counselling: issues and approaches
By Gill Holden, Deborah Russell & Dr Catherine Paterson
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.
For those of you who do not know much about the British Pregnancy
Advisory Service (BPAS), it was set up after the 1967 Abortion
Act to provide counselling, advice, information and referral for
termination of pregnancy (TOP).
We are a not-for-profit charitable organisation offering private
and NHS contracted-out TOP, and now see in excess of 40 000 women
per year for TOP, contraception and pregnancy testing services
through our network of 30 consultation centres and nine clinics
throughout the UK. The background to counselling as part of the
service In the social and political climate of the late 1960s
and early 70s there was a great need to lead women seeking TOP
through the legal and psychological minefield of services and
to counter negative and hostile attitudes to their situation.
It was in this context that pre-termination counselling emerged.
Little was known about the possible psychological effects of being
in an unplanned pregnancy situation and the after effects of undergoing
TOP. The early stages of pregnancy counselling responded to the
experience of individual counsellors. Traditionally then BPAS
as with others in the charitable sector, believed that women had
to have in-depth counselling to support them in making the decision
to terminate pregnancy. However, in the late 1980s, BPAS began
the process of taking a second look at client satisfaction and
in particular pregnancy counselling, and it is from this body
of work that we chose to revise our working practice.
In 1985 BPAS in partnership with the Department of Social Administration
at the University of Birmingham and the Health Services Management
Centre commissioned a three year Quality Assurance Research Project,
which involved in depth interviews with clients, BPAS Managers
and Staff. The project determined attributes of quality which
all groups rated as valued components of a quality managed abortion
service. These attributes were: information; professionalism and
safety; individual attention; confidentiality; waiting time; staff
attitude; access; and privacy (this was identified as an important
attribute by the Branch Standards Group at a later forum).
BPAS and pregnancy counselling
This research contributed an insight into the clients' perspective
in producing a structure of stages and aspects of service on which
clients judge the quality of their experience in seeking an abortion.
From this lead we needed as an organisation to look at whether
the service being offered and the way it was being offered was
consistent with what clients had already defined as 'quality'.
In December 1989, BPAS therefore established a working party consisting
of four Board members and the Director of BPAS, to review BPAS
counselling services. The terms of reference were:
To review the appropriateness of BPAS counselling practice to
the needs of our clients.
To review arrangements for assuring quality and consistency of
To review relevant professional and research literature and take
evidence from staff.
The first step of this working party was to commission a literature
review about women's needs in abortion counselling to up-date
the exiting review which had been conducted in 1981. The new work
was published in 1990 and seemed to uphold previous findings.
These in essence were:
Most women cope well with abortion. Very few women appear to feel
that their decision to terminate was the wrong one, although this
does not mean that they will not experience some sadness or distress.
Long-term psychological trauma is extremely rare and often with
further investigation it becomes clear that the problems leading
to psychological problems are likely to have been present prior
to the termination. The needs of women at this time seem to be
more related to information provision and referral. A lack of
factual information was the most common complaint.
In our work we know that for some women the decision and procedure
need very little intervention, given an accepting and supportive
environment, but for others a lot of support and help is needed.
Nevertheless, previously most women would have seen what they
had from their contact with us as being the same. In other words,
the staff could define who had received 'counselling' and who
had had 'support' but in being asked if they were counselled they
all said yes. So an aim of the review was a move towards client
self-determination: that women seeking abortion should be able
to identify their own requirements for the amount of counselling,
caring, support and information they need providing that they
are fully aware of the choices available to them.
By 1990 the working party had devised a new approach to the counselling
process which we were ready to pilot. There was one final stage
however, in that in order to encourage a woman to make her own
choices concerning her care, these choices needed explanation.
A new leaflet was therefore designed explaining the process and
the choices and staff were trained in the introduction of the
new system and the use of the leaflet within the session. By early
1991 there was a widespread implementation of this new system
and initial evaluation of the numbers of women requesting 'counselling'
More detailed evaluation followed in the form of an in-depth questionnaire
to clients looking at their overall experience of the service,
and more particularly to identify the percentage of women opting
for counselling in the hope of assessing the level of satisfaction
from clients in the new system.
We found a confusion about the term 'counselling', and if not
confusion then certainly a number of different interpretations.
A large number of clients still saw counselling as only necessary
if no decision had been made, although a few clearly request counselling
if the decision proved difficult.
When the system of 'offering' counselling was first implemented
there was anxiety that the client opting for 'no counselling'
would not be encouraged to discuss any areas of concern or doubt
or get her needs met or questions answered. However, one message
was clear from the surveys is that whatever the clients received,
whether this was counselling, help, information or support, in
most cases they felt it met their needs if given a private space
and non directive support -as is the case in BPAS.
Of the total number of replies received at that time just over
60 per cent identified themselves as not having had counselling,
31 per cent said they had received counselling and 8 per cent
could not be analysed.
A quality service once attained does not automatically maintain
itself, but needs constant assessment and adjustment. BPAS has
gone on to devise an ad hoc and constant monitoring system for
client feedback in the form of client satisfaction questionnaires
and client commentary forms as well as annual audits.
What was shown to be important during our survey, and now informs
our approach in the process of consultation are the following:
being accepted as individuals
having decisions accepted
not waiting around
being well informed
not being neglected or patronised
being treated as adults
the client feeling they are being treated by 'professionals'
privacy and confidentiality
In fact these are all the quality attributes identified in the
BPAS Quality Assurance Research Project. We are also using our
experiences of listening to women at the pre-abortion stage to
develop services for women post-abortion and later on in their
lives. As a provider we believe we have a responsibility to women
who have come to us for help at whatever stage.
A definition of counselling that is appropriate for BPAS is 'counselling
is a process through which one person helps another by purposeful
conversation in an understanding atmosphere'.
Our awareness to an individual woman's needs means that we understand
counselling means different things to different people. Our experience
in supporting women means we understand the anxiety for women
is to gain prompt access to abortion which can override any provision
of pre-abortion counselling.
Our current policy is one of adapting to each individual by :
the provision of information
the provision of support
clarifying that every woman understands all options open to her
This will enable a woman to be respected in her decision and make
an informed choice. BPAS continues to move towards a 'total care
system'. Our latest focus for development is around increased
inclusion of partners at the request of the women and the provision
of post-abortion care once the woman had had time to reflect on
I would like to discuss the approach taken by Marie Stopes House
to offering optional counselling for women seeking termination
Marie Stopes House approach to counselling
The principle which underlies our approach is 'person-centred
counselling', by which we mean listening to the client in order
to gain some insight about her thoughts and feelings about her
situation. We then encourage her to explore her feelings, so that
she can make the decision she feels is right for her. This is
done without judgement or criticism, making the client feel comfortable
and supported, and I'm sure this is a standard that many other
organisations use too.
Choice in counselling
For some time, we at Marie Stopes International had realised that
some clients did not wish to go through counselling. Our telephonists
were constantly answering callers who were making it clear that
they positively did not want to see a counsellor. There may be
all kinds of reasons for this, such as they might think that the
counsellor may try to dissuade them from having an abortion or
perhaps they have a negative view of counselling. The result was
that the resident Marie Stopes House counsellor would see these
women for five or 10 minutes at the most out of a 30 minute slot.
We recognised that before calling us, many women had been able
to call on a variety of other sources, partners, friends or family,
so they already felt quite supported in their decision. For women
who are so very sure of their choice to terminate pregnancy, and
we felt it was important to offer choice in our service to them.
Our belief in offering choice led us to implement a trial in the
latter part of 1994, bearing in mind that this was not only new
for Marie Stopes International but also for Marie Stopes House
to do this. In this trial we offered our clients the choice to
see a qualified lay counsellor. We then split our appointments
throughout the day into slots where counselling was included and
slots where it was not. There was always a counsellor available,
so even if a woman had chosen a non-counselling appointment, she
could still see a counsellor if she so wished.
In offering this choice of counselling or non-counselling appointments,
our objectives were:
To offer women an optional counselling choice.
To improve the counselling service provided at Marie Stopes House
with counsellors able to give quality attention to those who choose
the counselling option.
We hoped to meet the individual's needs, for example by being
able to slow or speed up the process, according to the individual
client. Overall we hoped to provide a more streamlined service.
Our initial worries and concerns
In offering this kind of service, we did have some initial worries
Clients who need counselling would be missed.
Emotional issues may arise within the consultation time and doctors
would be unable to deal with them.
Post-abortion counselling client figures would rise.
Concern about the legality of offering non-counselling appointments.
There would be opposition to this kind of service from counsellors.
There would be opposition from administrative team members. They
might feel unable to deal with problems that might arise where
women were not counselled.
Some members of staff felt that women sometimes do not realise
they need counselling until they see the counsellor. Some also
suggested that women who say they do not want to see a counsellor
may be the women who need to most.
We began to monitor uptake of counselling and non-counselling
slots on a monthly basis in January 1995. Over that year there
was no consistent pattern, with each different month giving different
results (see graph 1 overleaf). At the end of the year the average
rate of clients opting for non- counselling appointments was 54
per cent. We therefore thought it worthwhile to continue the trial
into 1996. In 1996, the rate of uptake of non-counselling slots
started to change dramatically in May that year. The reasons for
this are not clear, but there was a steady increase in the number
of clients choosing the non-counselling option, peaking in December
1996, with over 70 per cent of appointments of this type in that
month (see graph 2 overleaf). Results from the first months of
1997 have been no different, with over 64 per cent of clients
choosing non-counselling appointments during January to April,
so the trend is continuing.
Issues that affect the results
We felt that were certain issues that would affect the results,
one being local area health authority contracts, which can be
problematic. At Marie Stopes House all clients referred to us
by the local health authority have to receive counselling. This
requirement is often part of the contract between us the health
authority. At Marie Stopes we would like to question whether this
should be a requirement, who makes the decision that counselling
must be provided, and on what grounds has the decision has been
made to make counselling an obligatory been made. Dealing with
problems that arise during consultations There are a small number
of non-counselling clients who are very distressed. At that point
we can stop the consultation and ask the client if they wish to
see a counsellor, showing we can slow down the process if necessary.
Doctors or administrative staff always offer to stop the consultation
and let the woman see a counsellor if this is needed.
In our previous system, everybody saw a counsellor. The counsellor
carried out various administrative tasks. She made the booking
for the appropriate centre, while the client was in front of her.
Clients who now opt for counselling have a full 30 minutes available
to them. The counsellor does not make bookings into other centres,
she is merely there to listen, discuss and answer questions. The
client has her full attention, without the pressure of crammed
Some of the counsellors who work with us still feel that we 'miss'
some women who may need counselling, and they might be right.
However, we receive only a very small number of complaints and
our satisfaction ratings remain high.
We have at one and the same time been surprised at how easily
team members have adapted to this system and how the take up for
non-counselling slots has increased and yet shrugged our shoulders
and said that, in the end, this was our gut feeling about the
likely outcome to begin with.
We like to feel that by offering optional counselling we are ensuring
a client chooses her own path in termination of pregnancy, by
Her choice of consultation type.
Her choice of termination method, whether surgical or medical.
Her choice of anaesthetic, between local or general.
Her choice of centre to attend for the procedure.
It is interesting for us to mull over the idea of what would happen
if we were to offer clients the choice of same day procedures,
or what would happen if the current law were amended to give abortion
on request, which would give women real choice.
Dr Catherine Paterson
I work in one NHS unit which has a dedicated abortion service.
I thought it might be useful to explain how we run a counselling
session for those coming to us for an abortion, and who talks
to the women at various stages of her contact with us.
We started out originally with counselling for all women as we
felt that this was an important component of the service. However
it was obvious that some women did not want to see a counsellor,
and only did it under duress because they felt that it was a necessary
hurdle in the path to getting an abortion.
Originally counsellors were provided by that local authority social
service department, to provide support to women requesting abortion.
About four years ago, following restructuring of their service,
the local authority no longer had adequate resources to provide
this. This provided and opportunity to review our counselling
services. We decided that while many women did not wish to receive
formal counselling, about 25 per cent of women needed more support.
Social workers are not fully trained counsellors in the classical
sense but they all have counselling training and, in addition,
are very practical and understand the problems that women can
have with an unplanned pregnancy. They can also give advice, if
required, about adoption, fostering and benefits available to
women. We therefore approached the local social services department
and arranged for a social worker to attend each abortion assessment
clinic and to be available to those women who needed them on the
day of assessment. Because of the infrastructure of their own
department this allowed much more flexibility than employing specific
people for each session and generated a bank of six counsellors
for three assessment clinics each week. They will also see women
outside clinic times if necessary. This service is financed by
the hospital as part of the abortion services contract.
Women who are referred come to the service via several routes.
The majority are referred from GPs, some of whom have their own
counselling services. The next largest group are from family planning
clinics, and women also come from other hospital departments,
especially genitourinary medicine, and from the Brook Advisory
Services. Women from Brook have already seen a counsellor, and
some women such as those who are HIV positive, or are substance
abusers may have had access to specialist counselling from within
those fields. These counsellors can relate the problems of unplanned
pregnancy to the medical and social problems particular to these
A small proportion of women are very uncertain about what they
want to do when they find they have an unplanned pregnancy. They
will be offered a counselling appointment before they decide whether
they want an abortion assessment appointment. This means a small
number of women will actually have counselling but never come
to the service to request an abortion.
The assessment procedure
The majority of women are initially booked by an administrator.
They are then seen by a family planning nurse, who will take a
medical history and a social history. We don't note down all of
the social history, but we might use it to highlight points that
suggest that the woman needs more support and time to talk through
her decision. In particular this may apply to women who are young
or women who are socially isolated. I emphasise again what has
previously been said however, that many women have given their
decision a lot of thought, talked issues through with friends
and family and don't need to see a counsellor.
After they have been seen by the nurse, they see a doctor. Between
the nurse and the doctor, the woman will have the course of events
that will take place described to her. She will be told what options
are available-medical or surgical abortion and how long she will
stay in hospital. The doctor fills in any gaps and answers any
questions she has. Once everything is arranged (or not if she
is still ambivalent) she will be asked if she wants to see a counsellor.
About 20 per cent of women do. What has been said before in this
discussion applies to the NHS setting too. The counsellor has
plenty of time to give to the woman. The other experience we have
quite often is that women don't want to see a counsellor pre-termination,
but say they might want to see one later. We make it clear to
women that they can come back to the clinic at any time after
the abortion to see someone. Interestingly enough, the take up
of post-abortion counselling is very low. I get the feeling that
women feel well supported knowing that they can come back. They
know what they want to do, and think they are going to cope well,
but are anxious that they might not. So knowing that there is
someone they can go to afterwards is I think helpful and supportive.
Although the service is not used much, women know it is there
if they need it.
We look at the counselling session as giving information, explaining
all the options available and trying to encourage women to make
their own choice. By doing this we hope to avoid regrets in the
future. What is clear to us from the various people that see these
women, is that the abortion procedure itself is a source of anxiety.
The questions women ask are: What will happen? Will it hurt? How
long does it take? Will I be able to have a baby in the future?
We try to answer these questions for them.
There isn't time for detailed counselling. One of the awful things
about finding yourself with an unplanned pregnancy is that decisions
have to be made in a fairly limited time, and therefore it is
difficult to open up a box of anxieties and worries that women
There have been a few women, who from seeing a counsellor in our
service, have then moved on to more formal counselling, but generally
in relation to other aspects of their lives. You cannot undo an
unplanned pregnancy, but offering a woman abortion offers relief
from that particular problem. The fact that a woman has become
pregnant accidentally, and the fact either she didn't want to
or was unable to continue with the pregnancy. are things that
cannot be undone.
I think it is important that women are able to think their decision
through, make a choice and be at peace with their choice, so really
in an actual abortion clinic we are not offering unbiased counselling.
We are offering counselling to give women strength to have confidence
about the decision they have made. They are worried about what
people might say. The most important thing is to support them
in their decision, if necessary offer counselling off site at
a different time, if they really want to talk about whether or
not they want to terminate pregnancy.
Women want to talk to someone who is friendly, who understands
their problem and who will explain everything to them, and who
they don't feel embarrassed to ask questions of and get answers