The 'community turn': Relational citizenship in the Psychoanalytic Community Collaboratory®.

Drawn from five years of experience in the web-based Psychoanalytic Community Collaboratory, this paper explores implications of the 'community turn' in psychoanalysis for roles, methods, clinical theory, and training. With participants from many parts of the world, the Collaboratory has become a creative generator of projects including documentary films, community memorial initiatives, and mental health interventions in highly stressed communities. The Collaboratory's unique pedagogy offers valuable experiential learning about the complex intersubjective dynamics common to group and community life. Through reflection on the interpersonal dynamics of three critical incidents, we illustrate the interplay of intra-psychic and political aspects of identity--what we have termed 'relational citizenship', an intersubjective self-state in which the individual and the sociopolitical are psychically linked and where the challenges of identifying with and belonging to one or more collectivities are recognized and negotiated.

Addressing Abortion Provider Stigma: A Pilot Implementation of the Providers Share Workshop in Sub-Saharan Africa and Latin America.

CONTEXT: In much of Sub-Saharan Africa and Latin America, abortion is legally restricted, and abortion providers experience stigma and legal jeopardy. The Providers Share Workshop group intervention has been shown to reduce provider stigma in the United States, but has not been evaluated in other settings. METHODS: In 2014-2015, the Providers Share Workshop was adapted and piloted among 59 abortion caregivers from three Sub-Saharan African countries and 93 caregivers from seven Latin American countries. Survey data collected before, directly following and six months after each workshop measured stigma, attitudes, and legal safety and advocacy engagement, using original items and adapted scales. Univariate analyses and baseline pairwise correlations were used to measure changes in outcomes over time, and between demographic characteristics and outcomes. Mixed-effects linear regressions and multivariable models controlling for demographics were used to assess changes in outcomes over time. RESULTS: Six months after workshop participation, total abortion stigma had decreased among caregivers in Sub-Saharan Africa and in Latin America (beta coefficients, -0.2 and -0.4, respectively). Unfavorable attitudes had decreased in Africa (-0.2) but not in Latin America, where attitudes were favorable to start; emotional exhaustion and depersonalization also had decreased in Africa (-2.9 and -1.2), and legal safety had increased (0.8). Increased total abortion stigma was negatively associated with legal safety, in both Africa and Latin America (-1.9 and -0.6), and with legal advocacy in Africa (-1.5). CONCLUSIONS: The Providers Share Workshop is a promising intervention to support the abortion care workforce in Sub-Saharan African and Latin American settings.

RESUMEN Contexto: En gran parte del África subsahariana y América Latina, el aborto está legalmente restringido y los proveedores de servicios de aborto experimentan estigma y riesgo legal. Se ha demostrado que la intervención grupal del Taller de Proveedores para Compartir Experiencias reduce el estigma del proveedor en los Estados Unidos, pero no se ha evaluado en otros entornos. Métodos: Entre 2014 y 2015, el Taller de Proveedores para Compartir Experiencias fue adaptado y puesto a prueba entre 59 proveedores de servicios de aborto de tres países del África subsahariana y 93 proveedores de servicios de siete países latinoamericanos. Los datos de la encuesta recopilados antes, inmediatamente después y seis meses después de cada taller, mediante el uso de elementos originales y escalas adaptadas, midieron el estigma, las actitudes y la seguridad jurídica, así como el compromiso con la defensa y promoción del aborto. Se utilizaron análisis univariados y correlaciones de referencia por pares para medir los cambios en los resultados a través del tiempo y entre la demografía y los resultados. Se utilizaron regresiones lineales de efectos mixtos y modelos multivariables que controlan las variables demográficas para evaluar los cambios en los resultados a través del tiempo. Resultados: Seis meses después de la participación en el taller, el estigma total del aborto había disminuido entre los proveedores en África y América Latina (coeficientes beta, ­0.2 y ­0.4, respectivamente). Las actitudes desfavorables habían disminuido en África (­0.2) pero no en América Latina, donde las actitudes eran favorables para el inicio; el desgste emocional y la despersonalización también habían disminuido en África (­2.9 y ­1.2, respectivamente) y la seguridad legal había aumentado (0.8). El aumento del estigma total del aborto se asoció negativamente con la seguridad jurídica, tanto en África como en América Latina (coeficientes beta, ­1.9 y ­0.6, respectivamente) y con la defensa jurídica en África (­1.5). Conclusiones: El Taller de Proveedores para Compartir Experiencias es una intervención prometedora para apoyar a la fuerza laboral de atención del aborto en entornos de África subsahariana y América Latina.

RÉSUMÉ Contexte: Dans une grande partie de l'Afrique subsaharienne et de l'Amérique latine, l'avortement est limité par la loi et ses prestataires sont en proie à la stigmatisation et au péril judiciaire. Comme l'indiquent les études, l'intervention du groupe Providers Share Workshop réduit cette stigmatisation aux États-Unis; elle n'a cependant pas été évaluée dans d'autres contextes. Méthodes: En 2014­2015, l'atelier Providers Share Workshop a été adapté et piloté auprès de 59 membres du personnel de soins de l'avortement de trois pays d'Afrique subsaharienne et 93 soignants de sept pays d'Amérique latine. Les données d'enquête collectées avant, directement après et six mois après chaque atelier ont mesuré la stigmatisation, les attitudes et l'engagement de sécurité et de défense juridique sur la base des questions originales et d'échelles adaptées. Les changements de résultats au fil du temps, et entre les caractéristiques démographiques et les résultats, ont été mesurés par analyses univariées et par corrélations par paires de référence. Des régressions linéaires à effets mixtes et des modèles multivariés tenant compte des caractéristiques démographiques ont servi à évaluer les changements de résultats au fil du temps. Résultats: Six mois après la participation à l'atelier, la stigmatisation totale de l'avortement s'était réduite parmi le personnel soignant d'Afrique et d'Amérique latine (coefficients bêta de ­0,2 et ­0,4, respectivement). Les attitudes défavorables étaient en baisse en Afrique (­0,2) mais pas en Amérique latine, où les attitudes étaient favorables dès le début; l'épuisement affectif et la dépersonnalisation étaient en baisse aussi en Afrique (­2,9 et ­1,2, respectivement), tandis que la sécurité juridique était en hausse (0,8). Une stigmatisation totale supérieure de l'avortement s'est révélée associée négativement avec la sécurité juridique, en Afrique aussi bien qu'en Amérique latine (coefficients bêta de ­1,9 et ­0,6, respectivement), et avec la défense juridique en Afrique (­1,5). Conclusions: L'atelier Providers Share Workshop est une intervention prometteuse de soutien du personnel de soins de l'avortement en Afrique subsaharienne et en Amérique latine.

Stigma and abortion complications: stories from three continents.

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively "marked" by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma - particularly its impact on abortion complications - have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.

Evaluation of Abortion Stigma in the Workforce: Development of the Revised Abortion Providers Stigma Scale.

OBJECTIVES: We report on the development of a scale measuring abortion providers' experiences of stigma. STUDY DESIGN: Using previous measures, qualitative data, and expert review, we created a 49-item question pool. We administered questions to 315 abortion providers before participation in the Providers Share Workshop. We explored the factor structure and item quality using exploratory factor analysis. We assessed reliability using Cronbach's alpha. To test construct validity, we calculated Pearson's correlation coefficients between the stigma scales, the Maslach Burnout Inventory, and the K10 measure of psychological distress. We used Stata SE/12.0 for analyses. RESULTS: Factor analysis revealed a 35-item, five-factor model: worries about disclosure, internalized states, social judgment, social isolation, and discrimination (Cronbach's alphas 0.79-0.94). Our stigma measure was correlated with psychological distress (r = 0.40; p < .001), and with Maslach Burnout Inventory's emotional exhaustion (r = 0.27; p < .001), and depersonalization (0.23; p < .001) subscales, and was inversely correlated with Maslach Burnout Inventory's personal accomplishment subscale (r = -0.15; p < .05). CONCLUSIONS: Psychometric analysis of this scale reveals that it is a reliable and valid tool for measuring stigma in abortion providers, and may be helpful in evaluating stigma reduction programs.

Dangertalk: Voices of abortion providers.

Researchers have described the difficulties of doing abortion work, including the psychosocial costs to individual providers. Some have discussed the self-censorship in which providers engage in to protect themselves and the pro-choice movement. However, few have examined the costs of this self-censorship to public discourse and social movements in the US. Using qualitative data collected during abortion providers' discussions of their work, we explore the tensions between their narratives and pro-choice discourse, and examine the types of stories that are routinely silenced - narratives we name "dangertalk". Using these data, we theorize about the ways in which giving voice to these tensions might transform current abortion discourse by disrupting false dichotomies and better reflecting the complex realities of abortion. We present a conceptual model for dangertalk in abortion discourse, connecting it to functions of dangertalk in social movements more broadly.

Experiences With the Providers Share Workshop Method: Abortion Worker Support and Research in Tandem.

Abortion providers work in an environment characterized by the stresses of the helping professions as well as by the marginalization and devaluation that accompany work in a stigmatized field. We created the Providers Share Workshop (PSW), a five-session workshop carried out at seven abortion care sites around the United States, to support workers and better understand the complexities of working in abortion care. Qualitative analysis suggests that the experience of participating in the workshop fosters connection, and that the group process creates unique data about the abortion care team. Taken together, these results show that PSW fulfills the dual role of a supportive group intervention-helping create connections and foster resilience-and a research tool, producing rich, multi-perspective narratives of the abortion provision team. This method provides useful insight into supporting abortion care workers specifically, and may also prove useful in the study and support of other stigmatized workers generally.

Developing patient-centered teams: The role of sharing stories about patients and patient care.

Research indicates that health care teams are good for staff, patients, and organizations. The characteristics that make teams effective include shared objectives, mutual respect, clarity of roles, communication, trust, and collaboration. We were interested in examining how teams develop these positive characteristics. This paper explores the role of sharing stories about patients in developing patient-centered teams. Data for this paper came from 1 primary care clinic as part of a larger Providers Share Workshop study conducted by the University of Michigan. Each workshop included 5 facilitated group sessions in which staff met to talk about their work. This paper analyzes qualitative data from the workshops. Through an iterative process, research team members identified major themes, developed a coding scheme, and coded transcripts for qualitative data analysis. One of the most powerful ways group members connected was through sharing stories about their patients. Sharing clinical cases and stories helped participants bond around their shared mission of patient-centered care, build supportive relationships, enhance compassion for patients, communicate and resolve conflict, better understand workflows and job roles, develop trust, and increase morale. These attributes highlighted by participants correspond to those documented in the literature as important elements of teambuilding and key indicators of team effectiveness. The sharing of stories about patients seems to be a promising tool for positive team development in a primary care clinical setting and should be investigated further.

Abortion providers, stigma and professional quality of life.

OBJECTIVES: The Providers Share Workshop (PSW) provides abortion providers safe space to discuss their work experiences. Our objectives were to assess changes in abortion stigma over time and explore how stigma is related to aspects of professional quality of life, including compassion satisfaction, burnout and compassion fatigue for providers participating in the workshops. STUDY DESIGN: Seventy-nine providers were recruited to the PSW study. Surveys were completed prior to, immediately following and 1 year after the workshops. The outcome measures were the Abortion Provider Stigma Survey and the Professional Quality of Life (ProQOL) survey. Baseline ProQOL scores were compared to published averages using t tests. Changes in abortion stigma and aspects of professional quality of life were assessed by fitting a two-level random-effects model with repeated measures at level 1 (period-level) and static measures (e.g., demographic data) at level 2 (person-level). Potential covariates included age, parenting status, education, organizational tenure, job type and clinic type (stand-alone vs. hospital-based clinics). RESULTS: Compared to other healthcare workers, abortion providers reported higher compassion satisfaction (t=2.65, p=.009) and lower burnout (t=5.13, p<.0001). Repeated-measures analysis revealed statistically significant decreases in stigma over time. Regression analysis identified abortion stigma as a significant predictor of lower compassion satisfaction, higher burnout and higher compassion fatigue. CONCLUSIONS: Participants in PSW reported a reduction in abortion stigma over time. Further, stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue, suggesting that interventions aimed at supporting the abortion providing workforce should likely assess abortion stigma. IMPLICATIONS: Stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue among abortion care providers. Therefore, strengthening human resources for abortion care requires stigma reduction efforts. Participants in the PSWs show reductions in stigma over time.

Measuring stigma among abortion providers: assessing the Abortion Provider Stigma Survey instrument.

We explored the psychometric properties of 15 survey questions that assessed abortion providers' perceptions of stigma and its impact on providers' professional and personal lives referred to as the Abortion Provider Stigma Survey (APSS). We administered the survey to a sample of abortion providers recruited for the Providers' Share Workshop (N = 55). We then completed analyses using Stata SE/12.0. Exploratory factor analysis, which resulted in 13 retained items and identified three subscales: disclosure management, resistance and resilience, and discrimination. Stigma was salient in abortion provider's lives: they identified difficulties surrounding disclosure (66%) and felt unappreciated by society (89%). Simultaneously, workers felt they made a positive contribution to society (92%) and took pride in their work (98%). Paired t-test analyses of the pre- and post-Workshop APSS scores showed no changes in the total score. However, the Disclosure Management subscale scores were significantly lower (indicating decreased stigma) for two subgroups of participants: those over the age of 30 and those with children. This analysis is a promising first step in the development of a quantitative tool for capturing abortion providers' experiences of and responses to pervasive abortion stigma.

Creating a charter of collaboration for international university partnerships: the Elmina Declaration for Human Resources for Health.

The potential of international academic partnerships to build global capacity is critical in efforts to improve health in poorer countries. Academic collaborations, however, are challenged by distance, communication issues, cultural differences, and historical context. The Collaborative Health Alliance for Reshaping Training, Education, and Research project (funded by the Bill and Melinda Gates Foundation and implemented through academic medicine and public health and governmental institutions in Michigan and Ghana) took a prospective approach to address these issues. The project had four objectives: to create a "charter for collaboration" (CFC), to improve data-driven policy making, to enhance health care provider education, and to increase research capacity. The goal of the CFC was to establish principles to guide the course of the technical work. All participants participated at an initial conference in Elmina, Ghana. Nine months later, the CFC had been revised and adopted. A qualitative investigation of the CFC's effects identified three themes: the CFC's unique value, the influence of the process of creating the CFC on patterns of communication, and the creation of a context for research and collaboration. Creating the CFC established a context in which implementing technical interventions became an opportunity for dialogue and developing a mutually beneficial partnership. To increase the likelihood that research results would be translated into policy reforms, the CFC made explicit the opportunities, potential problems, and institutional barriers to be overcome. The process of creating a CFC and the resulting document define a new standard in academic and governmental partnerships.

Why women are dying from unsafe abortion: narratives of Ghanaian abortion providers.

In Ghana, despite the availability of safe, legally permissible abortion services, high rates of morbidity and mortality from unsafe abortion persist. Through interviews with Ghanaian physicians on the front lines of abortion provision, we begin to describe major barriers to widespread safe abortion. Their stories illustrate the life-threatening impact that stigma, financial restraints, and confusion regarding abortion law have on the women of Ghana who seek abortion. They posit that the vast majority of serious abortion complications arise in the setting of clandestine or self-induced second trimester attempts, suggesting that training greater numbers of physicians to perform second trimester abortion is prerequisite to reducing maternal mortality. They also recognized that an adequate supply of abortion providers alone is a necessary but insufficient step toward reducing death from unsafe abortion. Rather, improved accessibility and cultural acceptability of abortion are integral to the actual utilization of safe services. Their insights suggest that any comprehensive plan aimed at reducing maternal mortality must consider avenues that address the multiple dimensions which influence the practice and utilization of safe abortion, especially in the second trimester.

Physicians, abortion provision and the legitimacy paradox.

Physicians who provide abortion care are targets of stigma, harassment and violence. As a result, many providers do not speak openly about their work. We hypothesize that stigma and silence produce a vicious cycle: when abortion providers do not disclose their work in everyday encounters, their silence perpetuates a stereotype that abortion work is unusual or deviant, or that legitimate, mainstream doctors do not perform abortions. This contributes to marginalization of abortion providers within medicine and the ongoing targeting of providers for harassment and violence. This reinforces reluctance to disclose abortion work, and the cycle continues. We call this phenomenon a "legitimacy paradox." The paradox is that although many highly trained, legitimate physicians provide abortion care, abortion providers continue to be depicted as illegitimate, deviant or substandard doctors. The legitimacy paradox has adverse consequences for abortion human resources, for women's experiences of abortion care and for abortion law and policy.

Dynamics of stigma in abortion work: findings from a pilot study of the Providers Share Workshop.

Abortion is highly stigmatized in the United States. The consequences of stigma for abortion providers are not well understood, nor are there published accounts of tools to assess or alleviate its burdens. We designed The Providers Share Workshop to address this gap. Providers Share is a six-session workshop in which abortion providers meet to discuss their experiences, guided by an experienced facilitator. Seventeen workers at one US abortion clinic participated in a pilot workshop. Sessions were recorded and transcribed, and an iterative process was used to identify major themes. Participants highlighted stigma, located in cultural discourse, law, politics, communities, institutions (including the abortion clinic itself), and relationships with family, friends and patients. All faced decisions about disclosure of abortion work. Some chose silence, fearing judgment and violence, while others chose disclosure to maintain psychological consistency and be a resource to others. Either approach led to painful interpersonal disconnections. Speaking in the safe space of the Workshop fostered interpersonal connections, and appeared to serve as an effective stigma management tool. Participants reflected favorably upon the experience. We conclude that the Providers Share Workshop may alleviate some of the burdens of abortion stigma, and may be an important intervention in abortion human resources. We present a conceptual model of the dynamics of stigma in abortion work.