A therapeutic approach to working with women in the perinatal period

pregnancy2

Non-directive counselling has its origins in psychotherapy, particularly in the theory of Carl Rogers, where it was used to foster free associations in long-term therapy (Kessler 2001). Roger’s theory, based within a humanistic (‘self’) framework, was initially known as non-directive therapy, and later, ‘client-centred’ therapy, because the client was seen as the director of the process of therapy – setting agenda, pace and direction (Kessler 1997). The primary tool of Rogers’ ‘client-centred’ therapist is the process of ‘reflection’ – of mirroring the client’s emotional communication, in an effort to communicate to the client that what they have said has been heard and to engender a feeling of acceptance. (Dr C.G. Boeree Psychology Department Shippensburg University http://www.ship.edu/~cgboeree/rogers.html)

Rogers identified three ‘necessary and sufficient’ qualities required of a non-directive, or client-centred therapist (without which, no form of therapy would be successful):

1.   Congruence: is about being in the same ‘place’ as your client and using individualised communication rather than ‘professional-speak’ or jargon. Jargon can alienate the client giving the impression that you respond to everyone in the same way. Being genuine and honest will assist you to be congruent.

2.   Empathy: Expressing empathy can be defined as ‘the process wherein an individual is able to see beyond outward behaviour and sense accurately another’s inner experience’ (Townsend 1993 p59). Empathy is not to be confused with sympathy, where ‘the nurse actually feels what the (woman) is feeling, objectivity is lost, and the nurse may become focused on relief of personal distress rather than on assisting the (woman) to resolve the problem at hand’ (Townsend 1993 p59).

3.   Respect: is showing acceptance and unconditional positive regard for the client – respecting the person as a worthwhile human being. Using the person’s name, letting them do the talking and being open and respectful in interactions are key characteristics. Establishing a basis for trust – a foundation for the development of the relationship beyond the superficial, is also important. This can be achieved very simply by doing concrete things to demonstrate caring and a willingness to help e.g. offering a cushion to sit on to increase the client’s comfort, keeping a box of tissues handy in preparation for the situation where the client becomes tearful.

Go to http://www.ship.edu/~cgboeree/rogers.html for more information about the theory upon which Carl Rogers based his idea about client-centred therapy.

In the 60s, non-directiveness was introduced into the field of genetics counselling (GC) and by the mid 80s was widely endorsed as an appropriate industry model, this in response to a shift in thinking in line with the growth of the consumerism movement (Kessler 1997). In 1991 its ethos was incorporated into the GC Code of Ethics.

The code of ethics for genetic counsellors states:

The counsellor-client relationship is based on values of care and respect for the client’s autonomy, individuality, welfare, and freedom. The primary concern of genetic counsellors is the interests of their clients. Counsellors strive to… Enable their clients to make informed independent decisions, free of coercion, by providing or illuminating the necessary facts and clarifying the alternatives and anticipated consequences,… [or] refer clients to other competent professionals who can, when they are unable to support the clients [National Society of Genetic Counsellors, 1991]. (In Bartels et al 1997)

It is relevant to this CPD program to investigate non-directiveness as it has evolved in the genetic counselling literature/setting, as it is this form of approach which most closely resembles the type of approach required for pregnancy-related concerns. Genetic counselling, while being non-directive, is neither Rogerian nor client-centred as such, primarily because in a genetic counselling session the client is never fully in control of the agenda, pace or direction of the session (Kessler 1997), because it has a completely different purpose and clinical basis.

Pregnancy-related counselling and genetic counselling do, however, have a number of facets in common: both are brief interventions up to several sessions (in contrast with psychotherapy which is long-term); both require that counsellors respect the profoundly personal nature of reproductive decision making (Biesecker 1998 pp148–149); both are areas which are value laden, but which require the clinician to value neutrality in certain aspects of the process (particularly, in regard to the client’s decision (Biesecker 1998)); and both involve women, and sometimes men, who are having to address intense physiological as well as psychological and emotional situations.

This part of the program will provide participants with:

  • A brief overview of the discussion in the literature about what a non-directive approach is and what it is not
  • Review of basic communication strategies which should be used in a non-directive framework, and
  • An opportunity to test your understanding of the principles of a non-directive approach.