On June 24, 2022, the Supreme Court decided on Dobbs v. Jackson’s Women’s Health Organization, overturning 50 years of the landmark Roe v. Wade decision, which previously protected the right to healthcare privacy and abortion. States now have the right to set their own abortion laws, which vary enormously between states. For example, under California law abortion is legal until the fetus is viable outside the womb. Conversely, Texas seeks to make all abortions illegal unless it is medically necessary to save the pregnant person’s life (Messerly, 2022). These differences in state law pose unique ethical and legal challenges for healthcare professionals, including the right to privacy, mandated reporting, telehealth, resource referrals, and support for family planning (American Psychological Association, 2022c).

The public is also expected to face an increased need for mental health care services as lack of abortion access is linked to decreased mental wellness, strained resources, and compounding economic hardships (Foster, 2020). Regardless of political, moral, or social position, Dobbs poses significant ethical and legal challenges for clinicians of all levels, disciplines, and arenas. Decades of research highlight the negative biopsychosocial impact denied abortions have on generational wellness for both parent and child, as well as increased strain on an already limited social infrastructure (Foster et al., 2018). Now more than ever, it’s important clinicians understand the role we play in this issue. Dr. Eunie Jung, Program Director of Alliant International University’s PsyD program in Sacramento, states that as clinical psychologists, “we almost uniformly possess economic, social, and educational privilege. It is critically important that we do not forget that this power does not extend to everyone and that legal decisions, like the Dobbs ruling, will likely impact our clients and communities in ways that we may not see or understand.” In order to provide competent and equitable care to everyone, practitioners must stay informed about the impact these decisions have on our clients and the role we play in providing ethical resources, support, and healthcare access.

Complications for Child Bearers

Pregnancy intention has a large psychological, financial, and physical bearing on mothers, children, and families. It has been found to impact child development and parental attitudes and behaviors (Steinberg & Rubin, 2014; Su, 2012). A review paper found that mothers who carry unintended pregnancies to term experience disappointment, stress, and ambivalence from the possibility of their careers or other life aspirations being disrupted (Steinberg & Rubin, 2014). Additionally, those seeking abortions had fewer supportive resources as they were more likely to be disproportionately single, poor, and more likely to experience a violent relationship (Steinberg & Rubin, 2014). The authors note that people who are of lower income may not receive adequate maternity leave or paid time off after giving birth. This often results in job loss, fewer resources, and ultimately contributes to declines in health and wellness (Steinberg & Rubin, 2014).

Indeed, a longitudinal study found that women denied an abortion were four times more likely to be under the poverty level, three times more likely to be unemployed, and more likely to stay with a violent partner than were women who were granted an abortion (Foster, 2021). Researchers also found that unintended pregnancies were correlated with increased depressive symptoms in fathers and decreased happiness in mothers (Su, 2012). Because mothers were often the primary caregiver, they experienced additional isolation and depressive symptoms compounded by a lack of institutional support and social resources (Su, 2012). It’s important to note, that researchers found abortion was not associated with an increased risk of mental health problems (Steinberg & Rubin, 2014), but that being denied an abortion was associated with worse health and wellness outcomes for parent, child, and all subsequent children (Foster, 2021).

This research suggests that those experiencing unintended pregnancies are not only strained in psychosocial domains before pregnancy but that following through with unintended pregnancies results in a greater, more immediate need for resources and mental health care for all family members.

Generational Impact

The negative impact on a childbearing person being denied an abortion crosses generational lines, impacting more individuals than just the child bearer. The Guttmacher Institute found that “more than half of women aged 13- 44 (58%) live in a state that is hostile or extremely hostile towards abortion.” Because most people of childbearing age live in states that seek to heavily restrict abortion access, the ramifications of the Dobbs decision on the child bearer and the children of unintended pregnancies will grow exponentially. Children born to mothers who sought but were denied an abortion were 5 times more likely to meet the criteria for a “poor” bonding relationship with their mother figure. They were also 31% further below the poverty line than children who were the result of a planned pregnancy (Foster, Biggs, & Raifman, 2018).

Additionally, children of unintended pregnancies were significantly more likely to get hurt in accidents and falls than children of planned pregnancies and more likely to live in a home that did not have enough income to pay for basic living supplies (Foster, Biggs, & Raifman, 2018). Another study done in Prague found that children born after their mothers were denied abortions had higher rates of mental illness, including higher rates of in-patient psychiatric care (David, 2006). For these reasons, there will likely be a greater need for school-based interventions and a greater need for mental health professionals in school and community settings.

Children exposed to poverty have an increased risk of behavioral problems in school (West et al., 2001). However, access to appropriate mental health support in schools can vary widely, with less access in underserved communities where school funding is limited. The mental health field is likely to expect an exponential need for services in the generations to come, as denying abortion access results in poorer health and wellness outcomes for child bearers and their children (Foster, Biggs, Raifman, 2018).

Impact on Resources and Access

Moving forward we can expect much of our social infrastructure to be heavily burdened. States such as California, where reproductive rights continue to be protected, could see a 3,000 percent increase in out-of-state patients seeking abortions (California Future of Abortion Council, 2021). After Texas passed SB 8, which bans abortion after the fetus develops a heartbeat, neighboring states saw an increase in out-of-state patients seeking abortions that pushed their waiting times up to 3 weeks (White et al., 2022). One Planned Parenthood clinic in Denver saw a 520% increase in Texas patients (Schmidt, 2021). California is likely to see an influx of patients seeking abortions from states such as Arizona, Utah, New Mexico, Texas, Idaho, Montana, and Wyoming (Sears et al., 2022). The burden placed on existing clinics will be passed on to patients who might need to push time-sensitive appointments further out.

The American Psychological Association (APA) notes that a childbearing person’s ability to control when and if they become pregnant is frequently linked to socioeconomic standing and earning power (2022a). A 2022 study by the National Bureau of Economic Research found that people who were denied abortions experienced a significant increase in financial distress. They also found that unpaid debt more than doubled resulting in events such as evictions, bankruptcy, and below prime credit scores. From this data, it can be estimated that with less access to legal abortions there will be a higher demand for social safety net programs such as the Women Infants and Children (WIC) program, Section 8 housing, and unemployment. All of which are already underfunded and overburdened.

Socioeconomic disparities are already a barrier to accessing mental health services. In Oklahoma, where abortion laws are very restrictive, approximately 34% of people of childbearing age are either covered through Medicaid or uninsured (Guttmacher Institute, 2022). Access to mental health care is limited for those on Medicaid and barely accessible for those uninsured (Dembosky, 2021; Seo et. al., 2019). Furthermore, the cost of mental health services has high out-of-pocket expenses for those on private insurance (Leonhardt, 2021). Thus, what the overturning of Roe v. Wade will accomplish is a greater number of people with an increased need for mental health services who will fall through the cracks of an overburdened, barely accessible system. People at the lower echelons of our socioeconomic system are affected the most.

Professional Ambiguities

As professionals in this field, it is our duty to disseminate and advocate for ethical, scientific, and appropriate laws that uphold human rights (American Psychological Association, 2017). Overturning Roe v. Wade disregards decades of thorough, scientific research that has clearly found denying access to abortion and reproductive health rights negatively impacts mental, physical, and social health, compounds generational trauma, and increases disadvantage, particularly for marginalized communities (American Psychological Association, 2017; 2018; 2022a; 2022b; Foster, 2020).

Regardless, the Dobbs decision poses ethical and legal challenges for our field, practice, and profession. The Trust, an independent insurance and risk management program for psychologists, states that, currently, those at risk of liability are “abortion providers; those who recommend or who help others to obtain abortions; and women who seek abortions” (2022). They explain that psychologists are not immediately at risk, but the potential for litigation is still present due to the unprecedented circumstances and frequently changing political and legal landscape.

The Trust reports that some issues confronting psychologists include confidentiality and privilege, mandated reporting, interstate practice, and disagreements between professional ethics codes and state laws. While there are strong protections for privacy and confidentiality between psychologists and their clients, Dobbs may open the door for states to consider a fetus a child (American Psychological Association, 2022c; The Trust, 2022). Therefore, under Tarasoff and mandated reporting responsibilities, psychologists practicing in that state could be legally expected to report any potential abuse or harm that may befall the fetus, including the child bearer’s intention to terminate the pregnancy. Additional complications include interstate and telehealth practices which the field is currently navigating.

It’s not always clear if clinicians must follow the laws of the state they’re practicing from or delivering services to. For example, is a California based clinician, who delivers telehealth services to Texas residents, protected by California law or expected to follow Texas law? The Trust reports that extradition is a possibility, but this could be very difficult to complete with many standing protections for practitioners.

Lastly, ethical code 1.02 describes conflicts between ethical codes and regulations of the governing legal authority, but this code should not be used to validate or justify human rights violations. Some argue that restricting access to abortion is a human rights violation against women; thus, states restricting abortion access are in violation of these ethical and moral codes protecting human rights (The Trust, 2022). The Trust reports that refusing to follow such state laws “may be regarded as an act of civil disobedience and may not lead to prosecution, but only time will tell how licensing boards will deal with these situations” (2022). Because civil disobedience is an act of peacefully protesting the law, a psychologist may argue that not abiding by a state’s abortion laws may be an act of civil disobedience to protect the human rights of the child bearer. Nonetheless, while practitioners may have justification that could protect them from criminal prosecution, state licensing boards may be a separate issue entirely.

Recommendations

It is clear that the field of psychology has few clear-cut answers or guidance in the wake of this change. However, The Trust and the American Psychological Association have issued risk management tips and guidance to help psychologists navigate the upcoming sociopolitical impact this decision will have on the public’s health and the integrity of our field.

Overall, there seems to be a low risk regarding psychological practice and abortion law. Still, practitioners should keep up to date on their state’s abortion laws and maintain standards of professional practice, including prioritizing client welfare, confidentiality, and safety (American Psychological Association, 2022c). Additional recommendations include:

Note Taking, Privacy, and Confidentiality:

Keeping separate “psychotherapy notes” independent of chart notes and including careful documentation for all conversations involving abortion will help protect client-therapist confidentiality. Additionally, these “psychotherapy notes” may afford increased protection and privacy in the face of litigation.

Telehealth:

Out-of-state psychologists providing telehealth care should stay up to date on state laws for both the state they’re practicing from and delivering services to. As of now, telehealth psychologists should be relatively protected from legal action, with pro-choice states offering additional protection. However, legal action across state lines is still possible, although uncommon and quite difficult (American Psychological Association, 2022c; The Trust, 2022)

Client’s Seeking Abortions:

Some clinical activities and conversations may hold more legal risk than others. For example, discussions with clients about the emotional and mental burdens of unwanted pregnancies may be less liable for legal repercussions than helping a client schedule an abortion across state lines (American Psychological Association, 2022c). Clinicians should carefully monitor their state’s abortion laws to ensure they are providing clients with adequate healthcare access that maintains safety for both clinician and client.

Mandated Reporting:

Currently, psychologists nationwide are not mandated to report on abortion intent or action. Additionally, mandated reporting rules do not encompass a “fetus,” therefore, under HIPAA’s Privacy Rule, practitioners are protected in keeping their client’s information confidential and private. These rules may change as abortion laws shift in the wake of Dobbs. Clinicians should remain diligent and up to date on their state laws and legal resources (American Psychological Association, 2022c).

Personal Advocacy and Perspectives:

Some practitioners may feel strongly about the Dobbs decision. The APA Services Inc. offers ways to get involved that are aligned with the APA’s policies. Additionally, clinicians may attend rallies, hold healing circles, drive people to states with abortion access, disseminate information, use expert knowledge to speak on this issue or volunteer for events and agencies supporting reproductive health. The Trust reports that clinicians face little risk in their advocacy efforts “so long as those actions do not involve one’s clients” (2022). While clinicians have their own agency to disseminate research and assist people in accessing resources, it must not encroach on the agency of the practitioner’s clients. Therefore, The Trust suggests not including clients in these activities or events and being mindful of what clinicians post on social media. Ultimately, clinicians must protect clients’ rights by maintaining neutrality and prioritizing client agency over personal perspectives.

Bias:

Recognizing our own biases as clinicians is a regular part of our practice and cannot be overstated during these times. Psychologists have a duty to protect the rights and agency of our clients, especially given the power that we hold. The Trust offers that the safest choice for clinicians is to remain neutral on this subject during sessions, so clinicians don’t inadvertently guide their clients to a decision that may not entirely be their own. Consulting with colleagues, especially those with different viewpoints, challenging our biases, and reflecting on how our beliefs show up in the therapy room is essential to preserving our clients’ autonomy.

Summary

First and foremost, it is our right to protect the public by upholding ethical, equitable, and quality care for our clients. Given our position as experts on emotional, mental, and behavioral health, we have a duty to disseminate our knowledge and advocate for better societal practices that advance social wellness. Dr. Jung highlights the professional importance of providing ethical and unbiased care to clients during this unprecedented time. She states, “No matter our personal, political, or religious beliefs, it is our ethical duty to protect the health of our clients. Now that access to reproductive health care is not constitutionally protected, our duty as clinical psychologists to provide unbiased, compassionate, and ethical mental health care to our clients is more imperative than ever.” Although there is uncertainty around our professional practice, we hold the privilege and power to support our clients in navigating life changing circumstances and seemingly hopeless odds. It is our role to provide hope, opportunity, and unbiased support, prioritizing client safety and autonomy above all else.

These unprecedented circumstances are challenging and complex, yet with thoughtful action and careful attention to professional standards of practice, we can grow from these professional challenges and support our clients most in need of care.

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Deanna Young, MA

Deanna is a Clinical Psychology Doctoral Candidate at Alliant International University, Sacramento and founder of the Student Advocacy Club, a student led organization dedicated to engaging students in all levels of advocacy. Deanna’s clinical interests include trauma, serious mental illness, mood, and personality concerns. She has worked in a variety of community settings with justice-impacted, veteran, and adult populations managing serious mental illness and resource barriers. Deanna seeks to utilize psychological research to inform policy development and is currently researching factors that improve resilience and reduce burnout to better inform training and community-based programs. She hopes to bring culturally adapted services that incorporate creativity and community focused interventions for trauma impacted youth, families, and adults in under-resourced areas.