The Crisis of Unwed Motherhood: A Consultation Approach Karen A. Signell, Ph.D.
ABSTRACT: Unwed motherhood, particularly for the teenager, constitutes a series of subcrises: confrontation with the pregnancy, exclusion from school, physical changes, social isolation and interpersonal conflict, delivery, and caring for an infant. This paper describes the role which a mental health consultant can take in regard to interagency programs, research, and education. Specific consultation interventions, within the framework of crisis theory, are discussed for helping caregivers enable teenagers to cope with these subcrises. A high school principal asks his mental health center, "What can we do about illegitimate pregnancy among our girls? Already this year, 55 of our 6oo girls have become pregnant." This is not the traditional request for psychotherapy for a few deviant girls. The community is now asking for help with major social problems. To respond to such requests may require more than traditional methods on the part of mental health professionals. One method is consultation, within the more general framework of crisis theory and preventive community mental health (Caplan, 5964). This paper describes the role which a mental health consultant might take in providing crisis consultation to professional caregivers. It focuses on unwed teenage Negro girls, who are a particularly vulnerable high-risk group in terms of number of illegitimate births, immaturity, and lack of external resources. Traditional community services have generally been insufficient, alone, to handle this social problem. While maternity homes, adoption agencies, and private physicians have expanded their services, they are largely oriented toward the girls who relinquish their babies, rather than toward the majority who keep their babies. Agencies still cannot reach most girls, especially Dr. Signell, 8I 9 N. Humboldt St., San Mateo, Calif. 944o~, is a clinical psychologist, North County Mental Health Center, San Mateo Mental Health Services Division. At the time this article was written, she was a postdoctoral fellow, Community Mental Health Training Program, Langley Porter Neuropsychiatric Institute, San Francisco. The author gratefully acknozoledges the many contributions and guidance of Betty L. Kalis, Ph.D., and Benjamin L. Gross, M.D., Langley Porter Neuropsychiatric Institute and University of California School of Medicine, San Francisco; and the helpful participation of Elaine Wolfe Grady, M.S.W., Y.W.C.A., San Francisco, and San Francisco United School District. Community Mental Health Journal, Vol. 5 (4), 1969
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Negro girls (Garland, I966 ) . So far, traditional theories have not sufficiently oriented professionals for handling unwed motherhood as a social problem. However, a community mental health approach can supplement the traditional psychotherapeutic one--providing indirect services to community caregiver s. FOCUS OF CONSULTATION: SUBCRISES The aim of "secondary prevention" consultation is to alleviate the stress accompanying illegitimate pregnancy and birth in order to prevent more serious adverse effects. Essentially, the consultation is to various "therapeutic" agents who help girls in crisis. Efforts can be focused on the most critical times or subcrises confronting the girl, from the time when the pregnancy is discovered through the weeks and months following delivery. The most acute subcrisis can be the initial confrontation with the fact of pregnancy itself. The girl faces her own discovery of the fact, as well as informing her mother and other authorities. The highest pitch of anxiety for the girl's mother may take place at this time. On the other hand, the mother and daughter may deny throughout the pregnancy that there will be a delivery, motherhood, and a baby to care for.
Subcrisis example. Ethel May's mother at first refused to acknowledge that her daughter would have a baby. After delivery, she unexpectedly visited Ethel May at the hospital. Then she refused to let her bring the baby home. Ethel May, caught in a hostile-dependent relationship, was told, "You can't bring the baby home. There's no room, and you have to care for my new baby, anyhow. But if you don't come home, I'll send the court after you for running away from home." It may be no coincidence that during the girls' pregnancies there are various manifestations of their mothers' inner turmoil in confronting the pregnancy. One girl's mother went on a week-long alcoholic binge upon hearing the news and again about the time of delivery. A white girl's mother was severely depressed throughout the pregnancy. Another mother was almost fatally stabbed by her husband. A n o t h e r subcrisis is that the girl is usually excluded from school, which isolates her from her peers. Without strong encouragement and help, this interruption of schooling may easily be the termination of schooling--an important avenue of escape from the slum for these girls.
Subcrfsis example. Jane could barely read and write, although she had always managed to pass her courses each year, partly through the encouragement of her Negro boyfriend, a freshman in college. However, during the pregnancy, she found it increasingly difficult to keep up with her school work. There was constant activity at home. Her mother, who had many illegitimate children and drank heavily, would say "Close that book, and go do the dishes. Who do you think you are? Better than me? C'mon, Jane, you're just like me; you don't do well in those school things either." The local school system required unwed mothers to return to a different school, among strangers, and this also made Jane reluctant to return. Physical changes during pregnancy require special care, particularly for unwed mothers who are a high-risk group, having infant mortality rates that
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are double the rates for wed mothers (Adams, ~96~). Moreover, teenage girls have little knowledge about physical health or diet, and little support at home for prenatal care or using any new knowledge they gain from outside sources. A ~3-year-old girl asked, " W h y can't I go roller-skating?" Subcrisis example. Charlotte was grossly overweight, yet she did not ask her doctor questions or listen to his brief advice. Her mother continued to give her the usual food at home. At the seventh month examination, Charlotte was on a table for five hours, waiting and being examined by various doctors. She was too frightened to ask for any explanation. Then she was sent upstairs, as she found out afterward, for delivery of a defective child. There are also difficulties getting to the hospital for check-ups or delivery. Maxine's water broke at ~o o'clock one night, but she did not recognize the significance of this. When, at 2 A.M., in the midst of labor pains, her parents had not yet arrived home, she Started telephoning friends for transportation to the hospital. The usual intrapersonal stress and emotional reactiveness of pregnant women (Bibring, Dwyer, Huntington, & Valenstein, ~96z) are compounded by the teenage girls' own immaturity and lack of social support from ambivalent boyfriends and parents. One mother said, "She just sat in her room alone day after day, hardly eating a thing." There may be subtle hostility, or more overt interpersonal stress. A mother said: "You're dirty. All you wanted was to get between his legs." A girl may overreact to such rejection or to her own emotionalism. Subcrisis example. During her pregnancy, Irma visited the zoo. When she came home and told her mother and aunt, they became angry. Her looking at the giraffe apparently meant that her baby would have a long neck. Her looking at monkeys meant that the child would have a monkey's face. They beat her on the stomach with their fists and Irma flew into a temper. For days, she was quite anxious that her temper outburst meant that she was going insane. The question of disposition of the baby brings constant and conflicting pressures from relatives, boyfriends, and courts. For example, one girl wanted to keep her baby, but her foster mother refused to let her bring the baby home. The court refused to let her boyfriend's parents keep it. Therefore, the couple felt forced into a premature marriage to keep the baby. Delivery is fraught with anxiety, partly from ambivalence and ignorance. Usual anxiety concerning pain, death, and the birth of an abnormal baby is repressed, but emerges as unrealistic fears--"old wives' tales." These superstitious beliefs might serve an expressive function for pregnant women. However, they might also arouse undue anxiety, especially in teenagers, who are bereft of usual support, and who have not had much opportunity to learn about births of babies. For example, girls' mothers have said, "You're too little. Its head will get stuck, and it'll be born dead." "If you go swimming, you'll drown the baby." Other girls repress their anxiety. Anticipatory guidance about delivery, if too mild, will meet with vast denial. If too strong, e.g., a sensational technicolor movie that starts with a scalpel incision, it may bring panic and further repression. Subcrisis example. Hattie came from an ignorant and fear-provoking home. She had been denying her fears of delivery during ~the entire pregnancy, saying, "I don't think it'll hurt
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at all." Having done no anticipatory work, she then went to the hospital for delivery. She was in a panic state, screaming and violent. Then after delivery, she was extremely depressed, beating her head against the wall, not talking, just crying. A few weeks later at home, she was emerging from a milder depression when she died, probably by suicide. Perhaps the most stressful subcrisis occurs when the girl brings her baby home--confronting the fact that she is a mother and has the burden of giving constant care to a baby. It is difficult for her to see herself as a mother. Problems range from a girl who lets her baby lie on her lap, as if he were an inanimate object, to possible gross neglect or brutality. ("I'm afraid to hold it." "Memnurse a baby? .... Somebody'll take care of it.") For the girl who might not keep her baby, final decisions must be made. Separation from the baby--either by adoption or its going to a relative---is difficult, and the girl may have little opportunity to work through her feelings. These subcrises can be understood within the mental health consultant's framework of crisis theory. If the consultant confines attention largely to these subcrises, there is less likelihood that the caregivers will be overwhelmed by apparent pathology and overextended responsibilities which they cannot realistically meet. He conveys a limited goal: to help the girls cope with the crisis state. This goal is in keeping with the public health approach, which is to help all those in greatest need of preventive help. This critical subgroup can be served only if the caregivers do not continue their help across time, e.g., helping a girl beyond postnatal care; or across problems, e.g., attempting to alleviate chronic intrapersonal or social problems. Briefly, crisis theory focuses on specific reactions to current environmental or current developmental events, rather than on individual psychopathology. It describes the range of adaptive and maladaptive reactions that can be expected to occur in response to particular stressors. Regarding responsiveness to crisis interventions, the theory holds that when any person confronts certain stressors, his usual level of equilibrium is disrupted, and he is therefore more receptive to change. His usual coping mechanisms are obviously inadequate. Consequently, he may be more willing to try new ones. He needs support, and may enter more readily than usual into a therapeutic or supportive relationship. He is anxious, and may be more motivated to confront an evident problem. Also, at times of crisis, core conflicts (Kalis, Harris, Prestwood, & Freeman, ~96~) are often reactivated and are more accessible to awareness. Therefore, interventions during a crisis state are likely to be an efficient deployment of professional time. The goal of crisis interventions is limited to successful coping with the stressor and resulting reactions. There are often additional by-products of such interventions: increased confidence in one's general ability to cope through having had a "success experience," the resolution of an underlying conflict, the ability to use support, the acquisition of new coping mechanisms, or the motivation for further treatment. On the other hand, if a crisis is not satisfactorily resolved, it may lead to a lower general level of functioning. Therefore, intervention at time of crisis is likely to be crucial.
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However, before the mental health consultant can convey crisis concepts and interventions to caregivers, he may first need to understand and deal with professional and community attitudes toward unwed girls (Signell, i969 a). CONSULTATION TO CAREGIVERS Some of the caregivers in a position to provide crisis interventions either formal or informal are public health nurses, welfare workers, outpatient and inpatient maternity home staff, adoption agency staff, private physicians, hospital staff, attorneys, probation officers, clinic staff, and school staff. A consultant can serve as a catalyst for interagency cooperation. For example, he may consult with school principals about how they can refer girls, work with parents, and inform public health nurses so that girls automatically receive prenatal care. Or he may consult the kind of program which has already been developed or planned in his city, such as home teachers, a special school, home instructions via a telephone network, or an interagency project offering many sermces to a group of girls. A project for unwed teenagers was started by a YWCA in cooperation with a school system, welfare department, public health nurses' unit, and local hospital to help girls who might otherwise receive little or no help from existing agencies during the crisis of pregnancy. There were approximately ~8 girls, mostly Negro, aged from ~3 to 56. They met at the YWCA two mornings a week with a project director, two public health nurses, several home teachers, and recreation volunteers. A maior aim was to provide schooling, so that gifts would return to school after delivery. Therefore the project gave instruction in academic courses as well as nutrition, contraception, prenatal care, labor, delivery, and postnatal care. Another aim was to break into the girls' social isolation by providing a group atmosphere. In group counseling, the girls worked through some of their fears, decisions, and crises. There were home visits, meetings with relatives and boyfriends, and liaison with hospitals. A consultant met on alternate weeks with the director, and on alternate weeks with the entire staff and related professionals for (a) consultee-centered case consultation, (b) client-centered case consultation, and (c) administrative consultation.
Consultee-Centered Case Consultation Discussions about cases--either in the group or individual sessions with the director--raised various issues common to such projects. A recurrent issue is the limit of responsibility. At first the girls appeared so needy that they seemed to require that the consultees take almost unlimited responsibility for all their problems. To avoid being overwhelmed by such functional and emotional strain, the staff gradually set realizable goals and found alternative strategies. For instance, a reasonable ceiling was set on the number of girls who could be seen. If parents neglected to feed other children in the family, the problem was referred to another more ap-
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propriate agency. Attention could then be directed toward the primary aims of the program, rather than taking on other potentially conflicting or diffuse aims. Thus the consultant, by continually focusing on subcrises, reaffirmed the primary aim as helping the girls cope with the main crisis of unwed motherhood. Another issue is the handling of failure. Since unwed girls face many complicated problems, failure is inevitable: girls being persistently sullen in prenatal exercise class, absenteeism, a middle-class girl quitting the program, a girl or her baby dying. Such failures are difficult for any staff to accept, and lead to feelings of inadequacy, guilt, and failure. The consultant can question a staff's underlying assumptions of omnipotence and unrealistic expectations of themselves. What help can caregivers give a girl in crisis, and what are the limits of their help? When should they give up? For example, a group counseling leader might feel that she is failing professionally if some of the girls are not talking in the group. The consultant can compare the consultee's group to group therapy and its usual slow progress. This perspective Can relieve her feelings of inadequacy, which are based on unrealistically high expectations of the group and herself. Sometimes the fear of failure can be met head-on, by appraising probabilities, anticipating possible failures, sharing group frustrations, and accepting their failures. The consultant may remind the staff, "You can't save them all." The girls' problems are urgent; the nature of the problems is often unclear; and their solution is uncertain. Such problems provoke a need for certainty, which may lead to thinking, on th~ part of the staff and consultant, that they should be omniscient. A staff may sometimes attribute unrealistic expertise to the consultant, against which to contrast their own inadequacy. For instance, at a group consultation meeting there was a protracted discussion about whether a girl should see her baby's father. The group seemed uncomfortable about the possibility of making a wrong decision, and turned to the "expert." The consultant realized that she, too, did not know "the answer," and jokingly voiced this as, "We all have to make decisions, sometimes, on the basis of a 'good guess'!" This intervention seemed to help dispel the burden of omniscience and led to a group decision. Theme interference, i.e., consultees' misperceptions or fears, can block ability to cope with a case. At first a staff is likely to consider these multiproblem girls "frail," and be afraid to harm them by saying or doing the wrong thing. However, upon examining the girls' resilience over time, this over-protectiveness will give way to a more balanced view, and the insight that their role is to "help the girls find strength within themselves." A common underlying assumption or fear of any staff working with a client who has severe problems is that the client is "doomed" (Caplan, 5964). There are many pitfalls in the resolution of crises, any one of which can provoke such fears. For example, an unwed girl did not want to return to school after delivery. This was very frustrating for the staff, since their unspoken thought was that her only hope was to return. If not, she would "become
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just like her mother--a drunken prostitute." The consultant asked, "What would happen if she actually did not return to school?" The staff then examined probable outcomes and found that she was indeed somewhat different from her mother. Then they spontaneously suggested alternatives to schooling, such as secretarial training, or volunteer work. Sometimes there is denial of an underlying fear that a staff has about a case. Joan, a sullen Negro girl of 25, had wanted to place her baby in a foster home, but her aunt insisted that she keep it. Soon after the child was delivered, the director made a home visit, and asked Joan where the baby was. Joan retorted, "What baby? There's no baby. I'm the baby!" Moreover, as the staff talked, it emerged that Joan had not been listening tO the public health nurse about preparing her baby's formula. The import of the group's talk was that Joan was grossly disturbed, and might neglect or even brutalize her baby. The consultant's asking, "What might happen?" helped bring out this unspoken fear. It seemed to free everyone to share responsibility, handle their anxiety, and plan their respective roles to 'inform each other and make appropriate referral. Another illustration of theme interference is the case of Inez. She had been generally negligent during pregnancy, failing in her schoolwork, and looking increasingly unkempt and depressed. Then she was suddenly transformed --obviously coincident with her becoming a prostitute. She looked beautiful, contributed to group counseling, and began to do good schoolwork. The consultant voiced the group's dismay, and at the same time tried to reduce cognitive dissonance and perplexity, by joking, "It's wonderful what a goodpaying job does for a girl!" Client-Centered Case Consultation A key to understanding and helping some girls is understanding and helping their relatives. In fact, in dealing with crisis, a caregiver often needs the support of relatives. However, in their concentration on the problems of a particular girl, caregivers sometimes overlook relatives. The consultant can suggest that the relatives themselves 'be considered as persons in crisis, as a point of departure for estimating how much the relatives realistically can be expected to help a girl. For example, when a girl's mother left her on an alcoholic binge upon hearing of the pregnancy, the consultant shifted attention to the mother her feelings of deprivation, strategies for trying to reach her, and anticipating another alcoholic episode about the time of the girl's delivery. Understanding the girls' boyfriends and enlisting their support was also worthwhile. A 14-year-old girl clung to a romantic attachment--more fantasy than reality--to her boyfriend. She was depressed and less responsive to the project's program for days if he did not see her. She needed his support, but he seemed reluctant to see her. Turning attention to the boy revealed that he was only a ~5-year-old who seemed overwhelmed by her demands. He had easily complied with his mother's wishes not to see the girl, but then he felt
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guilty. A counseling session with him was planned, not to demand full support from him, but regular telephone calls--something which he could give. For boyfriends and other supporters may not ordinarily know that during the crisis of pregnancy a woman generally needs extra support. The caregivers can apprise them of a girl's needs and assure them that acquiescing to her demands does not necessarily set a precedent, as her critical need is only temporary. Also, the caregiver may extend support to a girl's usual supporters, so that they, in turn, can help the girl more, e.g., group counseling for unwed fathers, or mothers of unwed girls. Sometimes in discussing cases, the consultant can serve as a resource person concerning psychological understanding, crisis concepts, or information on referral procedures for additional psychiatric services in the community. An opportunity to transmit crisis concepts to caregivers arises frequently. For example, Barbara's baby had convulsions and paralysis after delivery and was expected to die. The mother had not been informed. Should the girl be told, and encouraged to see her baby? The consultant referred to the research on premature birth (Caplan, Mason, & Kaplan, 2965) and its principles of anticipatory griefwork in case the child dies, and the necessity for providing some bond between mother and child in case the child lives. The consultant and consultee also explored Barbara's possible interpretations of why it happened--that she was "bad," had become obese, and refused to diet. Sometimes the consultant briefly pointed out general mental health concepts, such as the protective function of certain defense mechanisms. For example, a Southern white girl had been depressed throughout her pregnancy, had given up her baby for adoption, and was returning home immediately afterward. The staff was afraid that she might "collapse" upon facing the hostile clan back home. However, recalling the girl's ability to angrily strike out at the staff, the consultant suggested that she had hostility as a good protection. In fact, she might handle a good fight at home better than a depression. Administrative Consultation Program and policy decisions may require discussion occasionally, such as deciding whether girls should stay in the program for the weeks following delivery. The consultant can bring out relevant information bearing on such a decision. According to the crisis framework, the postdelivery period presents particular difficulties. Also, clinical practice would indicate that separation from a counselor and one's usual peer group would intensify the crisis. Therefore, if a program can afford it, a decision might be made for girls to remain in the program for at least six weeks after delivery. However, a consultant might also point out the problems involved in mixing a group and the exceptions that might be made. A recurrent difficulty among gifts can reveal a need for possible program changes. For example, absenteeism was high at first in the project. An "epidemiological" approach showed that absenteeism occurred largely on a girl's
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first day in the program and when there had been no prior home visit to enlist the mother's cooperation. In such cases, plans can concentrate upon reducing absenteeism among this "high-risk" subgroup by such measures as routine home visits before the first clay, telephone calls, and other girls bringing new ones to a center. Group consultation can afford an opportunity to open up communication, and foster coordination of goals and mutual support among caregivers. The consultant can also encourage other formal or informal intrastaff communication, such as working out arrangements for home teachers to attend staff meetings, or to meet with the staff for lunch. In group consultation, interagency and role conflicts can be worked through to form better working relationships. For example, in one case a probation officer was taking the mother's part and the project staff was taking the girl's--both victims of their clients' manipulations and the relative narrowness of their sources of information. Also, they were reflecting the legitimate concerns of their respective agencies. The conflict of interests was partly resolved by the director inviting the probation officer to the regular group consultation where views were openly expressed, information exchanged, and plans worked out. CONSULTATION TO RESEARCHERS Secondary prevention research might reveal what stages of the crisis are more acute, how the subcrises affect girls, and what anticipatory guidance and outside support is needed. Also, what is the most effective use of resources? Which girls are most vulnerable? Does any identifiable group, such as minority girls, particularly need resources? For example, a consultant might help a particular professional group--a prenatal care staff, public health nurses, maternity home staff, or home teachers--develop research on which girls need help most, which girls do not come to agencies' attention, what kinds of help they need, and what might effect resolution of their crisis. Questions raised from a research perspective can also be helpful to agencies, without necessarily involving carefully controlled observations or extensive collection of data. Such inquiries can lead an agency to evaluate its program. A school system is in a critical case-finding position, especially in regard to unwed motherhood where various agencies may not already discharge their respective responsibilities for case finding. By merely comparing school suspensions and public health nursing reports, they can easily determine the percent of unwed girls who do not obtain prenatal care. The school can also find what percent of girls become pregnant one or more times, and what percent return to school after pregnancy, in order to adapt their school program accordingly. A health department, in shaping its program, might be interested in the number of unwed girls whose children are delivered at local hospitals, the rate of infant mortality and premature births for teen-age mothers, and where the girls obtain pre- and postnatal care.
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EDUCATION Educational efforts can be directed toward caregivers. For instance, the curricula of medical students might include more about the emotional reactions to the crisis of pregnancy (Bibring, et al., "f96i). More direct education for girls can consist of family-life education courses as part of the school curriculum. Films on pregnancy, prenatal care, childbirth, and postnatal care can provide information effectively and give an opportunity for anticipatory working through. For example, a film on the normal course of pregnancy can provide facts, then lead afterward to discussions of the stressful aspects to be encountered--physical changes, emotional reactions, supportive needs, and delivery. CONCLUDING COMMENT This paper has addressed itself only to secondary prev e n t i o n - h e l p i n g girls through the crisis of illegitimate pregnancy and the birth of a baby. However, the point of greatest leverage is primary prevention-preventing illegitimate births from occurring in the first place. Consultative efforts can be directed toward sex education, birth control, and other targets (Signell, 2969, b). Tertiary prevention might be mentioned briefly here as services to the mother and her growing child--postnatal care, rehabilitation, prevention of recidivism, counseling, and protection of illegitimate children's rights. REFERENCES Adams, Hannah H. Two studies of unmarried mothers in New York City. Children, x96z, 8, z84-188: Bibring, Grete L.; Dwyer, T. F.; Huntington, Dorothy S.; and Valenstein, A. F, A study of the psychologicalprocesses in pregnancy and of earliest mother-child relationship, I. Some propositions and comments. Psychoanalytic Study of the Child, 2961, XVI, 9-25Caplan, G. Principlesof preventive psychiatry. New York: BasicBooks, 2964. Caplan, G.; Mason, E. A.; and Kaplan, D. M. Four studies of crisis in parents of prematures. Community Mental Health Journal, I965, I, 2, I49-I6I. Garland, Patricia. Illegitimacy--a special minority-group problem in urban areas: new social welfare perspectives. Child Welfare, I966, XLV, 81-88. Kalis, Betty L.; Harris, M. R.; Prestwood, A. R.; and Freeman, Edith H. Precipitating stress as a focus in psychotherapy.Arch. Gen. Psychiat., I96I, 2;, 219-226. Signell, Karen A. Mental health consultation in the field of illegitimacy Social Work, ~969, ~4, 67-74. (a) Signell, Karefi A. Prevention of teenage illegitimate pregnancy: a consultation approach to sex education. The Family Coordinator, i969, I8, 3: (b)
ABSTRACT: Unwed motherhood, particularly for the teenager, constitutes a series of subcrises: confrontation with the pregnancy, exclusion from school, physical changes, social isolation and interpersonal conflict, delivery, and caring for an infant. This paper describes the role which a mental health consultant can take in regard to interagency programs, research, and education. Specific consultation interventions, within the framework of crisis theory, are discussed for helping caregivers enable teenagers to cope with these subcrises. A high school principal asks his mental health center, "What can we do about illegitimate pregnancy among our girls? Already this year, 55 of our 6oo girls have become pregnant." This is not the traditional request for psychotherapy for a few deviant girls. The community is now asking for help with major social problems. To respond to such requests may require more than traditional methods on the part of mental health professionals. One method is consultation, within the more general framework of crisis theory and preventive community mental health (Caplan, 5964). This paper describes the role which a mental health consultant might take in providing crisis consultation to professional caregivers. It focuses on unwed teenage Negro girls, who are a particularly vulnerable high-risk group in terms of number of illegitimate births, immaturity, and lack of external resources. Traditional community services have generally been insufficient, alone, to handle this social problem. While maternity homes, adoption agencies, and private physicians have expanded their services, they are largely oriented toward the girls who relinquish their babies, rather than toward the majority who keep their babies. Agencies still cannot reach most girls, especially Dr. Signell, 8I 9 N. Humboldt St., San Mateo, Calif. 944o~, is a clinical psychologist, North County Mental Health Center, San Mateo Mental Health Services Division. At the time this article was written, she was a postdoctoral fellow, Community Mental Health Training Program, Langley Porter Neuropsychiatric Institute, San Francisco. The author gratefully acknozoledges the many contributions and guidance of Betty L. Kalis, Ph.D., and Benjamin L. Gross, M.D., Langley Porter Neuropsychiatric Institute and University of California School of Medicine, San Francisco; and the helpful participation of Elaine Wolfe Grady, M.S.W., Y.W.C.A., San Francisco, and San Francisco United School District. Community Mental Health Journal, Vol. 5 (4), 1969
304
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Negro girls (Garland, I966 ) . So far, traditional theories have not sufficiently oriented professionals for handling unwed motherhood as a social problem. However, a community mental health approach can supplement the traditional psychotherapeutic one--providing indirect services to community caregiver s. FOCUS OF CONSULTATION: SUBCRISES The aim of "secondary prevention" consultation is to alleviate the stress accompanying illegitimate pregnancy and birth in order to prevent more serious adverse effects. Essentially, the consultation is to various "therapeutic" agents who help girls in crisis. Efforts can be focused on the most critical times or subcrises confronting the girl, from the time when the pregnancy is discovered through the weeks and months following delivery. The most acute subcrisis can be the initial confrontation with the fact of pregnancy itself. The girl faces her own discovery of the fact, as well as informing her mother and other authorities. The highest pitch of anxiety for the girl's mother may take place at this time. On the other hand, the mother and daughter may deny throughout the pregnancy that there will be a delivery, motherhood, and a baby to care for.
Subcrisis example. Ethel May's mother at first refused to acknowledge that her daughter would have a baby. After delivery, she unexpectedly visited Ethel May at the hospital. Then she refused to let her bring the baby home. Ethel May, caught in a hostile-dependent relationship, was told, "You can't bring the baby home. There's no room, and you have to care for my new baby, anyhow. But if you don't come home, I'll send the court after you for running away from home." It may be no coincidence that during the girls' pregnancies there are various manifestations of their mothers' inner turmoil in confronting the pregnancy. One girl's mother went on a week-long alcoholic binge upon hearing the news and again about the time of delivery. A white girl's mother was severely depressed throughout the pregnancy. Another mother was almost fatally stabbed by her husband. A n o t h e r subcrisis is that the girl is usually excluded from school, which isolates her from her peers. Without strong encouragement and help, this interruption of schooling may easily be the termination of schooling--an important avenue of escape from the slum for these girls.
Subcrfsis example. Jane could barely read and write, although she had always managed to pass her courses each year, partly through the encouragement of her Negro boyfriend, a freshman in college. However, during the pregnancy, she found it increasingly difficult to keep up with her school work. There was constant activity at home. Her mother, who had many illegitimate children and drank heavily, would say "Close that book, and go do the dishes. Who do you think you are? Better than me? C'mon, Jane, you're just like me; you don't do well in those school things either." The local school system required unwed mothers to return to a different school, among strangers, and this also made Jane reluctant to return. Physical changes during pregnancy require special care, particularly for unwed mothers who are a high-risk group, having infant mortality rates that
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are double the rates for wed mothers (Adams, ~96~). Moreover, teenage girls have little knowledge about physical health or diet, and little support at home for prenatal care or using any new knowledge they gain from outside sources. A ~3-year-old girl asked, " W h y can't I go roller-skating?" Subcrisis example. Charlotte was grossly overweight, yet she did not ask her doctor questions or listen to his brief advice. Her mother continued to give her the usual food at home. At the seventh month examination, Charlotte was on a table for five hours, waiting and being examined by various doctors. She was too frightened to ask for any explanation. Then she was sent upstairs, as she found out afterward, for delivery of a defective child. There are also difficulties getting to the hospital for check-ups or delivery. Maxine's water broke at ~o o'clock one night, but she did not recognize the significance of this. When, at 2 A.M., in the midst of labor pains, her parents had not yet arrived home, she Started telephoning friends for transportation to the hospital. The usual intrapersonal stress and emotional reactiveness of pregnant women (Bibring, Dwyer, Huntington, & Valenstein, ~96z) are compounded by the teenage girls' own immaturity and lack of social support from ambivalent boyfriends and parents. One mother said, "She just sat in her room alone day after day, hardly eating a thing." There may be subtle hostility, or more overt interpersonal stress. A mother said: "You're dirty. All you wanted was to get between his legs." A girl may overreact to such rejection or to her own emotionalism. Subcrisis example. During her pregnancy, Irma visited the zoo. When she came home and told her mother and aunt, they became angry. Her looking at the giraffe apparently meant that her baby would have a long neck. Her looking at monkeys meant that the child would have a monkey's face. They beat her on the stomach with their fists and Irma flew into a temper. For days, she was quite anxious that her temper outburst meant that she was going insane. The question of disposition of the baby brings constant and conflicting pressures from relatives, boyfriends, and courts. For example, one girl wanted to keep her baby, but her foster mother refused to let her bring the baby home. The court refused to let her boyfriend's parents keep it. Therefore, the couple felt forced into a premature marriage to keep the baby. Delivery is fraught with anxiety, partly from ambivalence and ignorance. Usual anxiety concerning pain, death, and the birth of an abnormal baby is repressed, but emerges as unrealistic fears--"old wives' tales." These superstitious beliefs might serve an expressive function for pregnant women. However, they might also arouse undue anxiety, especially in teenagers, who are bereft of usual support, and who have not had much opportunity to learn about births of babies. For example, girls' mothers have said, "You're too little. Its head will get stuck, and it'll be born dead." "If you go swimming, you'll drown the baby." Other girls repress their anxiety. Anticipatory guidance about delivery, if too mild, will meet with vast denial. If too strong, e.g., a sensational technicolor movie that starts with a scalpel incision, it may bring panic and further repression. Subcrisis example. Hattie came from an ignorant and fear-provoking home. She had been denying her fears of delivery during ~the entire pregnancy, saying, "I don't think it'll hurt
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at all." Having done no anticipatory work, she then went to the hospital for delivery. She was in a panic state, screaming and violent. Then after delivery, she was extremely depressed, beating her head against the wall, not talking, just crying. A few weeks later at home, she was emerging from a milder depression when she died, probably by suicide. Perhaps the most stressful subcrisis occurs when the girl brings her baby home--confronting the fact that she is a mother and has the burden of giving constant care to a baby. It is difficult for her to see herself as a mother. Problems range from a girl who lets her baby lie on her lap, as if he were an inanimate object, to possible gross neglect or brutality. ("I'm afraid to hold it." "Memnurse a baby? .... Somebody'll take care of it.") For the girl who might not keep her baby, final decisions must be made. Separation from the baby--either by adoption or its going to a relative---is difficult, and the girl may have little opportunity to work through her feelings. These subcrises can be understood within the mental health consultant's framework of crisis theory. If the consultant confines attention largely to these subcrises, there is less likelihood that the caregivers will be overwhelmed by apparent pathology and overextended responsibilities which they cannot realistically meet. He conveys a limited goal: to help the girls cope with the crisis state. This goal is in keeping with the public health approach, which is to help all those in greatest need of preventive help. This critical subgroup can be served only if the caregivers do not continue their help across time, e.g., helping a girl beyond postnatal care; or across problems, e.g., attempting to alleviate chronic intrapersonal or social problems. Briefly, crisis theory focuses on specific reactions to current environmental or current developmental events, rather than on individual psychopathology. It describes the range of adaptive and maladaptive reactions that can be expected to occur in response to particular stressors. Regarding responsiveness to crisis interventions, the theory holds that when any person confronts certain stressors, his usual level of equilibrium is disrupted, and he is therefore more receptive to change. His usual coping mechanisms are obviously inadequate. Consequently, he may be more willing to try new ones. He needs support, and may enter more readily than usual into a therapeutic or supportive relationship. He is anxious, and may be more motivated to confront an evident problem. Also, at times of crisis, core conflicts (Kalis, Harris, Prestwood, & Freeman, ~96~) are often reactivated and are more accessible to awareness. Therefore, interventions during a crisis state are likely to be an efficient deployment of professional time. The goal of crisis interventions is limited to successful coping with the stressor and resulting reactions. There are often additional by-products of such interventions: increased confidence in one's general ability to cope through having had a "success experience," the resolution of an underlying conflict, the ability to use support, the acquisition of new coping mechanisms, or the motivation for further treatment. On the other hand, if a crisis is not satisfactorily resolved, it may lead to a lower general level of functioning. Therefore, intervention at time of crisis is likely to be crucial.
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However, before the mental health consultant can convey crisis concepts and interventions to caregivers, he may first need to understand and deal with professional and community attitudes toward unwed girls (Signell, i969 a). CONSULTATION TO CAREGIVERS Some of the caregivers in a position to provide crisis interventions either formal or informal are public health nurses, welfare workers, outpatient and inpatient maternity home staff, adoption agency staff, private physicians, hospital staff, attorneys, probation officers, clinic staff, and school staff. A consultant can serve as a catalyst for interagency cooperation. For example, he may consult with school principals about how they can refer girls, work with parents, and inform public health nurses so that girls automatically receive prenatal care. Or he may consult the kind of program which has already been developed or planned in his city, such as home teachers, a special school, home instructions via a telephone network, or an interagency project offering many sermces to a group of girls. A project for unwed teenagers was started by a YWCA in cooperation with a school system, welfare department, public health nurses' unit, and local hospital to help girls who might otherwise receive little or no help from existing agencies during the crisis of pregnancy. There were approximately ~8 girls, mostly Negro, aged from ~3 to 56. They met at the YWCA two mornings a week with a project director, two public health nurses, several home teachers, and recreation volunteers. A maior aim was to provide schooling, so that gifts would return to school after delivery. Therefore the project gave instruction in academic courses as well as nutrition, contraception, prenatal care, labor, delivery, and postnatal care. Another aim was to break into the girls' social isolation by providing a group atmosphere. In group counseling, the girls worked through some of their fears, decisions, and crises. There were home visits, meetings with relatives and boyfriends, and liaison with hospitals. A consultant met on alternate weeks with the director, and on alternate weeks with the entire staff and related professionals for (a) consultee-centered case consultation, (b) client-centered case consultation, and (c) administrative consultation.
Consultee-Centered Case Consultation Discussions about cases--either in the group or individual sessions with the director--raised various issues common to such projects. A recurrent issue is the limit of responsibility. At first the girls appeared so needy that they seemed to require that the consultees take almost unlimited responsibility for all their problems. To avoid being overwhelmed by such functional and emotional strain, the staff gradually set realizable goals and found alternative strategies. For instance, a reasonable ceiling was set on the number of girls who could be seen. If parents neglected to feed other children in the family, the problem was referred to another more ap-
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propriate agency. Attention could then be directed toward the primary aims of the program, rather than taking on other potentially conflicting or diffuse aims. Thus the consultant, by continually focusing on subcrises, reaffirmed the primary aim as helping the girls cope with the main crisis of unwed motherhood. Another issue is the handling of failure. Since unwed girls face many complicated problems, failure is inevitable: girls being persistently sullen in prenatal exercise class, absenteeism, a middle-class girl quitting the program, a girl or her baby dying. Such failures are difficult for any staff to accept, and lead to feelings of inadequacy, guilt, and failure. The consultant can question a staff's underlying assumptions of omnipotence and unrealistic expectations of themselves. What help can caregivers give a girl in crisis, and what are the limits of their help? When should they give up? For example, a group counseling leader might feel that she is failing professionally if some of the girls are not talking in the group. The consultant can compare the consultee's group to group therapy and its usual slow progress. This perspective Can relieve her feelings of inadequacy, which are based on unrealistically high expectations of the group and herself. Sometimes the fear of failure can be met head-on, by appraising probabilities, anticipating possible failures, sharing group frustrations, and accepting their failures. The consultant may remind the staff, "You can't save them all." The girls' problems are urgent; the nature of the problems is often unclear; and their solution is uncertain. Such problems provoke a need for certainty, which may lead to thinking, on th~ part of the staff and consultant, that they should be omniscient. A staff may sometimes attribute unrealistic expertise to the consultant, against which to contrast their own inadequacy. For instance, at a group consultation meeting there was a protracted discussion about whether a girl should see her baby's father. The group seemed uncomfortable about the possibility of making a wrong decision, and turned to the "expert." The consultant realized that she, too, did not know "the answer," and jokingly voiced this as, "We all have to make decisions, sometimes, on the basis of a 'good guess'!" This intervention seemed to help dispel the burden of omniscience and led to a group decision. Theme interference, i.e., consultees' misperceptions or fears, can block ability to cope with a case. At first a staff is likely to consider these multiproblem girls "frail," and be afraid to harm them by saying or doing the wrong thing. However, upon examining the girls' resilience over time, this over-protectiveness will give way to a more balanced view, and the insight that their role is to "help the girls find strength within themselves." A common underlying assumption or fear of any staff working with a client who has severe problems is that the client is "doomed" (Caplan, 5964). There are many pitfalls in the resolution of crises, any one of which can provoke such fears. For example, an unwed girl did not want to return to school after delivery. This was very frustrating for the staff, since their unspoken thought was that her only hope was to return. If not, she would "become
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just like her mother--a drunken prostitute." The consultant asked, "What would happen if she actually did not return to school?" The staff then examined probable outcomes and found that she was indeed somewhat different from her mother. Then they spontaneously suggested alternatives to schooling, such as secretarial training, or volunteer work. Sometimes there is denial of an underlying fear that a staff has about a case. Joan, a sullen Negro girl of 25, had wanted to place her baby in a foster home, but her aunt insisted that she keep it. Soon after the child was delivered, the director made a home visit, and asked Joan where the baby was. Joan retorted, "What baby? There's no baby. I'm the baby!" Moreover, as the staff talked, it emerged that Joan had not been listening tO the public health nurse about preparing her baby's formula. The import of the group's talk was that Joan was grossly disturbed, and might neglect or even brutalize her baby. The consultant's asking, "What might happen?" helped bring out this unspoken fear. It seemed to free everyone to share responsibility, handle their anxiety, and plan their respective roles to 'inform each other and make appropriate referral. Another illustration of theme interference is the case of Inez. She had been generally negligent during pregnancy, failing in her schoolwork, and looking increasingly unkempt and depressed. Then she was suddenly transformed --obviously coincident with her becoming a prostitute. She looked beautiful, contributed to group counseling, and began to do good schoolwork. The consultant voiced the group's dismay, and at the same time tried to reduce cognitive dissonance and perplexity, by joking, "It's wonderful what a goodpaying job does for a girl!" Client-Centered Case Consultation A key to understanding and helping some girls is understanding and helping their relatives. In fact, in dealing with crisis, a caregiver often needs the support of relatives. However, in their concentration on the problems of a particular girl, caregivers sometimes overlook relatives. The consultant can suggest that the relatives themselves 'be considered as persons in crisis, as a point of departure for estimating how much the relatives realistically can be expected to help a girl. For example, when a girl's mother left her on an alcoholic binge upon hearing of the pregnancy, the consultant shifted attention to the mother her feelings of deprivation, strategies for trying to reach her, and anticipating another alcoholic episode about the time of the girl's delivery. Understanding the girls' boyfriends and enlisting their support was also worthwhile. A 14-year-old girl clung to a romantic attachment--more fantasy than reality--to her boyfriend. She was depressed and less responsive to the project's program for days if he did not see her. She needed his support, but he seemed reluctant to see her. Turning attention to the boy revealed that he was only a ~5-year-old who seemed overwhelmed by her demands. He had easily complied with his mother's wishes not to see the girl, but then he felt
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guilty. A counseling session with him was planned, not to demand full support from him, but regular telephone calls--something which he could give. For boyfriends and other supporters may not ordinarily know that during the crisis of pregnancy a woman generally needs extra support. The caregivers can apprise them of a girl's needs and assure them that acquiescing to her demands does not necessarily set a precedent, as her critical need is only temporary. Also, the caregiver may extend support to a girl's usual supporters, so that they, in turn, can help the girl more, e.g., group counseling for unwed fathers, or mothers of unwed girls. Sometimes in discussing cases, the consultant can serve as a resource person concerning psychological understanding, crisis concepts, or information on referral procedures for additional psychiatric services in the community. An opportunity to transmit crisis concepts to caregivers arises frequently. For example, Barbara's baby had convulsions and paralysis after delivery and was expected to die. The mother had not been informed. Should the girl be told, and encouraged to see her baby? The consultant referred to the research on premature birth (Caplan, Mason, & Kaplan, 2965) and its principles of anticipatory griefwork in case the child dies, and the necessity for providing some bond between mother and child in case the child lives. The consultant and consultee also explored Barbara's possible interpretations of why it happened--that she was "bad," had become obese, and refused to diet. Sometimes the consultant briefly pointed out general mental health concepts, such as the protective function of certain defense mechanisms. For example, a Southern white girl had been depressed throughout her pregnancy, had given up her baby for adoption, and was returning home immediately afterward. The staff was afraid that she might "collapse" upon facing the hostile clan back home. However, recalling the girl's ability to angrily strike out at the staff, the consultant suggested that she had hostility as a good protection. In fact, she might handle a good fight at home better than a depression. Administrative Consultation Program and policy decisions may require discussion occasionally, such as deciding whether girls should stay in the program for the weeks following delivery. The consultant can bring out relevant information bearing on such a decision. According to the crisis framework, the postdelivery period presents particular difficulties. Also, clinical practice would indicate that separation from a counselor and one's usual peer group would intensify the crisis. Therefore, if a program can afford it, a decision might be made for girls to remain in the program for at least six weeks after delivery. However, a consultant might also point out the problems involved in mixing a group and the exceptions that might be made. A recurrent difficulty among gifts can reveal a need for possible program changes. For example, absenteeism was high at first in the project. An "epidemiological" approach showed that absenteeism occurred largely on a girl's
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first day in the program and when there had been no prior home visit to enlist the mother's cooperation. In such cases, plans can concentrate upon reducing absenteeism among this "high-risk" subgroup by such measures as routine home visits before the first clay, telephone calls, and other girls bringing new ones to a center. Group consultation can afford an opportunity to open up communication, and foster coordination of goals and mutual support among caregivers. The consultant can also encourage other formal or informal intrastaff communication, such as working out arrangements for home teachers to attend staff meetings, or to meet with the staff for lunch. In group consultation, interagency and role conflicts can be worked through to form better working relationships. For example, in one case a probation officer was taking the mother's part and the project staff was taking the girl's--both victims of their clients' manipulations and the relative narrowness of their sources of information. Also, they were reflecting the legitimate concerns of their respective agencies. The conflict of interests was partly resolved by the director inviting the probation officer to the regular group consultation where views were openly expressed, information exchanged, and plans worked out. CONSULTATION TO RESEARCHERS Secondary prevention research might reveal what stages of the crisis are more acute, how the subcrises affect girls, and what anticipatory guidance and outside support is needed. Also, what is the most effective use of resources? Which girls are most vulnerable? Does any identifiable group, such as minority girls, particularly need resources? For example, a consultant might help a particular professional group--a prenatal care staff, public health nurses, maternity home staff, or home teachers--develop research on which girls need help most, which girls do not come to agencies' attention, what kinds of help they need, and what might effect resolution of their crisis. Questions raised from a research perspective can also be helpful to agencies, without necessarily involving carefully controlled observations or extensive collection of data. Such inquiries can lead an agency to evaluate its program. A school system is in a critical case-finding position, especially in regard to unwed motherhood where various agencies may not already discharge their respective responsibilities for case finding. By merely comparing school suspensions and public health nursing reports, they can easily determine the percent of unwed girls who do not obtain prenatal care. The school can also find what percent of girls become pregnant one or more times, and what percent return to school after pregnancy, in order to adapt their school program accordingly. A health department, in shaping its program, might be interested in the number of unwed girls whose children are delivered at local hospitals, the rate of infant mortality and premature births for teen-age mothers, and where the girls obtain pre- and postnatal care.
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EDUCATION Educational efforts can be directed toward caregivers. For instance, the curricula of medical students might include more about the emotional reactions to the crisis of pregnancy (Bibring, et al., "f96i). More direct education for girls can consist of family-life education courses as part of the school curriculum. Films on pregnancy, prenatal care, childbirth, and postnatal care can provide information effectively and give an opportunity for anticipatory working through. For example, a film on the normal course of pregnancy can provide facts, then lead afterward to discussions of the stressful aspects to be encountered--physical changes, emotional reactions, supportive needs, and delivery. CONCLUDING COMMENT This paper has addressed itself only to secondary prev e n t i o n - h e l p i n g girls through the crisis of illegitimate pregnancy and the birth of a baby. However, the point of greatest leverage is primary prevention-preventing illegitimate births from occurring in the first place. Consultative efforts can be directed toward sex education, birth control, and other targets (Signell, 2969, b). Tertiary prevention might be mentioned briefly here as services to the mother and her growing child--postnatal care, rehabilitation, prevention of recidivism, counseling, and protection of illegitimate children's rights. REFERENCES Adams, Hannah H. Two studies of unmarried mothers in New York City. Children, x96z, 8, z84-188: Bibring, Grete L.; Dwyer, T. F.; Huntington, Dorothy S.; and Valenstein, A. F, A study of the psychologicalprocesses in pregnancy and of earliest mother-child relationship, I. Some propositions and comments. Psychoanalytic Study of the Child, 2961, XVI, 9-25Caplan, G. Principlesof preventive psychiatry. New York: BasicBooks, 2964. Caplan, G.; Mason, E. A.; and Kaplan, D. M. Four studies of crisis in parents of prematures. Community Mental Health Journal, I965, I, 2, I49-I6I. Garland, Patricia. Illegitimacy--a special minority-group problem in urban areas: new social welfare perspectives. Child Welfare, I966, XLV, 81-88. Kalis, Betty L.; Harris, M. R.; Prestwood, A. R.; and Freeman, Edith H. Precipitating stress as a focus in psychotherapy.Arch. Gen. Psychiat., I96I, 2;, 219-226. Signell, Karen A. Mental health consultation in the field of illegitimacy Social Work, ~969, ~4, 67-74. (a) Signell, Karefi A. Prevention of teenage illegitimate pregnancy: a consultation approach to sex education. The Family Coordinator, i969, I8, 3: (b)
