Back when I started seeing clients as an intern, I was eager to delve into the world of reproductive mental health. I had gathered a fairly robust body of knowledge on postpartum depression, loss, and infertility. I felt like I knew (reasonably speaking, for a new therapist) what to expect.
What I didn't expect was how often the topic of abortion would come up in the therapy room.
It wasn't with every client, of course (1). But, there were a handful of people who disclosed this experience to me, or who were grappling with the decision while in therapy. And their stories made me realize that this is a part of the reproductive mental health conversation we need to be having.
So what does talking to a therapist, specifically this therapist, about abortion look like? Well first of all...
Let's Get This Out of the Way Now- Abortion Doesn't Make You Mentally Ill
I want to be clear here. I do not believe that an abortion in any way causes mental illness. I don't believe that because we have no empirical evidence to support that claim. According to the APA's Mental Health Health and Abortion Task Force, which completed a 2008 meta-review of multiple studies on termination and mental health, no correlative or causal relationship exists within the current research literature. (The review was completed in 2008 and updated again in 2009 with the same conclusion.)
"...The relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy for nontherapeutic reasons is no greater than the risk among women who deliver an unwanted pregnancy." - American Psychological Association (2)
In a 2000 study cited by that same APA task force, researchers found that most patients surveyed did not report feelings of regret or other negative associations with their abortion experience, either at a few months post-abortion or two years post-abortion (3). Again, it is clear from the literature that abortion itself does not cause mental illness or significant distress.
This is not to say, however, that having an abortion is easy or simple. In cases where the pregnancy is wanted but mistimed, or if there is a fetal abnormality contributing to the decision, the experience may involve some ambivalent feelings.
In addition to this, the APA notes several factors outside the abortion procedure that may contribute to mental distress:
Perceptions of stigma, need for secrecy, and low or anticipated social support for the abortion decision
A prior history of mental health problems
Personality factors such as low self-esteem and use of avoidance and denial coping strategies
Characteristics of the particular pregnancy, including the extent to which the woman* wanted and felt committed to it. (4)
Stigma, Support, and Social Context
Here's the thing. Like so many other things in life, it may not be the actual event that gets sticky in our heads, but the stories that surround that event. If you have a strong support network, if you have few barriers to abortion care, then your abortion story is unlikely to be one of distress. You may never need to mention it to a therapist.
But, what if you have a wanted pregnancy in unsafe circumstances, including intimate partner violence? What if you already have children you're struggling to support as it is? What if you could never tell your support network you're even considering a termination because of stigma and judgement? What if you have found out that there is a fetal abnormality involved and you need to make a really difficult decision that involves your heart and your head and it's just a whole lot to process no matter what you decide?
What if none of those things are happening and you still just need some additional support for this particular life event? That's where a therapist can help.
The Therapist's Role
Here's what I want my clients to know:
I have zero stake in your decision surrounding pregnancy termination, other than your personal mental health.
I don't feel a need to sway you one way or another.
I don't actually know what the best decision is for you. Only you can know that.
My goal is to provide you a safe, judgement-free place to discuss your decision if that's what you need.
I also want you to know that even if you don't need to process your decision, if it was or is going to be a largely non-event for you, you can still mention it to me as part of your medical record. Really. Because abortion, in my personal and professional outlook, is a medical reality. And I'm neither a doctor nor someone who is interested in should-ing my clients.
And if carrying a pregnancy to term and engaging in an adoption process is what you want, I am here to support you in that process as well. Because remember that mantra? I don't actually know what is best for you. But I am 100% certain that we all do better with compassionate support.
Processing (or Not Processing) the Past
Now, I've also met with clients who had abortions in the past and are now pregnant, this time prepared to carry to term. For those who didn't have support during their termination, or who were judged, shamed, or misinformed about the physical ramifications of abortion (no, it will not significantly increase your rate of future miscarriages), a new pregnancy can stir up some old feelings that need sorting through (5). I want my clients to know that my office is a space where you will receive compassionate care, and your story will be held without judgement.
So shout your abortion. Or don't. Or talk to me about it. Or don't. Or have one. Or don't. Or feel good and bad and confused and clear and messy. Or not. You and your story are welcome in my office any time.
*While the APA uses the term "woman" here, this is their language. I have tried to use gender neutral language in this post to reflect the reality that not all people who become pregnant are women, regardless of whether they have a uterus.
(1) The Guttmacher institute's 2008 research stating that 1 in every 3 adult women would have an abortion by age 45 is is restated in the media fairly frequently. But, since that year the overall rate of abortion has slowed, and experts posit that we are likely to see a lower figure come out of the next round of surveys. Source:
Yee Ha Lee, Michelle. (2015, September 25). The 'stale' claim that 1 in 3 women will have an abortion by age 45. The Washington Post. Retrieved from https://www.washingtonpost.com/news/fact-checker/wp/2015/09/30/the-stale-claim-that-one-in-three-women-will-have-an-abortion-by-age-45/?utm_term=.0b10be861f8f
(2) Major, Brenda, et al. (December 2009). Abortion and mental health: Evaluating the evidence. American Psychologist, 64, 863-890. doi:10.1037/a0017497
(3) Major, B., Cozzarelli, C., Cooper, M. L., Zubek, J., Richards, C., Wilhite, M., et al. (2000). Psychological responses of women after first-trimester abortion. Archives of General Psychiatry, 57, 777–784.
(4) APA Task Force on Mental Health and Abortion. (2008). Report of the APA Task Force on Mental Health and Abortion. Washington, DC: Author. Retrieved from http://www.apa.org/pi/women/programs/abortion/executive-summary.pdf
(5) Kurtzman, Laura. (2014, December 8). Major complication rate after abortion is extremely low, study shows. Retrieved from https://www.ucsf.edu/news/2014/12/121781/major-complication-rate-after-abortion-extremely-low-study-shows