Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Sunday, September 16, 2012

More About Post Adoption Depression


Some recent correspondence I’ve had with an adoptive mother has made me more concerned than ever about the possibility of depression following adoption and its potential impact on the adoptive family as a whole, as well as on the developing adopted child. My correspondent describes her experience with depression as “a living hell” with “three monsters” and states that “I did things then that I would never even consider doing now” (following treatment). She sent the children to her mother’s house because she knew they were not safe at home; she reports that “most of my thoughts were about being overwhelmed, running away, and wanting to die”.

When I searched Academic Search Complete for material on Post Adoption Depression, I was interested to see that many of the papers that came up were on depression in adopted children rather than in adoptive parents. It was over 15 years ago that the term Post Adoption Depression was first used, but a clear description and explanation of the phenomenon are still very much in the works. The common belief that hormonal changes cause post-partum mood disorders made it—and still makes it--  difficult for many people to accept that a post-adoption problem can also exist. A 1999 paper (Gair, S.[1999]. Distress and depression in new motherhood: Research with adoptive mothers highlights contributing factors. Child and Family Social Work, 4, 55-66) reported that about 30% of the adoptive mothers studied scored high on a questionnaire used in assessment of depression. A number of the mothers spontaneously stated that what they had was “post-natal depression”. Interestingly, Gair noted that “Typically, in Western society, the source of discontent in mothering is not seen to have its origins in the tasks of caring and mothering… Rather the fault is seen to lie with individual mothers”--  a belief that minimizes the actual stress of caring for children and may be a cause for depression when new mothers discover how demanding these tasks actually are. As Gair pointed out, this would be intensified by the lack of social support more common in adoption than in pregnancy and childbirth. Gair summarized the evidence that hormonal factors are not a major cause of post-partum depression and argued that the events that cause depression are similar in both birth mothers and adoptive mothers.

More recently (Payne et al., [2010]. Post adoption depression. Archives of Women’s Health, 13, 147-151), researchers concluded that “Significant depression symptoms were relatively common [about 30% of the group] in adoptive mothers within the first year after adoption and were associated with environmental stress”.  Most of the mothers in this study had adopted because of infertility, a condition associated with painful and intrusive treatment and with a sense of shame and loss of self-esteem, possibly making them more vulnerable to the effects of later environmental stress (my statement, not Payne’s—J.M.).  In another recent study (Foli, K., & Gibson, G.C. [2011] . Sad adoptive dads: Paternal depression in the post-adoptive period. International Journal of Men’s Health, 10, 153-162.), the researchers described the occurrence of depression—often expressed as anger--  in adoptive fathers, possibly in response to their wives’ depression.

As for the impact of parental depression on children, there has been an examination of this issue focused on adopted children (Natsuaki, M.N., et al. [2010]. Genetic liability, environment, and the development of fussiness in toddlers: The roles of maternal depression and parental responsiveness. Developmental Psychology, 46, 1147-1158). The concern of this study was of the role caregivers’ responsiveness can play in helping infants grow into toddlerhood with less negative emotion than they might otherwise show. Parents who were responsive to their 9-month-old babies’ signals were shown to have less irritable toddlers when the children were 18 months old. One major effect of depression is to reduce the adult’s responsiveness to child communications, especially when the signals are hard to understand, so depression is likely to be linked to unresponsiveness and later to child fussiness. This and much other evidence points to parental depression as playing an important role in children’s development--  treatment of depression is not just for the comfort of the adult, but for the development (and even the safety) of the child.

Unfortunately, as an article by Foli and Gibson has pointed out (2011; Training “adoption smart” professionals. Journal of Psychiatric and Mental Health Nursing, 18, 463-467), not only is there relatively little research on Post Adoption Depression (and that research has a number of problems that I haven’t mentioned here), but adoption caseworkers do not have much awareness of what is known on the subject, and adoptive parents receive little or no training about it.

I want to voice a particular concern about untreated depression in adoptive parents. I must ask, to what extent does depression create vulnerability to inaccurate statements about adoption--  for example, that even children adopted at birth are grieving for their birth mothers? To what extent does depression make adoptive parents ready to accept stern, repressive, even dangerous regimens claimed to “cure” their children? Does thinking about harming your children (as an aspect of depression) make you more likely to let someone else hurt or endanger them?  I once came across a description of “holding therapy” as what parents can choose when they want someone else to hurt their child for them. Do unconventional treatments like “holding therapy” exploit the undiagnosed and untreated depressions of some adoptive parents? I don’t know the answers, but I believe this topic is one that needs much further exploration. 

34 comments:

  1. "...vulnerability to inaccurate statements about adoption--for example, that even children adopted at birth are grieving for their birth mother?"

    Um, it's not inaccurate, it's true. And, maybe these adoptive mothers are depressed because they realize what they just bought with their $35,000 is not perfect and is a lot of work.

    They should be sad - for the coerced, browbeaten and targeted "real" mother out there.

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  2. Can you give us some evidence for your statements, and explain why you equate depression with disappointment?

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  3. Please read "The Primal Wound", "Being Adopted" and "Adoption Healing".

    The internet has hundreds of stories by adoptive mothers who "didn't get what they wanted".

    My own daughter adopted my grandaughter, and this is what hers cost. She claims many others in her group paid about the same.

    I was coerced in 1976. So I understand how that stuff works.

    Disappointment often leads to depression, especially when you might think you have made a huge mistake and realize that your life has changed forever.

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    1. Serious depression is vastly different from "not getting what you want". And it has the potential for seriously negative influence on children's development.

      The books you mention are by no means evidence-based. They rely on anecdotes and personal experiences, which may speak to someone's condition but are not appropriate material for drawing general conclusions.

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  4. So, in the past when lots of mothers died in childbirth, all those infants were grieving at birth?

    "Not perfect and a lot of work" is a good description of any newbown, though.

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  5. And to add to previous post - you actually said in your article:


    When I searched Academic Search Complete for material on Post Adoption Depression, I was interested to see that many of the papers that came up were on depression in adopted children rather than in adoptive parents.

    So did you not bother to read that? I mean, why are adopted children depressed?

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  6. Your question is a good one, and there is material about that issue-- but that wasn't what I was writing about. I was focusing on a story told me in an e-mail.

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  7. Could post-adoption depression in adoptive mothers be comparable to stress and depression that hits some people after any favorable but stressful event like a new job, new marriage, new home? I do not see it as peculiar to adoption.

    I do not see where it really compares to post-partum depression in biological mothers, except in the unfortunate effects on the child being raised by a depressed mother. Could a factor be trying so hard and expending so much energy and often money to get a baby, and in the end, all you have is a kid who is a lot of work, who may not meet one's idealized expectations? Is depression also a factor in successful assisted reproduction births, where a great deal of money and effort have also been expended to get a child?

    Also, could the fact that there is very little written about post-adoption depression be an indication that it is rare, not a common thing at all?

    What I would like to know is how many adoptive mothers hit with post adoption depression had depressive tendencies and episodes before even thinking about adopting, and why were they allowed to adopt given that history? This all merits wider investigation.

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  8. These are all good questions. I would certainly agree that neither post adoption depression nor perinatal mood disorders are necessarily different from other types of depression (excluding the rare post-partum psychosis, as in the Andrea Yates case). I'm not sure why you say post-partum depression is different-- are you assuming that the hormonal factor is a major one?

    Vivian Shapiro in about 2000 wrote a fascinating book about emotional responses to complex adoption and assisted reproductive technologues. Those are rare, so the number of people responding with mood changes would be small-- but adoption is not very common (about 2% of children in the U.S.) so we're probably not talking about a very large number of cases there either.

    A past history of depression is certainly an important risk factor. But of course, if post adoption depression has not been studied much, caseworkers may not know this, and in any case I don't think assessment for mood disorders is a common part of pre-adoption screening, where generally the goal is to get kids adopted as soon as possible.

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  9. Trying to understand: if there is not a hormonal component to post partum depression that strikes mothers who have given birth who wanted a child, do have a supportive husband and family, do have some help and respite in caring for the newborn, but are struck by serious depression anyhow, what causes it? Is it really just like any other depressive episode and the physical and hormonal changes and stresses of giving birth really have nothing to do with it at all?

    Women who seem to be in ideal family situations do develop serious post-partum depression with no apparent outer cause, serious enough to require hospitalization, as do those in stressful, less than ideal situations. Does this happen to adoptive mothers as well, not just sad and tired but serious, non-functionally depressed?

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  10. I don't want to go out on a limb and say hormones had nothing to do with it for no one, no time, no how. As I pointed out, though, post-partum depression isn't treated with hormones, although it would be easy enough medically to alter someone's hormone balance.

    The symptoms of serious depression (i.e., as you say, not just sad and tired) are similar under many circumstances (although depressed men are more likely to feel angry than depressed women, and depressed children are more likely to be irritable than depressed adults). I think the reason we've given special status to post-partum depression is its special impact on vulnerable infants and children. When they don't have young children, depressed women can sometimes hide their condition, self-medicate with alcohol, etc. But somebody is going to notice if the baby isn't gaining weight or has horrible diaper rash because it's not kept clean, and that will bring the mother's situation to the fore.

    The few reports are that, yes, adoptive mothers may also experience real depression and need serious treatment.

    If you're asking about post-partum psychosis,the kind where voices tell the mother to kill the child and she does, that is so rare that it's difficult to say a lot about it. But in recent years we have seen case after case of adopted children being abused, tortured, and finally killed. Are the conditions of those adoptive mothers like those of women with post-partum psychosis? What about the fathers who are involved in the abuse? Is there a reasonable analogy to the irritability of depressed biological mothers or the thoughts of harming the children that they often experience? I can't answer these questions, but I think they're important and hope that some time in the future we will have this kind of information.

    To go back to the hormone issue for a minute-- at the end of one of these posts, I commented on evidence that rats undergo hormonal changes when they're exposed to rat pups. Maybe humans do this too? I haven't been able to find anything about hormone changes in adoptive parents. But there is such a thing as adoptive nursing, inducing lactation by having an adopted baby nurse, and that means some changes in oxytocin anyway-- changes that are caused by exposure to stimulation by the baby.

    There's still a lot to learn here.

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  11. Aha, finally get it about post partum depression not being treated with hormone replacement. I think I was using the wrong term, or looking at hormonal issues in too simplistic a way, the other side of those who see hormones as the sole cause of a biological mother's love for her baby. I don't think it is that simple in either case, or something that more or less hormones can cause or regulate.

    Hormones aside though, pregnancy and birth put all kinds of stress on every system in the body. Could an over-sensitivity to this physical and emotional stress contribute to post partum depression? I can see where adopting can be stressful too, as far as the hard work in caring for a child, but I am still having a hard time seeing it as the same thing with the same level of severity.

    But as you say, all this needs lots more study.

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  12. I think one aspect of adoption that might be equally stressful is the preceding infertility treatment that so many couples go through. Then there's a period of waiting to adopt, perhaps with a child being offered and then withdrawn-- and finally "here's a baby-- yes or no? If you hesitate, this baby goes to someone else."

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  13. It would be interesting to know more about the religious beliefs of the kinds of adoptive parents who turn to "holding therapy".
    Do you think it is possible that theologically conservative (fundamentalist) Christians who believe in the original sinfulness of mankind and the ability to be born again, would, because of the conflict between that and the commandment to "love thy neighbour as thyself", be more susceptible to the idea of HT.

    It's probably a stretch, but what I'm suggesting is that some of these adoptive parents might subconsciously view HT as a kind of secular exorcism, one that conveniently lets them off the hook for hurting their children while at the same time dangling the carrot that the children can be brought to "honor their father and mother" by conforming to conventionally acceptable standards.

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  14. What would you think would be the connection between the conflict you mention and the vulnerability to HT? I understand the conflict, and I think you're right that they are more susceptible, but I'm not sure how you're linking them together logically.

    I have an alternative guess (not that there need be only one reason), and that is that when people posit that salvation in some form depends on absolute obedience to God, it's quite easy to decide that children must be made obedient to their parents or they'll grow up to defy God too. This is certainly what they thought in the Plymouth Colony.

    I don't think the exorcism idea is a stretch at all. In fact, I recently submitted to a journal a paper arguing that HT is parallel to "deliverance" as practiced by Pentecostals. "Deliverance" practitioners also emphasize adoption as a situation that attracts demons, which will cause lots of trouble until exorcised. There may be no need to think of this as subconscious for a great many people.

    Incidentally, the HT proponent Nancy Thomas has said that she doesn't let foster children say grace, because "you don't know who they might be praying to".

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  15. From what I have read, the more horrendous torture and killing of children by adoptive and foster parents have usually involved fundamentalist religious beliefs. Of course these awful incidents are thankfully rare, but they should not be happening at all, or as often as they do.

    I think Haiga is onto something linking exorcism with holding therapy and other abuses. Also the idea of absolute obedience and worship of authority figures in a hierarchy from parents to husband to preacher to God is often a factor. Biological children growing up in homes with these beliefs are also subject to abuse, but when the extra "danger of demons" in adopted children and the idea that all disobedience is evil is factored in, I think the tendency to abuse increases as well.

    People with severe mental illness can get along well within extreme belief systems, if their delusions concur with the common beliefs, which they often do. Another factor might be the Evangelical push to adopt more and more "orphans" to save their souls, leaving ill-prepared adoptive parents overburdened with special needs kids they have not the capacity to care for decently.

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  16. From a practical point of view about protection of adoptive and foster children, I think the issue is about screening of parents for potentially harmful beliefs and behavior, as well as for risks of depression. I don't think most adoption caseworkers are concerned with this-- and that's especially true of the many adoption agencies that are sponsored by fundamentalist religious organizations.

    Years ago, winning Russia for the "true faith" was a concern of many-- either those who wanted to "win" from Communism or before that those who wanted to "win" from the Russian Orthodox Church. The whole Fatima thing stressed the conversion of Russia. I've often wondered if this has been passed on to today's fundamentalists and explains their fascination with adoption from Russia-- a connection with your last paragraph, Anonymous.

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    1. Fatima was so much a Catholic thing, I do not think Fundamentalists would be influenced by that. Yes, as a Catholic child in the 50s I remember praying for the conversion of Russia, and also being freaked out by the Fatima story as two of the kids died in childhood and the other became a nun, neither of which was attractive to me.

      However the general McCarthy era hysteria over "Godless Communism" in Russia may have some influence on Fundamentalist preference for kids from Eastern Europe, plus the fact that they are so white.

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    2. What did you pray that Russia be converted to, Maryanne? And do you think that was a newish, anti-communist thing, or an old, anti-Orthodox thing?

      I'm sure present-day fundamentalists wouldn't go for Fatima, but I do wonder if these ideas spread without some of the details and get picked up by those motivated to use them.

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    3. As a kid I was not aware of any anti-Orthodox sentiment, it was the Dirty Commies we were praying to save the Russians from. I think I thought that Russian Orthodox was similar to Catholic, especially since there was a Ukrainian Catholic church nearby and my Polish grandfather was friends with the married Ukrainian priest, and their church set up and Mass are similar to Eastern Orthodox.

      I now know that Ukrainian Orthodox and Ukrainian Catholic are separate and there was enmity in the past, but I do not think anyone in my suburban NJ parish was really aware of that distinction when praying for Russia. It was all about Godless Commies, at least here.

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  17. Wow, really interesting. I had one line of comment to follow, but I'm gonna go with the later one, the talk about religion's involvement. One can look at religion as a sort of voice for the most primal urge, reproduction. It's the old testament types who seem to calling the loudest for unbridled breeding. They're against homosexuality, abortion, contraception . . . it's almost an equivalency between the old testament God and the reproductive urge, as opposed to conscious, human directed living.
    Perhaps, though, adopted children don't quite qualify as progeny to the mind that is operation out of it's most basic places, the reproductive drives, and somehow the most abused children of some of these extreme adoption situations are paying for their unnatural origin, they're not really the successful product of the urge? And this genetic frustration is acted out on them?
    Just a thought.

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    1. Now, Jeff, really... genetic frustration? How can a gene, a little structure that instructs cells how to make certain proteins, be frustrated? Are you sure you're not talking about a Life Force or about Georg Groddeck's It (the universal force that governs all we do, said G.G.)?

      What makes you think there's a single reproductive drive, rather than a whole melange of different wishes and gratifications, from genital activity to thinking babies are cute? I think I detect Herr Doktor Freud at work here.

      Here, I can tell Just So stories too. Suppose that the evolutionary advantage of either post partum or post adoption depression was to force more people to take care of the child and therefore to strengthen social ties and cooperation within the group? Or, how about such depression causing babies to be passed on to others and encouraging increased outbreeding as a result of the social changes? No, I'm not really serious about either of these, just showing how easy it is to get ad hoc when post hoc.

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    2. Yeah, OK. I guess I sounded like some TV documentary talking about a lion's behaviour "in order to pass on his genes."
      That's kinda how I was thinking.
      Never mind.

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    3. It's okay, Jeff, I always have fun snapping at you-- and the great thing about you is that unlike most people you're capable of rethinking what you said in haste.

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  18. I like this article, it fits my worldview, in that it suggests that post-baby depression isn't probably hormonal, I mean that's an unlikely evolutionary development, isn't it?
    I prefer to see things as psychological, and the incidence of post-baby depression being pretty high no matter how one acquires the child makes more sense to me, that the causes are environmental, or situational. Certainly there are no shortages of possible reasons for depression; being an amateur, I won't propose any. But as one who tends toward nurture-over-nature, I do think the reasons are probably not two completely different sets of things.

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  19. I like the idea that post-adoption depression can lead to parents looking to extreme (or faddish) forms of child-rearing advice. That makes sense to me, especially considering that (1) raising adopted children is different than raising birth children in some respects, (b) there's a paucity of sound (evidence-based) advice for dealing specifically with adoption-related issues in child-rearing, as compared to the enormous amount of advice (albeit not all sound) related to child-rearing in general (perhaps due to the low incidence of adoption), and (c) raising older, foster/adopted children, often with multiple and severe special needs, which may not be documented or diagnosed prior to placement, is even more of a journey across an uncharted landscape.

    The allure of such approaches as attachment therapy, EMDR, tapping, "training up" a child, love & logic, tough love, etc., is twofold, I believe: it sets the parents apart as special (super-heroes even) because the obscurity of the approach suggests that their children are damaged and challenging beyond the norm (which may, in fact, be true), thus requiring both super-special treatment and super-special parenting; and it gives parents a way to dismiss any criticism that might come at them from outside the particular cult of treatment they've chosen as uninformed because "our kids" are not like other kids, so other parents have nothing to offer us.

    Not only do the treatment providers end up feeling and acting messianic, but the parents can as well.

    However, I'm not sure that it's post-adoption depression that leads parents to wanting (however unconsciously) to hurt or punish their children through punitive/shaming treatment approaches---or through simply nonstop "treatment," of whatever sort, which convinces the child that he/she is broken and in need of far more intervention than any other kid---that "our kids" thing, again, that Trauma Mamas so often bring up.

    Parents who are depressed aren't necessarily driven to punishing or hurting their children. In fact, that may take far more energy and focus than many depressed people can muster. One of the most damaging aspects of being raised by a severely depressed parent is the neglect born of parental depression. I'd be careful about equating depression with maleficent intent.

    Having said all that, I've personally felt the despair (and yes, also, post-placement depression) of raising children who are survivors of a foster care system (and the initial abuse/neglect of birth family) that left them traumatized beyond what I or local helping professionals could help them deal with in the short term. The task is large and can be overwhelming, and there's really not a whole lot of research-based help out there for, say, how to help a sexually abused child who witnessed lots of domestic violence, and then himself became a perpetrator of violence, who now suffers from PTSD, and who has ADHD (likely a genetic gift, given the birth family history) as well as FASD because his teen birth mom was already an alcoholic and drug addict by the time she got pregnant with him, and never got any prenatal care nor abstained from alcohol during her pregnancy, which she didn't fully recognize until after the first trimester, in any case.

    This is a not atypical story, sadly. And if the child has been passed from foster home to foster home, experienced multiple hospitalizations, a stay or two in residential treatment, and a cocktail of psychotropic drugs, reassigned whenever a new placement occurs, with its concomitant changes in mental health providers, no one, frankly, knows what the hell is the best approach to help this child.

    And, I've come to the conclusion, that that's the "gold standard"---that's where we are, currently, in the research. No one really knows what to do, or what to treat first, or how to manage it all, while childhood is speeding by and school calls for attention.

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  20. (cont'd)
    So, we do the best we can: we find a psychiatrist who can work on the most flagrant symptoms (PTSD-related insomnia and aggression, for example), we find a nutritionist who can work on the anorexia brought on by sexual abuse, for example, we find a psychotherapist who can work on the suicidal ideation and the externalizing threats and the complete (and understandable) lack of social skills, and we find a family behaviorist that will work on building a sense of safety and consistency in a home that is being torn apart by the effects of the traumatic history of a child who has grown up, for all practical purposes, in a war zone.

    So, yeah, a little holding therapy sounds good, especially if the professional proponents of it say that will cure *everything*---that the root of all the child's problems are attachment, and if we can go back and redo that terrible gap in mother/child attachment, all the rest of the trauma will not need to be addressed, or will be easily and secondarily treated.

    We mess up a few children in our culture really, really badly, and we don't yet have the means to repair the damage we cause. Perhaps we never will. And perhaps that's where we ought to start, when we talk about adopting older children, or any children whose prenatal circumstances we know nothing about (because "only" FASD is no picnic).

    We've adopted severely injured children, and they won't ever be "fixed" fully. All we can do is our best: our best to love them as fully human, to educate them as fully human, and to show them the respect and dignity they deserve no matter where they are currently standing on the injured/fixed spectrum.

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  21. Marianne, thanks so much for this well-thought-out and articulate view "from the trenches". As you point out, adoption is no longer just adoption,but involves treatment of many severe problems that existed before the adoption occurred, and our understanding of the tasks of adoptive parents needs to include that point. Focusing on separation, attachment, etc. alone prevents people from considering the reality that they're dealing with.

    I would like to publish what you've said here as a "guest post". Is that all right with you? I'm not sure how many of these comments get read.

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  22. Jean, I'd be honored if you posted my comment as a guest post. Thank you.

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  23. Okay,let me see if I can figure out how to do it without retyping the whole thing-- which I'll do if necessary

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  24. Thanks, Jean! Doesn't Control C (to copy) and then Control V (to move) work on blogspot? It works on WordPress---hope it works for you. If not, I can always resend it to you via email.

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  25. I'm about to try it. I have an e-mail program where you can't do anything like this, so I'm always pessimistic--

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