A model for improving psychological care for women adversely affected by
FGM
Lih-Mei Liao, PhD FBPsSConsultant Clinical Psychologist & Honorary Senior Lecturer
UCL Institute for Women’s Health, London UK
Aims
To suggest ways for delivering psychological expertise collaboratively in relation to FGM in the UK
Effects of FGM widely variable
Can be associated with none or all of these:
Physical – urinary problems, menstrual problems, infertility…, with impact on overall quality of life
Emotional - shame, fear, mistrust, low mood…
Sexual - diminished enjoyment, pain, lack of interest…
Social – compromised intimate relationships, withdrawal from social relationships…
Weaknesses in current psychological understanding
Few citable published studies
Personal testimonies and case studies:◦ Retrospective (subject to recall bias/demand
characteristics)◦ Uncertainty about representativeness
Confounding factors - women who have undergone FGM may have been subjected to other stressors (e.g. social dislocation, poverty) that could lead to adverse psychological outcome
Time lag between any psychological problems and FGM defies simplistic linkage
Hypothesising needs
Community factors(history, economics,
living conditions, etc.)
Familyfactors
Procedural factors: type, extent, practitioner, conditions
mitigating factors mitigating factorsImmediate consequences
long term constellation of consequenceslong term constellation of consequences
EMOTIONAL-e.g. shame, anxiety,
guilt, anger,mistrust, low mood
SEXUAL-e.g. painful
intercourse, poor relationships,
poor body imagePHYSICAL-e.g. pain,
incontinenceinfertility
SOCIAL-e.g. avoidance,
isolation
Potential mitigators for long term problems
emotionaldistress
sexualdifficulties
physicalill
health
social isolation
RECOGNIZING
NORMALIZTNG
EDUCATING
SIGNPOSTING
PSYCHO-SEXUAL
THERAPY
PSYCHOLOGICALTHERAPY
Psychological well being Damage limitation
PSYCHIATRICMANAGEMENT
Key examples of ‘talking therapies’
Type of help Client(s) Length of treatment
Focus Characteristic processes
Counselling
Usually 1:1 Unspecified; variable
Non-directive
Active listening
Psycho-analytic (psychodynamic) therapies
Usually 1:1;
but also couples and groups
Typically long term
Non-directive
Problem-focused
Development of insight through interpretation of feelings transferred from earlier attachments to therapist
Cognitive and behavioural therapies
1:1 and groups
Typically short- term
Directive
Problem- focused
Strength-focused
Goal-planning
Skills building
Agreed tasks between sessions
Systemic (family) therapies
Couples and families; but also individuals
Typically short-term
Directive
Problem- focused
Strength-focused
Communications between family members
Agreed tasks between sessions
Key service contexts
Difficult to rationalise services without clear evidence of problem prevalence and treatment evidence. Currently women with psychological problems associated with FGM may end up accessing the following services:
Community organizations (e.g. FORWARD)
Primary care services (e.g. GP, well women clinics)
Sexual health clinics
Psychological therapy services
Psychiatry
Barriers to optimal psychological care
Peer support and counselling may not be effective for treating complex problems and co-morbidities presented by some women who have undergone FGM
Formal psychological therapy may not be the most appropriate response
Responsive collaboration
A collaborative, integrated model combining evidence-based psychological skills and grass root experience that is currently less recognized, may be more ‘tailored’. For example, experienced psychologists and therapists could leave their consulting rooms in favour of:
- providing training, supervision and emotional support for peer supporters working with communities known to be affected by FGM- helping to produce user-friendly self-help resources for communities- engaging directly with clients by organizing open days, focus groups or workshops to offer additional coping strategies- producing signpost information for women requiring psychological treatment in addition to the peer support they are receiving- helping to disseminate good practices to build evidence base
Potential psychological contributions to education of mental health professionals
Raising the standard of care through education and training for mental and sexual health professionals via:
Assessment of knowledge and beliefs about FGM in select professional groups
Identify barriers to professional contributions using sound research methods
Target specific problems experienced by health professionals
Evaluate education and training initiatives
Disseminate good practices
Future psychological contributions to prevention
Build psycho-educational initiatives with FGM stakeholders using improved research methodology to:
Assess knowledge and beliefs about FGM in affected communities in UK using a range of methods
Target at risk groups
Evaluate preventive interventions
Disseminate good practices!
Conclusions
Psychological contributions are as yet unexploited
Potential contributions in future to improve ‘citable’ evidence of the psychological effects of FGM via research
Future contributions to clinical care and prevention initiatives to maximise effectiveness using evidence-based psychological methods