Aims in termination counselling
By Hilary Everett

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.

Hilary Everett

I work as a social worker with some counselling training, in the Gynaecology Unit at Bart's hospital. A lot of my experience has been with our Pregnancy Counselling Unit, which has in fact very recently moved to the Homerton hospital, so that some of what I am saying is based on the experience I have had there. My work now is involved much more in post-termination counselling.

I want to read a quotation to start with because I think it states my position on abortion and counselling. This is a quote taken from the Cairo Conference on Women, held in 1994, which was reported in the British Medical Journal. This was a statement that came out of the Conference about termination of pregnancy.

Women who have unwanted pregnancy should have ready access to reliable information and compassionate counselling. In circumstances in which abortion is not against the law such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from abortion.
The decision to have an abortion is a very private one and it is not necessarily made because a woman dislikes children. It is normally an expression of the fact that at this particular time of her life she feels she cannot offer a child the love, security and physical support which would meet her ideals.
Whereas young unmarried girls do not feel they can provide a baby with a happy development, married women often feel that another child will take away resources from their existing children, leading to deprivation of physical and emotional resources. The majority of women will resort to abortion in the face of religious, cultural and legal sanction and will expect considerable pain, danger and expenses to fulfil what they see as a crucial need.
Unlike most other problems, the decision to terminate a pregnancy depends upon a particularly complex perceived problem at the moment a woman is pregnant. Before and after the moment, she may be sincerely convinced that abortion is wrong.

I certainly find this approach to women's experience of abortion relevant to many aspects of my work. We have already discussed earlier the issue of values and our own personal values. I feel, from my experience, that it is vitally important, if you are engaged in this work to know your values as well as you possibly can in relation to this subject. I say that because abortion in our society is still a very tricky subject indeed. I am wondering how many of you may have had a termination of pregnancy? How many of you know someone who has had a termination of a pregnancy? It is just is not something we talk about even to our best friends.

In my setting we did try to set up post abortion groups. We may have gone about this the wrong way, but they certainly did not take off. I think it is something to do with the privacy and with the acute anxiety about what other people are going to think, which actually prevents women from sharing this experience very widely. Some women share it only with the professionals that they are coming to see-which always concerns us very much. This also means that we have the responsibility to be able to give as much of ourselves as possible in this context. We do not necessarily need to be pro or anti abortion, but we do need to know where we stand personally.

I know for myself that I am very comfortable with the work and it has always been one of my very favourite areas of work in gynaecology. I do know however that when I meet a woman who is considering an abortion of twins, there is some reverberation inside myself. This is not particularly rational but I am aware of it. I hope it does not get in the way of what I am trying to do but I suspect sometimes it does because that is my personal 'little twinge' if you like.

I hope the women I see, sometimes together with their partners, are seeing me by choice. I remember when I went to work at St Bartholemew's Hospital in the early 1980s, there were consultants who were extremely ambivalent about abortion. I was constantly being asked, as a social worker, to assess women and my interviews were clearly based on assessment. I was expected to write a report and the consultant would then make a decision which may or may not accord with my recommendation.

I realise how much that has changed. Certainly in recent years when we have had an identified service, with staff who have chosen to work within it and a consultant who sees this as part of her life's work, the way women come to me is very different. I hope that when they come to me they are coming because they want to or they feel they need to. I can actually, I think, spot very quickly when a woman has been sent to me. She will probably say so or she will sit and not speak. The way I deal with that is to say very straight: 'It seems to me that you may have been sent to me. You don't know me, you may not like the look of me, you may not like any thing about this. It really is your right not to have to see me and it really is up to you whether you have a termination or not, but I am here and if at any time you would like to talk with anyone, you know where I am'.

I think if you are offering a pre-termination counselling service, it is absolutely essential to offer a post-termination counselling service. Sometimes it is the same women who use both services, and I have certainly seen women who have booked ahead afterwards. These are quite often women who have had a termination before and who are very aware of how they were affected by that. Some women are very depressed afterwards, and they hope by booking in ahead of the operation for counselling afterwards, they will be able to get through it more easily. Sometimes it is women who had thought that they were absolutely fine with their decision, and have found afterwards that they want some counselling.

The counselling I offer in the hospital setting can be relatively independent and I think that is terribly important. Those of you who work in teams really need to have established that what you do is independent and that information does not go into medical notes, unless a woman particularly wants that. Sometimes women do, but it is important that they can feel they can speak in confidence.

In a pre-termination situation I try to give the woman a sense of there being a bit of time. I can allow an hour initially and I can allow more than that if she needs more time, in which I am concentrating on her. I am trying to listen very hard to her, and trying to help her tease out what this decision means for her. Some women do this by making lists, and some have prepared lists before (here is the pro termination side, and here is the anti). Counselling is really nothing very mystical, which was the word used earlier in the conference. I think it is a listening process. You are really trying to help this woman feel that you want to hear what she has to say, that you are not going to judge her and that you really are there to support her in whatever she decides to do.

I sometimes find it helpful to say something to women about feelings that they may have. You may not all agree with this but I think in my experience the women I see do have a range of emotions afterwards and sometimes before, so I have a little sort of check list, in my head, of the sort of feelings that may be around for them. At the top of my list is relief. I think it is terribly important that in the context of our society, which is extraordinarily ambivalent about abortion, that women should be absolutely entitled to feel relieved. The decision is made, the operation is arranged , and they can get on with their lives. It is equally important at the same time, to make it clear that women may feel extremely sad and that they are entitled to this feeling as well. It seems to me that some women facing a termination do not think they are allowed to mourn. They feel this is denied them, by society, by their family, if they know about the termination, and by the atmosphere in which we live.

Interestingly, not long ago a woman who had a termination came to see me afterwards. I had not met her before. She said to me that she had very much wanted to take the foetus home with her and she had not felt she could ask whether she could. She asked me about what happened to them. I think it is quite important to be truthful in the same way I think it is important to be truthful about what a foetus is. I do not think it is just a little cell. The way I describe it in context is that it is 'life potential'. I do not use the word baby. I am extremely careful not to use the word baby. If a woman uses the word baby, that is up to her and it may give an indication of her state of mind. Similarly, a woman I saw used the term murder to describe termination, and eventually decided to continue with the pregnancy. Some women want to know what will or has happened and I do not think it is very helpful not to be truthful.

Finally, a word about post-termination counselling. As I have said it is sometimes women I have met already who use this service, but very often is not. My referrals tend to come through GPs. We have quite a good network of GPs in the district, who know the networks. My classic example is a woman who went to her GP over a year after her termination, because she had a broken ankle and ended having counselling with me. She had a particularly good GP who actually sat down with this woman and started talking to her and found that apart from what was wrong with her ankle other things were concerning the woman. It is not that women are necessarily racked with guilt and are trying to deal with that, but sometimes they are. What happens is that terminating a pregnancy may trigger off other things that are troublesome for the woman. I think that if a woman has had a bereavement for example and then has a termination, at some point these two may connect and she may become depressed. Some of the women I have seen have been absolutely overwhelmed by the strength of their grief and have not known what to do with it. Some women will say 'I can't stop crying and I don't think I will ever stop crying'. I have spent time with women who may spend a number of sessions in tears, doing nothing else before they can actually start talking. Very often I have found that this is connected with something else to do with loss.