefore difficult to experience fully or not at all. There aremany situations, in addition to birthmother relinquish-ment, in which a sense of loss is experienced, but the socialconstructs are not in place to facilitate the healing process.Many birthmothers were promised, ‘You will forget’,and yet, few birthmothers ever forgot. Many authors(Robinson 2001, Fessler 2006, Roles 2007) argue that thegrief of a woman who has relinquished a child for adoptionis unique, and, therefore, does not and can not follow thetraditional prescription for grief and mourning.

As the child did not die, the birthmother is not expectedto mourn. The perception that since the baby was put upfor adoption and, therefore, a degree of comfort exists withthe decision, further negates the need for grieving. Thus,the work of grief which is so necessary for healing becomesnon-existent. Romanchik (2007) reported that in openadoption situations, the birthmother may enter a period ofdenial by focusing on the ability to maintain contact andpossibly see the child at intervals. She further describesdenial as a period of over activity, leaving the birthmother‘no time to grieve’. Often, the birthmother will avoidplaces, people or anything remindful of the pregnancy(Romanchik 1995). Depression, which can be manifestedby feelings of worthlessness, inability to concentrate,apathy, increased isolation, among others, is complicatedby comments such as, ‘Soon you’ll forget all about this.’‘You’ll have other babies.’ ‘It’s for the best.’ And, of course,‘The baby will have a better life.’ Anger towards God,parents, or the birthfather typically does not get expressed,only to grow and fester within; being fuelled by over-whelming feelings of guilt and regret (De-Simone 1996,Romanchik 2007). One birthmother expressed, ‘I often

found it interesting that people who adopted childrenreceived all the glory, while birthmothers were shunnedfrom society and looked down upon’ (Rogers 2006, p. 80).Often, the pregnancy is kept secret and not spoken ofamong family members. There is no public announcementof the pregnancy, the birth or the loss. The relinquishmentis not even seen as a loss. Rituals which would normallyhelp in the resolution of grief are non-existent. An attemptby the birthmother to proceed through the above five stagesis impossible. The following excerpts speak to the veil ofsecrecy which, for so many, can lead to feelings of aban-donment and hopelessness.

My parents were, like, this has ended, there’s nothingelse to say about it, nobody in town has to know. Imean, everybody knew but it was never, ever, ever talkedabout (Fessler 2006, p. 82).

I did a lot of crying but it was all private. I nevertalked about it with anybody. It was never mentioned inmy family and I just went on like nothing happened(Fessler 2006, p. 83).

Worden 1991, in his book Grief Counseling and GriefTherapy, presents a model of grief counseling whichincludes four aspects which he thinks are necessary forsuccessful grief resolution. First, the reality of the lossmust be accepted. Second, the pain of grief must be expe-rienced. Third, the grieving person must adjust to theenvironment from which the lost person or object ismissing. And, fourth, emotional energy must be with-drawn from the lost person or object and reinvested insomeone or something else. Robinson (2001) argues thatthe disenfranchised grief among birthmothers interfereswith the execution of these tasks, thus, making successfulresolution impossible.

In many cases, the birthmother has never seen or heldthe baby, making the first of Worden’s (1991) tasks difficultto deal with. Most hospital personnel know that a birth-mother has a right to see her child, but birthmothers maynot realize this, believe they have no rights, and, therefore,not ask to see the baby. There is a lack of finality to the lossoften resulting in dreams and fantasies about a possiblereunion. It is fairly common for the pregnancy to remain asecret, thus, robbing the birthmother of the opportunity toexperience and share the pain with loved ones. Robinson(Grief and Disenfranchised Grief 1997) describes the thirdtask as impossible for the birthmother: ‘How can she adjustto a new environment without her child when the child wasnever accorded a place in her life anyway? And yet her lifesituation and psychological environment has changed dra-matically.’ And, regarding the fourth task: ‘. . . how can shereinvest emotional energy in another relationship when thisone still exists, if only in her mind?’ (Robinson, Grief andDisenfranchised Grief 1997).

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The goal of successful grief resolution involves reachinga point at which one is ‘neither depressed nor angry abouthis fate’ (Kubler-Ross 1969, p. 99). The disenfranchisedgrief experienced by women who have relinquished babiesfor adoption requires a unique approach for this outcometo occur.

Disenfranchised grief

Doka (1989) offers three reasons for the occurrence ofdisenfranchised grief, all of which have implications forbirthmothers. First, when the relationship between thegriever and the lost person is not recognized, society doesnot expect the loss to produce much of a reaction.

After the birth of my first child I had nothing, not evena piece of paper. You walked out of the hospital withwhatever memories you had and the stretch marks onyour body, that’s it. There was no piece of paper.Nothing. It was as if it never happened (Fessler 2006,p. 176).

Another birthmother writes:But my father told me not to hold the baby, not to lookat the baby, because it never happened. It never hap-pened. I didn’t have a baby (Fessler 2006, p. 177).

Next, Doka (1989) states that disenfranchised griefoccurs when the loss is not recognized or socially validated.One birthmother reported the following from a home forunwed mothers:

Anytime they approached the subject of the baby, it was‘When you give up the baby’ or ‘After you leave here.’They were telling me that I could just forget all aboutthis, go home, and pick up my life where I left off(Fessler 2006, p. 133).

Doka 1989 describes the third situation as one in whichthe griever is considered incapable of grief and cites theyoung and the very old as examples, despite evidence to thecontrary.

From everything I see, I think the general public believesthat mothers who give babies away are glad to be rid ofthem, they’re glad to be rid of the problem. They think,‘She didn’t care about that kid. She just wanted him outof the way so that she could go on having a good time’.I’ve heard people say that (Fessler 2006, p. 97).

In Doka’s (2002) later work Disenfranchised Grief:New Directions, Challenges and Strategies for Practice, headded two additional categories to the above three; circum-stances of the death and ways individuals grieve. He pointsout that the nature of the death might discourage thegriever from seeking support from others as well as dimin-ishing the willingness or interest of others in providingsupport. Birthmothers have reported cases in whichsupport was withheld punitively, such as the following:

. . . my dad said, ‘Don’t come home’ . . . he did not wanta daughter like me around. It was fine while I was classvaledictorian and the shining star, but not while I waspregnant, no (Fessler 2006, p. 67).

Doka (2002) suggests that there are different styles ofgrieving. Expressions of grief that are more physical, cog-nitive, behavioural, or that fall beyond the societal rulescan be disenfranchising by nurses, hospital personnel,counsellors and the larger community.

The effects of disenfranchised grief

The difficulties following relinquishment are expressionsof disenfranchised grief. The thoughts, feelings and expe-riences described by birthmothers resonate with the con-cepts put forth by Doka (2002). He calls the problemsparadoxical: ‘The very nature of disenfranchised griefcreates additional problems for grievers while removing orminimizing their sources of support’.

The emotions associated with grief are intensified andcomplicated when grief is disenfranchised (Doka 2002,p. 17). Often, birthmothers believe that they are unde-serving and inherently bad people, resulting in seriousself-esteem issues. Some feel punished for their actions.Psychosomatic illnesses, difficulties in relationships, depres-sion, self-destructive tendencies, over or underachieving,obsessive-compulsive disorders, and panic disorders or onlysome of the outcomes reported from the experience (De-Simone 1996, Robinson 2001, Doka 2002, Fessler 2006).Resultant substance abuse is not uncommon (Robinson2001). Secondary infertility problems have been reported.Many women who later give birth to other children areoverprotective out of fear of subsequent child loss. Often,the ability to love and trust again becomes arrested (Pur-tuesi 1995), thus fostering a sense of loneliness and aban-donment. The emotional scars are numerous as seen below.

. . . I was filled with rage. I have to say, it was the mostaltering event of my whole life – a defining moment, adefining time. I believe that the way that I led my life,let’s say the first ten years after, was reckless, waswithout regard for myself, my health, well-being, any-thing, because I had no value. And it was probablywithout regard for other people as well, because it wasdifficult for me to respect other people, it was difficultfor me to trust (Fessler 2006, p. 208).

It has been noted by Doka (2002) that people withdisenfranchised grief often have difficulty coping with sub-sequent losses. The pattern tends to repeat itself resulting infurther disenfranchisement and unhealthy coping mecha-nisms. For many birthmothers, the relinquishment was thefirst major loss in their lives. Attempts at resolution of

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further losses will be insufficient or inappropriate for truehealing of grief to occur.

Resolution of disenfranchised grief

There is substantial evidence that a significant number ofwomen who have relinquished babies for adoption suffersevere and long-lasting psychological problems. Mostauthors (Lauderdale & Boyle 1994, Robinson 2001, Doka2002, Soll & Buterbaugh 2003) agree that because theproblems are so deep-seated, healing is difficult, but notimpossible. They concur that the birthmother must firstand foremost acknowledge and validate the loss in order towork through the grief process. Lauderdale & Boyle (1994)noted that women who chose open adoption receivedsupport from families, friends and co-workers throughoutthe pregnancy and relinquishment period. In contrast,those who chose closed adoption described their experienceas ‘dehumanizing’, ‘demoralizing’ and ‘secretive’. Althoughboth groups reported an overwhelming sense of pain, loss,embarrassment and social misunderstanding, the womenwho chose open adoption benefited from the communica-tion, control, participation and support that they received.It is critical that nursing intervention must include ways tohelp the griever recognize the loss.

Ideally, the nursing staff has been informed beforehandwhen a birthmother who is relinquishing a child for adop-tion is admitted to the hospital. Nurses may mistakenlythink that the birthmother merely wants to get rid of thebaby and move on. They may be unsure about how to treatthe birthmother, avoid any quality interaction and focus onthe physical aspects of nursing care. An avoidant approachon the part of the nursing staff may foster feelings of shameand cause further disenfranchisement. Birthmothers maybe afraid to bring up the subject for fear of being judged asuncaring or irresponsible, or worse. An understanding,positive, accepting approach will help to create a climate inwhich thoughts and feelings can be expressed. Lauderdale& Boyle (1994) stressed that birthmothers who had linger-ing doubts about the relinquishment were those that wereunable to grieve and come to peace with their decision. Thenurse may gently bring up the subject in order to display awillingness to talk and foster an exchange. Listening,without offering advice, is needed by the birthmother, oftenmore than the need for physical care. The nurse’s use ofrecognition and validation of the birthmother’s feelings canhelp her towards effective resolution by allowing her togrieve her loss.

Roles (2007) insists that the grief process for birthmoth-ers is similar but not identical to other forms of grief. Shedescribes: numbness and denial, eruption of feelings,accepting the adoption decision, accommodation to and

living with uncertainty, and re-evaluating and rebuilding asphases patterned after healthy grief responses. She suggestsactivities for the rituals that have been denied such asdrawing, tape recording, letters, poems, and talking aloudto stimulate the expression of feelings (Lenhardt 1997).Lauderdale & Boyle (1994) cited that the creation ofmemories was extremely helpful to the group of women intheir study that chose open adoption. This group had theopportunity to hold and become familiar with their child,thus, confirming the reality of the event. The nurse mayoffer the birthmother the opportunity to say goodbye to thechild. Holding the child, confirming that the baby is physi-cally well, telling the child her reasons for her decision andexpressing wishes to the child for his future may help thetherapeutic process. The nurse may also suggest that thebirthmother bring home a momento to affirm the reality ofthe event. The value of self-help support groups is empha-sized by all (Lenhardt 1997, Doka 2002, Soll & Buter-baugh 2003) and should be recommended by the nurse.

Conclusion

Research often centres on what is said, seen or done;leaving much of what is left unsaid a mystery. Partly for thisreason, attention to these mothers has been a neglectedarea of study. The absence of recognition by nurses, hos-pital personnel and society and, also, lack of support havebeen identified as key factors in the disenfranchised griefexperienced by birthmothers who have relinquished chil-dren for adoption. These factors contribute to the ineffec-tiveness of traditional grief models. There is a need fornurses, counsellors and researchers to recognize thisgap and respond with further studies and alternativeapproaches to the healing process for this population. Thepsychiatric nurse specialist needs to provide in-service edu-cation to help staff develop self-awareness and enhancetheir understanding of the birthmother experience. Thiswould enable nurses to provide the compassionate careneeded by this very unique group.

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