Editor’s note: Based on her clinical observations, our writer, also a practicing psychotherapist, recognized the need for guidance about the mental health implications of the recent anti-abortion legislation. To that end, she interviewed several experts to learn how providers can adequately and ethically address patients’ needs regarding this topic.

In May 2019, the governor of Alabama signed the most restrictive anti-abortion bill in the nation since the US Supreme Court affirmed the constitutional right to safe and legal abortion with their 1973 ruling on Roe v Wade.1 The Alabama bill bans abortion in all cases unless the procedure is necessary to “prevent a serious health risk” to the mother, with no exceptions for cases of rape and incest. Physicians who provide abortions in Alabama under any other circumstances could be convicted of a Class A felony and sentenced to up to 99 years in prison.1

In addition to Alabama, eight other states have passed extremely restrictive abortion laws, with the ultimate aim of reaching the Supreme Court to overturn Roe v Wade altogether.2 (See more details and physician interviews on the topic at “Physicians Weigh In on Wave of Fetal Heartbeat Bills Across the United States.”) Although these laws have not yet been implemented, and several have already been blocked by federal courts, the effect on women’s health, and specifically their mental health, may already be in effect.

As reports of these anti-abortion bills have become a mainstay in the media, reactions have ranged from applause to outrage, and women in the latter group may feel distressed about the various implications of these laws. As such, some clincians will inevitably hear about such concerns from patients who are affected by the legislation. However, there have been no published reports regarding the mental health aspect of this situation, or how practitioners should respond to it.

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To further explore the topic, Psychiatry Advisor interviewed the following experts: Laura S. Brown, PhD, a clinical and forensic psychologist in private practice in Seattle, Washington; Nada L. Stotland, MD, MPH, a reproductive psychiatry expert3 and past president of the American Psychiatric Association (2008-2009); and Joanne Bagshaw, PhD, a sex therapist certified by the American Association of Sexuality Educators Counselors & Therapists and psychology professor at Montgomery College in Germantown, Maryland.

Psychiatry Advisor: What are the mental health effects of extreme abortion restrictions, and if applicable, what are you seeing in your practice in this regard?

Dr Brown: I’m mostly hearing about this from women my age and older, the pre-Roe generation, all of whom are furious and worried sick about daughters, nieces, and granddaughters and the direction in which some states are going. 

We can look back to pre-Roe, and also to research done during that time with women denied abortions who had gone through the arduous process of attempting to get a legal one for mental health reasons. Women are feeling trapped and terrified. They are upping their contraceptive precautions when they can, but when in abusive relationships where sex is also often coerced, they feel even more out of control. There’s a more general sense that women are seen merely as a vessel for breeding a fetus, not as a human being, and thus feeling demeaned and devalued. This seems to strike survivors of rape and childhood sexual abuse particularly hard, as having the right to an abortion was often one of the things they clung to. 

Dr Stotland: At age 75, I have a very small practice and am not seeing this issue with clients at the moment. However, there are several levels of effects. Women who have had abortions realize how their lives and those of their families would be harmed under the new antiabortion laws. Sexually active women who don’t want to have babies are anxious because contraceptives can fail. Some are in abusive relationships where they could become pregnant against their will.

These laws…pose the threat of injury and death to women’s mental and physical health…[and] they will affect women disadvantaged by minority or financial status differentially.

Dr Bagshaw: Research has shown that being denied an abortion has negative effects on women’s health. In a 2017 study, women who were denied an abortion had more anxiety, decreased life-satisfaction, and lower self-esteem compared with women who were able to have an abortion.4

Note: Additional findings demonstrate that “having an abortion does not increase a woman’s risk for depression, anxiety or post-traumatic stress disorder,” according to the American Psychological Association.5 Also, a 2019 prospective cohort study by researchers from the University of California, Davis, found worse long-term physical health outcomes among women who gave birth after being denied an abortion compared with those who underwent abortion. At a 5-year follow-up, fair or poor health was reported by 27% of the women who gave birth vs 20% of those who underwent first-trimester abortion and 21% of those who underwent second-trimester abortion.6

In my practice, clients are reporting anxiety and fear from watching their rights being eroded, which is increasing stress. This is especially true for black, brown, LGBTQ, and low-income clients, who are most affected by abortion bans. In addition, even clients who would not be personally affected by abortion bans, because of age, availability of resources, and other variables, are experiencing stress, anxiety, and concern because they are aware of the effect these bans have on individuals and communities.

Psychiatry Advisor: How should clinicians address these issues when they came up in sessions?

Dr Brown: Clinicians should approach this as they would any painful issue: Have empathy and hold space for the client’s feelings, whatever those might be. Don’t prematurely reassure. Do invite clients to consider what the one small powerful thing is that they might do to increase their sense of safety. Clinicians should be extremely knowledgeable about contraception — there are lots of myths and misconceptions out there — and about places in their communities where contraception may be accessed at low cost. Even for women with insurance, if they work for any of the Catholic hospital systems (which in my area means almost all of the large hospital systems), contraception may not be covered, so knowing where to get it at low cost is essential. Become familiar with the ranges of options and their effectiveness, so as to have informed conversations with clients.

And remember, lesbians and trans men need to be included in these conversations as well. Lesbians do sometimes have unplanned consensual heterosexual intercourse, and some trans men are still able to become pregnant.

Dr Stotland: The fact that these issues can cause anxiety, fear, and depression has to be acknowledged. There will be some [posttraumtic stress]. Then we use the existing modalities to help patients bear the realities of their lives. 

It was always important to take good reproductive histories, including current practices and plans, but it was seldom done. Now clinicians in the relevant states have to help patients recognize and address their vulnerabilities. Those at risk should all have morning-after medication. 

Dr Bagshaw: It’s helpful to validate clients’ feelings and concerns, and also to give them factual information; for instance, that abortion is still legal in every state in the United States, and that none of the recent bans has taken effect yet.

Psychiatry Advisor: How should clinicians handle self-disclosure regarding their own views on the issue, and when should they refer out because of conflicting views?

Dr Brown: I would follow the client’s lead on this. Ask them, “Is this something important for you to know about me and where I stand?” For some clients, it will be. For others, it will be important not to know. I would not refer out based on not sharing views. I am adamantly pro-choice, which means I support a woman’s right to remain pregnant and then keep or relinquish her child or to terminate a pregnancy. In other words, to choose, period. Our jobs with our clients are not to share their perspectives; rather, to empower them to clarify their own values. If a client would have ever said to me, “I can’t work with a therapist who supports the right to abortion,” then I would have said, “Then you would not be able to work with me. Do you want to talk about that?” 

Dr Stotland: I believe that licensed clinicians have a legal and moral obligation to respect patients’ values and put patients first. The law is the law, and patients need to understand the implications of laws that directly affect them. In the case of a clinician who is not able to help patients protect themselves from these life-threatening restrictions, they must refer out. Many patients, especially the most vulnerable, will not have a referral option. In that case, the clinician might consult with their professional association for help with a major moral dilemma. 

Dr Bagshaw: That’s a great question, because it can seem sort of confusing about what self-disclosure can mean here when we are talking about abortion. It’s interesting and worrisome that a medical procedure has become so controversial that a therapist would feel the need to second-guess whether to identify as pro-choice. In my practice, I’m very clear that my work is science- and sexual health-based. I’m not willing or ethically able to counsel clients on reproductive health issues without coming from a factual, health- and science-based perspective. If a client is seeking therapy or treatment from a different perspective, a religious one, for instance, I would need to refer them out.

I understand that this might get sticky if a client comes in seeking treatment for an issue unrelated to reproductive rights or health, and yet the topic of abortion might come up during treatment. I would still validate my client’s feelings; however, I would remind them that my perspective on treatment and issues related to treatment are based primarily on science and health. And if the client is conflicted by that, I would recommend finding another therapist.

Psychiatry Advisor: What are some ways in which clinicians can advocate on behalf of patients regarding this issue?

Dr Brown: Support clients in their choices and empower them to have a plan to be sexually safe; that is, to not be coerced, to not be sexual under circumstances that are risky, to be informed about choices regarding contraception. If a client is choosing to terminate a pregnancy, hold the space to work through the range of possible emotions. Help prepare a client for encountering protesters if she goes to [a clinic that provides abortions] and be available soon afterward to help process both the termination and the encounter. 

Dr Stotland: There are several ways: write op-eds and letters to the editor; give talks at schools, community centers, and places of worship; call and visit elected officials; work within professional organizations, most of which forcefully oppose these laws; and actively support…elected and appointed officials and advocacy organizations. The American Psychiatric Association has had a strong pro-choice position since 1973.5

Dr Bagshaw: I recommend that clinicians have a list of resources, including nearby reproductive health centers, along with resources for fact-based information (eg, the Guttmacher Institute) and organizations that are looking for volunteers.

For clients and therapists who are experiencing anxiety and stress because of the bans, but are not in need of services, I recommend volunteering for organizations and getting involved in state or federal level politics, which is an empowering use of anger and anxiety.

Psychiatry Advisor: What are other recommendations for clinicians, or any other important points you would like to mention about the topic?

Dr Brown: If, as a clinician, you value people’s rights to self-determination about their bodies, then you need to ask yourself how you can be involved in that outside of work as well as in the office.

And take the fear seriously. I was an adolescent in pre-Roe times, and I saw what friends went through. It was terrifying, sometimes dangerous, and often demeaning. If you’re working in one of the states that has now effectively outlawed abortion, develop networks in those states where the right is preserved; for instance, many of my clients did not know that the right to abortion has been enshrined in the law here in Washington since 1971 by an initiative vote of the people. 

Dr Stotland: It is very important to understand that laws restricting women’s healthcare [can] have profound negative effects on children, families, and society.

References

1. Smith K. Alabama governor signs near-total abortion ban into law. CBS News. Updated on May 16, 2019.

2. Gordon M, Hurt A. Early abortion bans: which states have passed them? NPR. June 5, 2019.

3. Stotland NL. Reproductive rights and women’s mental health. Psychiatr Clin North Am. 2017;40(2):335-350.

4. Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s mental health and well-being 5 years after receiving or being denied an abortion: A prospective, longitudinal cohort study. JAMA Psychiatry. 2017;74(2):169-178.

5. American Psychological Association. Abortion and mental health. https://www.apa.org/pi/women/programs/abortion/. Accessed on June 14, 2019.

6. Ralph LJ, Schwarz EB, Grossman D, Foster DG. Self-reported physical health of women who did and did not terminate pregnancy after seeking abortion services: a cohort study. Ann Intern Med. 2019;171:238-247.