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