Issues in the provision of termination counselling
By Margaret Ross and Maxine Lattimer

Introduction

What follows is the text of a paper given at a conference organised by Pro-Choice Forum called 'Issues in Pregnancy Counselling: What do Women Need and Want?' The conference was held at Ruskin College, Oxford in May 1997. It's aim was to give students, academics, service providers and others interested in ensuring pregnancy services meet women's needs, the opportunity for a critical discussion of the provision of counselling as part of these services.

Margaret Ross

I am based in the Women's Centre at the John Radcliffe Hospital, Oxford, and I am currently employed by the Local Authority as a social worker. I offer non-directive counselling to women who are ambivalent, distressed or under pressure about their pregnancy for reasons which are non-medical; to women who are distressed following termination of pregnancy; to a small number of women following early miscarriage or ectopic pregnancy; and to women with hyperemesis (the very severe sickness in early pregnancy which makes hospital in-patient treatment necessary), where ambivalence is being expressed. I prefer the title of 'pregnancy counselling' to describe what I do because this covers all of the various situations I deal with. Often this kind of work is referred to as termination counselling, but this of course suggests the outcome is a foregone conclusion, which is not the case.

I have worked in my post for over 13 years, and I am privileged to work in a city where hospital social work has always been seen as vital. I am also privileged because the hospital I work in has a very good abortion service, and women are treated with respect. I have worked in the same post for a long time and I am in a strong position because of this, having forged good links with GPs and other referrers in the area over time. To a large degree I have been allowed to develop the job simply in response to need, and to work as a 'traditional' social worker, that is with a counselling approach. My position is therefore quite different from social work priorities in general, where now Child Protection and Community Care legislation define the work and the way it is performed. I have been able to drop other areas of work to concentrate on and build up the service I now offer to women, which is concerned with the issues I believe in most strongly.

I have no experience of similar work elsewhere apart from research carried out for a dissertation I wrote in 1991, which looked at two other NHS centres together with my own. I can speak only of my own experience therefore, and cannot generalise on this basis.

I have grouped together some issues I consider to be important under four headings in the form of questions we should be asking when talking about the provision of pregnancy counselling. I refer throughout to the counsellor as 'she' and the doctor as 'he' only to try to increase clarity.

1. Whose idea is it to provide counselling?

Is it a woman's choice to have counselling, or is it initiated by someone else? If it is initiated by someone else, is it with the woman's agreement: that is has she made a positive choice to be given information about a service which she may find helpful? Perhaps her GP has seen that she is distressed and, knowing he has neither the time nor expertise to offer what she needs, suggests counselling and gives help in arranging an appointment with me at her request.

Alternatively is it a negative choice: that is where counselling represents some sort of coercion or punishment on the referrer's part? Has it been suggested because the referrer wishes to erect some sort of barrier to 'make the woman realise what she is asking for', or to 'stop it being too easy for the woman' so as to alleviate the referrer's own moral or religious reservations about being involved with termination of pregnancy work, or to try to manoeuvre her into making a choice which is acceptable to the referrer? (For example, the doctor wants me to 'counsel the woman into continuing with the pregnancy'). If this is the case, then counselling will be doomed to failure because you cannot force someone to engage in a counselling relationship if she does not want to. She may feel obliged to keep an appointment, but no useful work is going to be done, or at least not until I have checked with her how she feels about being counselled, how the appointment was presented to her, and whether she feels it could be helpful.

If the counselling was initiated by the woman, then does it represents something relatively straightforward? Does it indicate a positive wish for counselling on the woman's part to help her look at what is happening, what she feels about it, and how she would like to resolve the crisis? Alternatively, is there something more complex at issue, another agenda, where she is not in doubt or distress but wants to appease someone who says she has not thought things through properly? (This can happen especially with a young woman with angry parents where they want her to have a termination of pregnancy, but she wants to continue with the pregnancy). Is she asking for counselling to enable her to have a discussion with someone important to her, perhaps her partner with whom she has been unable to talk herself? Either he has not said what he feels and wants or has been unwilling or unable to listen to what she is saying. Sometimes having a third person there, one who can contain the anxiety, is the only way that an essential discussion can ever take place. Even when those involved are saying the same things they may have been saying before, in counselling they often hear their own words and each others' in a new way which helps them to move on from the stuck position they have got into.

2. Who should have counselling?

Should everyone be counselled, as part of the process? If this is the case, unless there are a small number of patients and a large number of counsellors, the service risks becoming rushed and meaningless. Depending on numbers, it would be impossible for the counsellor to remain lively and engaged if she is seeing a succession of women, one after the other. It would probably end up as little more than a list of questions and statements covered in a perfunctory way with each woman as one of a queue rather than an individual.

From the woman's point of view, even if there were lots of counsellors and plenty of time, this policy would ignore any other counselling she has had, and the fact that she may have reached a decision without feeling the need for counselling at all. If counselling is forced on her, it is likely to breed resentment and a sense of choice being removed, just at a time when the woman is struggling to regain a feeling that she has some control over her life.

Should counselling be selective? If so, who decides who has access to the service? How is the service publicised? How can we ensure that no-one slips through the net? How do we limit the service and place boundaries around it to prevent it becoming overwhelmed?

My experience is of a selective service, and I am sure I could not work in the kind of judgmental, demeaning service described by other speakers, where a woman has to 'prove' to the counsellor she is 'unstable or inadequate' to gain access to termination of pregnancy. Even so, I see a large number of women. There is no way to guarantee that nobody slips through the net, but the better established the service, the better this becomes. Old doctors teach young ones and knowledge and experience are passed on. The system I have built up works so that a woman may be seen right at the start, when pregnancy is first confirmed, or picked up when she is seen at the out-patient clinic, as an in-patient or even post-treatment when the woman consults her GP, Family Planning clinic, college nurse or other potential referrer. It is therefore intended to be an open-ended service, starting when the woman herself wants counselling, and with the length of our contact decide by the woman and me jointly.

3. Who should be informed about the counselling or included in it?

This raises issues of confidentiality and who is the client? Is it only the woman? What about her partner, or parents in the case of a young teenager? My view is that the person I am concerned about, even if necessary to the exclusion of all others, is the woman. Whatever her age, what is said between us is confidential. Only if she divulged that she was pregnant as a result of being sexually abused and had not told anyone else in a position to help her, would I talk with her about the possible need to break confidentiality to ensure her safety and welfare.

For a woman with a partner, if she wants him to join the session then he can come in, if not he must wait outside. It can be hard on a partner or parent who is also very distressed and confused, but the woman is the patient of the Women's Centre, and the woman is my client. If need be, I will try to suggest other sources of help for those whom the woman does not want included in our session.

Nobody has any right to know I have seen the woman, let alone what has been said. With her permission, I will write a brief sentence in her medical notes, giving the date of our meeting and perhaps something like: 'She has found the decision difficult, but is now sure about termination of pregnancy'. This reassures the doctor that she is probably moving toward the decision to terminate the pregnancy and therefore needs admission arranged, but does not actually say anything specific or commit her to anything.

This issue also brings up the question of consent and confidentiality for under 16s. A consultant is within his professional rights to perform a termination of pregnancy on an under 16 year old without parental consent (this is given by the Fraser Guidelines, drawn up following the Gillick case). Again my role may be to look with her at her family situation, the implications of telling against keeping the pregnancy a secret, and other sources of support (for example a big sister, and aunt, a friend's mother or a teacher). In the Consultant's mind I share the task of assessing whether or not she meets the criteria for 'Gillick competence' and reassures him that the girl has had the opportunity to talk about her predicament at length with a trained and experienced professional.

In reality if she is very young and her parents are aware of her pregnancy, she may feel she has little choice but to go along with their wishes. If she is saying clearly that she wants the opposite to them however, I would look with her at the possibility of our talking with her parents, alerting the consultant to the situation and so on. After all, one could argue that to carry out a termination of pregnancy on someone who has said clearly that she does not want this could be seen as assault. On the other hand, to refuse to do so under pressure from someone other than your patient, where the patient is making a clear request for the procedure goes against all the normal rules of the doctor/patient relationship and respect for the patient's right to give or withhold informed consent.

What I would hope is that the woman who comes to me for counselling is treated with the same respect, accorded the same confidentiality, with her wishes and feelings listened to just as carefully as I would wish for myself or a member of my family, if roles were reversed.

4. Who does the counselling?

This raises the issue of cost: Who pays for the counselling service? The Social Services Department? The Health Authority? The woman herself? This will open up or limit the service and will also help define the kind of person who is appointed to do the work.

The issue of autonomy is also relevant here. If the counsellor is strictly managed (perhaps by someone who has little understanding of the work or is actively biased against it) and with little authority, the counsellor will have little say in how or where the work is done, and how the service should be developed or curtailed.

There may be a conflict of interests: for example if the counsellor is also involved in the actual treatment, the client may vet what she says in case treatment is refused or made more unpleasant by someone felt by the woman to be critical and disapproving of her. In any case, fear of pain or embarrassment about the procedures a doctor or nurse is going to perform are almost bound to affect the kind of relationship he or she forms with the client, particularly when there is little time to build up a relationship of trust and mutual respect.

There may be a conflict of priorities. If counselling is not the principal component of someone's work and she has other roles to perform too, how can they offer the kind of unhurried, focused attention necessary? The amount of time allowed for counselling is vitally important in defining the kind of work it is: for example 10 minutes in a crowded clinic with a queue before and after the client is not the kind of counselling I would consider in any way satisfactory. If the counselling is being done by someone with administrative duties too, she may feel she is trying to combine two jobs into one, to the detriment of both.

The place where the counselling takes place is central. It has to be private, with no interruptions, not overheard and away from any treatment area. It should definitely not be in the vicinity of an ante-natal clinic! I consider myself lucky, since I am based in a hospital where the out-patient department is situated, and to which women are admitted for treatment, so communication is easy and I am readily accessible, but still separate. Nobody can tell for certain why someone has come to my office.

The training and orientation of the counsellors. This sums up everything. I believe the work needs someone who has a particular interest and experience in this area, who has chosen specifically to do this work, who has explored her own motivations and blind spots and who has good, regular, clinical supervision. This service needs a trained counsellor, not simply a well-meaning soul who has done a weekend training course. The counsellor will be working with women who feel particularly vulnerable, anxious and temporarily out of control of their lives. The aim is to help them consider the options open to them and the implications of each option, so that they can reach an informed decision which they are satisfied is the best for them at that time in their lives. The calibre of counsellor, her status in the organisation, and her perception of her own worth are all very important.

I feel proud and excited at the knowledge that the service I provide in Oxford is held in very high regard by consultants, GPs and family planning doctors, who see it as an integral and essential part of the service offered to women. Thus although the Social Services Department, while recognising it as vital work to be done, has deemed it to be no longer a priority for them and has decided to withdraw funding, the Hospital Trust agreed to take over funding the post from 1 August 1997. This safeguards the service and recognises the post as a true counselling one. As has happened until now, this will continue to keep counselling separate from treatment. This means that medical and nursing staff can get on with the work they are trained to do, ensures that the ability to pay does not determine the criteria for access to the service and will hopefully enable me to continue to develop the service appropriately and sensitively.

Maxine Lattimer

This presentation draws on the anthropological fieldwork I conducted at two British pregnancy advisory bureaux in 1995 and 1996. I have focused on the debates among the staff at these two centres about the way in which pre-termination counselling is incorporated into the consultation procedure. The main questions were:

1. Should counselling be an option open to clients or an automatic part of the service?
2. Should the consultation be delivered by specialised counsellors, or by more general administrative staff?

I want to make some observations and illustrate them with quotes from the staff that I collected during the fieldwork. I am aiming here to highlight the fact that the meanings of 'counselling' are not just related to interactions between a counsellor and client in the counselling room. Counselling provision does not exist in a vacuum. It is provided in a particular organisational context and by particular staff members. Issues not relating to, though often expressed in terms of what is seen to be 'best' for women in relation to their wants and needs, are at play here.

At the first bureau in which I conducted fieldwork, the administrative staff were extremely concerned about taking on a 'counselling' role for which they felt they had no extra training or recognition. This added to their general feeling of being unhappy and overworked. The counselling staff themselves felt insecure and undervalued by the proposed changes. Here are some of the feelings expressed:

..I don't think anybody's very keen on it anyway, this non-counselling business...I don't think any of us um, without training um, can give information like that, and I think it would be wrong to put us in that position...

...you know they're trying to make us see women on what they call a 'non-counselling' basis, which is basically counselling by someone with a shit wage, which is what we get paid and..we're standing firm against that at the moment.

..if you're stuck in the room with them because they're at their consultation you can't palm everyone off onto the counsellor that finds they need a bit more than they anticipated.

...they say "oh well you do pregnancy tests results"..but at the moment you've got a line to draw of "well from your reaction and from what you're saying I really think you need to see a counsellor, can I make you an appointment?".....if somebody is very stressed you can calm them down, make them that appointment and know that they're being passed onto the right place.

...it just keeps piling up and piling up and piling up, and changes, they want to keep making changes...it's put to us that it is going to make such a difference to the women and..almost we should feel guilty, that we should want to provide all this service for women. And this thing about 'optional counselling' and one thing and another..and that it keeps our jobs open...It's like yeah, but hold on a minute! You're changing my job description completely, you're not giving me any credit for it, you're not giving me any more money for it, what..are you on here? What do we have to do? Be eternally grateful that we have a job? It's just not like that..

The staff's feelings about counselling provision were also an expression of their unhappiness over changes in service provision throughout the organisation. In particular they were concerned about the perceived changes in the ethos of the organisation to a business-led orientation, with cost-cutting and profit-maximising measures:

...as long as the same people are in charge at the top, not really being aware of how it works um, and wanting it just quick. And they have their ways of justifying that, that women should be able to come in, not be questioned, just get on with it, all that kind of thing. They have ways of making it sound very positive. But I think that um, as long as it's the same ethos that it's going to get less counselling orientated and more money orientated...

..I don't really think it's very satisfactory and this is all done in the name of 'choice' but really..I think it has much more to do with saving £9 an hour on counselling fees..

(It)...is predominantly a money saving device..I think it doesn't take into account the way in which you know, women are in the world and where they are in society and how they feel about it for all sorts of reasons which may be right or may be wrong, but nevertheless you have to start from where people are, not from, you know, where you want them to be.

It was also felt by the staff that the changes ignored women's need for support at this time, to feel cared for, to have the time and space, and not to have to make a snap decision about whether to see a counsellor or not on the telephone. Also it ignored the 'weightiness' of the whole issue. Here is what some staff members said about this:

(To have to)...make that decision on the 'phone, "do you want a counsellor or not?" when a lot of women will say "no, I've made up my mind".. But actually they may have made up their mind but they may still need to talk about it um, it's an extremely emotive decision.

(They are)...saying it should be a walk-in, walk-out service because that's what women want, but they don't and..I don't think so, you know. Maybe some do, there are a few that say "oh, I don't want any counselling" but often you find that when they get here they're the ones that spend the most time with the counsellor anyway, that they do want to talk about things. But I mean there are always going to be a few that do want that but I think the majority don't. They want the time, they want every single bit of information, they want to see a counsellor. So although they might not say anything at that time they feel that you know, that there was somebody there for them.

...it's not a subject that should be taken lightly, it's not like going out and..buying new underwear or something like that you know, it's an important issue..And because of the way people feel about it and the way it can change your life...it should be taken very seriously...and I definitely think that the counselling is an important part of that.

...I think it is really important. I mean even the people that say "Oh no, of course I don't need counselling" you know, I think everybody does need some kind of time...I'd hate to think that..the day you found out you were pregnant you could go and have an abortion.

Post-abortion problems and increase in post-abortion counselling needs was cited as the most likely consequence of a move to 'optional' counselling and staff used anecdotal cases to illustrate this:

...I think we're all very clear that half an hour spent with a counsellor berforehand is worth ten hours with somebody afterwards.

...well the majority of post-abortion counselling is for people who had nothing at the beginning...

...I think it is really, really dangerous the idea of getting rid of counsellors altogether because often the women that say they don't need counselling are the ones that desperately do, and already it seems that there are more people coming back for post-abortion counselling because they hadn't had enough time with the counsellor in the first place, or they weren't counselled at all...

..Well one woman apparently um, even to the point of almost suicidal tendencies. The fact that she went to her GP, and I mean the GP's got a lot to answer for, and he said something about um, "Oh well at your age you wouldn't want a child anyway would you?" So that, I suppose that triggered in her mind "Well, I shouldn't be doing this"...and again it's to do with our upbringing, we're told that doctors know best in a way. She was sent directly to the --- clinic who just told her the information and that was it, no counselling. And she said "I just feel so bad about it, I didn't have time to think about whether I wanted to continue the pregnancy". And now she's saying "I think I would have done". But then you're not to know because if she'd had the proper counselling she may have come to that decision anyway. But the point is now she's so messed up she doesn't know...I mean it's such a mess to sort out afterwards but beforehand it's so much easier.

At the second bureau the debate over counselling took place in the context of a take-over and planned changes in the manner of working. The most important change involved non-specialised staff providing 'counselling'. This then raised issues of counsellors' professional status, of the importance of counselling experience, qualifications and aptitude, and of 'real' counselling as opposed to 'processing' clients. There was much nostalgia for the old way of working which was perceived as more counselling-centred and therefore more woman-centred. Here are some of the feelings from staff:

..I think counselling will suffer.....if you've got people who...are not trained counsellors doing it, inevitably there are going to be things that are missed and not picked up on...if they just automatically train up everybody as an 'admin-counsellor' who comes into the organisation there are going to be some who haven't got the skills.

..my fear is that the really good staff...we'll lose them, we'll lose their years of experience in the counselling capacity...

..I do think that it's a big waste of all the counsellors that are there, if you think some have been there 20, 15..those sorts of years...they've got a lot of skills and experience behind them and I think it's going to be a big waste, either to use them pregnancy testing or to let them go.

Some staff did see possible advantages to the new system as well and most thought it would probably work quite well in the end:

..as an admin-counsellor you're supposed to be able to counsel them at the end as well, which is why it's quite valuable that they have the same person all the way through...they're supposed to be able to be counselled at any point...

...in theory it's a much more pleasant system to be with the same person all the way through than to see seven people in one session...they're spinning at the end of it...because you feel much safer and because you build up a relationship of trust with the person you spent time with...

..I still am a little bit concerned about the self selected counselling, but I think..that will probably be OK..It seems to me that if..you've got the woman, and if you say to her you know "are you sure about your decision or would you like to spend some time talking it through?" Even if they say "no" you've still got the sort of information side of it and there's still space within that to create a relationship where if something does suddenly come up, she'll bring it up. So there is that space even if someone's saying "no counselling", there's still...the reassurance, the support side of it.

The take-over and the new ways of working did lead some counsellors to really question their old way of working. This is what one counsellor had to say:

...I mean I sometimes wonder about this whole counselling thing that I've really accepted without question.. .....yes there are people who are going to 'slip through the net', yes the people who need counselling the most may be able to slide away from it by saying 'no, I don't want to talk about this at all'. But is it really our responsibility to do that for them? You know, or is it their responsibility at the end of the day?

...this was the whole thing we were hanging onto for so long...that every woman must have the opportunity to see a counsellor...They have the opportunity but the underlying thinking that went along with that really was 'we know better, we know that you all need counselling, and especially those of you who say you don't need counselling, we know you need extra counselling! Whether or not we can get it out of you remains to be seen.

In fact in this day and age, if you put yourself in the other position and you're a woman with an unplanned pregnancy, I think you should have the right to go somewhere like----whatever, go in, do your paperwork, pay your money and go out again and that's it.

Hopefully in this presentation I have begun to show some of ambiguities and conflicts in staff's attitudes towards counselling and the provision of counselling at my fieldwork sites, and have shown some of the other issues at play in the provision of counselling.