Birth Parents in Adoption: Using Research to Inform Practice

Amanda Baden & Mary O’leary Wiley. Handbook of Adoption: Implications for Researchers, Practitioners, and Families. Editor: Rafael A Javier, Amanda L Baden, Frank A Biafora, Alina Camacho-Gingerich. Sage Publication. 2007.

For Monica, From Her Birth Mother

We’ve grown together for two years.
We’ve shared together your laughter and tears.
Since your first moments in this world
So many, many things have unfurled.
Once a child, you’re grown now,
The time has come to pass.
Know I’ll always love you.
That’s all I’ll ever ask.
You’ve had the time to live and grow.
How was I to ever, ever know
I could’t give the care that you would need.
Mine would’t be the voice that you would heed.
When I had to say good-bye to you
I did’t know how much that I’d go through
Wanting to be with you all the while.
I pray you have someone to care
And friends that always, always will be there
A family to support you all the time
Who give the love I long to give a child of mine.

(Imelda Buckley, as cited in Roles, 1989, p. 7; reprinted by permission from the Child Welfare League of America.)

Although the feelings expressed in Imelda Buckley’s poem are widely understood, birth parents are the least studied, least understood, and least served members of the adoption triad (Freundlich, 2002; Reitz & Watson, 1992; Zamostny, O’Brien, Baden, & Wiley, 2003). Birth parents are often the invisible members of the adoption triad. For some, this is by choice; for some, this is an artifact of the adoption system and its historical legal requirements of full relinquishment, secrecy, and anonymity (Winkler, Brown, van Keppel, & Blanchard, 1988). In international adoptions, birth parents are often permanently invisible and silent due to the cultural norms and structures related to relinquishing their children (Lee, 2003; Steinberg & Hall, 2000).

Between 1 and 5 million Americans are adopted (Hollinger, 1998; Stolley, 1993), leading to the inference that up to 10 million people are birth parents of adoptees reared in America. These birth parents are from numerous countries, including the United States, making this group a global population. Terminology related to this group has changed over the years and has included natural parent, biological parent, genetic parent, and real parent. However, the terms birth parent, birth mother, and birth father have become accepted nomenclature for referring to the mother and father who gave birth to a child that was placed for adoption (A. Brodzinsky, 1990).

Historically, research has been more limited on this hard-to-access population than on other members of the adoption triad (Freundlich, 2002; Zamostny et al., 2003), although the theory and clinical observations related to the experience of birth parents have a longer history (A. Brodzinsky, 1990; Winkler & van Keppel, 1984). Both the clinical and empirical research literature related to birth parents originate within a wide variety of professional/academic disciplines and in a number of Western countries, but integration of this literature has been limited in part because of the paradigmatic differences in research and practice among disciplines. This lack of integration has slowed both the development of empirical research and the clinical treatment of birth parents. The purposes of this chapter are to provide a scientist-practitioner review of the interdisciplinary clinical and empirical literature on birth parents; to incorporate this literature with actual case studies; and to make recommendations for practice and research based on this literature.

Woven into this literature are several clinical case studies that have been derived from the authors’ combined 33 years of counseling experience and one author’s extensive experience with international adoption practice. Clinical interventions and issues are drawn from the literature, the authors’ experience, and model programs for birth parents (e.g., Barker Foundation, 2004; Center for Family Connections, 2004; Spence-Chapin, 2004).

This chapter first includes a review of the clinical and research literature for three periods in the life of a birth parent: (a) the pre-relinquishment period, including both voluntary and involuntary relinquishment, (b) the early post-relinquishment period, and (c) long-term post-relinquishment, including search and reunion. Each of these sections contains a case study of a birth mother in counseling, including presenting issues, background factors, assessment concerns, treatment issues, and effective treatment strategies. Following these are reviews of the clinical and research literature on birth fathers, international birth parents, and openness in adoption for birth parents. Finally, there are sections on structuring research and practice, and practice and research implications and future directions are discussed.

Pre-Relinquishment Period

Voluntary Relinquishment

The decision about whether to voluntarily relinquish one’s child for adoption is likely the most difficult decision a prospective parent will ever have to make (Winkler et al., 1988). Typically, it is the pregnant woman who seeks professional services, but increasingly the experience is shared by the father of the unborn child. The conflicting feelings of shame, pride, desolation, excitement, fear, terror, and denial can be overwhelming and disruptive. Women and men facing the possibility of relinquishing their children for adoption consistently report not talking about their feelings because they believe their feelings are abnormal or disproportionate to their crisis.

Different theoretical models have offered varied clinical interpretations of the issues that birth mothers face. Early psychodynamic models (Deutsch, 1945) viewed the unwed mother as using her pregnancy to regressively act out unconscious unmet needs toward her own mother. Jung (1989) used early family systems theory to describe the unplanned pregnancy as a statement of ambivalent feelings and powerlessness in the family. Less psychodynamic but no less influential was the description of adoption that Silverstein and Kaplan (1988) proposed, where they depicted adoption as a lifelong, intergenerational process that unites the triad of birth families, adoptees, and adoptive families forever. They proposed seven core issues in adoption that can assist triad members and professionals working in adoption better to understand each other and the residual effects of the adoption experience. These seven issues are (a) loss, (b) rejection, (c) guilt and shame, (d) grief, (e) identity, (f) intimacy, and (g) mastery/control. Shortly thereafter, D. M. Brodzinsky’s stress and coping model (1987, 1990) described the cognitive adjustments and adaptations undergone by the birth parents in adjusting to the pregnancy and making complex decisions regarding relinquishment. Most recently, attachment theory combined with developmental neurobiology was used to hypothesize that stress hormones and neurotransmitters of the birth mother affect the developing fetus differentially, depending on the level of attachment that the birth mother experiences toward her child (Axness, 2001; Maret, 1997; Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999).

Nine empirical studies were identified that compared samples of pregnant adolescents and young adults who relinquished with control groups who chose to parent, making pre-relinquishment the largest category of birth-parent research. These studies were all conducted in the United States or Canada, were primarily done in maternity homes or adoption agencies, and focused almost exclusively on predictive external variables such as age, race, educational level, socioeconomic status (SES), family situation, and attitudes. Several variables were consistently related to relinquishment, including race, age, socioeconomic level, educational level, preference of birth grandmother, vocational goals, and living arrangements (Chippindale-Bakker & Foster, 1996; Cocozzelli, 1989; Dworkin, Harding, & Schreiber, 1993; Herr, 1989; Low, Moely, & Willis, 1989; McLaughlin, Pearce, Manninen, & Winges, 1988; Resnick, Blum, Bose, Smith, & Toogood, 1990; Warren & Johnson, 1989; Weinman, Robinson, Simmons, Schreiber, & Stafford, 1989).

The literature consistently documented that White women relinquished their infants for adoption at higher rates than did women of color, including African American, Mexican American, and Filipino American women (Chippindale-Bakker & Foster, 1996; Cocozzelli, 1989; Dworkin et al., 1993; Herr, 1989; Warren & Johnson, 1989; Weinman et al., 1989). These studies found race to be a predictive variable of relinquishment, with White women being most likely to relinquish and African American (or African Canadian) women least likely to relinquish.

Moreover, the literature suggested that single mothers in African American communities were less likely to make adoption plans for their infants and more likely to use what has been termed informal adoption (Sandven & Resnick, 1990). An explanation offered for the lower rates of adoption among birth mothers of color is based on both cultural norms from African ancestors and survival norms from postslavery America, where family boundaries include the extended family and are not limited to the nuclear family. One legacy of the forced separations of families during slavery was the strong need reported by many African Americans to retain children of African heritage to be raised within their culture and among their community. Thus, the various forms of informal adoption arrangements included both shared parenting with extended family and “gifting” a child to an extended family member without legally relinquishing parental rights. Historically, this practice was unrelated to social class (Landrine & Klonoff, 1996). Other explanations for lower rates of relinquishment to adoption point to the lack of economic opportunity for birth mothers of color due to issues of oppression and privilege. Authors have not focused, however, on the possibility that birth mothers of color do not relinquish as often because children of color are less likely to be adopted (Lee, 2003).

Recent trends in adoption plans (i.e., decisions made to relinquish children for adoption) were also delineated in the research literature. Adoption plans tended to be made by single mothers who were of higher socioeconomic and educational groups than those who chose to parent (Chippindale-Bakker & Foster, 1996; McLaughlin et al., 1988; Resnick et al., 1990). Adolescent mothers who chose to parent tended to be younger (early to midteens) and of a lower SES, whereas those who made an adoption plan tended to be older (late teens) and of a higher SES (Dworkin et al., 1993; Warren & Johnson, 1989). Mothers who made adoption plans were also found to have higher vocational aspirations and more goal-directed life plans than those who parented (Cocozzelli, 1989; Low et al., 1989).

Family attitudes and dynamics were found to predict the likelihood of a woman making an adoption plan versus choosing to parent. Several studies found that one of the strongest predictors of relinquishment was the preference of the pregnant woman’s mother (Chippindale-Bakker & Foster, 1996; Dworkin et al., 1993; Herr, 1989; Low et al., 1989). The relationship between the mother and father was also found to be predictive of relinquishment, particularly when the mother changes from an adoption to a parenting plan (Dworkin et al., 1993).

In summarizing the reasons given by birth mothers for making an adoption plan, Chippindale-Bakker and Foster (1996) stated that most “do so out of a belief that it will offer a better life for their child than they are able to provide” (p. 341). Resnick et al. (1990) added an additional factor in their summary and reported that both the baby’s best interests and the birth mother’s own school plans were primary motivators for making an adoption plan.

As the case above illustrates, Kathleen’s experience of the pre-relinquishment period is a typical one in many ways. Her symptoms of depression and anxiety are common. Background factors in Kathleen’s life as well as her personal feelings are reflected in the literature’s findings regarding her likelihood of making an adoption plan (i.e., her mother preferred that she make an adoption plan, she was a Caucasian teen from a middle-class family, and she did not feel ready for the responsibility of a baby). However, given the pressure and negative judgments that she received from others regarding her choice to relinquish her baby, Kathleen clearly needed structured pre-relinquishment support that could come in the form of therapy, support groups, or other supportive resources. Her therapist provided this adoption-sensitive support (Janus, 1997) for her decision making and assisted Kathleen in three crucial ways: (a) by providing referrals to a support group of other pregnant women making choices about adoption plans and to an adoption agency with a strong and sensitive birth-parent program, (b) by demonstrating competence regarding the issues for relinquishing birth mothers and being nonjudgmental and supportive of Kathleen’s decisions, and (c) by creating an atmosphere where Kathleen could prepare for the relinquishment and provide a link (by choosing the adoptive parents and by writing a letter and sharing photographs) for her child following the relinquishment. Adoption specialists report that pre-relinquishment counseling for the prospective birth mother is best for her and may prevent disrupted adoptions. This case study illustrates several aspects of the specific and crucial knowledge for effective therapy during the pre-relinquishment period and is reflective of the points elucidated for adoption-sensitive counselors (Janus, 1997).

Case Study 1

Presenting Issues: Kathleen, a 17-year-old Caucasian from a middle-class family, was 6 months pregnant and was experiencing symptoms of panic, depression, and anxiety.

Background Factors: Kathleen is the elder of two children. Her parents have been married for 18 years, and she is a senior in high school. Kathleen had been dating her boyfriend, Tommy, for more than a year but did not want to marry him and did not want to “wreck my [her] life” by becoming a mother at this stage. After she contacted a private attorney to make an adoption plan for her child, Kathleen’s school counselor referred her for more comprehensive therapy.

Assessment Concerns: Kathleen’s judgment and insight appeared to be good, but she was experiencing ambivalence and fear about making what she called a “popular” choice for her baby. Kathleen’s parents were encouraging relinquishment and adoption although Kathleen heard negative comments about her plan from numerous friends, teachers, and relatives. Even the nurse in her obstetrician’s office had said that she didn’t know how she could “do such a thing.” Kathleen was preparing to review histories of prospective adoptive parents for her baby and knew she wanted this for herself and her baby, but she felt alone, isolated, and sad.

Treatment Issues: Kathleen was trying to avoid internalizing the judgments of others and repeatedly stated the need to do what is right for her baby and herself, but her limited social support was a vital area to address in treatment. Kathleen’s fears resulted in multiple changes to her adoption plan (i.e., wavering between keeping and relinquishing the baby) and thereby limited her ability to feel comfortable and safe in her choice. These fears also hindered her progress through the grieving and relinquishment process.

Effective Treatment Strategies: Her therapist validated all options as potential choices (either relin-quishment or parenting) and also provided her a nonjudgmental place in which to talk about her ambivalent feelings. Using knowledge of the adoption system and the lifelong impact of relin-quishment, Kathleen’s therapist urged her to join a support group for relinquishing mothers at a local private adoption agency and to explore placement through an adoption agency with a strong birth-parent support program. The therapist knew that working with such an agency would enable Kathleen to receive support for the relinquishment issues she would experience throughout her lifetime (support a private attorney could not provide). The agency Kathleen chose to work with had an ongoing birth-parent support program that she could work with at any time throughout her lifetime. This agency sent materials to Kathleen’s physician and to the obstetrics unit where Kathleen would deliver her baby so that they would understand the unique needs of a mother planning to relinquish her child for adoption (Melina & Melina, 1988). Kathleen worked with her social worker at the agency, chose a mediated contact adoption for her baby (one with limited exchange of information between birth parents and adoptive parents), and participated in choosing the adoptive parents. With her therapist’s support, during her eighth month, Kathleen met the adoptive parents and wrote a letter to her baby that included photographs. Kathleen wavered on her adoption plan a few times toward the end of her pregnancy but followed through with her decision to allow the adopting parents to be with the baby immediately after delivery. Her widened support system of her parents, therapist, agency, and birth mother support group was invaluable to her both before and after relinquishment.

Course of Treatment: Kathleen found herself alternating between numbness and grief both in the hospital and after returning home. She spent time with her baby girl in the hospital, and her mother took a few photographs of the baby with Kathleen and with her adoptive parents before they left the hospital with their newly adoptive daughter. Others wanted her to “get on with her life,” but she sensed that a change had occurred in her that wouldn’t go away. She tried to remember details of her baby’s birth and the hours after she was born, but she found herself unable to, as is common for birth mothers. Kathleen found that both physical and emotional changes were overwhelming and that her feelings would erupt at unpredictable times.

Effective Treatment Strategies: Kathleen worked with both her therapist and her birth mother support group to express her feelings. She also worked at accepting and owning her decision, getting past blaming others for her circumstances, and becoming able to share her story and defend her decision. Kathleen realized that it was normal to think about her child and discussed her fantasies with her therapist. She learned through continued reading that living with the unknown has been identified by birth parents as the most difficult part to cope with throughout life, and she worked to become more comfortable with this unknown. Kathleen’s counselor became more didactic during this period of treatment, teaching her about the stages of grief, and she found comfort in hearing her feelings echoed in the stories of other birth mothers, both in her group and from her therapist’s experience.

Relinquishment Continuum and Coerced Relinquishment

It is important to note that the distinction between voluntary and involuntary relinquishments is actually a continuum rather than a dichotomy. Whereas some parents who sign voluntary relinquishment papers actually feel coerced by loved ones, spouses, parents, or even their culture (i.e., cultural norms against childbearing out of wedlock) to relinquish their children (DeSimone, 1996), other parents who formally have their rights terminated by the court system can be in agreement with that plan. This continuum and the issue of coercion have not been addressed in the birth-parent literature and have only been addressed as an ethical issue more recently in the adoption literature (Post, 1996). Although no literature currently exists that documents this phenomenon, the personal stories and communications of many birth parents coping with relinquishment, particularly birth mothers, strongly support this concept of a continuum. Such a distinction between the legal category of relinquishment (voluntary vs. involuntary) and the emotional experience of the parent(s) dealing with relinquishment (totally voluntary vs. coerced) is important to make in both practice and research.

Involuntary Relinquishment

When parents do not choose to relinquish their children voluntarily, the experiences of parents during the pre-relinquishment period differ greatly. Involuntary relinquishment is accompanied by legal processes and court decisions that culminate in a process known as the termination of parental rights (Edelstein, Burge, & Waterman, 2002; Wattenberg, Kelley, & Kim, 2001). Likened to the “death penalty” for parents due to its finality and gravity (Hewett, 1983), the termination of parental rights is a path that leads to distress and a unique and different set of issues for parents who become birth parents.

Prior to relinquishment via the termination of parental rights, parents whose children were removed due to findings of neglect or maltreatment were given visitation rights, and the children entered foster care. But who are these parents who no longer have the legal right to parent their children? Although they have been briefly described in the literature, national statistics on these individuals, developmental histories, and outcomes are difficult to determine (Freundlich, 2002). What is known about these parents are reported reasons for the termination of rights (e.g., mental illness, abusive domestic relationships, substance abuse, limited intellectual functioning, legal problems or incarceration, or inability to maintain stable housing; Wattenberg et al., 2001) and background histories of the women whose rights were terminated (e.g., little formal education, unemployment, abuse, out-of-home placement as children, birth of first child at young ages, children by multiple fathers, chaotic home environments; Wattenberg et al., 2001). Statistics on the numbers of children whose parents have had their rights terminated can be readily accessed (e.g., in 2001, parents of 65,000 children in the United States had their parental rights terminated; Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, U.S. Department of Health and Human Services, 2003), but statistics on the actual numbers of parents whose rights were terminated are not available. Despite this lack of reported statistics, recent trends in family preservation supported the rehabilitation of parents who were deemed neglectful or maltreating, and attempts at family reunification are now built into the system (Wattenberg et al., 2001). However, increasing concerns about the length of time spent in foster care without permanency planning incited movement toward legislation that speeds the process of parental rights termination for parents who fail to make substantial progress in their rehabilitation efforts (Festinger & Pratt, 2002).

Also missing from the statistics on these parents whose rights were terminated are data on their racial/ethnic backgrounds. Extrapolating from the available 2001 data (Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, U.S. Department of Health and Human Services, 2003) and assuming a similar distribution among children in foster care and their parents, the racial ethnic backgrounds of parents whose rights were terminated may generally fit the following categorization: (a) 2% American Indian non-Hispanic; (b) 1% Asian non-Hispanic; (c) 38% Black non-Hispanic; (d) 17% Hispanic; (e) 37% White; (f) 3% unknown; and (g) 2% two or more races non-Hispanic. However, the racial ethnic distribution of people in the United States reflects very different proportions of racial ethnic minorities, as follows: (a) 75.1% White; (b) 12.3% African American; (c) 13% Hispanic or Latino; (d) 0.9% American Indian non-Hispanic; (e) 3.7% Asian Pacific Islander non-Hispanic; and (f) 5.5% other race (Grieco & Cassidy, 2001). Thus, disparity in the figures between the proportion of racial ethnic minorities in the population and the proportion of racial ethnic minorities whose parental rights were terminated suggests some degree of inequity in several systems that affect involuntary relinquishment. This bias can be attributed to institutions (e.g., the judicial system and children’s welfare agencies) and can be a reflection of the system of disadvantage (e.g., racism) and oppression all too commonly found in these institutions. Although these disparate figures may also reflect bias and oppression related to social class, the degree to which social class affects the likelihood of involuntary termination of parental rights is not fully explained in the literature.

A clear determination of the experiences of parents whose rights were terminated is difficult to discern. Research on the impact of rights terminations reflects little attention to the impact of involuntary relinquishment on parents and focuses more on the adoption or placement outcomes for the children. The only research to address outcomes for parents who lost their rights has repeatedly found long-term psychological distress (Freundlich, 2002). Some outcomes commonly found among these parents are (a) ongoing anger and guilt; (b) substantial psychological problems; (c) health problems usually associated with bereavement (e.g., sleep and appetite disruption, dreams about loss and search); and (d) relationship problems (Charlton, Crank, Kansara, & Oliver, 1998; Hughes & Logan, 1993; Mason & Selman, 1997). Other deficits in the research literature and in practice with parents whose rights were involuntarily terminated include the lack of attention to posttermination issues for parents (e.g., no counseling programs after termination of rights). Although a single study was found that discussed group therapy issues for birth parents whose children were in foster care (Charbonneau & Kaplan, 1989), no literature addressed treatment following involuntary relinquishment.

Early Post-Relinquishment Period

During the early post-relinquishment period (defined broadly as the first 2 years following relinquishment), the reported impact of relinquishment on birth parents, but especially birth mothers, varies greatly, depending on their coping skills, support system, and degree of involvement in the adoption plan (e.g., extent to which they chose and met the adoptive parents).

Clinically, birth mothers frequently reported that relinquishment involves a powerful sense of loss and isolation (A. Brodzinsky, 1990) and that these feelings accompany both closed adoptions (i.e., traditional adoptions where no contact or information transfer occurs between birth and adoptive families either before or after placement) and open adoptions (i.e., adoptions where information and/or contact between birth families and adoptive families is shared directly or via a mediator along a continuum of contact) (Zamostny et al., 2003). Birth mothers in more open arrangements may become childlike in their dependence on the adopting parents, only to feel discarded and betrayed by them on the births of their babies. Birth mothers in more traditional, closed arrangements reported more traumatic dreams, sleep disruption, and experiences of surrealism. Physical, hormonal, and relationship changes brought disruption to the birth mothers’ lives, yet their hope that they would be able to “get on with their lives” did not reach fruition (A. Brodzinsky, 1990; Sorosky, Baran, & Pannor, 1976).

Three empirical studies were identified that studied birth mothers during the initial period following relinquishment (Cushman, Kalmuss, & Namerow, 1993; Donnelly & Voydanoff, 1996; McLaughlin et al., 1988). The findings indicated a complex combination of differences and similarities in the outcomes between mothers who placed their children for adoption (placers) and those who chose to parent (parenters). There were no differences between the groups in school enrollment at 6 months, high school graduation rate, and perceived quality of life (McLaughlin et al., 1988), and there were no differences in self-reports on SES, religion, depression, and self-efficacy. Both groups reported satisfaction with their decisions 2 years later (Donnelly & Voydanoff, 1996). However, Cushman et al. (1993), in the only multistate sample with interview data, found higher levels of grief at 6 months than at postpartum and the highest levels of grief in birth mothers whose babies went to foster placement prior to adoptive placement. They also reported that 55% of birth mothers found signing the adoption papers to be one of the most difficult parts of the adoption process, and 9% reported that they felt pressure from their agency to sign the papers. At 6 months after they gave birth, 38% of the placer sample reported feeling “a lot” and 27% reported feeling “some” grief. Kalmuss, Namerow, and Bauer (1992), using the same longitudinal data set, found that placers fared somewhat better than parenters on a set of sociodemographic outcomes assessed at 6 months postbirth. However, they also found that even when controlling for preplacement variables, placers were less comfortable with the pregnancy resolution decision than were parenters.

This case study demonstrates how Kathleen’s counselor allowed her to face her grief and also avoid the factors suggested by Roles (1989) to block, delay, or prolong mourning. These factors, which were based on clinical experience, are (a) lack of acknowledgment of the loss by society, family, friends, and professionals; (b) lack of expression of intense feelings; (c) not having a mental image of the baby due to lack of information or never seeing the baby; (d) preoccupation with the fantasy of reunion to avoid dealing with loss; (e) preoccupation with searching for something to fill the gap and to avoid facing painful feelings; (f) belief that having a choice takes away the right to grieve; (g) self-deprecation and self-blame; (h) pressure from others to decide on adoption making ownership of the decision to relinquish difficult; (i) lack of support; (j) numbing through abuse of alcohol or drugs; and (k) maintaining secrecy and not acknowledging the loss to yourself or others. The adoption-sensitive counselor’s knowledge about these factors, provision of psychoeducation regarding the grief reactions common for birth parents, and assistance in normalizing her anger, loss, and sadness were crucial in effectively treating Kathleen during the post-relinquishment period (Janus, 1997).

Because relinquishment of one’s parental role for one’s children is lifelong, counselors must recognize that many of these post-relinquishment reactions can revisit birth parents at any point during their lives. Counselors should also be prepared to address these issues during important transitions in the birth parents’ and the adoptee’s lives such as birthdays, holidays, Mother’s Day, and other events that mark the relationship.

Long-Term Post-Relinquishment

Long-term effects of relinquishment on birth mothers fill the clinical literature, with long-term defined broadly (i.e., more than 2 years post-relinquishment). The clinical literature includes many different personal accounts of birth mothers who experience lifelong symptoms of depression, anxiety, and posttrauma (A. Brodzinsky, 1990; Gediman & Brown, 1991; Guttman, 1999; Jones, 2000; Robinson, 2000; Schaefer, 1991). Birth mothers detail ongoing symptoms of grief, isolation, and difficulty setting aside the experience of relinquishment. They describe what Fravel, McRoy, and Grotevant (2000) termed the “psychological presence” of the relinquished child by the birth mother. At the same time, some research found reports of satisfaction with the relinquishment decision and favorable outcomes on some sociodemographic and social psychological outcomes 4 years after giving birth, in addition to continuing grief and loss (Namerow, Kalmuss, & Cushman, 1997).

Clinicians reported that the birth mothers they see in therapy alternate between denial of the relinquishment of their child and feelings of continuing shame, depression, and negative self-image. They felt they carried a serious secret and are unacceptable and unlovable. They reported difficulty attaching to romantic partners and, sometimes, future children. If the birth mother had an open support system, one in which she could honestly communicate, then these intense emotional sequelae were reduced. Those in closed adoptions worried about the safety and lives of their birth children, reported recurring dreams about their children, and wondered more intensely about their children near birthdays and holidays. If they had maintained secrecy, they often feared that others would reject them if the adoption placement were disclosed. Many reported losing their sense of faith and spirituality during this stage.

When viewing both the clinical and research literature on long-term outcomes, it is essential to remember that research has heavily focused on the birth mothers who continue to struggle with the loss of their child for years following the relinquishment. This is likely due to a sample bias in which research participants became participants in the studies because they were already seeking clinical treatment and they were open to and involved in exploring relinquishment. Thus, their preparedness and willingness to address their psychological needs and their adoption exploration may already make them different from those who do not seek treatment and who might not acknowledge their desire to understand their own adoption. No data were found in either the clinical or empirical literature on birth parents that suggested that birth parents cope well with their decision to relinquish, although Namerow et al. (1997) found some positive outcomes on both sociodemographic and social psychological variables.

Empirical studies implied that, at least for a percentage of birth mothers, the experience of relinquishment was a trauma in their lives due to unresolved grief (Carr, 2000; DeSimone, 1996; Deykin, Campbell, & Patti, 1984; Namerow et al., 1997; Rynearson, 1982; Winkler & van Keppel, 1984). Findings indicated a negative impact on future relationships and an increased incidence of secondary infertility (Carr, 2000; Condon, 1986; DeSimone, 1996; Deykin et al., 1984). In fact, even 30 years after relinquishment, birth mothers reported no decrease in feelings of sadness, anger, and guilt and told of ongoing dysfunctional relationships with subsequent children and with men. Birth mothers who were White and in their teens when they relinquished also reported feeling pressured by parents and by social and altruistic ideals to make an adoption plan (Rynearson, 1982). They described (a) dreading delivery, (b) remembering labor as a time of loneliness and painful panic, (c) feeling traumatized by signing the adoption papers, (d) having questions about the future of their children after leaving the hospital, and (e) experiencing recurring traumatic dreams about relinquishment and episodes of seeing strangers with babies and wondering if one was their child. In other research, DeSimone (1996) found that higher grief levels were related to (a) feelings of guilt/shame about the decision to relinquish, (b) the perception of coercion by others into relinquishment, (c) the lack of opportunity to express feelings about the relinquishment, and (d) involvement in searching for the relinquished child. Although grief levels were not related to the lack of social support, lower grief levels were related to high satisfaction with current marriage, more personal achievements, and having gained information about the children since placement. Carr (2000) found that 37% of the 87 birth mother participants had secondary infertility (higher than the national average) and that emotional pain, including grief, was a consistent long-term outcome in each of these studies of birth mothers. In spite of this grief, Namerow et al. (1997) reported that after 4 years postbirth, their longitudinal sample of adolescent placers from maternity homes fared better on external outcomes (e.g., high school graduation, employment outside the home) than did parenters. Moreover, 4 years after making their pregnancy resolution decision, more than 90% of the parenters versus 66% of the placers reported no regret and 3% of the parenters versus 10% of the placers reported high regret. Thus, a more complicated picture emerges as the sample becomes less clinical.

Using a somewhat different outcome measure of “psychological presence of the relinquished child,” Fravel et al. (2000) found that the adopted child remained psychologically present for relinquishers both on special occasions and as they went about their daily lives. Fravel et al. discussed these findings as an empirical discrediting of the “happily ever after” myth, in which birth mothers are to forget their children and get on with their lives. The adopted child, in their study, was psychologically present to some degree in every case.

Donna’s case illustrates the lifelong effects that relinquishment can have on a birth mother. However, in Donna’s case, her own traumatic history combined with the closed adoptions of her sons created additional stress reactions, grief, loss, intense guilt, and remorse. Donna’s psychological treatment was designed to address the multiple layers of trauma she experienced and to begin the grieving and self-forgiveness processes she needed (Janus, 1997). The treatment provided by Donna’s psychologist reflects the need to understand the powerful effects that relinquishment can have on birth parents when both diagnosing and treating them. Had the treating psychologist minimized the relinquishment of her three sons, Donna’s history of trauma prior to the relinquishment could have been the focus of treatment, with poor overall results. The effective use of techniques such as journaling, bibliotherapy, and letter writing required sensitivity to the grief, loss, guilt, anger, and trauma that often continue for many years following relinquishment. The use of family therapy following the search and reunion helped Donna better understand the role relinquishment had in her family (Reitz & Watson, 1992).

Search and Reunion

Feast, Marwood, Seabrook, and Webb (1994) noted recent increases in birth relatives initiating searches for children relinquished for adoption many years ago, but research has only addressed adoptee-initiated searches. Feast et al. (1994) reported that “some birthmothers [search because they] need to feel reassured that they did the right thing and want to make certain that their child knows they were very much loved and why they were adopted” (p. 9).

Research addressing search and reunions described and categorized the ensuing relationships that do or do not develop between birth parents and their relinquished children. Howe and Feast (2001) surveyed adoptees who were in reunion with their birth parent(s) an average of 10.6 years (63% women, 37% men; 93% in matched White same-race placements, 7% of mixed race and adopted transracially). They found that reunions were characterized by (a) continued contact and positive evaluation (30%), (b) ceased contact and positive evaluation (30%), (c) continued contact and mixed or negative evaluation (30%), and (d) ceased contact and mixed or negative evaluation (10%). Gladstone and Westhues (1998) surveyed 67 Canadian adoptees in reunion (mean age 42.5 years, 81% female, 19% male) and identified seven categories of postreunion relationships that can occur: close (35%), close but not too close (10%), distant (22%), tense (6%), ambivalent (14%), searching (8%), and no contact (6%). Factors found to affect the types of relationships developed included structural factors (geographic distance and time), interactive factors (boundaries of the relationships, adoptive family’s support, and birth family’s perceived level of responsiveness), motivating factors (sense of involvement or pleasure from contact), and the outlook of birth relatives (close matching on lifestyle, values, and desire regarding intensity of relationship). Feast et al. (1994) noted that “for the most part, though, birth parents are very pleased to see their children again” (p. 104).

Case Study 2

Presenting Issues: Donna is a 62-year-old African American woman who came to therapy for depression and anxiety.

Background Factors: Donna was raised in an orphanage along with her brother from age 9 because her mother was alcoholic and her father was out of the country in the military. Evidently, this was common practice at that point in history in this locale because Donna knew that others at the orphanage weren’t “orphans” either but were brought there due to various family circumstances by their parents. Older boys at the orphanage sexually molested Donna when she was 11 years old and continued to do so until she ran away at age 16. Donna married a 25-year-old when she was 18 and had four children in 5 years. Her husband drank heavily and soon left her. Donna became despondent, unable to support herself or her children, and developed pneumonia. She had no car, no income, and no social services or other social support. A cousin gave her food, which she gave to her children and not herself. She finally sought medical care for herself (she believed she was going to die) and went along with the suggestion of the physician to relinquish her children (ages 3, 2, 1, and newborn) for adoption because she feared they would end up in the orphanage as she had (and she refused to allow that for her children). Donna knew the adoptive families of each of her children and kept track of two of the three silently throughout their lives. The third left the area with his adoptive family when he was a toddler, and Donna always feared they moved to get far away from her. She backed out of relinquishing her youngest child and only daughter before it happened because she was afraid her daughter would be victimized as she had been. Donna married again, adopted another daughter herself through social services, and went on to live a healthy and productive life. However, the sexual abuse and trauma from relinquishing her sons tormented her most of her life, and her psychologist diagnosed her with posttraumatic stress disorder (PTSD).

Assessment Concerns: Donna’s insight and judgment appear to be strong despite her experience of multiple traumas. The accumulation of many years since the sexual abuse and the relinquishment have allowed her to feel buffered from their effects, but the PTSD symptoms suggest a 40- to 50-year history of trauma. Furthermore, Donna’s tracking of her sons’ movements suggests some fixation on the trauma without any apparent resolution to this point.

Treatment Issues: Donna had several major losses that complicated her PTSD issues—the abandonment by her parents, sexual abuse as a child, the abandonment by her husband, poverty and feeling powerless, her illness, the relinquishment of three children, and secrecy. Treatment included attention to Donna’s PTSD symptoms and issues but also recognized the close relationship between the losses and trauma. Donna’s actions suggested an interest in search and reunion. This required careful planning and support.

Effective Treatment Strategies: Treatment consisted of appropriate protocols for PTSD and special attention to the loss she experienced as a relinquishing birth mother. Donna was extremely harsh on herself for this relinquishment, yet her repetitive reviews of her pre-relinquishment situation always resulted in her reaching the conclusion that relinquishment had been “best” for her sons. She wished, however, that she could have placed them together. Nevertheless, she found it very hard to forgive herself. Her therapist used journaling, photo reviews, bibliotherapy, and psychoeducation as strategies for facing this loss. They also used grief strategies such as writing letters to each of her sons on numerous occasions. Her therapist used her own knowledge of adoptee development to reassure Donna that the vast majority of adoptees do quite well (Zamostny et al., 2003) and gave her reading material on the birth-parent experience (e.g., Jones, 2000) to decrease her feelings of isolation. Donna eventually decided to contact each birth son and established caring relationships with two of them; the third preferred no contact, but she made it clear that she was open to contact should he ever desire it. Her birth sons met her daughter and other family members and continually reassured Donna that they had had good lives and did not harbor resentment toward her. On the suggestion of Donna’s therapist, Donna’s two birth sons and her daughters entered family therapy for three sessions where family dynamics were addressed via family sculpting and other experiential techniques. Donna’s PTSD symptoms diminished (but did not disappear), but even with good treatment and appropriate medication, she continued to find it hard to forgive herself for relinquishing her children. She has, however, improved in her ability to speak about her traumas and has developed a group of supportive friends for the first time in her life.

Birth Fathers

Birth fathers are underrepresented in both the clinical and the research literature. Perhaps this is because they tend to be less involved in the pregnancy and less involved in the decision to relinquish compared with the birth mother. Perhaps it is because many birth fathers do not see the child prior to relinquishment. Very little clinical literature addresses birth fathers, although it is routine to decry their absence in the literature (Freundlich, 2002; Grotevant, 2003; Zamostny et al., 2003). Only two studies were located that specifically examined birth fathers. Deykin, Patti, and Ryan (1988) surveyed 125 American birth fathers and found that the birth fathers’ relationships with the birth mothers often continued beyond the relinquishment—44% of these birth fathers reported marrying the child’s birth mother at some point during their lives, and 25% reported that they were currently married to the birth mother. They also reported that the relinquishment had an effect on their relationship with the birth mother: 22% negative, 34% positive, and 44% mixed or none. Most did not see or hold the child prior to relinquishment, and half were not involved in the adoption process. Birth fathers who were older and who identified external pressure as a primary reason behind the adoption were almost five times as likely to be presently opposed to adoption compared with those who cited their unpreparedness for fatherhood or the best interest of the child as a reason for relinquishment.

Similarly, Cicchini (1993) did a study of 30 Australian birth fathers and found that the majority (66%) had no or minimal say in the adoption. Most remember it as “a most distressing experience,” and only 17% of the men reported feeling positive about the experience. A majority of the birth fathers in this sample took active steps to locate their child; however, most had not yet had reunions. The most frequently cited reason for searching was to ensure that their child was doing well. The authors concluded that the fathers retained an emotional and psychological feeling of responsibility for the child and challenged prevailing assumptions that birth fathers are irresponsible, uncaring, and uninvolved. Perhaps as the literature expands to include birth fathers, including those who have had contact with their birth children, our understanding of their experiences will increase. In any case, based on the current literature, while birth fathers may seem to be less affected by the relinquishment and adoption of their children than are birth mothers, an accurate assessment of the impact of relinquishment on birth fathers is difficult to determine, given the paucity of empirical investigation with this population.

International Birth Parents

Research on international birth parents is exceptionally limited despite the increased visibility of international adoption in America. The advent of media portrayals of transracial families that adopted internationally (e.g., celebrity international adoptions, print and television commercials, newspaper and magazine articles, Web-based adoption sites), an older population of “waiting parents,” increased acceptance of single-parent adoptions, and greater availability of healthy infants internationally have all led to a growing population of adoptive families who have power, influence, financial resources, and a thirst for information about the nations from which their children were adopted. Despite this growing population of internationally adopting families, very little is actually known about the birth parents from these countries. The perception of greater permanency related to non-U.S. relinquishments and the implications of relinquishing children to an entirely different culture are just a few of the issues that arise when considering treating birth parents who have relinquished internationally.

Johnson, Banghan, and Liyao (1998), in their descriptive work on infant abandonment in China, found that almost all the birth parents (n = 237) were married and that the abandonments were related to government birth regulations. Relinquishment decisions were most often made by the birth father (50%), although 40% were made by both birth parents. Relinquishing families (88%) came from rural areas, with their primary occupation being agriculture. Reasons given for relinquishment were the children’s gender (90% female), health (86% healthy), birth order (82% of females not firstborn; no data on males), and gender composition of siblings (88% of females had no brothers, 93% of females had older sister(s); no data on males). Relinquished male children were those having disabilities and those born to widowed or unwed mothers.

In Korea, 85% of unwed mothers in a maternity home relinquished their children (Dorow, 1999). Freundlich (2001) described the typical Korean birth mother as being very poor, coming from a large family in which she is the youngest, and lacking family and social support.

These data, although very limited, represent the infancy of research on two countries that place children for adoption in the United States. Research on birth parents in many other countries (e.g., Latin America and Eastern Europe) is not yet found in the literature at all. Clearly, research that leads to an increased understanding of international birth parents in many countries needs to be done.

Openness in Adoption for Birth Parents

Over the past 10 years, birth mothers making adoption plans for their children increasingly chose alternatives that included some degree of openness between themselves and the adopting family. Three studies were identified as assessing openness and its effect on birth parents (Christian, McRoy, Grotevant, & Bryant, 1997; Cushman, Kalmuss, & Namerow, 1997; Lauderdale & Boyle, 1994). In their interviews with 12 birth mothers planning open adoption compared with those planning closed adoption, Lauderdale and Boyle (1994) reported that those who planned open adoptions showed more attachment to their fetuses and were more likely to seek support and prenatal care although they experienced more grief in the immediate postadoption period than did mothers with closed adoption plans or bereaved parents. Birth mothers who planned closed adoption reported nonattachment to their fetuses, hid their pregnancies, were less likely to receive prenatal care, and reported more difficulty accepting the loss of the child after relinquishment. Four to 12 years after placing their children in open adoptions, birth mothers having ongoing contact with the adoptive family through either mediated or fully disclosed adoptions showed better resolution of grief than did birth mothers whose contact stopped (Christian et al., 1997). Furthermore, they found that those with fully disclosed adoptions also showed better grief resolution than those who never had contact (confidential adoptions).

In a study of the relationship between openness in adoption and social psychological outcomes for birth mothers, Cushman et al. (1997) interviewed 171 adolescent birth mothers who were maternity home residents at relinquishment and who were reinterviewed 4 years after relinquishment. They found that 69% helped choose the couple who ultimately adopted their babies, 28% met the adoptive couple, 62% had received letters or pictures since the adoption, and 12% had visited or talked on the phone with the adoptive parents since placement. The most notable pattern was the association between helping to choose the adoptive couple prior to relinquishment and positive social psychological outcomes for birth mothers 4 years later. Those who received letters or pictures reported significantly lower levels of worry and slightly higher levels of relief. Having ever visited or talked on the phone after relinquishment was strongly associated with lower levels of grief, regret, and worry, and greater feelings of relief and peace regarding the adoption. Continuing research is needed to assess the specific variants of openness in adoption and their effects on outcomes for birth parents. Early research suggested that open adoption might be a process that decreases the emergence of negative symptoms for birth parents. Given how serious and long term the psychological effects of relinquishment can be, a model that ameliorates these effects is greatly needed.

Practice Implications for Counseling Birth Parents

The case studies, the empirical findings regarding the lifelong trauma associated with relinquishment, and the sizable numbers of birth parents who currently exist both in the United States and abroad suggest that helping professionals should be well prepared to counsel birth parents. However, despite the recognition of the impact of relinquishment on birth parents and some identification of who relinquishes, for what reasons, and how that may affect these clients, clinicians have virtually no empirically validated guidelines for practice with birth parents.

Clinical practice with birth parents, therefore, has relied on best practices that were generated from the case studies, theoretical guidelines, and a few treatment programs developed with sensitivity to adoption-related and relinquishment issues. The literature reviewed and the cases analyzed above suggest several techniques and sensitivities to the unique and complex issues that birth parents face when relinquishing either voluntarily or involuntarily.

Janus (1997) proposed the term adoption-sensitive counseling and proposed that counselors are in an excellent position to become adoption counseling specialists. A review of the clinical and research literature on birth parents led to the following suggestions for counseling psychologists working with birth parents:

• Adoption-sensitive counselors and psychologists are attuned to their own attitudes and biases about birth parents, including their own feelings about giving birth, raising children, relinquishing children, the openness continuum in adoption, and the concept of an adoption kinship network. They are keenly sensitive to issues of ethics—both professional and adoption-related ethical practices (such as coerced relinquishments) (Post, 1996).

• Adoption-sensitive counselors and psychologists are always conscious of the social and cultural factors involved in the lives of birth parents and in the lives of all adoption triad members (Lee, 2003). These factors include race, culture (including religious and spiritual beliefs), family dynamics, and SES for birth parents and can be expanded to include civil unrest, cultural norms, and legal regulation of family size for international birth parents. Adoption-sensitive counselors and psychologists practice using the American Psychological Association’s (2003) multicultural guidelines ( and are aware of all adoptions as multicultural, broadly defined.

• Adoption-sensitive counselors and psychologists are aware of the political and economic aspects of adoption and their effects on birth parents. Zamostny et al. (2003) pointed to the increasing role of commercialization in the adoption process, and these economic forces have a significant impact on birth parents both prior to relinquishment and after. Grotevant (2003) described advocacy groups that are calling for reform within the birth-parent community such as Concerned United Birthparents (2004) and the American Adoption Congress (2004). Counselors must be aware of the wide range of political awareness and activism among birth parents.

• Adoption-sensitive counselors and psychologists are familiar with community and national resources for birth parents, including support groups, agencies that have birth-parent support programs, online resources (e.g.,,, reading material, and search assistance. Some birth-parent specialists believe that adoption agency services present an inherent conflict of interest since they are also placing children for adoption. It is incumbent on the counselor to be familiar with agencies in their communities and refer birth parents carefully to services and organizations that will advocate for them.

• Adoption-sensitive counselors and psychologists allow birth parents to experience their loss, without minimizing it. They are aware of the seven core issues of adoption (Silverstein & Kaplan, 1988) and how they affect birth parents as described in the foregoing.

• Adoption-sensitive counselors and psychologists allow birth parents to experience their own resiliency and strength, increase their self-esteem, and plan for their own future. They are aware that not all birth parents share the same experience and that satisfaction with their relinquishment experience may be positive, having led to positive outcomes in their own lives.

• Finally, adoption-sensitive counselors and psychologists are aware of the complexity of each birth parent’s story. Grotevant (2003) pointed out that adoption refers to a surprisingly diverse set of family circumstances, which is certainly true for birth parents. To avoid overgeneralizing to this heterogeneous population, counselors and psychologists working with birth parents must respect the individuality of birth parents, regardless of their life circumstances.

Clinically Driven Research: Future Directions

Research has been more limited on birth parents than on other members of the adoption triad (Freundlich, 2002; Zamostny et al., 2003). Empirical research on birth parents would benefit from greater attention to make it both methodologically sound and clinically informed. First, the use of broad nonclinical samples, standardized instruments, process-outcome studies, and individual surveys or interview data with less reliance on retrospective reports and/or self-reports would increase the generalizability of birth-parent research. Because of methodological and sampling problems, much of the existing literature has limitations in its applicability to current-day relinquishing populations, so validity and reliability have suffered. Both short-term and long-term outcome studies can be improved by controlling for age at relinquishment and the pre-relinquishment adjustment level of birth parents, given that the developmental stage and psychological history at relinquishment could affect outcomes.

Birth-parent research would also benefit from greater attention to the complexity of the birth-parent experience. Rather than focus solely on self-reported indices of adjustment, outcomes for birth parents would be more informative if the inclusion of both internal (e.g., measures of grief, depression, self-esteem, coping skills, satisfaction) and external variables (e.g., SES, educational level, income, vocational level) is sought. More detailed and richer depictions of birth parents can also be obtained from the use of advanced statistical analysis to determine the interaction effects of these variables. With greater knowledge of the complexity of the experience of birth parents, more effective treatment interventions, counseling skills, therapeutic techniques, counseling process concerns, and treatment models can be proposed, empirically validated, and implemented in counseling and psychology preparation programs. This research could be built on further by comparing the effectiveness of treatment using adoption-sensitive therapy (via training) versus therapy without adoption training versus some other support or intervention.

Another major area for future research includes the background, clinical, and outcome issues for birth parents of color. A greater understanding of the factors leading to relinquishment for birth parents of color, of the inequities found in the racial ethnic distribution of involuntary relinquishment, of effective treatment strategies for assisting those coping with relinquishment (voluntary or involuntary), and of their post-relinquishment experiences would provide very useful treatment and research information. Furthermore, more research is needed on the experiences of birth parents whose parental rights have been terminated through the legal system.

Reasons for relinquishment by international birth parents also need to be assessed, including poverty, civil unrest, financial incentives, and urban migration. To serve the needs of international birth parents better, the profoundly intricate and often difficult circumstances, factors, treatment issues (e.g., stigma of therapy), and outcomes for international birth parents must be understood. The lifelong effects and outcomes need to be assessed for international birth parents with no less consideration than for domestic birth parents.

An area yet to be explored in the birth-parent literature involves attention to relinquishment coercion as an important variable. Specifically, in both voluntary and involuntary relinquishments, the phenomenological experience of birth parents on the relinquishment continuum (voluntary to coerced) should be considered in the design of future research. Empirical designs that account for this continuum may assist in elucidating possible differential outcomes based on the degree to which the birth parents felt empowered to make their own adoption plan.

More research needs to be conducted assessing both the short- and long-term effects of relinquishment and any subsequent treatment on nonclinical samples of birth parents. Longitudinal cohort studies of both birth mothers and birth fathers, including studies of openness and search, would be powerful additions to the outcome literature. Longitudinal studies of birth parents would also allow clinicians and researchers to make substantial progress in their knowledge of the developmental effects of relinquishing. Developmental issues could also be identified by additional research incorporating health psychology models about stress and pregnancy outcomes (e.g., Rini et al., 1999) that would elucidate the effect of the prenatal experience on both birth mothers and their children. This research would substantially aid our ability to choose or design effective and appropriate treatment models that account for the effects of these various dimensions of development.

Multicultural models must be used in the design and implementation of research with this global population. Models used for understanding oppression, privilege, identity, and awareness of difference experienced by many birth parents can be of assistance when considering the unique life circumstances that lead to relinquishment for birth parents.


Both the research and clinical literature reviewed on birth parents have shown that relinquishing a child for adoption is a traumatic experience for many birth parents, in spite of some positive outcomes shown in more recent research. The development of research and practice that explicitly use trauma as a framework for the study of the birth-parent experience could also add to our understanding. Moving beyond a trauma paradigm, however, to incorporate an epidemiological stress and coping model for the study of the birth-parent experience and the incorporation of a multicultural perspective in all research and practice with birth parents would allow counseling psychologists to set a powerful agenda for research and practice in the field of adoption in the 21st century.

Reflection Questions

  1. If you could design a pre- and post-relinquishment birth-parent counseling program, what structures, goals, and clinical skills would be advisable for the most positive outcomes?
  2. What are other potential issues that birth parents who relinquish to either international or domestic transracial placements might experience? What clinical needs are they likely to report?
  3. What similarities and differences are likely to exist between voluntary and involuntary relinquishing parents? What might be additional or unexplored problems for involuntary relinquishers, and how can clinicians help them?