BIRTHMOTHER RESEARCH PROJECT SURVEY

Appendix A

BIRTHMOTHER RESEARCH PROJECT

Are you a birthmother who surrendered your infant to adoption between 1965 and 1972?

Please join other birthmothers in this research project designed to study the

birthmother's experience of relinquishment. Collectively, as birthmothers, you have

an opportunity to voice your experience and participate in the creation of

knowledge.

Participation involves completing a questionnaire which requires about 15 minutes.

Your answers will help to educate professionals and society to understand the

experience of relinquishment and its longterm effects. Your answers may also help

you to develop a better understanding of the impact of this experience on you. You

will receive a copy of the results of the study if requested. All responses will be

kept confidential.

If you are ready to participate

and would like to Please

receive the questionnaire, Send

please click here Questionnaire

RESEARCHER:

Judy Kelly

Candidate for MA in Counseling Psychology Goddard College

Plainfield, VT

email address: judy.kelly@worldnet.att.net

This research project is being conducted as part of the requirements for a Master's Thesis. Judy Kelly is herself a birthmother who was recently reunited with her 31-year old son.

YES, PLEASE SEND

QUESTIONNAIRE . . .

You are eligible to participate in this study if you are a birthmother and relinquished

your infant to adoption during the years 1965 through 1972. If you are unsure about

your eligibility, please e-mail me at judy.kelly@worldnet.att.net and I will be happy to answer any questions you might have. If you would like to receive the research questionnaire, please provide your name, e-mail address, and mailing address below.

The questionnaire will be sent by mail. When finished, click on the SUBMIT button at

the bottom of this form.

Please enter your name (Required) :

Please enter your Email Address (Required) :

Street Address Line 1 (Required)

Street Address Line 2 (Optional)

City/State/Zip (Required)

Submit Reset

Your request has been submitted.

You should receive your questionnaire

by POSTAL MAIL within a few days.

Thank you for your participation!

Click to return to home page.

Appendix B

COVER LETTER

December 21, 1998

Dear Survey Participant,

I am a birthmother and a graduate student at Goddard College. Although much research has been done in the area of adoption, almost none of it pertains to the birthmother's experience. In recognition of this, I wish to devote my Master's Thesis to this topic and, hopefully, provide an avenue for the birthmother's experience to be added to this body of knowledge. A number of birthmothers have begun to tell their stories through autobiographical writings. I would like to support their efforts through this study.

The Internet provides a unique opportunity to collect information from a group of women who, for the most part, have remained invisible to society. In this study, I hope to obtain information and to educate others about the effects of relinquishment on the birthmother. The majority of the questions are related to the assessment of trauma. Other questions are demographic (marital status, year of birth, etc.) and will assist in interpreting the information provided. Additional questions concern health history and the presence of symptoms often associated with the experience of stressful life events. All information will be kept strictly confidential.

Only birthmothers who gave birth during the years 1965 through 1972 and relinquished their infants to adoption are asked to respond.

The survey should take about 15 minutes to complete. Please take the time to add your voice to this study. Please complete the enclosed questionnaire and return it to me, together with the consent form, in the stamped return envelope by January 11, 1999.

A few birthmothers will be invited to participate in a small group discussion to reflect on and discuss the summarized survey results. If you live in or near New York City and would like to participate in the follow-up discussion group, please e-mail me at judy.kelly@worldnet.att.net and include the words "DISCUSSION GROUP" in the subject line.

Thank you for your participation in this study. May we, as birthmothers, begin to share our stories and enlighten those who follow.

Sincerely,

Judy Kelly

Appendix C

CONSENT FORM

(For Survey)

You are invited to participate in a research study of birthmothers who gave birth during the years 1965-1972 and have relinquished their infants to adoption. The purpose of this study is to gain knowledge of the long-term stress reactions that may be experienced by birthmothers who relinquish. Completion of the questionnaire will take approximately 15 minutes. You will be asked to provide your responses to a series of questions. Some of these questions are directly related to the relinquishment; others concern your physical and emotional state. Due to the sensitivity of this topic, it is possible that feelings may arise that may be difficult to deal with. If this occurs, please feel free to contact me. Online support groups, such as the Sunflower Birthmom Support Group (http://members.aol.com/alanamil/birthmom.html) or Birthmother's Support (http://members.tripod.com/~ncampbell/birthmothers.html) are also available for emotional support. Participation in this study may help you to better understand the impact that this experience may have had on you.

Your participation is voluntary. You may choose to not answer any question. Results will be reported in summary form only. Detailed information will not be linked to a specific individual. All information will be kept strictly confidential. If you have any questions, please feel free to contact me at judy.kelly@worldnet.att.net or call me at xxx-xxx-xxxx.

Please sign this form to show that you have read and understand its contents and consent to participate in this study. Surveys cannot be processed unless accompanied by a signed consent form. Thank you!

_______________________________________(Signed)

_______________________________________(Printed)

Date:____________________

Appendix D

BIRTHMOTHER RESEARCH PROJECT SURVEY

(This document has been reformatted for viewing.)

SECTION "A" INSTRUCTIONS: Below are some questions which will help us to understand the information provided by participants. Please supply the information in the space provided. For "Yes/No" responses, please circle your response.

1. In what year did you give birth? ___

2. How old were you when you gave birth? ___

3. What is your current relationship status?

Single

Married

Divorced

Living with someone

Separated

Widowed

4. How many other children do you have? ___

5.	Have you raised any other children you have had?	Yes	No
6.	Was the adoption a closed adoption?	Yes	No
7.	Have you searched for your relinquished child?	Yes	No
8.	Have you been reunited with your relinquished child?	Yes	No
9.	If yes, are you still in contact with your relinquished child?	Yes	No
10.	Have you received psychotherapy because of the relinquishment?	Yes	No
11.	If yes, did it help?	Yes	No
12.	How long were you in therapy? ____
13.	Have you participated in any birthmother support groups?	Yes	No
14.	If yes, did it help?	Yes	No
15.	How long were you a member? ____

SECTION "B" INSTRUCTIONS: Below is a list of statements made by people after stressful life events. Please respond to the following statements thinking about your entire relinquishment experience. (For the purpose of this survey, the "entire relinquishment experience" includes the time you first learned you were pregnant until the signing of the relinquishment papers.) Please circle the response for each statement indicating how frequently these statements were true for you since the relinquishment.

		Not at All	Rarely	Some-times	Often

1.	Any reminder brought back feelings about it.........	0	1	3	5
2.	I had trouble staying asleep.............................	0	1	3	5
3.	Other things kept making me think about it..........	0	1	3	5
4.	I felt irritable and angry.................................	0	1	3	5
5.	I avoided letting myself get upset when I thought about it or was reminded of it.........................	0	1	3	5
6.	I thought about it when I didn't mean to.............	0	1	3	5
7.	I felt as if it hadn't happened or wasn't real..........	0	1	3	5
8.	I stayed away from reminders about it................	0	1	3	5
9.	Pictures about it popped into my mind................	0	1	3	5
10.	I was jumpy and easily startled........................	0	1	3	5
11.	I tried not to think about it.............................	0	1	3	5
12.	I was aware that I still had a lot of feelings about it, but I didn't deal with them..............................	0	1	3	5
13.	My feelings about it were kind of numb...............	0	1	3	5
14.	I found myself acting or feeling like I was back at that time...................................................	0	1	3	5
15.	I had trouble falling asleep..............................	0	1	3	5
16.	I had waves of strong feelings about it...............	0	1	3	5
17.	I tried to remove it from my memory..................	0	1	3	5
18.	I had trouble concentrating.............................	0	1	3	5
19.	Reminders of it caused me to have physical reactions such as sweating, trouble breathing, nausea, or a pounding heart............................	0	1	3	5
20.	I had dreams about it....................................	0	1	3	5
21.	I felt watchful and on-guard............................	0	1	3	5
22.	I tried not to talk about it..............................	0	1	3	5

SECTION "C" INSTRUCTIONS: For each statement, please circle the response that best describes your experience.

		Not at all true	Some-what true	Very true	Extremely true

1.	Relinquishing my child was a great relief............	0	1	3	5
2.	I have forgotten details surrounding the birth, such as date of birth, name of hospital, etc.................	0	1	3	5
3.	I feel emotionally "stuck" and unable to move forward...................................................	0	1	3	5
4.	I tend to do things to extremes........................	0	1	3	5
5.	Relinquishing my child was a traumatic experience..	0	1	3	5
6.	I have no regrets about relinquishing..................	0	1	3	5
7.	I remember the details of leaving the hospital and the first day home........................................	0	1	3	5
8.	I was either misled or not informed of the effects that relinquishment would have on me................	0	1	3	5
9.	I don't feel particularly guilty...........................	0	1	3	5
10.	I have thought about killing myself....................	0	1	3	5
11.	I don't feel I am being punished........................	0	1	3	5
12.	I received adequate counseling at the time of the relinquishment............................................	0	1	3	5

SECTION "D" INSTRUCTIONS: The following questions concern your health history. Please indicate whether any of the following conditions or treatments have occurred since the relinquishment. Please check as many as apply.

Breast cancer

Cancer of the uterus (womb)

Cancer of the ovary

Colon or rectum cancer

Endometriosis

Hysterectomy

Removal of ovary

Miscarriage

Infertility

Cervicitis

Cervical dysplasia

SECTION "E" INSTRUCTIONS: The following items describe emotions and behaviors often associated with stressful life events. For each item, please circle the response that best describes your experience.

Since the relinquishment, have you experienced . . .

	Not at All	Mild	Moderate	Severe

low self-esteem.....................	0	1	3	5
eating disorders.....................	0	1	3	5
drug dependencies..................	0	1	3	5
difficulty giving/receiving love....	0	1	3	5
depression...........................	0	1	3	5
phobias..............................	0	1	3	5
grieving for the loss of your child	0	1	3	5
relationship problems...............	0	1	3	5
memory loss (repression)..........	0	1	3	5
powerlessness.......................	0	1	3	5
sexual problems.....................	0	1	3	5

Since the relinquishment, have you experienced . . .

	Not at All	Rarely	Sometimes	Often

grieving for the loss of your child	0	1	3	5
problems forgiving..................	0	1	3	5
excessive smoking..................	0	1	3	5
excessive drinking..................	0	1	3	5
being out of touch with feelings..	0	1	3	5
depression...........................	0	1	3	5
compulsive shopping binges.......	0	1	3	5
uncontrollable yelling...............	0	1	3	5
excessive napping..................	0	1	3	5
low self-esteem.....................	0	1	3	5
powerlessness.......................	0	1	3	5
denial of feelings....................	0	1	3	5
self-hatred...........................	0	1	3	5
avoidance of situations that bring up painful memories................	0	1	3	5

3. Since the relinquishment, do you feel . . .

	Not at All	Rarely	Sometimes	Often

Anger................	0	1	3	5
Shame...............	0	1	3	5
Remorse.............	0	1	3	5
Guilt.................	0	1	3	5
Hurt..................	0	1	3	5
Loneliness..........	0	1	3	5
Numbness..........	0	1	3	5
Happiness...........	0	1	3	5

Please remember to sign the attached consent form.

Surveys cannot be processed without consent.

Thank you for your participation in this study!

Return survey and consent form to:

Judy Kelly

P. O. Box xxxx

Grand Central Station

New York, NY 10163

Appendix E

CONSENT FORM

(For Group Discussion)

I, Judy Kelly, am conducting research on "The Impact of Relinquishment on Birthmothers" as part of a thesis fulfilling the requirements for the Master's in Counseling Psychology degree at Goddard College, Plainfield, Vermont. This project is under the guidance of Goddard College faculty advisor, Beth Culler Ed.D. and has been approved by the psychology faculty at Goddard College.

Your role in this research will be as a participant in a small group discussion concerning relinquishment. The purpose of the discussion group is to interpret and provide a greater depth of meaning to the summarized results of a survey previously conducted. I will act as facilitator of the discussion group and will pose several questions concerning the survey results. The group discussion will be audiotaped in case I need to review the discussion material for accuracy. Confidentiality and anonymity will be strictly maintained. All participants are asked to refrain from discussing any of the discussion material outside of the group. Any discussion material included in the thesis will be done so either anonymously or using an alias, unless you request otherwise. Your involvement in this project is completely voluntary. You may decline to answer any question. You may choose to withdraw at any time.

I do not foresee any risks concerning your involvement in this discussion group. However, due to the topic, emotions and feelings may surface. I will make every effort to facilitate this discussion so as to create a safe space for the exploration of this topic.

The final product, the thesis, will be maintained as a public document in the Goddard College Library and may in part be submitted for publication or presented orally. An oral presentation of my findings will be given to Goddard faculty and graduate psychology students in fulfillment of my Master's program requirements.

By signing below, you indicate that you have read and understood the above material. With this signature, you consent to participate in this study and permit me, Judy Kelly, to facilitate the discussion group for the purposes explained above.

_______________________________Participant Date:________________

_______________________________Facilitator Date:________________

Appendix F

PARTICIPANT PROFILE

1. In what year did you give birth? 19____

2. How old were you when you gave birth? _____

3. What is your current relationship status? (Check one)

1 Single___ 3 Divorced___ 5 Separated___

2 Married___ 4 Living with someone___ 6 Widowed___

4. How many other children do you have? _____

5. Have you raised any other children you have had? 1-Yes 2-No

6. Was the adoption a closed adoption? 1-Yes 2-No

7. Have you searched for your relinquished child? 1-Yes 2-No

8. Have you been reunited with your relinquished child? 1-Yes 2-No

9. If yes, are you still in contact with this child? 1-Yes 2-No

10. Have you received psychotherapy because of the relinquishment? 1-Yes 2-No

11. Have you participated in any birthmother support groups? 1-Yes 2-No

12. What is your current age? __________

Appendix G

"Extreme/Not at all/Often/Severe" - where greater than 50% responded

94% C12. I received adequate counseling at the time of relinquishment. (Not at all

true)

89% C5. Relinquishing my child was a traumatic experience. (Extremely true)

85% C8. I was either misled or not informed of the effects that relinquishment would

have on me. (Extremely true)

73% B1. Any reminder brought back feelings about it. (Often)

73% C1. Relinquishing my child was a great relief. (Not at all true).

73% C6. I have no regrets about relinquishing. (Not at all true).

71% E2. Since the relinquishment, experienced grieving for the loss of child. (Often)

70% E3. Since the relinquishment, felt hurt. (Often)

70% C9. I don't feel particularly guilty. (Not at all true).

66% E1. Since the relinquishment, experienced grieving for the loss of child. (Severe)

66% B6. I thought about it when I didn't mean to. (Often)

65% B12. I was aware that I still had a lot of feelings about it, but I didn't deal with

them. (Often)

62% C2. I have forgotten details surrounding the birth, such as date of birth, name of

hospital, etc. (Not at all)

58% B9. Pictures about it popped into my mind. (Often)

58% E3. Since the relinquishment, felt remorse. (Often)

57% E3. Since the relinquishment, felt loneliness. (Often)

56% B16. I had waves of strong feelings about it. (Often)

55% B13. My feelings about it were kind of numb. (Often)

53% E2. Since the relinquishment, experienced depression. (Often)

52% E2. Since the relinquishment, experienced low self-esteem. (Often)

51% E1. Since the relinquishment, experienced drug dependencies. (Not at all)

51% E1. Since the relinquishment, experienced depression. (Severe)

51% B22. I tried not to talk about it. (Often)

41% D6. Hysterectomy

Appendix H

CHARACTERISTIC

DERIVATION

Unresolved grief

Respondents selected one or more of the following items:

I felt irritable and angry often.

My feelings about it were kind of numb often.

Since the relinquishment, experienced severe depression.

Since the relinquishment, experienced severe grieving for

loss of child.

Since the relinquishment, experienced grieving for the loss

of child often.

Since the relinquishment, experienced depression often.

Since the relinquishment experienced denial of feelings

often.

Since the relinquishment, feel anger often.

Traumatic Stress: Intrusive thoughts

Respondents selected one or more of the following items:

Any reminder brought back feelings about it often.

I had trouble staying asleep often.

Other things kept making me think about it often.

I thought about it when I didn't mean to often.

Pictures about it popped into my mind often.

I had waves of strong feelings about it often.

I had dreams about it often.

Traumatic Stress: Avoidance

Respondents selected one or more of the following items:

I avoided letting myself get upset when I thought about it

or was reminded of it often.

I felt as if it hadn't happened or wasn't real often.

I stayed away from reminders about it often.

I tried not to think about it often.

I was aware that I still had a lot of feelings about it, but I

didn't deal with them often.

My feelings about it were kind of numb often.

I tried to remove it from my memory often.

I tried not to talk about it often.

Traumatic Stress: Hypervigilance

Respondents selected one or more of the following items:

I felt irritable and angry often.

I was jumpy and easily startled often.

I found myself acting or feeling like I was back at that time

often.

I had trouble falling asleep often.

I had trouble concentrating often.

Reminders of it caused me to have physical reactions such

as sweating, trouble breathing, nausea, or a pounding

heart often.

I felt watchful and on-guard often.

Self-punishment

Respondents selected one or more of the following items:

I have thought about killing myself . (Extremely true)

I don't feel I am being punished. (Not at all true)

Since the relinquishment, experienced severe eating

disorders.

Since the relinquishment, experienced severe drug

dependencies.

Since the relinquishment, experienced excessive smoking

often.

Since the relinquishment, experienced excessive drinking

often.

Since the relinquishment, experienced self-hatred often.

Low self-esteem

Respondents selected one or more of the following items:

Since the relinquishment, experienced severe low-self

esteem.

Since the relinquishment, experienced severe powerlessness.

Since the relinquishment, experienced low self-esteem

often.

Arrested emotional development

Respondents selected one or more of the following items:

I found myself acting or feeling like I was back at that time

often.

I feel emotionally "stuck" and unable to move forward.

(Extremely true)

Hysterectomy

Occurred since the relinquishment.

Living at extremes

I tend to do things to extremes. (Extremely true)

Problems forgiving

Since the relinquishment, experienced problems forgiving often.

Being out of touch with feelings

Since the relinquishment, experienced being out of touch with

feelings often.

Difficulty giving and receiving love

Since the relinquishment, experienced severe difficulty

giving/receiving love.

Relationship problems

Since the relinquishment, experienced severe relationship

problems.

Self-hatred

Since the relinquishment, experienced self-hatred often.

Dysfunctional sexual problems

Since the relinquishment, experienced severe sexual problems.

CHARACTERISTIC	DERIVATION
Unresolved grief	Respondents selected one or more of the following items: I felt irritable and angry often. My feelings about it were kind of numb often. Since the relinquishment, experienced severe depression. Since the relinquishment, experienced severe grieving for loss of child. Since the relinquishment, experienced grieving for the loss of child often. Since the relinquishment, experienced depression often. Since the relinquishment experienced denial of feelings often. Since the relinquishment, feel anger often.
Traumatic Stress: Intrusive thoughts	Respondents selected one or more of the following items: Any reminder brought back feelings about it often. I had trouble staying asleep often. Other things kept making me think about it often. I thought about it when I didn't mean to often. Pictures about it popped into my mind often. I had waves of strong feelings about it often. I had dreams about it often.
Traumatic Stress: Avoidance	Respondents selected one or more of the following items: I avoided letting myself get upset when I thought about it or was reminded of it often. I felt as if it hadn't happened or wasn't real often. I stayed away from reminders about it often. I tried not to think about it often. I was aware that I still had a lot of feelings about it, but I didn't deal with them often. My feelings about it were kind of numb often. I tried to remove it from my memory often. I tried not to talk about it often.
Traumatic Stress: Hypervigilance	Respondents selected one or more of the following items: I felt irritable and angry often. I was jumpy and easily startled often. I found myself acting or feeling like I was back at that time often. I had trouble falling asleep often. I had trouble concentrating often. Reminders of it caused me to have physical reactions such as sweating, trouble breathing, nausea, or a pounding heart often. I felt watchful and on-guard often.
Self-punishment	Respondents selected one or more of the following items: I have thought about killing myself . (Extremely true) I don't feel I am being punished. (Not at all true) Since the relinquishment, experienced severe eating disorders. Since the relinquishment, experienced severe drug dependencies. Since the relinquishment, experienced excessive smoking often. Since the relinquishment, experienced excessive drinking often. Since the relinquishment, experienced self-hatred often.
Low self-esteem	Respondents selected one or more of the following items: Since the relinquishment, experienced severe low-self esteem. Since the relinquishment, experienced severe powerlessness. Since the relinquishment, experienced low self-esteem often.
Arrested emotional development	Respondents selected one or more of the following items: I found myself acting or feeling like I was back at that time often. I feel emotionally "stuck" and unable to move forward. (Extremely true)
Hysterectomy	Occurred since the relinquishment.
Living at extremes	I tend to do things to extremes. (Extremely true)
Problems forgiving	Since the relinquishment, experienced problems forgiving often.
Being out of touch with feelings	Since the relinquishment, experienced being out of touch with feelings often.
Difficulty giving and receiving love	Since the relinquishment, experienced severe difficulty giving/receiving love.
Relationship problems	Since the relinquishment, experienced severe relationship problems.
Self-hatred	Since the relinquishment, experienced self-hatred often.
Dysfunctional sexual problems	Since the relinquishment, experienced severe sexual problems.