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Oct. 5, 2022

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How abortion and mental health intersect: Experts weigh in

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Although abortion is legal in Washington, Lauren B. Simonds can quickly list ways Washingtonians — and those who come here for abortions — will be affected mentally and emotionally as abortion policy heads back to the states.

Simonds has a unique understanding of how the abortion debate intersects with mental health. She used to run two clinics that provided abortions, and for three years she led the abortion advocacy organization NARAL Pro-Choice Washington. For the past decade, she been the executive director of the Washington chapter of the National Alliance on Mental Illness.

“Just this decision itself causes anxiety for people,” she said of the recent Supreme Court ruling that ends the national right to abortion. As abortion providers across Washington brace for an influx of patients, she added, “I can only imagine the stress and anxiety that abortion providers are feeling.”

To better understand the ways the abortion decision intersects with mental health, The Seattle Times Mental Health Project spoke with legal experts and clinicians, reviewed various states’ new abortion laws and compiled scientific studies. We found that although some things are clear — like where the science stands on abortion and mental health — other questions are subject to how state legislators act, how people vote and how courts decide to enforce new legal standards.

1. What does research tell us about mental health and abortion?

The most significant research on mental health and abortion comes from the landmark Turnaway Study, which spanned five years, included nearly 1,000 participants at 30 facilities and examined the consequences of being denied an abortion. The study compared people who were able to access abortion to those who couldn’t because they’d passed the facility’s gestational age limit.

The study found having an abortion wasn’t tied to mental health problems. Several other studies, including a 2008 report from the American Psychological Association, confirm this finding, though there’s evidence that having an abortion can lead to a mix of emotions: Some women report feeling sadness, grief or loss while others report relief. Both the Turnaway and APA studies also suggest a person’s prior history of mental health concerns — not whether they received an abortion — are a predictor of their later mental well-being.

But the effects of being turned away are broad: Those denied an abortion were more likely to have serious health problems, raise children alone without the help of family and be unable to pay for basic needs like food. When it came to participants’ mental health, those turned away experienced more symptoms of short-term anxiety and low self-esteem. Those symptoms largely resolved over time, and by the end of the study, the mental well-being of both those who received and were denied abortion had improved.

A handful of other studies suggest that in countries with abortion restrictions, like El Salvador, teenage pregnancy is tied to a heightened risk of suicide. Studies in Bangladesh and Kenya have similar findings.

2. States with abortion bans have exceptions when a pregnant person’s life is at stake. Are mental health concerns, like suicide risk, considered?

Most states’ new abortion laws, including those in North Dakota and Mississippi, make general exceptions when the life of the pregnant person is threatened. But many of these laws are vaguely worded and don’t specifically call out suicidality as a reasonable exception to their abortion bans.

Lawmakers in some states, including Idaho and Tennessee, seemed to have foreseen the possibility that banning abortion could cause some pregnant people to experience suicidal thoughts, actions or other serious mental health concerns. Yet these states don’t offer exceptions for mental illness or suicidality.

Instead, both states’ trigger laws expressly state that a pregnant person’s threat to harm themselves is not a suitable defense for an abortion provider facing criminal charges. In other words, it’s illegal for a physician to provide an abortion to a patient who threatens to kill themselves if they can’t terminate their pregnancy.

The Tennessee law also offers no exceptions for incest or rape. Victims of these crimes are significantly , according to a large body of research.

Legal advocates for abortion who are following Idaho’s ban said a lack of protection for suicidal people contradicts the state’s stated interest in protecting fetal life.

“It serves no purpose whatsoever because it results in the death of the pregnant person and the fetus,” said Kim Clark, senior attorney for reproductive rights, health and justice at Legal Voice in Seattle.

Gemma Collins, a licensed clinical social worker and psychodynamic psychotherapist in Seattle, sees the merits of having an exception for mental health conditions but pointed out how it could backfire.

“If you’re documented as having PTSD, anxiety, bipolar disorder, depression and if we’ve defined those things as dangerous to your life as a way to get access to abortion, then what are we doing? And how does that impact your right to bear children in the future?”

3. Will new laws compel providers to share information about patients who disclose an abortion or intent to have one?

Legal experts and Washington’s mental health professional associations are currently examining this question. The issue is especially important since Washington providers now have more access to out-of-state patients than ever before. Washington recently joined a multistate compact that allows licensed psychologists here to offer telehealth appointments to patients in all other compact states, including several with strict abortion laws.

On Thursday, a group of the nation’s psychologists affiliated with the American Psychological Association discussed how the decision could affect cross-border care. Topics included whether states will consider abortion child abuse, which could have ripple effects for mandatory reporters like mental health professionals, said Samantha Slaughter, director of professional affairs for the Washington State Psychological Association.

In general, psychologists and other medical professionals are bound and protected by patient privacy laws. That means they should be protected from sharing clinical notes or a patients’ records with state authorities, including those outside of Washington.

But federal law offers few protections if law enforcement gets a court order for patient records, which is why some states, like Connecticut, are passing legislation that prevents government and health providers from participating in out-of-state investigations.

On Thursday, Gov. Jay Inslee issued a directive that prevents the Washington State Patrol from cooperating in such investigations.

“There’s nothing the state of Washington can do to stop a criminal or civil case in another state,” said Clark, of Legal Voice. “What the state can do, and I think the governor is looking into, is ensuring that Washington to the extent possible is not complicit in those investigations.”

4. Are Washington mental health providers planning to make any changes to how they document or conduct therapy sessions?

Some say they’re considering changes.

Lesli Desai, a licensed independent clinical social worker in Seattle who specializes in therapy for pregnant and postpartum women, has talked with other clinicians about how they will take notes in future sessions.

They follow standards from the Washington Administrative Code, but, “everybody has their own style and technique,” she said. “Some therapists are very detailed in what they document and some therapists, either by their choice or by client choice, take little to no notes and documentation.”

She said some clinicians are thinking about launching their practice as both therapy and life coaching because there are fewer regulations for life coaches.

“Will it be safer to do life coaching versus therapy because it’s unregulated?” she said. “How do we ethically and morally continue to serve in ways that we believe are important and that we value but also protect our licenses and protect our clients from prosecution?”

5. What are Washington mental health providers hearing from their clients?

Alicia Ferris, a licensed mental health counselor in Olympia specializing in reproductive health, said an individual’s mental health can be affected when personal medical decisions become the subject of a public debate loaded with stigma and judgment.

She also said short-term effects may differ from long-term effects, vary from person to person and change over time. For example, someone who had an abortion at 16 may feel significant relief, but new emotions can surface if, at 35, they experience infertility.

Desai said she has already seen clients bringing this issue up and expects that to grow.

“I think we may see an influx of clients who want to process this. It is definitely triggering for clients who have any form of this in their history,” Desai said.

Providers, Desai and Ferris said, need to make it clear where they stand on abortion rights and have the appropriate training to help clients.

Gladys Rodriguez, a licensed associate therapist in Seattle, said in an email that she predicts anxiety and depression will increase in women.

“I expect PTSD cases to absolutely increase whether from carrying an unplanned pregnancy, labor and delivery, or from an already existent diagnosis of PTSD,” Rodriguez said.

Slaughter noted that mental health providers are experiencing a range of emotions, too.

“Just when you didn’t think you could take any more there’s something else that you are having to manage,” she said. “Psychologists and mental health clinicians are no different from anyone else.”

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