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