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					                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4


Module 4: Social, Cultural and Personal Influences
on Patient/Client

  Objectives:
       Participants will understand various influences on the woman’s decision: religious beliefs;
        extended family; peers; cultural myths; the birth father; acculturation levels; teen pregnancy;
        and grief and loss issues.

  Competencies:
  Participants will be able to:
       Identify social, cultural, and personal influences with an individual patient/client and openly
        discuss these issues with her.




Content
Influence of Family, Community, Culture in Pregnancy
Birth Father Issues and Considerations
Special Issues in Working with Teens
Impact of Pregnancy on the Adolescent’s Development
Grief and Loss Issues




                                                                 Module 4 Page 1
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Introduction

This module is designed to provide experience in assessing and counseling pregnant women and
teens through the use of role playing, large group discussion and team exercises.

This module begins with a discussion on the Influence of Family, Community, and Culture on a
pregnant woman. You will then receive information on the special issues of counseling a teen
and teen development. You will also receive information on engaging the father and the
implications of Options Counseling and Adoption Planning for the father. Furthermore, there
will be information on the special issues involved in working with a teen as well as a review of
grief and loss issues related to pregnancy options.

Summary of key points of this module are presented to the group, and then the session is
adjourned.




                                                                 Module 4 Page 2
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Influence of Family, Community, Culture
What do we mean by culture? It is language, patterns of dress, foods, mores, habits, world view,
vocation/career, common language, common history, common recreational/leisure activities,
family roles, and methods of child rearing. The list could go on.


A component of culture is our values and beliefs, i.e. the messages we live by.


There are no right answers, no right or wrong values.


What are the values influencing a woman trying to make a decision about her pregnancy?


What might be important to remember when working with someone of a culture different than
your own?




                                                                 Module 4 Page 3
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Providing Culturally Responsive Services
What does a culturally responsive service look like?s

Cultural responsiveness requires that the health care provider be aware and respectful of the
cultural norms held by the patient/client that may influence his/her decision making or his/her
perception of the available options.

Culturally responsive services treat the individual first, while simultaneously considering his/her
cultural norms and values as expressed by the patient/client.

If the health care provider does not know much about the patient’s/client’s culture, being
sincerely open about his/her lack of knowledge and desire to learn is a sign of respect.

For example, you may tell a patient, “My experience in working with Latinos/Hispanics is
limited. Help me understand your unique experiences.”

Health care providers need to be aware of the perceived power differential that can exist between
them and their patients/clients. For example, some Latino/Hispanic patients who are less
acculturated may defer decisions to you as a sign of respect for your position. Therefore, it is
important that you maintain a neutral position.

Family members, close friends, and/or the perceptions of the patient’s/client’s community may
play a role in the decision making process. Therefore, you need to be open to including extended
family members in your discussions if the patient client requests.

The health care provider will want to be prepared to include these members of the
patient’s/client’s circle in the process if the patient/client chooses to have them included.

It is important to remember that diversity within cultures exists and that the best approach is to
work with every patient/client as an individual.

A client’s level of acculturation plays a major factor in the decision making process. Levels of
acculturation depend on how long an immigrant has lived in the United States and how they
make sense of their values from their country of origin and integrate those values from their
country of origin and integrate those values in their new host country.

Levels of acculturation vary within individual family members.

If trainers have a personal experience, it is helpful to share your individual story.




                                                                 Module 4 Page 4
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Birth Father Issues and Considerations
Someone who may bear a great deal of influence on the decision to be made is the father of the
baby.

It is the mother of the baby’s decision to determine how she wants the father of the baby engaged
in the process of discussing pregnancy options with the health care professional.

Once she makes the decision to include him in the discussion, it is the health care professional’s
responsibility to engage him in the process.

When indicated, health care professionals can be welcoming and helpful in encouraging him to
support the birth mother and setting the couple on the right path for getting the help they need to
make options decisions together.

Health care professionals can facilitate informed decision making by identifying birth mother
and birth father strengths and building on those in making referrals.

It is important for health care professionals to engage interested birth fathers using the same
techniques used to engage others: treating them with dignity and respect; actively listening to
their concerns and being nonjudgmental.

Birth fathers can be encouraged to take an interest in their partner and the pregnancy and attend
prenatal and perinatal visits, if that is what the birth mother chooses or wants.

Birth fathers can be encouraged to become informed about the experiences and issues of
pregnancy so that they can become a partner in informed decision making regarding pregnancy
options. However, the decision to involve him is totally within the control of the pregnant
woman.

Birth fathers who release their parental rights may experience loss and may find it helpful to talk
about this with others, either in a professional or peer support setting.

Birth fathers can be encouraged to provide information about themselves, their medical history,
and their interest in contact with their child when he/she is an adult.

Birth fathers can become custodial parent.

This information needs to be given to the person and/or agency completing the adoption.

In open adoptions, birth fathers may be able to maintain on-going contact with their child and
update any personal or medical information for the adoptive family.




                                                                 Module 4 Page 5
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Engaging the Birth Father
If the father is at all involved with the mother, he will play a significant role in her pregnancy
option decision. Therefore, he should have as much information as possible to help him support
her decision-making process.

Should the decision be to parent a child, the birth fathers involvement is beneficial to life and
well being of that child. Therefore, the father of the baby is engaged in the process from the
beginning.

If both mother and father agree it would be beneficial if the paternal relatives are also
encouraged to be part of the process. For so long fathers have not been encouraged to participate
much less the paternal relatives. Extended family support can be very important during these
times.

Ideas to engage the birth father:
                      If the mother chooses to involve him, the health care professional can facilitate
                       engagement.
                      Attending to his questions and concerns using the same nondirective, noncoercive
                       techniques discussed previously.
                      Having resource information available about the role of the father in pregnancy
                       care, birth, and parenting.
                      Making sure the birth father feels welcomed by all staff.
                      Have male oriented items in the office including décor, magazines, coffee, and
                       information about fathering and fatherhood programs.
                      Discussing honestly with staff what their feelings are about the birth father of the
                       baby and men in general.
When to engage?
                      It would be beneficial for all parties involved to have the father of the baby
                       involved as soon as possible so that he can be a positive support to the mother as
                       she makes her decisions.
                      Historically birth fathers have not been encouraged to participate in the pregnancy
                       planning much less the paternal relatives. If birth parents agree it would be
                       beneficial if the maternal/paternal relatives are also encouraged to be part of the
                       process. Extended family support from both sides can be very important during
                       these times.




                                                                 Module 4 Page 6
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Grief and Loss Issues

          Birthparents may experience a variety of feelings related to the different pregnancy
           options

          Birthparents may experience much sadness about planning an adoption even if they have
           seriously considered all of other options
          Need to remember that adoption happens as a result of the loss; the loss of birthparents,
           extended relatives, community, culture and sometimes language
          It would be helpful for birthparents to be given a brief overview of common grief and
           loss stages. One of the most common grief and loss models is Dr. Kubler Ross DABDA.
           This model describes common coping strategies that people may experience when faced
           with difficult and at times life altering events.
          It is important to understand that this model does not necessarily follow a specific
           sequence and a multitude of feelings may be experienced at any one time.
          A brief overview of each stage follows as it relates to an unexpected pregnancy.
          The first stage is Denial. Birthparents may deny the pregnancy as a means protecting
           themselves from dealing with this reality and the subsequent consequences.
          The second stage is Anger. Birthparents may be angry at themselves, their
           boyfriend/girlfriend, and their family for the pregnancy. They may blame others for their
           situation.
          The third state is bargaining. In this state the birthparent may internally negotiate their
           various options with the intention of minimizing the impact of the pregnancy in their life.
          The last stage is Acceptance. This stage is usually referred to the resolution of the
           situation. It should not be interpreted as the birthparent having complete acceptance of
           their decision, but rather as a resolution they have made about their pregnancy option.
           This resolution can be a life long process.
          Research supports that the more engaged a birthparent is in the decision of making an
           adoption option, the likelihood of unresolved grief and loss is minimized
          Research also reports that many birthparents especially birthmother’s experience
           “anniversary reactions” which trigger grief and loss issues. Anniversary reactions surface
           most often during dates and holidays of special significance. Most common include: the
           date they found out about the pregnancy, the birthday of their child, the day the signed
           adoption papers, Christmas and mother’s day.
          It is also helpful to note that extended relatives may also experience grief and loss as a
           result of a planned adoption. They too are experiencing the loss of a family member who
           did have the opportunity to be raised with the family
          If a birthmother has a history of depression a mental health referral would be helpful.
           Research indicates that pregnant women who have a history of depression are more prone
           to post partum depression.



                                                                 Module 4 Page 7
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Special Issues When Working With Teens

          Adolescence is a time of tremendous physical, cognitive, emotional and social change.
           We will focus on early and middle adolescence
          Cognitively, they are still formulating their own points of view. They do this by trying
           out different ways of doing things and adjusting what they do based on the reactions of
           others or their demands and expectations.
          Socially, they look primarily to the peer group for information and guidance.
          Emotionally, they are egocentric in nature, operating in a self-centered manner, for
           example:
                      Early and middle adolescents have difficulty anticipating the needs of others and
                       putting them above their own particularly the unborn child.
                      Teens are often moody and have coping skills that are not fully developed.
                Teens require help with future planning which begins with the identification of their
                 resources and supports.
                Teens can be withdrawn and appear disinterested in information provided by helping
                 professionals; however, this is often not the case.
                 Normal Adolescent Development:
                      Physical, social, emotional, cognitive change
                      Developing view of self and ability to see other points of view
                      Look to peers for information
                      Egocentric
                      Often reject parental input
                      Difficulty anticipating needs of others
                      Moody with poor coping skills
                      Have difficulty with future planning


                For pregnant teens this normal stage of development can make them appear to be
                 undecided, unpredictable and non-compliant.
                An unwanted pregnancy often strips the adolescent of this time for transition and
                 requires him/her to make decisions and follow through with tasks on an adult level.




                                                                 Module 4 Page 8
                                                               Participant Handbook

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                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4


                Some pregnant teens may not follow through on medical advice or may not keep
                 medical appointments, because these activities may set them aside from the peer
                 group and/or they underestimate its importance.
                Pregnant teens, in general, have a level of egocentrism that does not allow them to
                 think beyond their own needs to those of their unborn child.
                Egocentric thinking has adolescents viewing the child in terms of what he/she can
                 provide for the teen including unconditional love; a way to get out of a bad life
                 situation; a boyfriend staying with them and/or supporting them; a disorganized or
                 dysfunctional family staying together; a higher social status and/or increased
                 independence.
                Early and middle adolescents have difficulty with future thinking, anticipatory
                 problem solving and often underestimate the task of parenting until they face the day
                 to day challenges of raising a child.
                Brainstorming sessions with teens throughout their pregnancies to identify their
                 ongoing social support network can help them look toward the future.
                Helping teens practice how to handle difficult situations that arise during the
                 pregnancy and beyond can be accomplished through role-playing that allows the teen
                 to rehearse what he/she will say and do if and when a particular situation arises.
                Anticipatory guidance is a technique to help the teen identify future issues that will
                 need to be addressed, can help him/her develop a future plan that makes sense in
                 his/her life.
                Research shows that many pregnant teens, especially those in middle adolescence,
                 mature quickly throughout their pregnancy and are able to make good decisions for
                 themselves and their child.
                Adolescents, who do best with unplanned pregnancies, have the help and support of
                 all of the adults in their lives.
                Because adolescents are experiencing a time of great change that is heightened by the
                 crisis of an unplanned pregnancy they may need information to be repeated and
                 presented in a number of different ways.
                For some teens pregnancy may bring added status in their peer support group.
                 Some teens may also decide to get married and maternal/paternal relatives may or
                 may not support this plan. Extended relative support varies depending on a variety of
                 factors including family values, levels of acculturation, religious beliefs and feelings
                 towards single parenthood.
                Some teens coming from lower acculturated families may feel pressured to quit
                 school to support the baby especially for teenage fathers. In these cases it would be
                 helpful to refer these families to their school counselors and community based
                 organizations to explore the reality of this option.

                                                                 Module 4 Page 9
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4




Large Group Discussion
           How does being a teenager influence decision making?
Participants will be asked to view a brief video about a teenager who is about to learn that she is
pregnant, and will be asked to list a couple of the teen characteristics they observe while
watching the video, and how these characteristics can impact the teens decision making about the
pregnancy.




                                                                Module 4 Page 10
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Team Activity

Influences Activity: Small Groups
The following exercise is designed to have you experience the many influences pregnant women
face making a choice. You will be assigned different roles and then have 5 minutes to role play
and answer the following questions.

You’re Assigned Role:

What would you tell the pregnant person?

If you are assigned to be the pregnant person:

“What decision might you make in this situation? What does it feel like to have so many people
telling you what to do? How is this input affecting your decision-making?”

After reading the scenario, please answer the following questions in your discussion
activities:

           ●      Teens unable to process pregnancy results

           ●      Supportive boyfriend (both are scared)

           ●      Religious upbringing/education

           ●      Educational goals

           ●      Feelings of disappointment for their families

           ●      Financial impact for both families




                                                                Module 4 Page 11
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Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Scenario I - Anne

Pregnant person (1): 35-year-old woman. Very career
oriented. She works long hours and is often away from home. She is 20 weeks pregnant. She
never wanted children. She is an only child.

Health Care Provider – OB/GYN Nurse (2): Her sister has been trying to have a baby
unsuccessfully for 10 years. She has been considering adoption.

Father of the baby (3): Also career oriented. Has always wanted to raise a family. Has had a
two-year relationship with the pregnant person. Has gone to prenatal appointments and is
supportive.

Mother of pregnant person (4): Had difficulty getting pregnant and carrying a child to term.
She and her husband always wanted more children.

Friend of Pregnant Person (5): Best friend is married with two children. She regrets the time
her children take away from her career.

Work associate (6): She works in fast paced banking business. Work projects are completed as
a team.




                                                                Module 4 Page 12
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4




Scenario II- Wilma

Pregnant person (1): A seventeen-year-old Native American girl who just delivered baby in the
hospital. She is graduating from high school in one month and plans on joining the Navy. She is
the oldest of six children.

Her parents (mother or father...pick one) (2): Are very upset, as they didn’t know about the
pregnancy. They struggle to make ends meet for six children. Parents were excited for daughter
to enter the Navy as they feel it is the first “career” in their family.

Health care provider – OB/GYN Nurse (3): Raising a grandbaby.

Father of the baby (4): Is fifteen years old and a sophomore in high school.

Navy recruiter (5): Can’t join the Navy with dependents.

Friend (6): Attends alternative school and has 6-month-old baby in home. She often complains
about how she has no time to hang out with her friends and that no one helps her with her baby.




                                                                Module 4 Page 13
                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Scenario III - Mary

Pregnant person (1): Twenty-two years old. She has two children ages four and two years. She
currently lives with her mother who helps her raise the children. She is 10 weeks pregnant and an
ultrasound reveals the baby has possible birth defects, as the head size is larger than normal.
Mother works part time at Walgreen’s and is attending junior college at night for a degree as a
pharmacy technician.

Father of the baby (2): Not recently in touch. They had a casual relationship. He lives in a
neighboring town. He is married with two children. She just told him that she is pregnant.

Health care provider – OB/GYN Nurse (3): Single parent raising two children. One of the
children has spina bifida.

Mother of pregnant person (4): Very religious and involved in the community church. She
expresses her wish to have more free time to herself as she is overwhelmed with caring for her
grandchildren while Mary works and goes to school.

Friend (5): Married, has four children. Full time stay at home mother, enjoys being a mother
but wishes she had completed college and had a career. She envies Mary somewhat in that she is
pursuing her degree.

Boss at work (6): Wants to give her more hours and promises her a job as a pharmacy
technician upon completion of degree.




                                                                Module 4 Page 14
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Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4



Scenario IV - Regina

Regina (1): Regina a 16-year-old Latina, just received news that her pregnancy test is positive.
She is in shock and unable to process the information. Her boyfriend is with her and he is in the
same state of shock. Her first response is; “How am I going to tell my parents? They have
struggled to keep me in catholic/private school; I was going to be the first one in my family to
attend college.” Her boyfriend also agrees with her statement. The boyfriend is trying to be
supportive but both are holding back their full emotions.

Birth father David (2): David, a 16-year-old Latino, is with his girlfriend when they receive the
news that the pregnancy test is positive. He is an honor roll student and actively involved in
school activities. He plans on attending a major university and intends to further his education
and receive his master’s degree. He is very supportive of his girlfriend but is now unsure of their
futures.

Health care provider- medical assistant (3): She was also a teen mother who was unable to
continue her education to become a registered nurse. Being a single mother with responsibilities
had a financial impact on her ability to further her education.
         Health care provider, describes options
                Due to religious upbringing, termination of the pregnancy is not an option.
                Health care provider mentions how she was a teen mom and her struggles.
                Opportunity to mention adoption options.
Parents of girl (4): Parents had been on the strict side, but since she had been doing well in
school and has never given her parents any problems they both agreed that it would be okay for
her to have a boyfriend, as long as it did not interfere with school. The daughter is the eldest of
four children two bothers and a younger sister. Both parents work and are very involved in
church activities. In the past, she has overheard her parents talking about someone’s daughter
who was pregnant and how disappointing it must be for her parents after they provided her with
everything. How could she do this to them? (betrayal or ungrateful feelings towards daughter)

Parents of boy (5): Parents have a very open relationship with their son; he is the eldest child of
three brothers. Both parents are employed and have placed a high value on education. They have
also struggled to keep him in catholic/private school. They have been forthcoming regarding his
education by explaining the importance of attending college in order to better himself. His
parents have constantly spoken to him regarding sexual activity and reminded him of individuals
who did not continue their education because their girlfriends became pregnant. They have high
educational expectations for their son.




                                                                Module 4 Page 15
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                                                                                                                           Unified Curriculum
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Scenario V: Trainee’s Develop Scenario Common to their Settings




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                                                                                                                           Unified Curriculum
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To Find Out More About It
Applegate, Jeffrey. (1988). Adolescent Fatherhood: Developmental Perils and Potentials.
Child and Adolescent Social Work, 5, 3 205-217.
Berry, Helen, Shillington, Audrey, Peak, Terry, Hohman, Melinda. (2000). Multi-Ethnic
Comparison of Risk and Protective Factors for Adolescent Pregnancy. Child and Adolescent
Social Work Journal, 17, 2, 79-96.
Blake, Susan, Simkin, Linda, Ledsky, Rebecca, Perkins, Cheryl, Calabrese, Joseph. (2001).
Effects of a Parent-Child Communications Intervention on Young Adolescents’ Risk for Early
Onset of Sexual Intercourse. Family Planning Perspectives, 33, 2, 52-61.
Brindis, Claire, Boggess, Jan, Katsuranis, Frances, Mantell, Maxine, McCarter, Virginia, Wolfe,
Amy. (1998). Family Planning Perspectives, 30, 2, 63-123.
Christmon, Kenneth. (1990). The Unwed Adolescent Father’s Perceptions of his Family and of
Himself as a Father. Child and Adolescent Social Work Journal, 7, 4. 275-283.
Clapton, G. (1997). Birth fathers, the adoption process and fatherhood. Adoption & Fostering,
21 (1), 29-36.
Corcoran, Jacqueline. (2001). Multi-Systemic Influences on the Family Functioning of Teens
Attending Pregnancy Prevention Programs. Child and Adolescent Social Work Journal, 18, 1,
37-49.
Cushman, Linda, Kalmuss, Debra Namerow, Pearila. Placing an Infant for Adoption: The
Experiences of Young Birth mothers. ( 1993) Social Work, 38, 3, 264-279.
Dunst, C., Trifetter, C., Deal, A. (1988). Enabling and Empowering Families: Principles and
Guidelines for Practice. Cambridge: Brookline Books.
Dworkin, R.J., Harding, J.T., Schreiber, N.B. (1993). Parenting or placing: Decision making by
pregnant teens. Youth and Society, 25, 75-92.
Gold, Rachel, Sonfield, Adam. (2001). Family Planning Perspectives, 33, 2, 81-87.
Harner, Holly M., Burgess, Ann W., Asher, Janice B. (2001). Caring for Pregnant Teenagers:
Mediolegal Issues for Nurses. Journal of Obstetrics, Gynecologic and Neonatal Nursing, 30, 2,
139-147.
Kalmuss, D. (1992). Adoption and Black teenagers: The viability of a pregnancy resolution
strategy. Journal of Marriage and the Family, 54, 75-92
Kingon, Yvonne S., O’Sullivan, Ann L. (2001). The Family as a Protective Asset in Adolescent
Development. Journal of Holistic Nursing, 19, 2, 102-121.
Koniak-Griffin, Deborah, Turner-Pluta, Carmen. (2000). Health Risks and Psychosocial
Outcomes of Early Childbearing: A Review of the Literature. Journal of Perinatal & Neonatal
Nursing, 15, 2, 1-17.


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                                                               Participant Handbook

Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org
                                                                                                                           Unified Curriculum
                                                                                                                                    Module 4


Kring, Thomas C. (1998) The Adolescent Family Life Program and Adoption Research.
Adoption Quarterly, 2, 47-54.
Lane, Terry S., Clay, Cassandra. (2000). Meeting the Service Needs of Young Fathers. Child
and Adolescent Social Work Journal, 17, 1, 35-53.
Mason, M.M. (1995). Out of the shadows: Birth fathers’ stories. Edina, MN: O.J. Howard
Publishing.
Propst, Maureen G., Phillips, Billie Rhea, Andrew, Michael. (2001) Addressing Sexuality-
Related Needs in Practice: Perspectives of Maternal/Child and Women’s Health Nurses.
Journal of Continuing Education in Nursing, 32, 4, 177-182.
Risley-Curtiss, Christina. (1997). Sexual Activity and Contraceptive Use Among Children
Entering Out-of-Home care. Child Welfare, LSSVI, 4, 475-497.
Sachdev, P. (1991). The birth father: A neglected element in the adoption equation. Families in
Society, 72, 131-138.
Santelli, John, Robin, Leah, Brener, Nancy, Lowry, Richard. (2001). Timing of Alcohol and
Other Drug Use and Sexual Risk Behaviors Among Unmarried Adolescents and Young Adults.
Family Planning Perspectives, 33, 5, 200-205.
Santelli, John, Lindberg, Laura, Adma, Joyce, McNeely Clea, Resnick, Michael. (2000)
Adolescent Sexual Behavior: Estimates and Trends From Four Nationally Representative
Surveys. Family Planning Perspectives, 32, 4, 156-165.
Somers, Cheryl, Fahlman, Mariane. (2001). Effectiveness of the “Baby Think It Over” Teen
Pregnancy Program. Journal of School Health, 71, 5, 188-195.
Stevenson, Wendy, Maton, Kenneth, Teti, Douglas. (1999). Social support, relationship quality,
and well-being among pregnant adolescents. Journal of Adolescence. 22, 109-121.
VanOrnum, W., Mordock, J.B. (1991). Crisis Counseling with Children and Adolescents: A
guide for Nonprofessional Counselors. New York: Continuum Publishing Co.
Vincent, Murray L., Paine-Andrews, Adrienne, Fisher, Jacquie, Deveraux, Randolph, Dolan,
Holly, Harris, Kari, Reinger, Belinda. (2000). Replication of a Community-Based
Multicomponent Teen Pregnancy Prevention Model: Realities and Challenges. Family
Community Health, 23, 28-45.
Whitaker, Daniel, Miller, Kis, Clark, Leslie. (2000). Reconceptualizing Adolescent Sexual
Behavior: Beyond Did They or Didn’t They? Family Planning Perspectives, 32, 3, 111-117.
Williams, Elizabeth, Sadler Lois. (2001). Effects of an Urban High School-Based Child Care
Center on Self-Selected Adolescent Parents and Their Children. Journal of School Health, 71, 2,
47-51.
Zavodny, Madeline. (2001). The Effect of Partners’ Characteristics on Teenage Pregnancy and
Its Resolution. Family Planning Perspectives, 33,5, 192-199.


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Cultural Responsiveness in Providing Options Counseling
This article will provide foundational information on offering options counseling that is
culturally responsive and engagement oriented. Its intent is to provide insight on how the health
care professional may better operate in providing options counseling in an ever increasing multi-
cultural society and not to give a “one step” formula for culturally competent practice.

The concept of cultural competence continues to evolve, as various professions tackle this
challenging subject matter. Along with its underlying issues of racism and discrimination,
conversations regarding cultural competence can leave persons vulnerable to criticism and guilt.
As the health care profession strives to provide equal treatment to all patients/clients, health care
professionals, adoption counselors and social workers must consider their own cultural
association and how it impacts their practice. Health care professionals must also take a critical
look at how a patient’s/client’s culture may influence his/her decision making skills and how
he/she is likely to respond to the options that are offered.

Definition of Culture, Cultural Responsiveness, and Cultural Competence
According to the Office of Women and Minority Health in the Bureau of Primary Health Care
(HRSA), culture refers to “...integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic,
religious, or social groups.” This definition can be broadened by Diller’s idea that traditional
ideas and related values are “...transferred from generation to generation,” thus providing people
with ways to live and cope with life’s problems. (Diller, 1999)

Some believe that culture is learned, as it is partially made up of behaviors, values, and beliefs,
which are passed on from generation to generation. Culture is threaded both consciously and
subconsciously throughout the workings of everyday life, and can impact day to day decisions.
It can illustrate an individual’s personal identification such as race, ethnicity, religion, gender,
class, nationality and has influence on thoughts, actions and interactions with others. (Williams-
Gray, 2001)

Cultural responsiveness is an active term that requires the health care professional to treat every
patient/client as an individual first and understand that he/she will not automatically respond in a
manner that is consistent with his/her culture’s norms and values. Furthermore, the actions or
responses of a patient/client from a represented cultural group, will not provide the template of
responses for all other members of the same culture.

Cultural competence requires continuous self-assessment; expansion of one’s knowledge base of
other cultures; respect for cultural differences, and the ability to adapt to meet the needs of
diverse populations. (Cross, 1988) As it relates to health care, the American Association of
Colleges of Nursing recommends that nursing graduates have the capabilities to “...provide
holistic care that addresses the needs of diverse populations.” (American Association of Colleges
of Nursing, 1998)

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Cultural Self Awareness
One step in becoming more culturally responsive is to “become grounded in learning about one’s
own cultural background and heritage, and then proceed to learn about other groups’ cultural
values and beliefs.”(Lecca et.al, 1998). Another step would be to consciously recognize the
effect of one’s culture in viewing the world. Cross-cultural misunderstanding may be evident
when it is consciously or subconsciously assumed that one’s own cultural norms are the
standards everyone else follows. (Diller, 1999) According to Williams-Gray (2001), “...cultural
differences may produce perceptions, coping styles, or beliefs that appear strange or even
irrational to practitioners.” Health professionals need to check and recheck their perceptions and
interpretations of behaviors. This is particularly true when working cross-culturally. It can also
be helpful for health practitioners to learn as much about other cultures as possible. Asking
patients/clients to be “cultural guides” is one strengths-based technique for doing this. However,
the practitioner should continue to keep in mind that one person’s views are not necessarily a
representative of an entire cultural group, nor should one be placed in that representative role.
Furthermore, the patient/client may possess feelings of ambivalence or resistance in being asked
to “teach” the uninformed health professional.

Engagement
Health care provider’s perceptions about different cultures may impact engagement with
patients/clients and the types of options that are offered. When working with people of varying
cultures, it is important to make sure that the language used is universally understood. The
culturally responsive health care provider needs to ensure that the patient/client understands all
of the options available. This may be as simple as speaking in clear, easily understandable terms;
having a translator present or referring the patient/client to an agency that can communicate in
his/her native tongue.

The health care practitioner can use the same techniques to engage a multi-cultural patient/client
as he/she uses with clients of similar backgrounds; being respectful, warm, and sincere. The goal
is to gain the patient’s/client’s trust. This can be done by explaining what will happen during the
interaction and such important concepts as confidentiality.

During the assessment process, open-ended questions can be useful in the avoidance of cultural
stereotyping, and providing individualized treatment. The patient/client needs to be allowed to
“tell his/her story in his/her own words” while the health practitioner is respectful and supportive
of the emotional feelings the situation might illicit. Open-ended questions also provide answers
to “...a woman’s beliefs and values, health related behaviors, and cultural rituals and practices.”
(Callister, 2000) Patients/clients need to be encouraged to ask questions, while the health
professional continuously checks to insure the information that is being disseminated is
understood. The health care practitioner needs to be open to including a patient’s/client’s family
members, close friends, and/or members of their “community” in the decision making process as
per the patient’s/client’s wishes.

Due to the history and current existence of racism and discrimination, health care providers must
be aware that there could be perceived power differentials that exist between them and their
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patients/clients. Patients/clients from non-dominant, cultural groups may be mistrusting, and not
fully engaged in options counseling. Culturally responsive health care providers however, can
engage a mistrusting patient/client by shifting perceived power through what is called the
“ultimate connection.” (Jordan, 1998) Jordan (1998) further states “…the ultimate connection
must be the need we find between us…it is not only who you are, but what we can do for each
other.”

Becoming a culturally competent health care professional is a lifelong process. All humans
struggle with the pitfalls of stereotyping, cross-cultural misunderstanding, and language barriers.
However, when a commitment is made to provide culturally responsive services, patients/clients
can receive high quality health care services that are nonjudgmental and facilitate informed
decision-making.




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References:
Abrums, M. and Leppa, C. (2001). “Beyond Cultural Competence: Teaching about Race,
Gender, Class, and Sexual Orientation”. Journal of Nursing Education, 40(6) 270-275.

American Association of Colleges of Nursing. (1998). The Essentials of Baccalaureate
Education for Professional Nursing Practice. Washington, DC.

Boyd-Webb, Nancy (2001). “Strains and Challenges of Culturally Diverse Practice: A Review
with Suggestions to Avoid Culturally Based Impasses.” (pp. 337-350) Culturally Diverse
Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners.
New York, Columbia University Press Publishers.

Boyd-Webb, Nancy (2001). “Educating Students and Practitioners for Culturally Responsive
Practice.”(pp. 351-360) Culturally Diverse Parent-Child and Family Relationships: A Guide for
Social Workers and other Practitioners. New York, Columbia University Press Publishers.

Callister, Lynn Clark. (2001). “Culturally Competent Care of Women and Newborns:
Knowledge, Attitude, and Skills”. JOGNN Clinical Issues, 30( 2) 209-215.

Cross, T.L. (1988). “Services to Minority Populations: What Does It Mean to be a Culturally
Competent Professional?” Focal Point. Portland, OR” Research and Training Center, Portland
State University.

Diller, Jerry (1999). Cultural Diversity: A Primer for the Human Services. Belmont, CA.
Wadsworth Publishing.

Jordan, J. (1998). “Report from the Bahamas”. In M.L. Anderson, & P.H. Collins (Eds.), Race,
Class, and Gender: An Anthology. (pp. 34-43). Belmont, CA. Wadsworth Publishing Co.

Lecca, Pedro J., Quervalu, Ivan, Nunes, Joao, Gonzales, Hector F. (1998). Cultural Competency
In Health, Social, & Human Services. New York, Garland Publishing, Inc.

William-Gray, Brenda (2001). “A Framework for Culturally Responsive Practice” Culturally
Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other
Practitioners. (pp. 55-83). New York, Columbia University Press Publishers.


                                                                                                                        Natalie Lyons, MSW
                                                                                                                      Spaulding For Children

                                                                                                                              February 2002


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Social, Cultural and Personal Influences
Latino/Hispanic families have always had a long-standing history of adoption. The adoption
practice most commonly found in the Latino/Hispanic culture is that of informal kinship care.
Latino/Hispanic families have traditionally believed that there was no need to formalize this
process for a child who was blood related, a godchild and/or a close family friend. Most families
feel that as long as the need of the child is being met, that the child is cared for and safe there
was no need to formalize the situation. Adoption in most Latin American cultures has been
viewed as a luxury that only wealthy people could afford. Even today, in the United States you
will find that a good majority of Latino/Hispanic families continue with the tradition of informal
adoption.

Concerns for informal adoption care providers’ surface when they attempt to meet the medical
needs of the children in their care. Medical issues for most Latino/Hispanic children are handled
through medical clinics where information is not as cumbersome as to parental information or
guardianship unless there is a major medical problem with the child. It is not until the child is
ready to enroll in pre-school or school, do they begin to encounter problems with guardianship of
the child. At this point a family may consider seeking legal advice regarding their options.

Statistics on the number of children in an informal kinship care setting are unknown. We can
only estimate the number of children who are being taken care of by grandparents, aunts, uncles
and godparents. Most of these children that are in an informal setting are not receiving any type
of monetary or medical assistance. The statistics that we can refer to are through the actual
Department of Children and Family Services, (DCFS) system that truly do not reflect accurate
numbers.

The reasons why most Latino/Hispanic families do not formalize kinship adoptions range from
mistrust of government agencies, cultural and linguistic barriers along with agencies unable to
make the personal connections with families. A major issue facing some Latino/Hispanic
families that may prevent them from formalizing adoption is their immigration status or the
immigration status of the child.

In order for Latino/Hispanic families to formalize the adoption process, agencies must be willing
to meet the needs of families and children both culturally and linguistically. Ideally we need to
focus on a recruitment plan that targets not only kinship care but also one that recruits adoptive
parents in open, semi-open or closed adoptions. In doing this, we must address the cultural
myths through the years about adoption.

Emphasis must be put on why a birth mother chooses adoption for her infant. It is not that the
birth mother is abandoning the infant. She is making a life long decision to give her infant a
better life. We must clarify that making this type of decision is not abandonment or letting go of
her responsibility but in fact the birth mother is making a decision that is in the best interest of
the infant and herself. That adoption will provide a loving and stable environment for the infant.

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In cases of kinship care, it is just as important for families to formalize the adoption process.
Even though Latino/Hispanic families have traditionally been supportive of family members or
close friends that is no longer sufficient because of the changes in today’s society. Today’s
families must prove they have authorization to act on the best interest of a child when accessing
medical attention, financial and when enrolling the child into school. We need to stress that
kinship care adoption is not taking the place of the birth mother instead it is providing the infant
with life long connection to their birth family and security in a stable home environment.

Latino /Hispanic culture has traditionally been viewed adoption as a luxury that only wealthy
families who were unable to have birth children could obtain. But along with this myth is the
underlying sentiment that there must be a reason why “God” has not blessed a couple with birth
children. The question then arises regarding fertility whether he is not man enough to give his
wife a child or vice versa she is not a whole woman because she is unable to bear a child for her
husband; why would a couple want to adopt a child that is no relation to them; why would a
couple want to care for children who most likely will have problems? We must address these old
myths, that there are medical reasons why a couple cannot bare birth children of their own. We
need to stress that regardless if a child is a birth child or an adoptive child, they deserve to have a
loving stable home.

Religious pressures within the Roman Catholic and other Christian faiths impact cultural myths.
The Roman Catholic faith is the dominant religion of most Latin American countries followed by
other Christian faiths. Religion has always played a major role within Latin/Hispanic families
especially with recent immigrants and first/second generations. Levels of acculturations depend
on how long an immigrant has lived in the United States and how they make sense of their values
from their county of origin and integrate those values in their new host country. A person’s
acculturation level may also impact their preferences in types of music, food and language.
Religious examples pertaining to differences in acculturation can be observed by religious
artifacts worn by patients, going to religious services on a weekly basis, having alters in their
home. More acculturated Latinos (third and fourth generation) may attend religious services on
major religious holidays and may not display religious items in their homes or display them in
private areas of their home.

In some instances a birth mother may seek counsel from the pastor of her church before going to
any family members or friends. This is additional pressure the birth mother faces while making
her decision. The overtone that most pastors will advise is “Accept what God has given you” or
“Children are a gift from God and should be accepted regardless the situation.”

A longtime myth is that Latina/Hispanic mothers do not make adoption plans. In the past this
may have been true but we are now seeing increasing numbers of birth mothers moving in this
direction especially when given their full options. Latina/Hispanic birth mothers are just like any
other women who are trying to make fully informed decisions.



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Historically Latino families have had strong religious, cultural, linguistic and family ties. Any
issues arising within the family ranging from personal, medical, social to financial have always
been taken care of within the family. A common statement or sentiment that most
Latino/Hispanic reference to in the context or format that “God” will take care of us or he will
guide us to making the right decision or all we can do is leave it in the hands of the lord. This
frame of thought, arranges from relationships, marriage, finances, child bearing and death.
Regardless of the living situation or financial impact, Latino/Hispanic families are very proud
and share whatever resources they have to help someone in need especially a family member or
close family friend.

In dealing with Latino families today, especially in California and across the United States, there
are different levels of acculturation that range from recent immigrants, first generation to fourth
and fifth generations. These differences can also be found inter-racially among
Latinos/Hispanics. There are slight differences among Latinos/Hispanics ranging from their
food to their pronunciation of the Spanish language. The underlying commonality is that they
are all family and religiously focused. Culturally and linguistically there will be differences in
the type of approach used when counseling a family or providing them with information and
resources. Responses may also vary pending on their acculturation level.

Health care providers must be aware of these dynamics and how levels of acculturation in their
patients may impact services delivery. This awareness will help with the delivery of culturally
sensitive in working with these families. A recent immigrant and/or first generation Latino will
have values or cultural pressures that are tied closer to their home of origin. Wherein a third or
fourth generation Latino would be considered to be more Americanized and less adapt to have
direct cultural or religious pressures. Family relationships may be distant instead of the close knit
structure of an immigrant or first generation Latino.


                                                   Maria L Quintanilla, MSW, LCSW, Executive Director
                                                                               Latino Family Institute Inc.
                                                                                  West Covina, California
                                Francis Marron-Zamerripa, IAATP Program Director Latino Family Institute
                                                            Gloria Cortez, Liaison Latino Family Institute
                                                                                            January 2005




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Techniques for Engaging Birth Father
Someone who may bear a great deal of influence on the decision to be made is the father of the
baby. It is the mother of the baby’s decision to determine how she wants the father of the baby
engaged in the process of discussing pregnancy options with the health care professional. Once
she makes the decision to include him in the discussion, it is the health care professional’s
responsibility to engage him in the process. It would be beneficial for all parties involved to
have the father of the baby involved as soon as possible so that he can be a positive support to
the mother as she makes her decisions.

Skills to engage the fathers:
Health care professionals should be welcoming and helpful in encouraging him to support the
birth mother and setting the couple on the right path for getting the help they need to make
options decisions together.

Health care professionals can facilitate informed decision making by identifying birth father
strengths and building on those in making referrals.

It is important for health care professionals to engage interested birth fathers using the same
techniques used to engage others: treating them with dignity and respect; actively listening to
their concerns and being nonjudgmental.

If the father is at all involved with the mother, he will play a significant role in her pregnancy
option decision. Therefore, he should have as much information as possible to help him support
her decision-making process and issues of pregnancy so that he can become a partner in
informed decision-making regarding pregnancy options. However, the decision to involve him is
totally within the control of the pregnant woman.

Birth fathers can be encouraged to become informed about the experiences and issues of
pregnancy.

Birth fathers who release their parental rights may experience loss and may find it helpful to talk
about this with others, either in a professional or peer support setting. Therefore it is beneficial to
provide referrals to local resources and support groups for fathers.

Once the choice has been made to make an adoption plan, birth fathers can be encouraged to
provide information about themselves, their medical history and their interest in contact with
their child when he/she is an adult.

In open adoption, birth fathers may be able to maintain on-going contact with their child and
update any personal or medical information for the adoptive family

    Attending to his questions and concerns using the same nondirective, noncoercive techniques
     discussed previously.
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    Having resource information available about the role of the father in pregnancy care, birth,
     and parenting.
    Have male oriented items in the office including décor, magazines, coffee, and information
     about fathering and fatherhood programs.




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Checklist:
    Are there visual cues to tell men that they are welcome?
    Are staff comfortable talking to men, of all backgrounds?
    Are staff utilizing engagement skills to welcome and involve the fathers?
    Are there strategies in place to engage fathers when they arrive at the center or clinic?
    Are there male friendly books, magazines, activities?
    Are there father friendly posters or displays in the lobby and rooms of the clinic?
    Are there written materials specific to the needs of the fathers?
    Are there specific referrals and resources available for males?
    Are there any other supportive activities geared toward men?




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Adolescence and the Adoption Option
Research indicates that 1%- 5% of teens faced with an unplanned pregnancy are likely to choose
adoption as an option for their child. The last 50 years has seen tremendous change in society’s
perception of unmarried women who elect to keep their babies and raise them as single parents.
Gone are the days when family and friends routinely coerced unwed mothers to conceal their
pregnancies and subsequently release their child for adoption. The pendulum has swung to the
other extreme where the expectation is often that young women will raise their child. Even
adolescents who are ill equipped to parent a child feel a tremendous amount of societal pressure
to do so. Often teens feel that considering placing their babies for adoption signifies that they do
not care about their infants and that even considering the adoption option will be seen negatively
by peers and family. Research confirms this trend as very young teens are becoming pregnant
and the number of teens raising their children as single parents is increasing. Adolescents who
are likely to consider adoption are those who have aspirations for college or other life goals and
whose family and friends support the idea of adoption.
The Impact of Adolescent Development on the Adoption Option:
Anyone raising or working with adolescents recognizes that the psychological developmental
tasks of this age group bear a striking resemblance to those of preschool children. The primary
task for both age groups is to separate from the family. The goal of preschoolers is to find their
place as individuals within the family, while the goal of adolescents is to find their place as
independent individuals within society. This developmental imperative requires that the
adolescent revisit many earlier stages of development including egocentrism, magical thinking
and differentiation from caregivers. Any developmental issues that were poorly handled in the
preschool years may reemerge in the adolescent years.
Adolescence also serves as the staging area for teens to learn how to make decisions, often
through trial and error and without the benefit of good coping skills when problems arise.
Resolution of these developmental issues can result in frustration and the reemergence of control
battles between teens and authority figures. Normal developmental tasks can be complicated by
pregnancy and impact how the adolescent views the option of adoption.
Choosing adoption is often referred to as an unselfish act that a mother can perform for her child.
This level of selflessness requires that the individual put their own needs aside to meet the needs
of another. Pregnant teens, especially those in early and middle adolescence (11 – 17 years of
age) or those who have experienced trauma that has impacted their development, are at a stage
where they see the world as revolving around them. This level of egocentrism does not allow
them to think beyond their own needs to those of their unborn child.
Egocentric thinking has adolescents viewing the child in terms of what he/she can provide for the
teen including: unconditional love; a way to get out of a bad life situation; a boyfriend staying
with them and/or supporting them; a disorganized or dysfunctional family staying together; a
higher social status and/or increased independence. Egocentric and magical thinking also hinders
a teens’ ability to learn from others or take the experiences of other teens and apply them to their
situation. These are the teens that have difficulty considering future planning and who refuse to
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believe that they will have difficulty after the child is born. Their feeling is ‘it won’t happen to
me’.
Developmentally, teens are more likely to discount or reject advice and direction from parents
and other adults as part of the task of establishing themselves as independent beings. Pregnant
teens are being asked to follow doctors orders, get plenty of rest, eat nutritious foods, stop
smoking, etc., all of which contradicts the adolescent’s need to test the rules and push the
boundaries. Teens who perceive that adults have a ‘hidden agenda’ around adoption or are
exerting pressure on them to release the child for adoption are likely to engage in control battles
as a way to exert their independence. Suspicion of adoption as an adult controlled process
designed to exploit them may also be an issue for teens who are striving for independence.


Implications for Health Care Providers:
Respecting the pregnant teen and understanding her world-view is the first step in offering
effective services. This perspective keeps in mind that the pregnant adolescent’s need to strive
for independence during a time of crisis will bring all of her dependency issues to the surface.
Often this process includes angry outbursts that may be directed toward the health care
professional. Not taking this behavior personally is vital in effectively working with teens.
Allowing the teen as much control over the process as possible, despite outburst of anger and
immaturity, is the key. Offering choices whenever possible will also help the teen to feel a sense
of control.
Despite the fact that teens tend not to be verbal and to give superficial answers when initially
dealing with authority figures, they still need information. Pregnant teens need concrete
information that will help them explore options. Even if the teen is likely to initially dismiss
adoption as an option she needs information about adoption to demystify the process. Teens need
to be given the message that they can ask questions about the adoption process and to know that
no question they ask is going to be perceived as unimportant. Pregnant teens are being asked to
consider information and make decisions that require mature decision-making skills. They need
to hear all of the information and they may need to hear it more than once and in different ways
to be able to utilize it. They also may need help to evaluate the information and weigh
alternatives such as looking at the pros and cons of placing their child for adoption.
Because adolescents have difficulty with future thinking and anticipatory problem solving, they
often underestimate the task of parenting until they are faced with the challenges of raising a
child. Often it is not until the child is three to six months of age that the reality sets in for the teen
mother. Even though the societal expectation is that teens will raise their children, the extent of
the support they can expect from family and friends is changing. The mothers of very young
teens who become pregnant may still be in the work force and unable or unwilling to offer the
level of care that both the teen mother and her child will require. As families have become more
mobile and more nuclear in nature, extended family as a support to teens raising babies may not
be an option.


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Peers who were supportive during the pregnancy often leave the new mother behind as they go
on with their lives as adolescents; a life style the teen mother no longer has the luxury of
enjoying. For the first time she may understand that she is giving up her adolescence to become a
parent. Health care and other helping professionals may want to consider keeping the adoption
option open for discussion after the birth of the child when the teen is faced with the reality of
parenting an infant. Raising the subject of what is best for the child and the teen at this stage,
may be an issue the teen mother is now willing to explore. The timing of an intervention is often
what makes it successful.
Adolescents who have placed their infants for adoption require long-term support. Health care
providers who will be having an ongoing relationship with a teen who has placed her child for
adoption will need to provide opportunities for the adolescent to process the adoption experience.
Being open to the adolescents’ feelings of grief and loss will help her integrate the experience
and develop coping skills that serve to meet her emotional needs. Often referrals to support
groups for teens that have placed their babies for adoption can be helpful.


Managing Conflict Between Parents and Teens Facing an Unplanned Pregnancy:
The very nature of adolescence is to work through the task of differentiating from adult authority
figures. Pregnancy in the life of the teen may refocus this struggle and can precipitate crisis in
the family. Many parents will attempt to assert control over the pregnant teen by trying to make
all of the decisions. For many teens this is their cue to become defiant, rejecting the parents
attempt to control. Many regress to more infantile behavior that engages the parent and teen in a
counterproductive control battle. Often the health care provider finds himself/herself in the
midst of this conflict. Assessing the nature of the conflict and acting as a mediator to defuse the
anger and/or negative emotions is a role that can fall to the health care provider.
The first step in this process is to allow the parent and the teen to have an opportunity to vent
their feelings. This requires that the health care professional be able to take a step back and
listen in a nonjudgmental way. Letting the parties know that they have been heard will make it
easier to move the interaction from venting to working on the issues at hand.
A parents’ anger is never the primary emotional reaction when a teen is pregnant. Anger almost
always occurs after a fear reaction and is used to hide the fear. This anger can be misdirected to
the helping professional, but it is important to remember not to take on the anger. This is vital for
the health care provider to be able to listen for what the parents are fearful of and to be able to
address that fear. The fear can be addressed directly if the parent will not feel ashamed of being
afraid. A direct response to a parent’s anger might include the following: “I know you are
anxious about how this pregnancy will affect your daughter’s future, and I want you to know that
I am willing to help you look at all of the options.” If the parent is likely to feel ashamed of being
afraid, more anger will occur in an attempt to hide the shame if the fear is addressed directly. In
this instance an indirect response might include the following: “It takes a lot of courage to ask
for help in supporting your daughter, I can help you find the assistance you will need to work
through the issues” Letting the parent know that help and support are available may help to
lessen the fear and defuse the anger.
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Listening for the underlying message in what the parent is saying may give clues to his/her self-
esteem or self-evaluation, which may be the reason for his/her anger. Sometimes an angry
person’s words are the opposite of his/her true feelings and sometimes the words reflect a past
experience in a similar situation. Shifting the parents’ perspective to work on helping and
supporting the teen may help to defuse the anger.
Developmentally, teens face a host of difficulties coping with an unplanned pregnancy. Health
care providers will need to understand the developmental issues impacting the teens’ ability to
make future planning and to assist parents in helping to support the teen to make sound decisions
for herself and her child. Parents may need help to avoid control battles that encourage the teen
to act out around the pregnancy and interfere with the parent providing the support that the teen
will need. Teens need ongoing help and support to look at all of the options available to them
during their pregnancy and beyond.


References:
Harner, Holly M., Burgess, Ann W., Asher, Janice B. (2001). Caring for Pregnant Teenagers:
Mediolegal Issues for Nurses. Journal of Obstetrics, Gynecologic and Neonatal Nursing, 30, 2,
139-147.
Bilodeau, Lorrainne, (2001) Responding to Anger, A Workbook. Center City, MN: Hazelden.


                                                                                                    Rosemary Jackson, MSW, ACSW
                                                                                                      Karal Wasserman, MSW, CSW
                                                                                                         New View Consultants, Inc.
                                                                                                                      February 2002




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                                                                                                                                    Module 4



Families in Crisis
Family crisis is a stressful and disruptive event or series of events that comes with or without
warning and disturbs the equilibrium of the family. A family crisis can also occur when the
usual problem-solving methods of the family no longer work. All families will experience crisis
at some point.
Families respond to crisis in different ways. Some see them as challenges to be overcome.
Others become overwhelmed, feel helpless, hopeless and give up. Some seek help, others do it
on their own. Some emerge stronger and with a greater repertoire of resources and supports and
still others suffer severe psychological damage that can be demonstrated in the form of rage,
frustration or techniques to intimidate others in their lives.
Regardless of how they respond, families in crisis need help. It is also important to keep in mind
that families in crisis have resources and they can build on their strengths. Helping professionals
have a unique opportunity and responsibility to be of assistance to families facing crisis in a
broad variety of situations.

Crisis Theory:
The nature of crises has been well documented in the literature, which applies to both behavioral
health and physical health practitioners. Experts agree that a crisis occurs when some internal or
external force disrupts a family’s balance, altering its functioning and causing a loss of
equilibrium.
Coping strategies are those actions and ways of thinking that help families deal with and survive
difficult situations. In crisis, previously used coping strategies may no longer work. A crisis is
not simply the event that has occurred, but rather the way in which the family perceives that
event. Their perceptions are based on their previous “track record” of coping with adversity and
change, and the strength of their social support system.
Crisis is usually resolved in a short period of time, and can have either a strengthening or
weakening effect on the family unit. Although the crisis itself can be resolved, sometimes it’s
effects will influence the family for years to come. The new balance of the family can result in
changed relationships among it’s members, within it’s community and within each individual
member.




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Types of Crisis:
Developmental crises are periods of disruption that occur at identifiable, somewhat predictable
transition points during normal growth and development. One such crisis can be unplanned
pregnancy or parenthood, particularly for adolescents. There are many worries that accompany
this new role, including the fear of the unknown, the health of the child, the ability of the teen to
provide good care for the baby and the ambivalence about being responsible for the welfare of
another human being and giving up personal freedom.
Situational crises arise from external events that occur suddenly, without warning. The terrorist
attack upon the World Trade Center in New York on September 11, 2001 is an example of such
a crisis. Not only was it traumatic for the individuals directly touched by the tragedy, but it
impacted the entire nation and world. Situational crises cannot be planned or predicted and bring
up feelings of helplessness in many individuals. These feelings can be overcome by
participating in helping activities, such as donating blood, supporting the Red Cross or the
families of those killed in the bombing.
Other, more health related situational crises can include debilitating disease, domestic violence,
divorce, or unwanted pregnancy. These are all situations where families or one of their members
may seek out health care professionals to provide support and/or to intervene.
Multiple crises are those that overlap, or come in such quick succession that families are no
longer successful using their previous coping strategies. Research has shown that multiple crises
compound the stress, and can lead to ill health. It also points out that families who are able to
work through one crisis may find that multiple crises overwhelm them and cause more stress
than they can handle.

Crisis Intervention Techniques:
Nursing literature describes two methods of intervening in crisis situations, generic and
individual. The generic approach addresses the nature and course of the crisis rather than the
psychosocial functioning of the individual. This type of intervention does not require advanced
professional counseling skills and allows health care practitioners to work with any group of
people who have a crisis in common. An example would be a support group for early
adolescents who are pregnant.
There are five important elements in providing generic interventions: (1) encouraging
individuals and/or families to use the adaptive behaviors and coping strategies that have proven
helpful in the past (2) social support and the opportunity to be listened to without judgment (3)
the opportunity to identify strategies to cope with the practical and emotional future and (4)
anticipatory guidance or the opportunity to practice the strategies identified in element three (5)
providing the family with feelings of control and hope.
The individual approach works best with people who do not respond to generic intervention. It
is often wise to refer these families and/or individuals to counseling professionals who can
facilitate action toward gaining insight into the crisis, developing specific coping strategies and
regaining a sense of equilibrium and hope.
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The Role of the Health Care Provider:
The most important tool of the health care provider is a thorough, comprehensive assessment.
Asking the right questions and being a careful observer are key. In cases of domestic violence,
or child abuse, following the correct reporting and recording procedures are critical. In an
unplanned pregnancy, it is critical to discover the potential impact on the family system of
bringing another child into the family. A thorough assessment can be rapid if it focuses on
specific issues.
Some critical questions to assist in crisis assessment can include:
How does the family define or perceive the crisis?
Why has the family asked for help now?
How severe is the crisis?
What risks does the family face as a result of their feeling out of control?
Are others also at risk?
How does the family think the crisis will affect their future?
What precipitated the crisis?
When did the crisis occur?
Was the crisis situational or developmental?
Were there multiple crises?
What coping strategies have been successful for this family in the past?
What coping strategies has the family tried in this situation?
What new coping strategies is the family willing to try now?
What gives the family hope that things will improve?
The health care provider can use a problem- solving model to form the basis for the family crisis
resolution plan. This model includes the development of realistic future goals and perhaps some
preventive planning. It also includes techniques for helping the family find ways to resolve the
crisis. Assessment of the family’s needs are critical to good problem solving and are based on
the type of crisis the family is experiencing; the effect the crisis is having on the family’s life; the
ways other important people in their lives are effected and their strengths and available
resources.
While the plan is being carried out, it is important to have ongoing communication between the
health care provider and the family. The plan needs to be reviewed and updated as often as
possible so that it continues to be viable. Whenever possible, tasks need to be assigned with
timeframes attached so the family regains a feeling of control over their life.
To stabilize the changes the family makes to successfully master the crisis, the health care
provider can identify and reinforce all of the positive coping mechanisms and behaviors that
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were used. He/she can go on to discuss how these strategies worked and how they can be used to
handle future stressors. It is important to summarize the crisis experience by emphasizing the
family’s success. This will reinforce their feelings of self-confidence and of their abilities to
handle adversity in the future. It will also help them grow closer and feel stronger as a result of
their success. Most importantly, it will provide them with hope.


References:
Aguilera, D. (1990). Crisis Intervention: Theory and Methodology. St. Louis MO: The D.V.
Mosby Co.
Allender, Judith Ann RN,C, MSN, EdD, Spradley, Barbara Walton RN MN, (2001). Community
Health Nursing: Concepts and Practice. Fifth Edition. Lippincott Press, Philadelphia, New
York, Baltimore.
VanOrnum, W., Mordock, J.B. (1991) Crisis Counseling with Children and Adolescents: A
Guide for Nonprofessional Counselors. New York: Continuum Publishing Co.


                                                                                                       Karal Wasseman, MSW, CSW
                                                                                                    Rosemary Jackson, MSW, ACSW
                                                                                                         New View Consultants, Inc.
                                                                                                                      February 2002




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                                                                                                                           Unified Curriculum
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Helping Teens with Future Planning
Health care providers can adapt some of the person-centered-planning techniques used by mental
health professionals to help teens take responsibility for themselves and their pregnancy. These
techniques are similar to brief, nondirective, noncoercive interventions in that they involve a core
set of beliefs which include treating the patient/client with dignity and respect; providing them
with information so that they can make an informed decision and a lifeplan. They also include
ways to ask questions to really understand how a patient/client perceives his/her situation;
listening and hearing the patient’s/client’s story; and putting the patient/client in charge of
solving his/her problems.
Strategies for working with teens will differ depending on whether they are in early adolescence
(11-14 years of age); middle adolescence (15-17 years of age) or older adolescence (18 - 21
years of age). Chronological age cannot stand alone. Rather, a teen’s life experiences and
developmental age need to be factored in as well. While many teens appear much younger than
their years, there are those who are much older and wiser. Knowing the individual pregnant teen
that has come to you for guidance is vital.

Identify and increase social support:
The first step in helping a pregnant teen make a good future plan is to help her identify her
resources and support. This can begin as a brainstorming exercise, and can be reviewed
throughout the relationship with the health care provider. It can be expected that as the
pregnancy progresses, the teen’s social support network will change. This change can be a focus
of discussion that will help the teen look toward the future.
This can also be a time for teens to meet other teens who have experienced pregnancy. It will be
helpful to refer her to resources that will introduce her to women who chose to keep their babies,
those who chose to terminate their pregnancies and those who chose adoption. If at all possible,
the teen needs to have repeated contact with all of these “role models” so that as she thinks and
rethinks her situation, she can ask more questions and obtain more information.
While peer support is helpful, it is also crucial for teens to talk with a caring adult about these
interactions. During this process, inaccurate information can be corrected; myths can be
demystified; and the teen can have the guidance of a nonjudgmental, noncoercive adult who
cares. Often times, the health care provider is the only such adult in a teen’s life, and will be the
one to play this pivotal role.




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Role play and/or anticipatory guidance:
Helping pregnant teens practice how to handle difficult decisions, discussions and/or
relationships can be a key factor in building trust with a health care provider. This can be done
through role play, in which the teen rehearses what they will say to a parent or birth father and
the health care provider responds in the character of the parent or birth father. The process
involves refining the dialogue until the pregnant teen is comfortable with her words and the
potential responses they will elicit.
Anticipatory guidance is a technique in which the health care provider helps the pregnant teen
identify future issues that will need to be addressed, and works with her to develop a plan that
makes sense in her life. It involves asking future oriented questions and then helping the teen see
the issues that he/she will need to address. For example, asking what will change when the baby
is born can help guide the teen to think about how her life may change; the increased
responsibility she may take on; the ways in which relationships with friends and family may
change. Each of these areas can be explored through the use of open-ended questions that are
designed to help the pregnant teen make an informed decision.

Information:
As is true with adults, informed health-related decisions are key for teens. Because they are
experiencing a time of great change, that is heightened by pregnancy, they may need to have
information presented in a number of different ways, a number of different times. It is important
that the health care provider be patient, and present the options and/or facts each time as though
it were the first. It is also helpful to provide written materials, videotapes and to discuss each
resource to see how much the teen understands and how she sees the information applying to her.

Working with family crisis:
Pregnant teens often find themselves in conflict with their families, which creates a time of
crisis. The health care provider can work to defuse some of the emotions within the family and
to help them develop ways of coping with the pregnancy. Acknowledging that the family
balance is out of equilibrium as a result of the pregnancy and giving them hope that they have
options will result in a renewed sense of control. This control will enable them to make
informed decisions.
With teens, it is especially important to let them know that they have time after the baby is born
to rethink the option of adoption. Rather than pressure the teen to make an immediate decision
that will result in feelings of unresolved grief, shame and/or coercion, it will be important to
maintain long-term contact and revisit adoption. If the health care provider is unable to do this,
perhaps a referral to a community based program would be best.
Research shows that many pregnant teens mature quickly throughout their pregnancy and are
able to be good parents. Health care providers need to assess this throughout their relationship
with the teen, and continue to offer choices, hope and nonjudgmental support.


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References:
Allender, Judith Ann RN,C, MSN, EdD, Spradley, Barbara Walton RN MN, (2001). Community
Health Nursing: Concepts and Practice. Fifth Edition. Lippincott Press, Philadelphia, New
York, Baltimore.
Bilodeau, L.(2001). Responding to Anger, A Workbook. Center City, MN: Hazelden.
Dunst, C., Trivette, C, Deal, A. (1988). Enabling and Empowering Families: Principles and
Guidelines for Practice. Brookline Books, Cambridge.
VanOrnum, W., Mordock, J.B. (1991) Crisis Counseling with Children and Adolescents: A
Guide for Nonprofessional Counselors. New York: Continuum Publishing Co.


                                                                                               Karal Wasserman, MSW, CSW
                                                                                             Rosemary Jackson, MSW, ACSW
                                                                                      New View Consultants, Inc. February 2002




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Special Concerns for Adult and Teens


          Domestic Violence
          Substance Abuse
          Depression
          Mental Physically Impaired




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Domestic Violence
          Definition
          DV behaviors
          Power and control
          Cycle of violence
          Why people can’t just leave?

The Center for Disease Control defines domestic violence during pregnancy as “Physical, sexual,
or psychological/emotional violence, or threats of physical or sexual violence that are inflicted
on a pregnant woman”.
Furthermore, domestic violence can be a pattern of behavior in a relationship where one person
tries to gain power and control over another person. Because it is a pattern of behavior it can
continue to happen again and again in a relationship. Often, a victim will hope the abuse will
never happen again; but unfortunately, evidence has shown that the violence will continue.
Another characteristic of domestic violence is that the batterer will use physical harm to gain
power and control over the victim. (Please refer to Power and Control Wheel resource
information in Participant’s Handbook page 42)
It is also important to keep in mind that when you are providing care for a woman or teen with an
unplanned pregnancy that she is “four times more likely to suffer increased abuse as a result of
the unintended or wanted pregnancy.”
It is also important to consider that your patient/client might have a difficult time leaving
because the batterer has spent the entire relationship cutting that person off from other resources.
The person does not have the contacts with friends or family any longer and would have no one
to turn to if they did leave. Often a batterer will also threaten to further harm or kill the
individual or the children if she leaves.




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Domestic Violence Wheel
Individuals usually see domestic violence as only a physical act. The purpose of this sheet is to
show that batterers will use many methods to exert power and control over their partner.
Domestic violence is about power and control, not about being angry or losing your temper.
Other types of domestic violence are:
          Using coercion and threats
          Using intimidation
          Using emotional abuse
          Using isolation
          Minimizing, denying and blaming
          Using children
          Using male privilege
          Using economic abuse


Batterers will often use more than one of these behaviors to exert power and control over their
partner




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Substance Abuse
          You know the physical effects of drugs, alcohol and tobacco on the mother and the baby.
          Additionally it is important to consider the safety of the home environment in which the
           substance abuse occurs.
          The pregnant woman may be at risk of physical harm from persons in or entering the
           home under the influence of substances.
          Is home a safe environment for the pregnant woman? Consider having referral resources
           available which may include drug treatment centers, housing resources, substance abuse
           counselors, and domestic violence shelters.




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Clinical Depression
          What is clinical depression?
                 o Clinical depression is a serious and common disorder of mood that is pervasive,
                   intense and attacks the mind and body at the same time. Current theories indicate
                   that clinical depression may be associated with an imbalance of chemicals in the
                   brain that carry communications between nerve cells that control mood and other
                   bodily systems. Other factors may also come into play, such as negative life
                   experiences such as stress or loss, medication, other medical illnesses, and certain
                   personality traits and genetic factors.
          What are the signs and symptoms of depression?
                 o The symptoms of depression include feeling sad and blue, not enjoying activities
                   once found pleasurable, having difficulty doing things that used to be easy to do,
                   restlessness, fatigue, changes in sleep, appetite or weight, inability to make
                   decisions, feelings of worthlessness, and thoughts of death or suicide.
          Symptoms of depression
                 o persistent, sad, anxious or empty mood
                 o feelings of hopelessness or pessimism
                 o feelings of guilt, worthlessness or helplessness
                 o loss of interest or pleasure in ordinary activities
                 o decreased energy, a feeling of fatigue
                 o difficulty concentrating or making decisions
                 o restlessness or irritability
                 o inability to sleep or oversleeping
                 o changes in appetite or weight
                 o unexplained aches and pains
                 o thoughts of death or suicide




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          There are several types of depression -- major depression, dysthymia, bipolar
           depression, and Seasonal Affective Disorder.


                 o Major depression is the most common type of depression and is characterized by
                   at least five of the major symptoms of depression.
                 o Dysthymia is a milder form of depression that lasts two years or more. It is the
                   second most common type of depression but because people with dysthymia may
                   only have two or three symptoms, may be overlooked and go undiagnosed and
                   untreated.
                 o Bipolar depression is the depressive phase of manic-depressive illness, in which
                   there are both extreme highs and extreme lows. Bipolar depression symptoms are
                   similar to those of major depression, with certain variations such as excessive
                   sleep and increase in appetite.
                 o Seasonal Affective Disorder is a type of depression that follows seasonal
                   rhythms, with symptoms occurring in the winter months and diminishing in spring
                   and summer. Current research indicates that the absence of sunlight triggers a
                   biochemical reaction that may cause symptoms such as loss of energy, decreased
                   activity, sadness, excessive eating and sleeping.
          Recently, research produced as a result of the last several National Depression Screening
           Days has revealed that some people may experience depression without necessarily
           suffering from significant or very troublesome changes in sleep and appetite. This is an
           intriguing finding because changes in sleep and appetite are usually considered to be
           hallmarks of depression.




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Mental/Physical Impairments
          Discuss openly with the individual the impairments they may have and how they may
           impact their decision regarding the unplanned pregnancy. Have referral resources
           available that will assist the individual in meeting the challenges of any impairment they
           may be working with.
          In general in working with special issues a person must remember to be non-coercive,
           non-biased which will take a lot of work in you exploring your own values. Health care
           professionals must avoid making assumptions about the individual or situation, be willing
           to challenge your own beliefs. Also important is creating a support network for yourself
           and your staff where you can discuss potential biases.
          Consider the possibility that you may have to make a referral to Adult Protective
           Services. It would be beneficial to keep the referral number with your resource
           information.



Notes:




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                                                                                                                                 Unified Curriculum
EARLY & MIDDLE ADOLESCENCE                                                                                                                Module 4



      Pregnant Teens: Discussing Family Involvement
  COGNITIVE                   EMOTIONAL
      Discuss anticipated family response to pregnancy: explore with the teen what the possible
      reaction of her parents will be to the pregnancy. Role play these possible reactions so teen feels
      prepared to have a conversation with her parents about the pregnancy.
             Adolescent

      Offer to facilitate a meeting: encourage the teen to invite her family to her next appointment
     with a
  PHYSICAL HCP.     The teen can use the health care professional or social worker as a source of
                          SOCIAL
      support when discussing the pregnancy and options with her parents.
      Prepare to possibly manage conflict: If the teen’s parent is in the interview, the first step in this
      process is to allow the parent and the teen to have an opportunity to vent their feelings. This
      requires that the health care professional be able to take a step back and listen in a
      nonjudgmental way. Letting the parties know that they have been heard will make it easier to
      move the interaction from venting to working on the issues at hand.
      A parents’ anger is never the primary emotional reaction when a teen is pregnant. Anger almost
      always occurs after a fear reaction and is used to hide the fear. This anger can be misdirected to
      the helping professional, but it is important to remember not to take on the anger. This is vital
      for the health care provider to be able to listen for what the parents are fearful of and to be able
      to address that fear. The fear can be addressed directly if the parent will not feel ashamed of
      being afraid. A direct response to a parent’s anger might include the following: “I know you are
      anxious about how this pregnancy will affect your daughter’s future, and I want you to know that
      I am willing to help you look at all of the options.” if the parent is likely to feel ashamed of
      being afraid, more anger will occur in an attempt to hide the shame if the fear is addressed
      directly. In this instance an indirect response might include the following: “it takes a lot of
      courage to ask for help in supporting your daughter, I can help you find the assistance you will
      need to work through the issues” letting the parent know that help and support are available may
      help to lessen the fear and defuse the anger.
      Listening for the underlying message in what the parent is saying may give clues to his/her self-
      esteem or self-evaluation, which may be the reason for this/her anger. Sometimes an angry
      person’s words are the opposite of his/her true feelings and sometimes the words reflect a past
      experience in a similar situation. Shifting the parents’ perspective to work on helping and
      supporting the teen may help to defuse the anger.




                                                                      Module 4, Page 48
                                                                     Participant Handbook

      Latino Family Institute Inc, 1501 W. Cameron Avenue, Suite 240, West Covina, CA 91790 (626) 472-0123 www.lfiservices.org

				
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