EMOTIONAL SUPPORT FOR ADOLESCENTS WHO OPTED FOR TERMINATION OF PREGNANCY

The “Choice on Termination of Pregnancy Act” (CTOP) (No. 92 of 1996), is viewed by most women as a means by which their wishes and expectations will be realised for the first time (Orr, 1995:140). Women now have the opportunity to terminate a pregnancy under supervision, and are able to express and share their feelings, without pretending to be emotionally strong. In a research study, Mpshe (2000:30-50) found that women got counseled on a cognitive level only and therefore guidelines were derived from this research to support women, including adolescents, on a more emotional level (Mpshe, Gmeiner & van Wyk, 2002). From the qualitative, explorative, descriptive and contextual research study conducted to identify the experiences of adolescents who chose to terminate a pregnancy, data was collected and themes and sub-themes were identified. The data from the interviews, as well as the literature, formed the basis for deriving guidelines to support these adolescents on an emotional level. The focus of this article is on the description of guidelines for support for these adolescents in order to promote their mental health. Guidelines include a framework for supportive counselling consisting of a pre-termination phase, an intra-termination phase, and a post-termination phase. These guidelines are discussed in depth in this article.


INTRODUCTION AND BACKGROUND
The Choice on Termination of Pregnancy Act (No. 92 of 1996) provides that a woman from the age of 12 years old can choose to terminate a pregnancy without the consent of parents, guardians or friends.This Act also provides for counselling of women before and after the procedure (Choice on Termination of Pregnancy Act, No. 92 of 1996:6).
The impact of the above is that young adolescents choose to terminate their pregnancies without any family involvement, and studies indicate that there is an increase in the utilisation of the termination of pregnancy services by women under the age of 20 years.
In one research study it was found that 16% of women utilising the service was under 18 years of age (Reproductive Rights Alliance, 1998:1).

Figures/statistics from research done in South Africa
regarding the utilisation of services for the termination of pregnancy by adolescents who did not involve their parents or any other decision-makers is not yet known, but in the United States of America, issues relating to maturity of an adolescent to make a good judgement on the pregnancy, was promulgated for a certain age group of adolescents (± 18) (Griffin-Carlson & Schwanenflugel, 1998:543).
In South Africa, studies indicate that 50% of women who chose to terminate their pregnancies were teenagers and were still studying (Maforah, Wood & Jewkes, 1997:80).Although specific figures are not known, it seems as though these adolescents did not involve their parents or caregivers in their decisions, for fear of being rejected, abused, or of being a disappointment to their parents/caregivers.This is a cause of concern as studies also indicate that despite the positive emotions of relief experienced due to termination of pregnancy, women suffer negative emotional experiences such as shame, guilt, depression, regret, anxiety, doubt and extreme anger (Howard, 1985:29;Adler, 1979:11;Suffla, 1997:219).
The Choice of Termination of Pregnancy Act (No. 92 of 1996:4) stipulates that non-mandatory and non-directive counselling should be given to women who choose to terminate a pregnancy, as they experience many negative emotions and are unable to deal with this on their own.In a study conducted by Gmeiner, Van Wyk, Poggenpoel & Myburgh (1999:28-29) it was found that counselling did not address the emotional and psychological needs of women who opted for TOP.Nurses tend to focus on cognitive and external issues like the physical procedure of termination of pregnancy, providing information and giving advice on these issues.This enables them to avoid the unpleasant reality, as a safeguard against their own pain and unpleasant feelings (Gmeiner, Van Wyk, Poggenpoel & Myburgh, 1999:30).Therefore, the feelings and emotions of the women who had a termination of pregnancy are ignored and their needs are not met.
Since the promulgation of the Choice of Termination of Pregnancy Act (No. 92 of 1996) in South Africa, most research studies to date focuses on the financial and labour issues related to the services for termination of pregnancy, and less on the intra-psychic effects of termination of pregnancy on women (De Pinho, 1998:1-13;Maluleke, 1997:15;Tancred, 1997:35).
No previous research has been done in South Africa to hear the voices of adolescents and to describe their needs with regard to support.

PROBLEM STATEMENT
Research done by Mpshe (2000:1-70) indicated that adolescents who terminated their pregnancies experienced emotional turmoil related to the process of decision-making to terminate their pregnancies, as they feared the reaction of their family if they were to disclose to their family that they were sexually active and pregnant as a result thereof.They therefore had to keep the decision to terminate their pregnancy to themselves.
The adolescents experienced physical distress related to the procedure of termination of pregnancy, as none of the women in this study were given any form of anaesthesia.They experienced a vast amount of pain due to the evacuation of the uterus.In addition, these adolescents utilised psychological defense mechanisms of denial, rationalisation and intellectualisation as a way of coping with the emotional pain of having to terminate their pregnancies.Finally, the adolescents experienced a sense of emotional growth and maturation through the painful process of termination of pregnancy.
This was a clear indication that these adolescents who opted for termination of pregnancy need support to provide them with the opportunity to ventilate their thoughts, feelings and behaviour, in order to put the termination of pregnancy into perspective as a starting process for constructive change and facilitation of their mental health.It could help them in taking personal accountability for their destinations in life (Mpshe, 2000:49).
In lieu of the above, the following research question was posed: What guidelines can be described for the advanced psychiatric nurse practitioner to support adolescents who chose to terminate their pregnancies?

OBJECTIVE
The objective of this article is to describe guidelines for the advanced psychiatric nurse practitioner to support adolescents who choose to terminate their pregnancies, and to assist them in mobilising their resources to facilitate the promotion of their mental health.A literature control was also completed to recontextualise guidelines, as well as verify it.

Adolescents
In this study adolescents were female persons of different ethnic background, between ages 11-20 years and who understood and spoke Tswana or English, because these are the languages the researcher speaks and understands (Kaplan & Sadock, 1998:42;Mpshe, 2000:9).

Termination of Pregnancy
According to the Choice on Termination of Pregnancy Act (No. 92 of 1996), termination of pregnancy means the separation and expulsion, by medical or surgical means, of the contents of the uterus of a pregnant woman.In this study termination of pregnancy means interruption or expulsion of the uterine contents for a pregnancy of 12-17 weeks gestation, as this is the time period when termination of pregnancy is performed at the private clinic where this study was conducted.

Advanced Psychiatric Nurse Practitioner
A professional nurse, registered with the South African Nursing Council as an Advanced Psychiatric Nurse.This person has either a master's degree or an advanced diploma in Psychiatric Nursing.

SAMPLING
A purposive sampling of nine participants, who met the sampling criteria, was utilised.Sampling criteria included: • All participants were between the ages of 11-20 years of age.
• They were of any ethnic background in South Africa.
• They all could speak Tswana or English.
• Adolescents all gave permission to participate in this research project.
• Adolescents who had their termination of pregnancy during 1999/2000, as the researcher was conducting the interviews during that time.
The participants displayed the following characteristics.
• They all lived within the Gauteng Province and had terminated their pregnancies at a specific clinic in the Gauteng Province.
• All the participants were single and between the ages 11-20 years.
• Two participants (14 years and 19 years) were pregnant once before.
• All participants were still attending school.
• Seven participants' pregnancy exceeded 12 weeks and two had pregnancies less than 12 weeks.
• All participants had their pregnancies surgically terminated by vacuum aspiration.
• Eight participants were from middle-class families, as one or both parents were professionals, and only one participant was from a low socio-economic class family, with the mother being the breadwinner and working as a domestic worker.

DATA GATHERING
Data was gathered by means of in-depth, semi-structured phenomenological interviews (Kvale, 1983:81-107) and field notes (De Vos, 1998:285).Interviews were done until saturation of data occurred with repetition of themes, and not by the amount of interviews done (Kvale, 1983:106).Data gathered for the purpose of this article included results from the phenomenological interviews and a literature control.

DATA ANALYSIS
Data were analysed by means of the descriptive method of open coding of Tesch (in Creswell, 1994:154-156).
A literature control was done to verify and recontextualise the guidelines within the context of psychiatric nursing.For the purpose of this article the focus is on the derivation of supportive guidelines.

DESCRIPTION OF GUIDELINES AND LIT-ERATURE CONTROL
From the results of the in-depth, semi-structured phenomenological interviews (Mphse, Gmeiner & Van Wyk, 2002:68-81) it became clear that adolescents who chose to terminate their pregnancies, needed to ventilate and express their feelings.They expressed a need for counselling to address their psychological and emotional needs, and not only advice and cognitive information (Mphse, Gmeiner & van Wyk, 2002).The counselling process should be available pre-termination, intra-termination, and post-termination for all adolescents.
The guidelines described for the advanced psychiatric nurse is in a therapeutic, supportive counselling format and is short-term oriented.
Figure 1 provides a conceptual framework within which the guidelines will be discussed.

Goal: Promotion of mental health of the black adolescents who choose to terminate a pregnancy
The framework of the guidelines for therapeutic, supportive counselling will be discussed under the following headings adapted from the phases of the therapeutic nurse-patient relationship (Perko & Kreigh, 1988:275;Shives, 1998:108).

The structure of therapeutic supportive counselling
Therapeutic, supportive counselling will now be discussed under the following headings: • Pre-termination phase; • Intra-termination phase; and • Post-termination phase.

Pre-termination phase (before actual termination of pregnancy is conducted)
It is important to note that the adolescent can enter the supportive, therapeutic counselling at any phase of the termination of her pregnancy.
The objective of this phase is for the advanced psychiatric nurse practitioner to build a strong, trusting therapeutic relationship with the adolescents.
The advanced psychiatric nurse practitioner, as a knowledgeable person, needs to know that during this phase, adolescents seek assistance because they need stepping stones to help them overcome stumbling blocks that are interfering with their decision to terminate a pregnancy.
Although the adolescents are looking for help, they are usually full of mistrust and have lowered self-esteem (Okun, 1992:113;Brammer, Shostrom & Abrego, 1989:92).Shives (1998:108) also states that the adolescent, though in need of help, might view the advanced psychiatric nurse practitioner as a stranger.For this reason she finds it difficult to trust and talk to the counselor.
The adolescents can become filled with fear and anger because they are not being supported during this phase.The advanced psychiatric nurse practitioner can either "make or break" the adolescent during this phase.
She needs to build trust by being non-judgmental and by offering the adolescents a therapeutic environment to tell their stories.
The advanced psychiatric nurse practitioner should take a neutral stance and not make negative remarks.Herbert (1987:108) observed that some of these adolescents may have previously supported the rights of an unborn child and now changed their minds because their lives were in danger.Beck, Rawlins and Williams (1994:18) suggest that The advanced psychiatric nurse practitioner should empathise by unconditionally accepting these adolescents, as they struggle to take an independent decision to have their pregnancies terminated.
Anger for not being supported by family also needs to be dealt with by the advanced psychiatric nurse practitioner, although there is nothing much that she can do to involve adolescents' families until these adolescents feel ready to do so.Empathising is also suffi-  Wells (1995Wells ( :1051) ) supports this pre-termination phase counselling, because it was noted that primary depres-sion occurs before abortion with substantial reduction during the few hours after the procedure.

Intra-termination phase (during the actual evacuation of the contents of the uterus and two weeks thereafter)
The objective of this phase is to relieve emotional and physical distress.During this phase, adolescents are seen by the advanced psychiatric nurse practitioner after they have decided that they want to terminate their pregnancy.
Since the adolescents experienced evacuation of the contents of the uterus during this phase, relaxation exercises might not be effective to contain all the physical distress.
Adolescents will use psychological defense mechanisms in a maladaptive way in an attempt to numb their feelings and to experience emotional equilibrium.
The advanced psychiatric nurse practitioner needs not question or challenge the use of psychological defense mechanisms.They might soften the integrity of the self by an increased feeling of personal worth (Herbert, 1987:18-19).Beck, Rawlins and Williams (1994:37) suggest that the adolescents be assisted to cope by focussing on their spirituality and instill hopefulness.The advanced psychiatric nurse practitioner's task is to work in the "here and now" and reflect on the feelings the adolescents are experiencing and to encourage them to verbalise them.
The here and now will allow the advanced psychiatric nurse practitioner to explore some of the themes that emanated from the experiences of adolescents.Working in the here and now is also supported by Yalom (1995:45-48).He emphasises the importance of focussing on the two symbiotic tiers.In the first tier, which is the experiencing one, the adolescents live in the here and now and this calls for the advanced psychiatric nurse practitioner to concentrate on the immediate events taking place, over the events in their current outside life, and this will facilitate catharsis and meaningful self-disclosure.The second tier, which is the elimination process, takes place when the advanced psychiatric nurse practitioner and the adolescents exam-ine the here and now behavioural experiences that occurred in the therapeutic counselling session.
The adolescent experiences emotional turmoil, in the form of guilt feelings, during this phase, after the uterus has been emptied of its contents.The advanced psychiatric nurse practitioner needs to instill feelings of hopefulness by assisting them to develop feelings of self-value (Beck, et al. 1992:37).
The advanced psychiatric nurse practitioner can engage the adolescent in self-talk or self-instruction which will help them to separate themselves from the effects the termination of pregnancy is having on their lives (Figley, 1989:114-115).The task of the advanced psychiatric nurse practitioner can be to suggest that the adolescents verbally and loudly express their negative feelings when they experience them (Corsini & Wedding, 1995:10).This method will help to relieve adolescents from internalising the negative emotions that are related to having to terminate a pregnancy.
The advanced psychiatric nurse practitioner can also assist the adolescents in disengaging negative thoughts that are likely to cloud their thinking.She/he can encourage them to engage in positive thinking.
This will help to improve their self-concept.Brammer et al. (1989:181) suggests the use of statements like "You feel angry with yourself" and "You think it is awful to feel that way."This will help the adolescents to interpret their negative perceptions about themselves positively.
Relaxation methods can be taught to the adolescents by the advanced psychiatric nurse practitioner.Adolescents can be asked to imagine a pleasurable situation or events in order to relieve physiological and emotional distress (Brammer, et al. 1989:190).
Distraction is another method similar to imagination and it entails providing interference with dysfunctional thought.The adolescents are taught to focus on external or internal distracters to effectively deal with dysfunctional thoughts (Figley, 1989:115).
The focus of the advanced psychiatric nurse practitioner's interventions is based on the here and now, and this will help to increase the adolescents' selfawareness and understanding.Questions that can be asked are "What in your life are you most concerned with now?" Yalom (1995:27) states that the here and now have a self-reflective loop that assists in turning the emotional experience into a therapeutic experience.

Post-termination phase (starting two weeks after the termination of pregnancy took place)
The object of this phase of therapeutic counselling is to assist the adolescent to experience positive reframing of her mind after having gone through a barrage of emotional turmoil.
During this phase, adolescents may come for therapeutic counselling for the first time, but for those others who attended counselling since the pre-termination phase, it will be the end of a long journey.
During this phase, some adolescents may still be experiencing residual distress related to the emotional turmoil they experienced during the pre-termination phase.Some adolescents will attend therapeutic, supportive counselling with the advanced psychiatric nurse practitioner to share their experience of emotional growth from the termination of their pregnancy.
The advanced psychiatric nurse practitioner needs to appreciate and affirm these adolescents and encourage them to take active responsibility towards their sexual practices and refrain from relying on their boyfriends.
The advanced psychiatric nurse practitioner should engage those adolescents who are still experiencing guilt feelings in debriefing sessions because there is a danger that these may lead to unresolved grief and dysfunctional mourn, which can result in more serious mental disorders.The debriefing is conducted to empower the adolescents and to provide them with some form of control that is often lost due to the experience of terminating a pregnancy.
Figley (1989:282) supports a three-day counselling session that can be conducted as follows: Session one: The adolescents are encouraged to share their experience of terminating a pregnancy.During this session, the advanced psychiatric nurse practitioner supports the adolescent so that no selfharm takes place as the adolescent is ventilating feelings and difficult matters are made explicit (Figley, 1989:282).The advanced psychiatric nurse practitioner makes the adolescents aware that the thoughts related to termination of pregnancy will reappear and that it is normal and not an indication of being emotionally unbalanced.
There are coping skills that the adolescents can be taught by the advanced psychiatric nurse practitioner for relaxation to reduce the recurrence of these thoughts.
In order for them to participate, the advanced psychiatric nurse practitioner should also inform the adolescents that recovery also takes place outside of the counselling session.Home assignments should be given to adolescents to complete for the next session.
All healthy adaptive behaviour by the adolescents is reinforced during the last session of debriefing.Figley (1989:285) also supports the idea that the advanced psychiatric nurse practitioner should convey caring, by encouraging the adolescents to keep in touch, should they so wish, after the debriefing sessions are over.
Relief is the common feeling experienced by the majority of adolescents and this feeling needs to be appraised positively to encourage positive reframing.The adolescents, who experienced a sense of maturational growth from terminating a pregnancy, are supported and assisted to implement measures, which will decrease the recurrence of unwanted pregnancies.Advise on available birth control methods should be given to them.The adolescents should be supported to be autonomous and to manage reproductive issues without relying on their boyfriends.
The adolescents, who did not adjust positively during the post-termination counselling phase, can be referred for further management, but this referral should be done in their interest (Gillis, 1994:90).
If more sessions with the adolescents are needed during post-termination supportive counselling, this should be scheduled to meet the need of these adolescents.Howie, Henshaw, Naji, Russel and Templeton (1997:829) observed that women who terminated a pregnancy are reluctant to participate in long-term posttermination counselling because they want to forget an upsetting period in their lives.Butler (1996:399) observes that women who are able to fully explore their decisions prior to terminating their pregnancies, experience better psychological adjustment after the termination of a pregnancy, and this could reduce the number of adolescents turning up for post-termination counselling.
Post-termination counselling with adolescents should not be abruptly terminated because it can result in them experiencing feelings of discomfort, ambivalence, fear, anxiety, pain and anger (Perko & Kreigh, 1988:270).
Successful termination of the post-abortion counselling will require from the advanced psychiatric nurse practitioner the ability to assist the adolescent to resolve any negative feelings when dealing with the posttermination phase of therapeutic, supportive counselling (Perko & Kreigh, 1988:279).

RECOMMENDATIONS
Women, and in this case adolescents, who chose to terminate a pregnancy need more than being told about the procedure for termination of pregnancy and all the accessories that is going to be used.They need professional help and support to deal with their emotional experiences and the impact these have on their lives.
The advanced psychiatric nurse practitioner could be involved as a consultant to those health care professionals (abortion clinic nurses), who are engaged with the termination of pregnancy, in order to apply the supportive counselling guidelines proposed in this study.
The advanced psychiatric nurse can also become part of the health care team within the clinics, but this is not always economically viable.She/he can rather act as a consultant to various clinics, and facilitate the process of counselling.

CONCLUSIONS
Very little is known about the experience of, and support for adolescents in South Africa who chose to terminate their pregnancies.It is clear that the advanced psychiatric nurse practitioner, other health care professionals and the community need to work together to support women who choose to terminate a pregnancy in order to ensure a mentally healthy society.
This study was part of an NRF-funded, national project on Termination of Pregnancy, under project management of Prof. Marie Poggenpoel and Prof. Chris Myburgh

Figure 1 :
Figure 1: Conceptual framework for proposed guidelines Figley (1989:111-112)  suggest that the counselling should be related to what really concerns the adolescent.The advanced psychiatric nurse practitioner works within the frame of reference of the adolescents.The adolescents are sometimes avoidant and would not like to take responsibility for their own decision-making; therefore the therapist should be particularly sensitive towards this issue.
cient to convey caring to unsupported adolescents in order to support them to develop their own self-iden-NAVORSING tity.The advanced psychiatric nurse practitioner can empathise by allowing adolescents to share their stories whilst she concentrates on their cognitive and emotional experiences in order to increase trust and self-disclosure.She must demonstrate sensitivity to the adolescents' physical and verbal cues and suspends any judgement or criticism.The advanced psychiatric nurse practitioner can achieve this by experiencing the situation from the adolescents' viewpoint, make use of touch, and express such utterances, as "It really seems very difficult for you now."For adolescents to develop self-identity,Irvine   (1994:40)  suggests that making disconnection between the self and relationships and between inner world of thoughts and feelings should help them.Adolescents must be assisted to know who they are and what they want.This will enable them to develop a strong self-concept and self-identity.Value conflicts also form part of the emotional turmoil that contributes to the stumbling blocks experienced by adolescents.The advanced psychiatric nurse practitioner's task is to clarify values with these adolescents and not to pontificate or moralise them.The advanced psychiatric nurse practitioner should clarify with the adolescents what their values around the issue of termination of pregnancy are.The advanced psychiatric nurse practitioner should allow adolescents to clarify and verbalise their value systems to enable them to decide whether to terminate their pregnancies or not.The advanced psychiatric nurse practitioner can use clarifying responses in order to identify what the adolescent's value system is.According to Cozzarelli, Sumer and Major (1998:456) such clarifying responses can be: "For whom are you doing this abortion?"or "Do you believe you can go through this abortion alone?"or "What do you think you have learned from this?" The adolescent who experiences more self-worth will gain internal energy and feel more competent to believe in her decision to have the pregnancy terminated.

Session two :
During this session, the adolescents are encouraged to reflect on the previous debriefing session and any dreams that they had are explored.The advanced psychiatric nurse practitioner assists the adolescents in dealing with distorted ideas and with leftover distress following the termination of pregnancy.The advanced psychiatric nurse practitioner needs to share with the adolescents how their lives changed during the termination of their pregnancies and help them to move away from viewing themselves as victims.The adolescents are also assisted to get in touch with their humanness and vulnerability during this second session.Session three: During this session the adolescents are helped to integrate their decision to terminate a pregnancy as part of themselves.The advanced psychiatric nurse practitioner should continue to support and help the adolescents modify dysfunctional thoughts and feelings.