Abortion in the family: a systemic perspective
 „Abortion – causes, ramifications, therapy” International Conference organized by the Polish Academy of Science and the Warsaw Institute of Psychiatry and Neurology, 20-22 June 2004

Ágnes Kónya, MD
Zoltán Kónya, MD

AGAPE Psychotherapy Centre, Cluj, Romania


I would like to say a few words about the source of the ideas that inform this paper.

In December 1989 the Ceauşescu regime collapsed in Romania. The legalization of abortion was one of the most immediate and visible changes following this event. The number of induced abortions increased dramatically and became three times higher than the number of births. It was in this context, that in 1997 a group of physicians and psychologists initiated a psychotherapy center in Cluj. The center, among other therapeutic services, offers group therapy for people whose difficulties seem to be connected with childhood trauma and pregnancy loss. The programme is delivered to groups of 4 to 7 people. The therapeutic process unfolds in 25 to 30 sessions.[i]

In working with therapeutic groups we borrow and use ideas and skills from systemic family therapy, particularly ideas connected with the work of Gregory Bateson, the Milan school of family therapy and social constructionism.

In what follows I would like to focus on two aspects of this work. First, from a systemic perspective I am going to look at the effects of abortion on the family. In doing this I will concentrate on the patterns of interaction that may develop between parents who had an abortion and their children who in this case can be seen as survivors. Secondly, I am going to present our experience of using systemic thinking in group therapy. Here I will focus on how using a systemic mindset enhanced the usefulness of the “abortion survivor” concept.

Surviving abortion

In what ways can abortion be present in the family system?

∙ abortion can be an actual event in the life of the family. In this situation some children for some reason live while one or more of their siblings are aborted.

How do the survivors know about the abortion? Sometimes parents explicitly tell them about it. In other cases a child simply observes mother being pregnant, leaving for the hospital and coming back without a baby. Children may also accidentally overhear a discussion between adults about the abortion or read letters in which the abortion is mentioned. It can be hypothesized that even if children don’t actually know about the abortion, the abortion can still have an impact on them indirectly, through the changes in the parents’ behavior following the abortion.

Mirela, member in one of our groups, recalled her memory of directly observing her mother undergoing abortion. She was 6 years old. At that time abortion was illegal, so the parents secretly invited a nurse who performed the intervention on their dining-room table. This is an extreme example of direct presence of the abortion experience in the life of a young person.

∙ in other situations the parents never actually have an abortion but abortion is a theme of conversation in the family. For example, parents consider abortion but cannot make up their mind until it’s too late for the intervention to be performed or want to have an abortion but for various reasons it cannot be done. Sometimes the theme of abortion is used in bitter arguments between parents and their disappointing adolescent, e.g. “It would have been better for the whole family if I had aborted you...”

∙ it has also been suggested that an unresolved loss in one generation can affect the development of later generations in the family. Abortion in the family of origin of one or both parents can thus have an impact on the development of their own family. The distress associated with abortion in the previous generation can be seen as a grave heritage that will affect the development of subsequent generations.[ii]

Cristina sought therapy for low self-esteem and difficulty in making relationships. It turned out that there were several abortions in her grandparents’ generation on both sides. Her parents had difficulty communicating both with each other and with their children. Cristina remembered painful memories from her early childhood when she was crying; her parents entered the room but failed to comfort her and left her again on her own. It was in this world of silence and neglect that she eventually became the victim of sexual abuse as well. As an adult, she saw a connection between the grandparents’ abortions and the difficulties in later generations. She mourned the loss of the family life she could have experienced had the grandparents decided to welcome all their children.

∙ lastly, abortion can affect families when it represents a widespread practice in the larger social system the family is part of. For example, in some Eastern European countries like Romania or the Ukraine, the womb of the mother is a dangerous place and being conceived in such a geographical area implies a statistically high risk of being aborted.

Let me now trace the history of the abortion-survivor concept. Some of the important milestones are the following:

∙ survival refers to a situation where some people stay alive when the risk of being killed is high and others die. A connection between survival and later emotional difficulties was first described in survivors of the Holocaust. Many people who survived the concentration camps later experienced various emotional problems like survivor guilt and depression or showed suicidal behaviour.

The story of Liviu illustrates the diversity of the ways in which one can become a survivor. While presenting his family tree in the group, it turned out that there were no abortions in his extended family but three of his male relatives, all wearing the same name (Liviu) died in a violent way: one in a fire, another in a train accident while the third was shot in the army. In all of these instances the unexpected death of the respective person seemed to be dictated by fate over which none of the victims could exercise any control. As the last Liviu in the family, he had a sense that the same tragic fate is awaiting him and consequently decided not to develop his talents or invest in his future. Similar difficulties are reported by those who survive an abortion.

∙ the next important idea relevant to our topic was that in families where one of the children dies because of an accident or a severe illness, his or her siblings can be seen as survivors and from this situation certain characteristic family dynamics may follow. Krell and Rabkin in their article about “The effects of sibling death on the surviving child” (1979) described three such patterns.

a. In the “conspiracy of silence” scenario both the parents and the surviving children experience guilt and shame connected with the death of one of the children. They all attempt to cope with these uncomfortable feelings by avoiding to openly talk about these feelings and the events surrounding the loss. Parents and children collude in maintaining a pseudo-secret. Each family member fears that open exploration of the tragic events would expose him or her as the one to be blamed for the loss. Silence provides an equal, more bearable distribution of blame and acts as a blanket of protection for the family. Children may also fear that if they mention the unspeakable the family will fall apart. The survivors then learn to collude in maintaining the pseudo-secret in order to maintain the stability of the family. The pattern of evasive communication in the area of the death of the child will generalize into other areas as well. Children learn not to be curious and not to ask questions, which will impede the development of their intelligence. Being careful not to say certain things will also interfere with their spontaneity – for example, they may have difficulty expressing positive feelings, like enthusiasm or joy.

b. In the “the preciousness of the survivor” model the surviving child is accorded a special status. The experience of the death of one of their children makes the parents look at the world through the lens of possible dangers and hostility, some of which are real and some are imagined. The parents try to control the destructive forces that destroyed one of their children, wanting to make sure that the tragedy will not happen again. The survivor is overprotected against projected hostilities and constantly warned about the possible dangers. The child is immobilized by parental control and as a result she cannot freely explore the environment. She is thus deprived of important opportunities for learning.

c. The “substitution for the lost child” pattern can develop between parents and a child born after the loss of one of her siblings. In this situation she may have been conceived in order to replace the child who died. Metaphorically speaking, the replacement child has to live two lives, one of her own and one for the one who died. The dead child is in this way kept alive so that the parent don’t have to fully face the loss. The parents may project unto the survivor their idealized image of the lost child and the survivor has to carry the heavy burden of her parents’ unrealistic expectations toward her.

∙ the Canadian psychiatrist Ney (1983) suggested that the emotional difficulties originally described in holocaust survivors can also develop in individuals who survive an abortion and that the patterns of family interaction described by Krell and Rabkin may also apply to families where the loss of one or more children is through abortion. In addition to the personal and interpersonal conflicts that generally characterize survivors and their families, like survivor guilt and difficulty in communicating, Ney described certain psychological conflicts peculiar to abortion survivors.

  1. on the level of the individual, the essential psychological conflict characterizing abortion survivors has to do with being wanted. The survivor is alive because his parents wanted him to live, while these same parents decided to abort one or more of his siblings. Consequently, his existence depends upon whether or not his parents want him. Staying wanted then becomes an issue of life and death: in order to live, the survivor needs to remain wanted by the parents. He needs to be perfect, to perform and to please the parents. The surviving child grows into an adult who always tries to please others and seeks recognition from them. His value as a person depends on how much others want or appreciate him: he develops a sense of relative, extrinsic, value – as opposed to the healthy sense of intrinsic and absolute worth, experienced by those lucky children in whose family abortion was never considered.

Radu’s story illustrates the complexity of real life situations with regard to being rejected or welcome. While his mother was pregnant with him, his parents decided to abort him. His father administered his mother an injection meant to terminate the pregnancy. However, the attempt was unsuccessful and Radu survived. As the pregnancy progressed, the parents gradually came to accept his arrival. He now considers himself a welcomed child.

b. another interesting suggestion is that the aborted child, whose death and loss has never been consciously acknowledged by the family, may keep being present in family members’ life. This presence may take the form of an imaginary playmate of the survivor. As an adult, the survivor can look for the lost sibling in others. They may also decide to live a life not only for themselves but also for a lost sibling. The survivor may hear the voice or even see the dead sibling in the form of hallucinations.

∙ from the early nineties therapists in various countries began to use the above ideas in their work with groups for adults affected by various types of trauma and loss. Many people in our therapy and training groups found these ideas relevant to their experience. The personal stories we hear continuously reshape and enrich our professional story.

With regard to any theoretical idea, the main concern of psychotherapists is whether they are useful in practice. The “abortion survivor” idea seems to be therapeutically helpful on different levels:

∙ first, it helps people to make sense of their experience – to generate an explanation for what happened to them when they were children and why they feel, think and behave the way they do in the present.

∙ secondly, it points to issues that need to be addressed in therapy if the survivor is to regain freedom from the hold of personal and interpersonal conflicts. In our group program the tasks most directly connected with these conflicts are the following:

a. group members gain a substitute experience of being truly welcomed in this world and valued for who they are. This helps the person to deal with survivor guilt and to develop a sense of intrinsic worth as a unique human being.

b. second, the group process initiates and facilitates the mourning of the loss of a sibling through abortion.

c. lastly, reconciliation is encouraged, with the people who contributed to the loss of a sibling, particularly reconciliation with one’s own parents.

In what ways can a systemic perspective enhance the usefulness of the abortion survivor idea?[iii]

One of the often-asked questions is this: do abortion survivors really exist? Or are they a purely theoretical construction, which is coherent in itself but doesn’t have a lot to do with what actually happens in a family or what people really experience?

The questions “what is reality” and “how do we know reality” represent central preoccupations in the field of systemic family therapy. There has recently been a shift from seeing reality as something “out there” that can objectively be known by an outside observer to a reality that is something constructed by the mind of the observer.[iv] Social constructionism emphasizes the importance of language and the conversations between humans in creating social realities. In line with these ideas, we privilege the unique, subjective, personal realities that people share in the group in the form of stories.

The question of what reality is also preoccupies our patients while they attempt to reconstruct events of their past. For example, Anda was coping with mild but persistent depression. She was born as the only child in the family, 10 years after the abortion of her mother. Neither Anda, nor her mother were sure about whether or not the mother was actually pregnant at the time the curettage was performed. However, Anda felt that the abortion survivor theory offered a coherent explanation for her experience and, encouraged by the group, she was able to visualize her lost brother and could subsequently mourn the loss of this person. The question of whether or not her brother really existed is less important now in light of the fact that following this experience her depression lifted and, in her own words, transformed into a small sadness that found its proper place in her life.

Influenced by the new epistemology of family therapy, we view the abortion survivor theory as one possible explanation among many. We adopt a therapeutic stance which might be called “invitational”: clients are invited to consider ideas like the difference between being wanted and being welcomed, extrinsic and intrinsic worth, survivorhood and the conflicts possibly connected with it. They are free to pick up any of these and use them to construct a coherent explanation that fits their unique circumstances. They are equally free to discard the theory altogether in case they find it irrelevant to their experience. Indeed, many of our patients are not touched by the concept and need a different explanation.

Rodica’s main problem was her inability to resist the temptation to take money from others whenever she had the possibility to do so. The episodes of stealing were followed by feelings of intense guilt. She was strongly attached to her dog, with the dog being the central preoccupation in her life. She was the third child of her parents and the second child, the one before her, was aborted. Looked at through the lens of abortion survivors, several hypotheses could be formulated. The meaning of the deviant behavior could have been that it provided her with a sense of vicarious guilt, a guilt that she could legitimately feel instead of the survivor guilt resulting from the death of her sibling. She could not trust her parents because of the abortion and therefore preferred to develop a strong and safe attachment with a dog that would never disappoint or harm her. But the ideas about survivorhood didn’t seem to make much sense to Rodica as an explanation. However, she underwent the welcoming experience, rehumanized and mourned the loss of her sibling and wrote a reconciliation letter to her mother in which she mentioned the abortion as an event that contributed to her hurts. Eventually she was able to let go of the habit of stealing and began to develop trusting relationships with people.

Adopting a systemic mindset involves looking at the issue in question from multiple perspectives. In the case of the abortion survivor concept a different perspective is looking at ways in which this idea can be unhelpful or even dangerous. We think the concept becomes unhelpful when it is imposed on people or is offered as the only explanation for a wide range of problems. When we consider a certain theory the only possible explanation, we may fail to see or hear those aspects of a client’s story that contradict our favoured explanation. The theory can also be unhelpful if people become too attached to it and get stuck with the problem identity of the survivor on a long term. They may label both themselves and others abortion survivors and come to see the world through the lens of survivorhood conflicts. To prevent this side effect in therapy we gradually shift focus from self to others and from the past to the present and the future.

It is an ethical imperative to complement treatment with prevention. Social constructionism offers fresh ways of thinking about the prevention of abortions. The practice of abortion can be seen as part of a dominant societal discourse. Change in the practice goes hand in hand with a transformation of discourse. Dominant discourses change to the extent that hitherto marginalized voices come to be heard and given importance.

In what ways can group treatment contribute to this transformation? The group process first initiates an inner dialogue in participants, followed by the voicing in the group of a wide range of ideas about the value of children or the meaning of abortion. These new narratives, co-constructed by the therapeutic group, include voices that are generally not part of the dominant discourse, like the voice of the unborn child or that of the surviving sibling. People are likely to voice these ideas outside the group context as well, in the conversations they have with significant others in their lives and that their voice will act as micro-contributions to a transformation of the dominant discourse.

Recognizing the different voices that coexist in one person, in each of us - the pro-life voice, the pro-choice voice, the voice of the unborn and that of the survivor – represents the basis of real dialogue with others and only through dialogue between people can dominant beliefs and practices change. Of course, how each of us sees the desirable direction of such transformation is determined by one’s personal values and convictions. One of the important messages of social constructionist thinking is that one cannot not have personal values and convictions and these values always influence the way we do therapy. One cannot be truly neutral and the best thing we can do is to be aware of the prejudices that guide our actions. From the perspective of our own personal values and prejudices the desirable transformation of discourse would be a distancing from the argument between “right to life” and “freedom to choose” toward a shared discourse of “freedom to choose life”.


Jordan, J.R., Kraus, D.R., Ware, E.S. (1993). Observations on Loss and Family Development. Family Process, 32:425-40.

Gergen, K. (2001). Social construction in context. London: Sage Publications.

Krell, R., Rabkin, L. (1979). The Effects of Sibling Death on the Surviving Child: A Family Perspective. Family Process, 18:471-7.

Ney, P.G. (1983). A consideration of abortion survivors. Child Psychiatry & Human Development, 13:168-79.


[i] The name of the programme is NEST (New Experience for Survivors of Trauma). The main ideas underlying this type of group work include the following:


∙ first, the program proposes that all types of pregnancy losses, including miscarriages and induced abortions, represent significant personal losses for both parents, even though this loss may not always be consciously acknowledged. In our culture the proper grieving of these losses is impeded by several factors. The difficulties experienced by a person, like e.g. depression, may reflect uncompleted or pathological grief. In light of this assumption, the essential component of treatment is initiation and facilitation of the natural grieving process.


∙ another belief is that there is a certain connection between mistreatment suffered in childhood and abortion in the sense that persons who were mistreated are more likely to have abortion and vice versa, in families where there is an abortion present an increased risk for child abuse. Accordingly, the therapeutic programme addresses the psychological conflicts engendered by both abuse and abortion. It is believed that one can only engage in addressing the loss of a child through abortion when one has already properly dealt with early traumas, conflicts and difficulties connected with abuse and neglect.

∙ it is suggested that abortion affects not only unborn children and their parents, but also have some kind of impact on the siblings of the aborted child, who in this situation can be seen as survivors. Therapy addresses survivor guilt and provides an experience of being welcomed, to counteract the sense of rejection or relative value that the survivor experienced. The programme offers a space for grieving not only one’s own aborted children, but also siblings who died because of an abortion.

∙ lastly, reconciliation between persons who in one way or another have contributed to the abortion is considered essential. Parents who had abortion need to forgive themselves, each other, the physician who performed the abortion and anybody who may be partially responsible for the loss of their child through abortion. The suggested means for reconciliation is writing and sending reconciliation letters.

[ii] The transmission can happen through various mechanisms:

∙ patterns of interacting between family members, for example the style of communication characterizing families where there was an abortion, will be learned by children and thus can be replicated in the next generation. The child, now an adult, tends to avoid talking openly about difficult issues with his own children, as this is the model he experienced in his family of origin.

∙ looked at through the lens of individual psychological conflicts, it could be argued that the trauma of abortion in the family creates certain psychological key-conflicts in surviving children. These include basic dilemmas like “to be or not to be”, “should I trust or distrust others” and so on. When they become adults, they will tend to re-enact this key-conflict by exposing themselves to the same trauma that originally caused the conflict or contributing to its occurrence in their own family. Such reenactments can be seen as unconscious attempts on part of the individual to solve their inner conflict.

∙ lastly, it has been suggested that the successful creation of a family system in one generation depends upon the transformation of attachments and loyalties in the previous generation. If G1, G2 and G3 represent subsequent generations, successful development of the G2/G3 family requires the loosening of the bonds between G1 and G2. Unresolved losses affecting the original G1/G2 family can increase the intensity of attachments in this unit and thus interfere with the development of the new, G2/G3 family.

[iii] It should be noted that this idea is a good illustration of one of the basic characteristics of systems: change in one part of the system will involve change in the other parts, as well as in the functioning of the system as a whole. If we consider the family a system, the abortion affecting one of its members will have an impact not only on the parents, but also on surviving children and on the ways in which parents and children interact with one another.

[iv] This implies that our earlier experiences, beliefs, the expert theories we subscribe to and so on, will all intervene in the way we perceive reality. This new epistemology does not deny the existence of an objective, ontologically unified reality, but emphasizes the difficulties inherent in attempting to objectively know something.



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 Feedback. The Magazine of the Family Therapy Association of Ireland, Summer 2003, Vol. 9, No. 3, pp. 26-28

» Family therapy in Romania
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» Abortion in the family: a systemic perspective
 „Abortion – causes, ramifications, therapy” International Conference organized by the Polish Academy of Science and the Warsaw Institute of Psychiatry and Neurology, 20-22 June 2004

» Family Therapy in Romania
 Contemporary Family Therapy: An International Journal, Vol 35, No 1, March 2013, DOI 10.1007/s10591-013-9253-7

» NEST: the Use of a Structured Group Programme in Training
 Human Systems: The Journal of Therapy, Consultation and Training, 2008, Vol. 19, Issue 2, pp 129-141

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