Now that Americans’ constitutional right to abortion has been overturned, many therapists are finding themselves in a state of professional limbo. The field’s long been aware of research showing that clients denied abortions can experience higher levels of anxiety and depression, less life satisfaction, and more damaged self-esteem than those with access. But now licensing and professional organizations are struggling to make sense not only of how therapists can support women who want an abortion, but if merely offering them a safe space to work through the big feelings of keeping or ending a pregnancy could also run afoul of new restrictions.
At the time this issue went to press, abortion was banned or mostly banned in Alabama, Arizona, Arkansas, Georgia, Idaho, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, South Dakota, Tennessee, Texas, West Virginia, and Wisconsin. North Dakota, Wyoming, Utah, Indiana, South Carolina, and Ohio’s bans were being temporarily blocked by judges. Before these bans, it was believed that about one in four American women had an abortion by midlife. Now, one in three are without abortion care.
Famed feminist psychologist Carol Gilligan has thoughts on what this means for the struggle many women experience to find, value, and prioritize their own needs, desires, and authentic sense of self—their “voices,” in her shorthand. She reminds practitioners that regardless of their politics or personal views on abortion, protecting the psychological health of women in this patriarchal political climate is paramount. She concedes, “It’s not up to a therapist to decide what people should do or how they should live. But therapy itself has political implications, because democracy—whether it’s in relationships, families, societies, or states—depends on everyone having a voice.”
Silencing a Voice
Named one of Time magazine’s most influential Americans in 1996, Gilligan has written some of our culture’s most seminal books on women’s psychology, among them, In a Different Voice; Women, Girls, and Psychotherapy and The Birth of Pleasure. Now a professor at New York University, she had a long career at Harvard, where she was the university’s first professor of gender studies and worked alongside some of modern psychology’s most influential male theorists.
At Harvard, Gilligan undertook a landmark study of women wrestling with choice, just as Roe v. Wade was becoming law. This was in 1973, when the field’s pivotal theories hinged on the study of men and boys: foregrounding men as humans, Gilligan says, and women as “different.” But during her study, Gilligan unearthed the now ubiquitous idea that women are not—as many major male researchers at that time were contending—less moral or emotionally evolved than men. Rather, listening to women led Gilligan to hear a different voice, a way of speaking about self and about morality that centers on interdependence and connectedness.
In the decades since, Gilligan’s remained interested in the mental health of women and girls, and the challenges to their well-being that patriarchal systems can create. She’s taught seminars on resisting injustice and developed workshops and retreats to help women embrace their strengths and voices. Now in her 80s, she says she’s not altogether surprised that a woman’s constitutional right to end or keep a pregnancy has been struck down by America’s highest court. “What did you expect?” she asked on the heels of Roe v. Wade’s revocation in June. “Did you think the patriarchy wouldn’t fight back?”
Of course, therapists’ feelings about the Court’s reversal of Roe are not monolithic. But Gilligan’s quick to emphasize that therapists who counsel clients struggling with an unwanted pregnancy need not wade into murky political waters; rather, their focus should be on providing a space for women to explore their voices that’s free from outside expectation and fear of reprisal. Because, she says, no matter what’s happening in the wider culture, research shows that identifying and solidifying our voices and choices, especially at challenging times, is vital to our well-being.
A Voice of Your Own
Before publishing In a Different Voice in 1982, Gilligan had been working alongside psychologists Erik Erikson and Lawrence Kohlberg at Harvard, and was deeply familiar with their theories of the stages of moral and emotional development and reasoning. In fact, she was preparing her own study of morality, in which she planned to interview male Harvard students who were about to be called up for the draft. The Vietnam war was still raging, and she wanted to know how they were thinking through whether to enlist, go to Canada, or do jail time when they graduated.
She had in mind, she says, “a very basic psychotherapy question: how do people think about choices in their lives? When the roads diverge and they have to decide, ‘What am I going to do?’—who’s the ‘I’ in the question? Does moral language come in, such as, “What should I do?” Or, “What’s the right thing to do?” I wasn’t interested in the abstract. I was interested in real life, when you have to live with the decisions.”
But just as she was about to launch her study in 1973, the draft suddenly ended. Around the same time, Roe became law—and she saw another compelling opportunity to study people facing life choices where issues of identity and morality are at stake. So she pivoted to interview pregnant women referred to her from clinics in Boston’s South End, as well as from university counseling centers and Planned Parenthood.
“At the time,” she says, “I was teaching the work of Freud, Erikson, Piaget, and Kohlberg, but I was listening to women and girls and hearing a voice that differed from psychological theory. Women weren’t deficient, as my colleagues claimed, in areas of moral and emotional development. But women, some women, did articulate a different way of speaking about morality that started from a premise that our lives are interdependent, a premise of connectedness rather than separateness.”
In particular, she remembers Nina, a woman in her 20s, who was in a serious relationship with a law student. When Nina told her she was having an abortion because her boyfriend wanted her to, so he could continue his studies, Gilligan says she responded with, “But what do you want to do?”
Gilligan recalls that Nina’s response was incredulous: “’What’s wrong with doing something for someone you love?’ she said. I said, ‘Nothing, but what do you want to do?’ She looked at me like, ‘How could you even ask that question?’ Well, play it out. What happens? She has the abortion and then blames him, realizing that, actually, she could have done what she wanted, which was keep the pregnancy. In other words, the decision that was made for the sake of the relationship ends up sabotaging the relationship.”
Gilligan says that what stood out for her was a tendency for women to label doing whatever they wanted to do as “selfish.” Subject after subject expressed it. “If she wanted to have the baby and people wanted her to have the abortion, she was selfish to have the baby. If she wanted to have the abortion and people wanted her to have the baby, she was selfish to have the abortion,” Gilligan says. “It’s like here were these pillars: on one side was the word selfish, which meant bad, and on the other side was selfless, which meant good. So to be a good woman was to live as though you had no voice of your own.”
Repeatedly she asked her interviewees, “If it’s good to be empathic and respond to people’s needs and concerns, why is it selfish to respond to yourself? Aren’t you a person too?” She recalls, “Woman after woman said to me, ‘Good question.’”
The Trouble with Voice
In a Different Voice was a sensation among academics and the general public. Both spheres had long fashioned the male experience of life as the norm, but Gilligan shifted the narrative of women’s psychology as being lesser than men’s to having its own essential strengths and unique challenges.
In the years since she decided to foreground how women thought and felt, there’s been measurable progress in the West on issues of gender equality. Female visibility in the public sphere has skyrocketed. The gender pay gap, though still significant, is shrinking. There’s been a reduction in gender segregation in workplaces. And, thanks to the passage of Title IX, the country’s seen not just a 900 percent increase in girls’ participation in sports, but more equal access to higher education, especially in the area of highly technical or well-paying careers.
Then there’s the more recent solidarity of the #MeToo movement. With its call to women and girls to go public with their experiences of sexual assault and harassment, it may be the apex of women using their voices to call out gender-based violence. Yet there are indicators that progress is stalling. Even beyond reproductive rights, political hostility is all too ugly when aimed at powerful women in office. Plus, “just look at what happened with the current administration’s bill that would’ve provided money for childcare, for things that fall disproportionately on women’” Gilligan says. “It doesn’t get support.” She considers the degradation in the public sphere of what are still considered “women and family issues” as a kind of wagging finger from the patriarchy.
Gilligan remains energized about confronting this quieting of women’s voices, and will make it plain to her students when she thinks theirs aren’t shining through. For instance, when she teaches new psychologists, she’ll explain that all research starts with a question, and makes a point of asking them to identify not what they think they should be looking into, but what they really want to know themselves. “What is your question?” she asks them. “What is your real question?”
“I still hear women in my seminars—incredible women: law students, graduate students, PhD students—who instead of saying, “This is a good question or an important question,” will say, “This is selfish, but what I really want to know is. . . .“
She recounts a visit to the Tavistock Institute in England, where she sat in on a session of Milan family therapy, a process where everyone in the family says what they think everyone else in the family is feeling. “In one session,” she remembers, “when the 11-year-old girl would say what her mother was feeling, the mother would start to cry, because no one had ever given voice to what she was feeling, including the mother herself. Everyone has a voice: we’re born with a voice. But that woman had learned that to be a good mother, she was supposed to speak for everyone else in the family except herself.”
Gilligan wants us to see that while the mother silencing her voice was ostensibly for the sake of her relationships, it was instead sabotaging those relationships, because she wasn’t truly present. “I think we have to ask ourselves how many societal structures depend on women not being present,” she says.
She warns that if in sessions a woman is struggling to know what she’s feeling or thinking, if she can tell you about everyone else’s wants but her own, then she’s not present for herself or for the therapy. As the therapist, your question ought to be, “What happened to her voice?”
What Happened to her Voice?
Much of Gilligan’s research into that question centered on her study of young girls crossing over into adolescence. “I came to see how at a certain point in development, a girl’s voice often went underground and got obscured by a cover voice,” Gilligan explains. Girls who a year earlier were bold and offered insights when she spoke with them as preteens, would suddenly answer, “I don’t know,” when asked for their thoughts.
“You have to question the cover voice if you want to hear the voice that’s underneath,” Gilligan says. “Therapists know that—they do it all the time. I started to learn that the real voice was often signaled by phrases like really or actually. For instance, one girl said to me, ‘I don’t like myself enough to look out for myself.’ And I questioned, ‘Do you really feel that way?’ To which she answered, ‘Actually, I look out for myself by not saying what I’m really feeling and thinking. That way, no matter what anybody says about me, I don’t care because they have no idea who I am.’ It’s brilliant, of course, but at the expense of having honest relationships.
“I think this word actually means, ‘Do you see me? Do you know me? Would you like to know what I really think?”
In the 1990s, Gilligan’s work on girls’ voices, which documented this psychological crossroads from an honest child to a more circumspect young woman, struck a chord nationally. Educators, researchers, and families took note. Inspired by her work, The American Association of University Women followed up with its own research and found persistent gender bias in schools that went hand-in-hand with adolescent girls’ low self-esteem. Efforts around the country to foreground schoolgirls’ real voices, including adding more diverse curricula and implementing workshops on self-esteem, began and remain to this day. These initiatives were largely driven by Gilligan’s warning that if girls continued to silence their true voices in an effort to be accepted by the people around them, they might lose themselves entirely. She also theorized that such self-silencing might be related to the rise in eating disorders, depression, and low self-esteem girls can exhibit at this age.
Girls are still learning to disappear their truer voices, but Gilligan sees hope in many heroes of the public realm, like international climate activist Greta Thunberg, who sailed across the Atlantic to protest carbon emissions; and Darnella Frazier, who was a high school student when she held her ground to film George Floyd’s death at the hands of police; and Malala Yousafzai, shot by the Taliban in her native Afghanistan while standing up for girls’ right to an education; and young feminists in Congress who regularly endure a stream of racist and sexist attacks.
As the new laws to enforce the Dobbs decision and the end of Roe v. Wade become clearer, Gilligan warns us to pay attention to a broader effort afoot to make the cost of speaking out prohibitively high for women and girls. In the end, she believes it matters little whether a therapist is for or against abortion. To do the job of helping their women clients, they must practice without favor of their own moral leanings and empower each client to speak her truth in session.
“If we don’t say what we really think, we learn what people want us to say. I don’t see how you do therapy with women if you’re not invested in a woman’s relationship with her own voice. That’s the core of psychotherapy.”
The Abortion Tangle and the Therapy Room
Currently, the legal risks to therapists of speaking with clients about abortion, and recording those discussions in their meeting notes, remain unclear. The American Psychological Association advises that in states that now ban or restrict abortion, therapists should not provide specific information about where and how to obtain an abortion in another state, help a client make an appointment for or related to the procedure, or offer transportation or funding for the procedure. APA suggests such actions could be construed as “aiding and abetting” and also affect malpractice coverage.
APA adds, however, that the “professional position of psychology is that access to reproductive health care is a human right. . . . Providing general information or resources for understanding reproductive healthcare is less risky than the actions above,” as is “focusing on the emotional, family/cultural, and mental health issues a client may face when contemplating an abortion.”
The American Counseling Association’s stance is that “clients should have access to high-quality professional counseling without the fear of having their confidentiality unjustly waived.” The association suggests counselors reach out to legal experts in their particular states to determine whether there are new restrictions on what they might say to clients regarding abortion, and if confidentiality is impacted in some way.
The National Association for Social Workers says it will continue advocating for reproductive rights on the local, state, and federal level. The organization has helped challenge cases around the country where abortion coverage has been restricted, and reminds its members that “given the nation’s history of overcriminalization within Black and Brown communities, it is likely that a disproportionate number of people of color will be arrested and jailed if they receive an abortion where the procedure is outlawed.”
Lauren Dockett is a senior writer at Psychotherapy Networker.
Lauren Dockett, MS, is Psychotherapy Networker’s senior writer. A longtime journalist, journalism lecturer, and book and magazine editor, she’s also a former caseworker taken with the complexity of mental health, who finds the ongoing evolution of the therapy field and its broadening reach an engrossing story. Prior to the Networker, she contributed to many outlets, including The Washington Post, NPR, and Salon. Her books include Facing 30, Sex Talk, and The Deepest Blue. Visit her website at laurendockett.com.