Pondering the ‘Abortion and Mental Health’ dilemma from a General Practice perspective

12 MINUTE READ

From Luke’s Journal 2022 | Termination of Pregnancy | Vol.27 No.3

I am reaching the end of my clinical work in General Practice. My hair is grey, the peripheral circulation is not as good as previously, and my senses are starting to grow a little dimmer, with eyesight changes and hearing aids needed as well! Nevertheless, it is still a joy to use generalist skills and knowledge to help others, to consider ways of being Christ to colleagues, and patients. To me, being a doctor is being a person united with Christ and letting His light and His love show through me. 

I rarely ‘evangelise,’ however He is mentioned often. I rarely pray aloud with people however we often sit together in God’s presence (hour after hour actually) whether they know it or not!

The last fifteen years of my practice have been purely counselling and mental health work. I currently work as a couples and relationship therapist. With clients, I sit and ponder the condition of their world, and their lives – due to their choices, their pain and loss, and their capacity to manage the next day or week. Some bring a Christian perspective; others are totally atheistic, sometimes aggressively so. However, because of the incarnation of Christ, I am compelled to be present with them (see the model from our Lord in Philippians 2).

It is in this arena that the topic of Luke’s Journal for this edition resonates for me.  I have taught students and young doctors to do the same – that is, to sit and ponder people’s stories, and their responses to those in similar circumstances.

May this small offering of my ponderings, and the thoughts of my colleagues and friends, be useful to you as you minister in YOUR medical space. 

My plan: 

1. Avoid the tussle for evidence that ‘finally stops any disputes’ about the ‘mental health challenges and abortion’ debate. 
2. Consider the biases that we bring to these conversations. Recognise how these affect our work with our patients and discussions with colleagues.
3. Offer thoughts about best practice in this place and consider the evidence base for this.
4. Encourage you to be good risk assessors
5. Challenge you for the ‘long obedience in the same direction’

Part 1

A synthesis of the literature regarding abortion and mental health is hard to create.  A web-based search will create a massive headache and the responses to these papers are becoming increasingly polarised.

Since the 1980s, papers have been written purporting both no increase in mental health symptoms post-abortion, and significant increases in mental health symptoms following it. There is such variation and emotion attached to the comments about these studies, and such a range of ways of researching this fraught subject.  I have listed some articles in the reference section that may be helpful for you to digest and consider. You could also follow the trails of their references. 

With many of the same reports being used both for and against abortion rights, it is a twisted, complicated journey.

The article by David Reardon¹ has useful tables comparing opposing views.  This might prompt dialogue with our colleagues.  It may also challenge the claims we make when we speak with our patients.

Research around this topic is challenging, too, because of methodology.

It is impossible to conduct randomized double-blind studies to investigate abortion-associated outcomes. Such studies would require random selection of women to have abortions. Notably, the very same fact that would make such a study unethical—forcing a group of women to have abortions—actually occurs in the real world wherein some women feel pressured or even forced into unwanted abortions by their partners, parents, employers, doctors, or other significant persons.²

…the Task Force on Mental Health and Abortion, of the American Psychological Association (TFMHA)  review concurred with the view that the complexity of this field “raises the question of whether empirical science is capable of informing understanding of the mental health implications of and public policy related to abortion,” admitting that many research “questions cannot be definitively answered through empirical research because they are not pragmatically or ethically possible.”³

Part 2

Bias is present in all of our discussions and ‘evidence’.

Let me put my cards on the table, as I would if I was having a conversation with students or colleagues… 

I am a believer and a follower of Christ. I do not believe in abortion as ‘birth control’, or a means to ‘reduce acute anguish’.  I choose not to say, `This person needs an abortion’, nor to refer. This is my bias, my values.  However, I cannot only read Christian literature on this subject.

Our biases are not just personal. They also have a communal element. We tend to adopt the biases of our peers for several practical reasons. First, by adopting the opinion of our peers as our own, we are embracing a collective wisdom that frees us from the need to deeply research and consider every idea on our own. Second, the more completely our beliefs are aligned within our community of peers, the less we will face conflict and suspicion. Obviously, there is never perfect alignment or cessation of independent thinking. But the tendency to accept the ‘conventional truths’ of one’s peers as ‘fact’ is a very real phenomenon.⁴

I find it helpful to read the material, and to be influenced in my thinking by honest men and women attempting to make ‘numbers and confidence Intervals’ mean something very important in the arenas of personal decision-making, policy, medical safety and moral choice.  These researchers may be atheistic, or humanistic, or Christian or Jewish, and yet with a passion for noticing patterns and taking seriously the phenomena evidenced in them. The result of this is that hypotheses can be derived, tested and rigorously debated, for the good of both patients and society. This is a form of growing in our truth-telling, and one of the character qualities that must be formed in us as we grow in Christ.

An article published by Cambridge University Press by Fergusson, D et al⁵ encourages me (fully published online):

These conclusions have implications for both service provision and the interpretation of the law in jurisdictions such as New Zealand, England and Wales. The finding that the extent of distress caused by the abortion is a predictor of subsequent mental health suggests the need for providers of abortion to:
conduct thorough screening of abortion-related distress; to carry out adequate follow-up of those showing distress; and to counsel those showing distress about future mental health risks and the need for support.  In terms of legal issues, our findings have important implications for jurisdictions such as England, Wales and New Zealand, where over 90% of abortions are authorised on the grounds that proceeding with the unwanted pregnancy would pose a serious threat to the woman’s mental health. There is no evidence in this research that would suggest that unwanted pregnancies that come to term were associated with increased risks of mental health problems or that abortion mitigated the risks of mental health problems in women having unwanted pregnancy. 

In addition, although recent reviews of the evidence have concluded that abortion is not associated with increased mental health risks when compared with unwanted pregnancies that come to term, no review to date has found that abortion is associated with a reduction in mental health risks. Collectively, this evidence raises important questions about the practice of justifying termination of pregnancy on the grounds that this procedure will reduce risks of mental health problems in women having an unwanted pregnancy. Currently there is no evidence to support the assumptions underlying this practice, and the findings of the present study suggest that abortion may, in fact, increase mental health risks among those women who find seeking and obtaining an abortion a distressing experience. (emphasis by the author).

We must continue these discussions, influence the researchers and policy-makers, and speak honestly to each other in medical tea rooms and consulting rooms.

Part 3

My decisions in work and in life are influenced by ‘the ONE’. The ONE person who presents with despair, the ONE person in conflict, the ONE family in crisis, the ONE unexpectedly-pregnant adolescent in my room who imagines life is over.  But more than that, it is influenced by the Holy One who is above all. This is the One True God, the Creator and Sustainer of Life, and who reaches down into this world of ONEs. 

So, my approach to abortion and mental health is to invite the ONE into the room:  welcome their presence and uniqueness, move towards them and just listen.

Is there evidence for this practice?

The General Practitioner who has worked in a town for many years, heard the stories of families for generations, listened to joy and heartbreak, knows that the evidence is in the relationship of trust which grows, the returning patient who allows you to do all manner of examinations and investigations to discover pathology, and tells others to come to that practice ‘because they look after you there’. But enough of anecdotes – the medical communication literature since Lucien Leape in 1991⁶ has been surprising doctors with evidence that suggests that blood pressure management is tighter when the Doctor and patient listen to each others’ ideas and needs;⁷  that the HbA1C level is significantly lower in patients with diabetes when the treating doctors listen to the struggles of the patient about their glucose control, then offer education and support for 5 minutes per visit.  In contrast, the recovery of a patient post-surgery is significantly negatively affected when there is tension in communication in the operating theatre, especially between medical and nursing staff, and the reverse is true when there is positive regard expressed between these two groups of carers.⁸

What do we notice if we listen to mental health conversations around pregnancy?

Joy, shock, loss of control. Rape, violence.  Mixed emotions – despair, and yet desire. Tiredness. Entitlement. Caring.  Moral outrage. Grief and sadness…. Conflict, lies, embellishment or exaggerating symptoms. Pressure, panic, embarrassment, caught out, trapped… The list of the experiences of these people is almost endless – for both men and women, our colleagues included.

Actually, we might not hear any of this, as if the ‘A-word’ is used, we may cease to be present to the ONE…. Our own pain and distress, especially around beliefs which are held dearly, may cause us to stop noticing or hearing the story that is being enacted in front of us. At this point, we may cease to be ONE who can become a trustworthy companion through the next part of the journey.

I am going to assume that you as a Christian are totally convinced of the position of the sanctity of life around abortion, and the final choice in not referring for termination of pregnancy; but this ONE needs us now.  There are risks in any procedure, to mental and physical health. There are other ways to manage this event which are safer for all.  The risks must be sought, and the care for the person evident in our discussion. The preventive nature of our work must be at the fore here.

How to start this mental health conversation

Be Christ to them – present, truthful and humble:

• Check your own self and attitudes: watch for panic, and avoidance

  • Do not usurp the qualities of God that are not ever ours –   particularly the ‘3 omnis’….. we do not know all, we are not all-powerful, cannot be ever present , AND we are NOT self-sufficient. That means, we must listen to another perspective.  We cannot control for everything, cannot save all people, and we must not stay unsupported in our processes.¹⁰

• Manage your calendar:

  • Time must be allotted: adequate for an exploring conversation, or divided into a number of appointments

• Welcome the stranger. (Deut 10:19)

  • Love the stranger even if they have a different position than ours. Use the minimal encouragers of, “Tell me more,” turning towards their ideas by thinking about them (linger on them rather than moving on), paraphrasing and reflecting emotions.

• Always look for the whole:

  • Hear about the whole person – their situation and background – with humility and curiosity. Don’t see them simply as a ‘person wanting an abortion’.

• Be incarnational  (we are Jesus to them, at this point):

  • Be with them in the pain, fear and the journey. This is through joining with them, and empathic statements that show that we see and hear them.

• Gentle probes towards truth telling, for example:

  • “Do you know about this way of managing a pregnancy?”

  • “Have you considered keeping the pregnancy?”

  • “What are your thoughts about regret? About grief? About physical consequences?”

“Every single person has a story that will break your heart. And if you’re paying attention, many people… have a story that will bring you to your knees..” – Brené Brown¹¹

• Pray for yourself and the other – silently and consistently as you work.

• Seek counsel with your mentors and debrief challenging conversations – a plug for General Practice Supervision!

Part 4

The research is clear about persons at high risk of adverse mental health outcomes, whilst some will continue to live with their decision in a way that is satisfying to them and not show any obvious significant mental health outcomes.  It is in the stories that we hear, while connecting with our patients, that we note the potential risk factors for future mental health challenges.

Table-PMC(nih.gov)¹²

Risk factors for mental health problems after an abortion identified by the American Psychological Association’s Task Force on Mental Health and Abortion (TFMHA) in 2008.

TFMHA identified risk factors	Percentage of women at risk (various studies)
Perceived pressure from others to terminate a pregnancy	20%; 23%; 32%; 64%
Terminating a pregnancy that is wanted or meaningful	30%–63%;26%–39%; 11%–56%; 25% foetus human, taking life; 7% morally wrong
Perceived opposition to the abortion from partners, family, and/or friends	10%–20%
Lack of perceived social support from others	44%
Feelings of stigma; perceived need for secrecy	47%–56%
Exposure to antiabortion picketing	87%
Low perceived or anticipated social support for the abortion decision	Percent at risk not reported
A prior history of mental health problems	31%–51%
Personality factors such as low self-esteem and low perceived control over her life	53%
Use of avoidance and denial coping strategies	19%–51%; 17%; 75%
Feelings of commitment to the pregnancy	15%–18%; 30%
Ambivalence about the abortion decision	38%–54%; 30%–44%; 65%; 22%; 11%–29%; 35%
Low perceived ability to cope with the abortion prior to its occurrence	36%; 40%
A history of prior abortion	48%–52%
Abortion after the first trimester	9%

Other risk factors: the presence of domestic violence, cultural beliefs and restrictions around pregnancy/abortion 

When the stories heard contain any of these risk factors, underscore the need to keep connection and intentionally make this appointment – either with you, or a referral to others.

Part 5

Let’s be very real here – though we have listened, loved, told truth, and encouraged in other alternatives, our patients may choose abortion as their next step.

What is the appropriate response in being mental health workers and advocates? ¹³

• Make steps towards relationship, regardless of their choice about continuation of the pregnancy.

• Book the next appointment.

• Let them know that you wish to check on them after the procedure to do duty-of-care follow up

• Attend to any affect changes early by doing the same as you did when you were hearing the story initially. Listen and welcome this ONE into your room. Treat appropriately if grief reactions are severe, or diagnosable conditions result.

• Notice if there is isolation, and work for more connection and support.

• Create opportunities to speak to the future – hope-filled conversations which build in the next months. Notice their dreams and imagine them. Connect with the affect in the imagined dreams and mark it with a response. 

• Record the conversations in your notes and refer to them when you see them again.

Make a tailored response to this persons’ conflict and thoughts or beliefs.  Another less mindful response is to categorise, or to create a medicalised syndrome.  If we do the latter we move away from the vulnerable, conflicted space, where we are being humbly immersed – God working through us for the good of the other.  Doing other than being immersed can sanitise the appointments and lessen the power of our presence for safety and healing.¹⁴

Summary

Your life in medicine will include discussion of topics around which you have strong beliefs and reactions.

There are researchers and writers wanting to collaborate and serve their profession honestly. Read them and think with them.  Check your statements and claims.

Build relationship.  Build trust with colleagues and patients.

Prevent the risky outcomes as much as possible by being aware and being a clinician who continues to listen to the whole, and responds to the complete story.  Working in mental health around the issue of abortion can be distressing and tiring, and just considering it reminds me of a book I read a long time ago, which encouraged me in my walk with Christ – A Long Obedience in the same Direction ¹⁵ – this is wearing the yoke of Christ. 

“Take my yoke upon you, and learn from me, for I am gentle and lowly in heart, and you will find rest for your souls.” Matthew 11.29 ESV

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References:

1. Reardon, D.A The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities – PMC (nih.gov)
2. Reardon, D.A
3. “Review of Task Force of the American Psychological Association on Abortion and Mental Health  Published 13/08/2008
4. Reardon,D.A  The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities – PMC (nih.gov)
5. David M. Fergusson, L. John Horwood and Joseph M. Boden  Reactions to abortion and subsequent mental health Cambridge University Press The British Journal of Psychiatry (2009) 195, 420–426. doi: 10.1192/bjp.bp.109.066068
6. IHI Lucian Leape Institute | IHI – Institute for Healthcare Improvement
7. Improving Hypertension Control in Primary Care With the Measure Accurately, Act Rapidly, and Partner With Patients Protocol | Hypertension (ahajournals.org)
8. Communication and relationship dynamics in surgical teams in the operating room: an ethnographic study | BMC Health Services Research | Full Text (biomedcentral.com)
9. Review of Task Force of the American Psychological Association on Abortion and Mental Health  Published 13/08/2008
10. Wilkin, Jen  None Like Him: 10 Ways God Is Different from Us (and Why That’s a Good Thing) Crossway 2016 Chapters 1 and 2
11. Brené Brown TED Talk (published quote)
12. Review of Task Force of the American Psychological Association on Abortion and Mental Health  Published 13/08/2008
13. Shared decision making | Australian Commission on Safety and Quality in Health Care
14. Lynch Dr Johanna A whole person approach to Well-being  ‎ Routledge; 1st edition (31 December 2020)
15. Peterson, Eugene:  A long obedience in the same Direction InterVarsity Press; Anniversary edition (1 June 2000)

 Psychological effects of abortion – O&G Magazine (ogmagazine.org.au)

Mental health post abortion – Family Planning NSW (reproductiveandsexualhealth.org.au)