Essay On Womens Issues In Counseling

Advocacy is a concept that can evoke visions of protesters and picket lines, phone banks and information booths, and maybe even knocking on doors and accosting strangers on the street.

But at its most basic level, advocacy means to help or assist, and isn’t that the essence of counseling?

“I feel that the basic principles of advocacy — helping people to be their best — have always been a part of the profession in some ways,” says Courtland Lee, a past president of the American Counseling Association and a pioneer in multiculturalism and social justice work. “But it’s evolved over time. People really started to use the word advocate in the real sense [in the] 1960s as the major social justice movements — the struggle for civil rights, the anti-Vietnam War movement and the call for women’s equality — began to transform society.”

Counselors, like the rest of society, were affected by these movements, Lee says. “It started as more of a philosophy that counselors need to be agents of social change. As it evolved, advocacy became part of the multicultural and social justice movements,” says Lee, a professor of counselling at the University of Malta and editor of the ACA books Multicultural Issues in Counseling and Counseling for Social Justice.

Counselors began realizing that working with the client one on one wasn’t always enough, Lee says. Making lasting differences in clients’ lives often required challenging the prevailing environment and working to change it.

Rita Chi-Ying Chung, an international expert on multicultural and cross-cultural counseling, discovered that truth at the beginning of her career when she began working with refugees, a population forced to navigate many cultural barriers when arriving in a new county.

“I felt that we were creating kind of a revolving door where we would see clients, they would feel better, and then leave and go back in their world and get exposed to whatever issues or injustices that were happening to them, and their pain and difficulties would just come back,” says Chung, an ACA member and professor in the counseling and development program at George Mason University (GMU) in Fairfax, Va. “As counselors, I just think a critical part of our counseling is advocacy — not just on an individual level but on a community as well as a systemic level.”

The need for advocacy isn’t limited to large societal movements or even large groups of people, however. The need is present in every counselor’s office, school or classroom.

“Advocacy is not an adjunct piece; it’s a core, fundamental piece of any counseling we do with anybody,” says Fred Bemak, Chung’s research partner, frequent collaborator and spouse.

Lee offers the example of a famous case in Maryland in which a mother struggling to make it paycheck to paycheck and who couldn’t afford health insurance was unable to take her son to the dentist when he got a toothache. Tragically, the tooth became infected, the infection spread to the boy’s brain and he died.

“So, imagine this mom coming in for grief counseling,” Lee says. “It’s one thing to help her process grief, but at the same time, she is stuck in a dead-end job [and] another son has never been to the dentist, so the same thing could happen to him. Grief counseling on its own is not sufficient.”

But how would a counselor advocate for the client? By addressing the circumstances that led to the tragedy, Lee says. For instance, he suggests, the mother needs a better job, so perhaps the counselor could find a program that would help her upgrade her skills. The counselor could make a simple phone call to the state’s social services department to see what assistance the client might be eligible for, such as help with energy bills, emergency cash that could go toward paying rent or food stamps. The counselor could assist in securing dental care for the other child by checking with the dental community to find a dentist or clinic willing to provide low-cost or pro bono work.

Many of today’s counselors are actively advocating for clients, causes, social change and even the profession itself. In this article, we share a few of their stories.

Stopping traffic

Since 2012, Rita Chi-Ying Chung has received both the Gilbert and Kathleen Wrenn Award for a Humanitarian and Caring Person and the Kitty Cole Human Rights Award from ACA. Much of her work focuses on social justice and human rights. But Chung, who is also a consultant, researcher and faculty member at GMU’s Diversity Research and Action Center, didn’t start her career looking to become an advocate. Instead, advocacy found her.

“I was trained in a more traditional way of counseling, and advocacy wasn’t a real part of it,” says Chung, who was born, raised and educated in New Zealand, where she received her master’s and doctoral degrees in psychology at Victoria University of Wellington. But then the so-called “boat people” — Southeast Asian refugees who fled by sea on makeshift rafts and boats — started arriving in New Zealand in the 1980s. These were the “second wave” of Southeast Asian refugees from Vietnam, Cambodia and Laos who were fleeing the postwar chaos that still lingered nearly a decade after the fall of Saigon and the end of the Vietnam War.

Chung was working in community mental health centers as the refugees poured in. Her superiors thought she was uniquely qualified to work with this emerging client population because she was the only Asian counselor in Queensland and perhaps in all of New Zealand at that time.

“I was bilingual in Chinese — not any other Asian languages, just Chinese — but many of the refugees were Chinese-speaking Vietnamese, so we were able to communicate,” Chung recalls. “Because of that, I think some of the social services staff thought, ‘OK, she’s Asian. She’s talking to some of them, so therefore, she must be able to speak to all of them.’’’

The hugely uninformed assumption that one Asian person could somehow communicate with all other Asian people made Chung consider that the mental health community was likely oblivious to other cultures and their specific psychosocial needs as well. After all, if professionals didn’t even know what language the refugees spoke, how could they begin to understand and help them cope with their trauma?

Chung has published numerous articles and books on advocacy, multiculturalism and social justice. Today, she continues to advocate for and work with refugees, immigrants, minorities and other at-risk groups. An international conference on at-risk children led Chung to her current primary focus: child sex trafficking, particularly of Asian girls. She spent approximately three years traveling to Burma (Myanmar) with the nongovernmental organization (NGO) Save the Children UK to work with trafficked children and study possible ways to stop child trafficking.

The issues surrounding child trafficking are complex, Chung says. Girls are often sold to traffickers by their parents, which most counselors (and most other people in the Western World, for that matter) find extremely difficult to understand. But these are areas that are extremely impoverished, Chung explains, and sometimes the choice boils down to taking money from the traffickers for one child or watching one or more of your children starve to death.

“If it’s a difference between someone in your family’s going to die if you don’t put food on the table or you may be trafficked to another country, what are you going to do?” asks Chung. “You also need to understand Asian culture. In general, there is this concept of filial piety. The obligation for any child is to take care of their parents, which includes not only taking care financially, but to obey and respect and sacrifice anything for the greater good of the family.”

Even when the police raid a brothel and the trafficked girls are “freed,” they may choose not to go home, Chung says. “It’s not because they love what they’re doing. In all my years studying the trafficking industry, I’ve never met anyone who said, ‘Yeah, I volunteered.’ The Asian girls don’t leave because they feel that leaving is letting their family down,” she says.

“At the same time, they can’t leave because there is nowhere to go,” she continues. “In this culture, there is such stigma about rape and abuse. There’s such shame and loss of face, which doesn’t just apply to the girl but to the whole family.”

“It’s difficult,” Chung says. “I suddenly realized that in such an economically depressed situation, we’re not going to stop trafficking. It took me awhile to just accept the fact because I came into it thinking I was going to help prevent it.”

What Chung does do is ease community reentry for girls who have the option of coming back, in part by helping communities develop realistic alternatives for making money.

Easing reentry also involves education, Chung says. Part of that is sitting down as a community and collectively talking about how the group can heal, she says. Sometimes the healing involves listening to the girls’ stories.

“Sometime we’ll do role-play where the girls play out what it is like to be trafficked, telling their stories in an indirect way,” explains Chung. “Survivors will take on different trafficking roles. One person will be a trafficked individual, one person will be the madam in the house, etc. During this kind of simplistic playing out of roles, you can look around the community, and people are just crying. They’ve never truly thought about what the girls’ experiences were like. Once we get those tears out, the healing begins.”

Even so, the process is never simple. In some cases, Chung says, the family won’t take the girl back, especially if she is pregnant. However, others in the community may step forward and offer her a place to stay. Sometimes girls who were trafficked will band together and find a facility where they can live as a group.

Regardless, it remains essential to provide the girls with ways other than sex work to make money. Sometimes, however, the suggestions aren’t practical.

“We’ve got to give girls education and skills, but there are these programs out there that want to teach girls to be hairdressers and then send [them] back to their villages. What’s the point?” Chung exclaims. “Because, quite frankly, if I’m poor and I’m having trouble putting food on the table, I’m not going to pay someone to wash my hair.”

“I say [instead], what are the local resources? In one area, they have all these grasses they can weave with, and people use natural products to make dyes,” she explains. “So we thought, why not make lots of baskets and dye them different colors? Maybe we can find someone to take them once or twice a week to local markets and sell them, and that’s a way of sustainable living.”

For those who are still being trafficked, Chung and others have tried to provide a few safeguards. “We set up toll-free numbers in countries so that if there’s been some coercion, fraud, some threat, there’s someplace they can call,” she says. “Sometimes girls don’t even realize they are being trafficked into the sex industry. They have been told that they are going to be a maid or waitress or nanny somewhere, earning a lot of money, and before [they] know it, they are in a situation where their passports have been taken and they’ve been told that they owe a lot of money.”

Any attempt to stop or reduce trafficking must also address the demand side, emphasizes Chung, who was invited in 2008 to give a presentation on the cultural issues surrounding child trafficking at the United Nations. “White European men will go to different countries in Europe or Asia to have sex with children, but they don’t classify themselves as pedophiles. In the trafficking world, we call them ‘casual pedophiles,’” she says.

Most people are also unaware of how much sex trafficking goes on in the United States, Chung says. People would be shocked to discover that sex trafficking can take place anywhere, in anybody’s neighborhood, she says. The victims are not only women and children brought in from other countries but, in some cases, underage American girls. According to an FBI report from 2011, more than 290,000 U.S. youth were considered to be at risk for becoming trafficking victims. Although most victims of trafficking come from impoverished backgrounds, traffickers also target girls from more affluent families who are vulnerable for a variety of reasons, such as a history of sexual abuse, drug addiction, extreme low-self esteem, a desire to fit in or even promises of a glamorous lifestyle. Chung points out that in Northern Virginia, where she lives, there have been recent cases of high school girls being pulled into the sex industry.

“Human trafficking goes way back in civilization — back to the days of the Roman Empire — and it’s big business,” concludes Chung.

Counseling and advocacy: Two parts of a whole

For Fred Bemak, the academic program coordinator for counseling and development at GMU, advocacy and counseling are fundamentally intertwined. He was an advocate even before he became a counselor, and that experience shaped how he viewed his training and the counseling profession.

While in college, Bemak served as a summer counselor in the Upward Bound program, which works with youth from diverse backgrounds, including those who are economically disadvantaged, to give them a jump start toward college. Bemak continued working with Upward Bound throughout his counseling training, and the juxtaposition created significant cognitive dissonance for him.

“I realized pretty quickly that helping people accommodate to those social conditions was not a good way to do counseling,” explains Bemak, the founder and director of GMU’s Diversity Research and Action Center. “The traditional counseling field said, ‘Let me help somebody feel better about themselves even though they’re poor and they’re hungry and they don’t have a job and people are discriminating against them, and let me help them adapt to all that so that they can manage their lives.’ … From my Upward Bound experiences, I learned that’s not quite enough. Because we’re helping people to adapt to oppressive situations and the conditions of their lives don’t change, we’re just trying to change their mental status to say [in essence], ‘I’m poor and I’m happy,’ and that’s ridiculous.”

Bemak trained in what was considered to be one of the more progressive programs of its time, but as he describes it, it was still based on European-American concepts that didn’t fit the circumstances he was seeing at all.

“In the morning, I’d have been in the African American community with parents who were frustrated and angry and upset about life, trying to figure out how to manage without food. And then,” he says, “I’d go to these counseling classes, and it would be like two different planets.

“There was my training, and then there was working with vulnerable people in difficult circumstances. I had to craft together … how do I take this training and capitalize on it for the purpose of meeting the needs of people who are in marginalized circumstances?”

Those dual, clashing experiences spurred Bemak to get his doctorate so he could qualify for positions through which he could influence policy and bring social justice, multiculturalism and advocacy to organizations across the United States and then abroad.

His international work began when one of Bemak’s friends, a Yale University psychiatrist, received a general call for assistance from community service providers to assist with the needs of incoming Southeast Asian refugees. “He said, ‘Call Fred. He knows about working with children,’” Bemak recounts. “I said, ‘But I haven’t even been to Vietnam or Cambodia!’ They said, ‘You’ve been to Asia, and that’s as close as we can get.’”

Bemak learned by doing. “I didn’t know much about that population and what was going on,” he says. “But very quickly, because there were very few people in the United States doing this work, I became an ‘expert.’ I didn’t know enough to deserve the title, but there was basically no one else, so I was getting calls from all over the country to do training and consulting, and everywhere I went, I learned more.”

Bemak’s work has since expanded to include refugee populations from around the world. He has helped provide services in 55 different countries. He says his experiences continually remind him of the importance of advocacy and how much more he still needs to learn and do.

“One of the things I’ve been doing recently that has been very, very intense is working with postwar/conflict youth. Working with child soldiers, working with abductees, working with orphans, working with people infected with HIV/AIDS as a result of war. I’ve been doing that in Uganda most recently and looking at some other projects in Liberia,” says Bemak, who consults for the NGO Invisible Children.

“It’s incredibly intense and painful work,” he continues. “Many times in these counseling sessions, I’ll have been the first person to hear these stories because people have not been able to tell them because they have not found the conditions in which they feel they can.”

All of Bemak’s advocacy counseling work revolves around helping diverse people and communities in need, but after Hurricane Katrina, he felt compelled to create a kind of urgent care counseling unit that would respond in the wake of disasters. Bemak was at a national counselor educators’ meeting when, roughly six weeks after the devastating storm, someone asked who among the attendees had been to the Gulf Coast and seen the horrible devastation. Only a few hands went up. Worse yet, in Bemak’s opinion, the counselors who had visited the region had assisted primarily by helping to clean up, not by putting their desperately needed counseling skills to good use with the affected population. Worst of all, he says, when he looked into relief efforts, he found that small, diverse communities in Mississippi were not getting the services they needed. He notes that most of the focus was on New Orleans, but even there, the need was so great that there weren’t enough mental health providers to go around. Bemak was afraid that smaller affected communities in Mississippi were getting lost in the shuffle.

“So, I created Counselors Without Borders in my head, right there,” he says. In addition to its work in Mississippi after Hurricane Katrina, Counselors Without Borders has also provided culturally sensitive services to migrant communities and on American Indian reservations when wildfires scorched Southern California in 2007, as well as in Haiti in the wake of the 2010 earthquake.

The organization only deploys where it is needed. “I only want to go to places where needs are not being already met,” Bemak says. “Counselors Without Borders is a backup organization to come in and do culturally responsive work where it’s not being done.”

The thread that runs throughout all of Bemak’s work is social justice — how to address human rights and help achieve equity in counseling. The answer, for him, is advocacy.

“In the work we’re doing [as counselors], I think we’re really contributing to problems by not addressing advocacy and by not incorporating that as a core part of our jobs,” he asserts. “I think we’re contributing to the social problems and the inequities and the social conditions that oppress and hurt people.”

The battle for mental health

Keith Myers, a licensed professional counselor in Atlanta, has always been interested in the military. It’s a bit of a family tradition. His father was in the Navy during World War II, and both of his brothers have also served.

Myers chose to take a different route. The ACA member has been a practicing counselor for approximately 11 years and has worked in a variety of clinical settings. One of those settings turned his interest in the military into a focus for advocacy.

Myers has been a private practitioner for almost a year now, but before that he spent about two and a half years working with and advocating for veterans and active-duty service members at the Shepherd Center in Atlanta, a private rehabilitation center that specializes in brain and spinal cord injuries. As he would learn, working with this population required an approach based on an understanding of the military’s unique culture.

Specifically, Myers worked in the SHARE (Shaping Hope and Recovery Excellence) Military Initiative, an intensive outpatient program for veterans and active-duty members who had sustained a traumatic brain injury (TBI). Although SHARE received referrals from the military, it was a privately funded initiative that provided something military services did not offer — a chance to receive physical rehabilitation and mental health treatment simultaneously, Myers says.

“Patients could receive treatment for both their TBI and PTSD [posttraumatic stress disorder], which is a great advantage because it can sometimes be difficult to tease out what is [caused by] TBI and what is PTSD since their symptoms often overlap,” says Myers, a member of both the ACA Veterans Interest Network and the ACA Traumatology Interest Network.

The treatment was comprehensive. Patients had access to physical therapists, occupational therapists, speech therapists, physiatrists and mental health treatment, including individual, group and, in some cases, family therapy, Myers explains.

To even begin the process, however, Myers had to earn the clients’ trust — to advocate through understanding. “Military clients can be a difficult population to establish trust with just because they have a general mistrust of anyone outside the military. … There are exceptions, but they are pretty distrustful of civilians in general,” he says.

That distrust extends particularly to mental health practitioners of any kind. In the military, a strong stigma is attached to mental health problems and treatment, Myers explains. And if a service member does get help within the military system, there is virtually no confidentiality, unlike in the private or public mental health sectors. Military mental health practitioners report to higher-ranking officers and must disclose any potential problems that come up in sessions, he says.

“In fact, among military personnel, the mental health professionals are known as ‘wizards’ because they can make you disappear from your unit,” Myers says ruefully.

So, with each of his clients, Myers began by explaining that confidentiality worked differently at the Shepherd Center. He would not be revealing their conversations to anyone. Although he was required to give general reports on progress, the details of what was said in the therapy room would stay in the therapy room.

Myers also used his background to start to connect. “I was a little looser with my professional and personal disclosures. I could see there was clinical value in disclosing that I came from a military family and sharing some of my experience,” he says.

Just having knowledge of military culture and knowing the differences between branches was a big help. “Always know your branches,” he advises. “Never call a Marine a soldier — that’s an Army designation. Don’t call someone a sailor unless they are in the Navy.”

It may sound like a small thing, he says, but the military and its branches have their own unique culture, and taking a multicultural approach and getting to know and understand this population’s customs is essential to establishing trust and counseling effectively.

“It’s a slow process in the beginning,” Myers says, “but once rapport is established, the sense of trust becomes an almost unbreakable bond.”

Now back in private practice while earning his doctoral degree, Myers’ desire to help military members has led to significant advocacy work, both at the individual and community levels. Myers currently sees several military clients and advocates for them by helping them fill out disability paperwork with the Department of Veterans Affairs. He also accompanies certain clients on visits to their physicians. The visits started when several clients confided to Myers that they didn’t really know what they wanted or needed from their doctors.

“We would sit down before the physician’s appointment, and the client and I would talk about the visit and what their needs were,” Myers explains. “Then we would kind of do a role-play of what I [as the client] might say to the physician, and sometimes the client would say, ‘What you said is better than how I would say it, so would you mind coming to my appointment?’”

The clients felt better having someone to help articulate all of their needs, and Myers liked being there to make sure his clients felt their needs were being addressed.

Myers is also advocating by educating other mental health and health professionals about the unique needs of the military population. He has presented at multiple health facilities in the Atlanta area, including an audience of 80 at an area psychiatric center. Myers also presents on the topic to faculty and students at Mercer University, where he is earning his doctorate.

Myers’ presentations educate audiences about the extreme physical and mental stressors that military clients experience. “The heat is extreme — often well over 100 degrees — and military members have to endure it, often while dressed in body armor,” he points out. “Missions require a high degree of vigilance and are sometimes ambiguous. They may be peacekeeping or diplomatic [missions], but there is always the threat of IEDs [improvised explosive devices] and the possibility of ambush or military fire.”

Those in combat also have to face things such as conflict within the unit, the loss of fellow unit members, general fear and horror, and the possibility of death or being maimed. And even when they return home, Myers says, they still must deal with the memories and the myriad emotions those memories engender.

Myers has been pleased with the feedback he receives, particularly from audience members who come up after his presentations to tell him they have always been interested in treating military members but haven’t known how or where to begin. He helps interested counselors and other mental health professionals to get started, whether it is through professional connections or simply working with nonprofit advocacy organizations such as the Wounded Warrior Project.

Myers says he will continue to present, and once he has finished his doctorate, he hopes to teach counselor trainees not just about military culture, but also combat and trauma.

“One of the most rewarding aspects of working with this population is being able to serve those who served,” he says.

The accidental advocate

When ACA member Kevin Feisthamel began his job at the Cleveland Clinic Foundation’s Melon Center for multiple sclerosis (MS), he knew little about the disease. He had just finished a counseling internship that focused on health psychology and had developed a strong interest in neuropsychology. So when a neuropsychological technician position opened up in the MS clinic, he jumped at the chance, despite not knowing anything about the symptoms, prognosis or treatment options for MS. At first, he simply focused on administering the personality and intelligence tests. After all, he reasoned, that was what he was there for.

But it didn’t take long for Feisthamel to recognize the devastation that MS can cause and to realize that the clinic patients needed more than just test administration — they needed empathy and knowledge.

After their initial baseline tests, patients would return about three months later to be retested. Feisthamel would score the tests, and the clinic neurologist and psychiatrist would evaluate the results, looking for decline or changes in cognition.

“Suddenly,” Feisthamel says, “I was seeing these highly intelligent people whose mental function was markedly decreasing over time. I would also see people — kids, really — who were 18 or 19 and in wheelchairs, and I was amazed at how debilitating this disease could be. I just couldn’t imagine what they were going through, and I tried to put myself in their shoes but realized that I didn’t even know enough to do that. That’s what got me started. I felt educating myself was crucial not only for myself but for the clients I was seeing.”

Although Feisthamel wasn’t addressing the decline and associated symptoms directly with the patients, he felt he needed to know more to better understand the bad news he sometimes had to deliver. He also wanted to help on a systemic level by participating in research that could uncover more about the effects of MS — in particular depression and fatigue, which were symptoms he witnessed so often.

Eventually, Feisthamel began sitting in with the neurologist and taking part in the discussions with patients. He also was invited to start taking part in presentations on the research the Cleveland Clinic was doing related to MS. He was involved in several studies, including one that focused on depression in MS patients. For that study, Feisthamel looked at the personality assessment data the clinic had collected and tried to identify specific personality characteristics that might help individuals cope with their depression.

Feisthamel eventually left the Cleveland Clinic to pursue his doctorate, but he retained his passion for research and advocacy. He no longer devoted so much time to MS, although he did write a meta-analysis of research on pharmacological and counseling interventions for MS patients with depression for his psychopharmacology class. The article was later published in a peer-reviewed journal in 2009.

Today, Feisthamel teaches at Walden University and is also director of the health center at Hiram College. He is still an enthusiastic advocate, but his current focus is on the science of happiness and positive psychology. He established a Hiram chapter of Active Minds, an organization that empowers students to speak openly about mental health to encourage help-seeking behaviors, and recently completed a week of education on suicide prevention. Feisthamel sees clients daily but says about 80 percent of his job at Hiram revolves around getting out and educating people about where and how to get help and what kinds of things they can do for themselves.

“I don’t worry a lot about the people I do see,” he says. “I worry about the ones I don’t. That’s why I have to get out of my office to talk about counseling services and to give presentations on campus to students and faculty.”

Feisthamel is also encouraging advocacy among future counselors. Walden’s counseling program is focused on social change, he says, and he regularly asks his students to think about what social change is and how they can use it to advocate for their clients.

“We can have a huge impact, not just at the national level, but at the community level,” he emphasizes.

Defending counselors everywhere

John Yasenchak, an ACA member from the Bangor, Maine, area, never really considered himself much of an advocate. He’d participated in a few things to help raise awareness around counselor identity, but mostly he was focused on his practice and the classes he taught at Husson University.

Then came the fight around MaineCare, the state’s Medicaid program. The state Legislature has been trying to cut the program’s funding for years, according to Yasenchak, and in 2013, lawmakers decided MaineCare should stop reimbursing licensed clinical professional counselors (LCPCs) for patients who had “dual eligibility,” meaning they were eligible for both MaineCare and Medicare.

“The justification was based on Medicare’s refusal to include counselors as legitimate mental health providers who deserve to be reimbursed,” he explains. “The state pointed to this regulation and asked why it should reimburse counselors if the national Medicare system wasn’t.”

The prospect of being locked out of MaineCare sent shock waves through the state’s counseling community, Yasenchak says, because it would put counselors’ income or positions in jeopardy and many clients wouldn’t be able to continue receiving care from their chosen LCPC providers. “I had students coming in asking me if they should continue in the counselor education program. Was there an actual future in counseling? Would they even be able to find jobs, or should they switch to another helping profession?” Yasenchak recounts.

The situation served as a real wake-up call about the need for Maine counselors to start lobbying for recognition as legitimate mental health providers, not just at the state level but at the national level too, Yasenchak says. They did lobby the state Legislature, but the Maine Counseling Association (MeCA), a branch of ACA, and the Maine Mental Health Counselors Association realized that counselors could never be secure professionally until the Medicare problem was addressed.

Yasenchak, then serving as president of MeCA, and others started reaching out to contacts who had connections to Susan Collins, one of Maine’s U.S. senators. In the meantime, the state lobbying effort was gathering support from consumers and the CEOs of federally backed medical centers and furiously raising awareness. This activity and the many written testimonials it garnered were part of the background information presented to Collins. Her office responded positively but wanted more information, even asking Yasenchak and others to do research in the Federal Register.

The legwork paid off. By the time Yasenchak and several of his colleagues met with Collins, she had agreed to help sponsor the Seniors Mental Health Access Improvement Act of 2013 in the U.S. Senate. The bill is currently being reviewed by the Senate Finance Committee. A companion bill that includes Medicare reimbursement for LPCs has also been introduced in the House of Representatives.

Yasenchak and colleagues Deb Drew and Jeri Stevens are sticking with the process. Despite the dedicated lobbying at the state level, the Maine Legislature passed legislation denying reimbursement to LCPCs for dually eligibl clients. This is a targeted exclusion that does not apply to any other mental health professionals, Yasenchak points outs. Clients who had previously seen an LCPC had to transfer care to other providers unless they pursued a special waver.

Yasenchak knows that counselors’ livelihoods and clients’ treatment will continue to be threatened — and, in some cases, eliminated — until the fight for Medicare reimbursement is won.

Looking back, moving forward

As the counseling profession moves forward, all counselors need to learn how to advocate for their clients, Lee says. Advocating for all clients means that counselors will help not just by talking about their clients’ presenting issues, but by ensuring that they have access to the resources necessary to meet their needs, he explains. This shift toward advocacy is reflected in the increasing number of counseling programs that train students in working for social change.

As calls for counselor advocacy grow, so does the need for strategies to carry out advocacy work. Rebecca Toporek helped provide counselors with practical steps for implementing advocacy efforts when she, Judy Lewis, Mary Smith Arnold and Reese House developed the ACA Advocacy Competencies as part of a task force. The ACA Governing Council endorsed the Advocacy Competencies in 2003.

“The Advocacy Competencies were created to provide counselors with definitions, strategies and guidance to facilitate the process of working with clients and client communities to identify the most appropriate action and strategize appropriate actions,” Toporek says.

The competencies define six domains of appropriate advocacy for counselors:

  • Client/student empowerment
  • Client/student advocacy
  • Community collaboration
  • Systems advocacy
  • Public information
  • Social/political advocacy

For more information on the Advocacy Competencies, go to

For Bemak, the issue is fairly simple. “If we’re not advocating for our clients,” he says, “we’re not doing our jobs.”




KCA advocates for its next generation

At the Kentucky Counseling Association (KCA), advocacy has taken the form of nurturing and supporting the next generation of counselors.

Over the past few years, KCA, a branch of the American Counseling Association, has launched a series of initiatives focused on counselors entering the profession. Those initiatives range from creating a special tab with graduate student resources on its website to increasing its educational offerings for entry-level counselors at its annual conference.

The effort has been “a win-win,” says KCA Associate Director Bill Braden. The entry-level counselors have brought fresh ideas and a new voice to KCA, while the association’s more experienced counselors have been able to mentor and network with the profession’s next generation.

Attendance at KCA’s annual conference has doubled, which KCA Executive Director Karen Cook attributes to the association’s recent focus on graduate students. KCA has expanded conference offerings for graduate students and new professionals, such as Q&A sessions on licensure, mock job interviews and the creation of a special lounge at the conference venue where graduate students can meet up and network.

The new programs and initiatives were created to focus on a challenging and critical time that can exist postgraduation for new counselors. Upon finishing graduate school, many budding counselors confront the pressures of finding a job and establishing themselves in the profession, all while burdened with student loan debt, Braden points out.

Cook and Braden say that KCA’s leadership team came to the realization that the association needed some type of outreach or mentorship initiative to connect new graduates with the state’s experienced counselors. A small task force, formed in 2012, developed a survey to identify graduate student needs and how KCA could help meet those needs. The survey was circulated at the annual conference and throughout the state. The task force then evolved into a student leadership team that includes representatives from universities throughout Kentucky.

“When we talked with our peers, [we] felt like students were missing out on how they fit into the bigger picture,” says Shana Goggins, a member of the original KCA task force who graduated from the master’s program at Eastern Kentucky University (EKU) in May 2013. “We felt like [we could do] more … to show students how much easier it is to get involved with a professional organization as a student, rather than waiting until you’ve graduated, you’re in the field and you’re trying to navigate work and just getting yourself oriented. We wanted to do something to show students that they were a viable part of the association.”

Goggins and her colleagues helped create a graduate student academy at KCA’s 2013 conference with a lineup of offerings tailored to new counselors, including the Q&A on licensure and sessions on self-care, public speaking, professional networking and other helpful topics.

“We want [new counselors] to understand how important it is to be proud of their profession and the importance of what we do,” Cook says. “We want to continue to listen to their voice and connect them with counselors in the field. We don’t want them to feel like they have to go it alone. … We love to see the interaction that goes on now between the grad students and the [experienced] counselors.”

KCA has also expanded its long-standing graduate school scholarship program. Each university in Kentucky now receives one scholarship for a counseling student to attend a summer class. The scholarship recipient, in turn, is invited to be involved with KCA’s annual conference in the fall, Cook says.

Panagiotis “Panos” Markopoulos, a classmate of Goggins’ at EKU who is now a doctoral student at the University of New Orleans, said KCA supports its members like a family. “It’s not just a one-way street, most definitely,” he says.

Markopoulos and Goggins were both involved in the 2012 task force and were instrumental in launching KCA’s focus on entry-level counselors, Braden says.

“As much as we’ve helped KCA, KCA has helped us,” says Goggins, a prelicensed counselor who is still involved with KCA. “I like to think that they’ve definitely helped us a lot more than we’ve helped them. But they would probably say the opposite. It’s a win-win, on everybody’s end.”


— Bethany Bray




To contact individuals interviewed for this article, email:

Courtland Lee at

Rita Chi-Ying Chung at

Keith Myers at

Kevin Feisthamel at

John Yasenchak at

Rebecca Toporek at



Social justice advocate and visionary Judy Lewis passed away as this article on counselor advocacy was being written. See page 48 of Counseling Today‘s May issue for an “In Memoriam” article on her life and legacy.



Laurie Meyers is a staff writer for Counseling Today. Contact her at

Letters to the editor:

advocate, Social Justice

The counselling context

The term ‘counselling context’ does not refer here to the physical location where counselling takes place (which we call the counselling environment) but relates to the social, cultural, economic, religious and political factors of the place where you work, and the communities in which the people you will counsel, live. This section examines how these different factors may influence the counselling context.

It is important for you to be aware of the different factors that have an effect on the counselling context within the community you work. In the previous sessions we highlighted how important it is to assess and understand the woman's own knowledge, skills and individual situation. It is also important to assess and understand the wider cultural and social context in which you work.

Economic conditions

Economic status refers to one's financial status and is strongly related to health and educational status. So in general, most people with a low economic status (e.g. a low income) are also likely to have a lower educational and health status.

On the other hand, those with a higher economic/financial status will have better access to education and health services and will have higher status in these areas. It is important to take into account the socio-economic status of a woman, couple or family because this status will affect the decisions they have to make as well as the needs they have. For example, a woman who is poor may not have money to attend a health facility (either for child care, transport or where she must pay user fees). Similarly if a woman has a low educational status she may not appreciate the benefits of birth in a health facility and her low health status may mean she is at higher risk of poor health outcomes for both her and her baby. Educational status is also related to literacy. You need to know the literacy level of people that you counsel so that you do not give them complex advice or instructions in words which are unfamiliar to them, materials that they cannot read, or forms which they are unable to understand or complete.


Be aware that this may be a sensitive topic for some women.

Try open-ended questions as you try to form an alliance:

“I'd like to get to know you a little more; perhaps you can tell me something about yourself and your home situation?”

At other times you will have to be more direct e.g. “What level of education did you finish?”

How does your household earn its income?”

It can help you to form an alliance with the woman if you are open with her about why you want to know this information. Tell her that knowing this type of information will help you to tailor the service you provide to her specific needs.

Social and cultural context

Culture is a term we use to describe the values, beliefs, practices and ways in which a community or society lives. It also includes the way the people express themselves, communicate, and interact with one another. The social context refers to how people are organized, in terms of family groupings (do they live in extended or nuclear /traditional families? or do husbands have several wives?) It also refers to group interactions and hierarchies within communities. For example, are there group leaders, chiefs, or headmen or women, and what role do they play? The cultural and social context affects all aspects of life, from how people greet one another, to how they interact in the household and how they make decisions.


Being aware of the social and cultural context will help you form an alliance with the woman or couple you are counselling and will help you decide appropriate ways to communicate in terms of how you ask questions, how you approach sensitive issues, and how you facilitate the process of problem-solving. It will also enable you to tailor your counselling to their specific needs.

Issues such as religion or social status affect peoples' ideas or feelings and this can influence communication and counselling. The cultural and social context can be expressed differently depending on the setting such as the home, schools, the workplace, or the health service. Your professional training took place within a particular perspective on health and you may feel it is the most appropriate way of approaching health issues. Other communities and cultures have their own ways of talking about health which may be different from yours. Thus it is important to reflect on what these different beliefs and values are, as they will have an impact on the way in which you interact with women and their families and the way they interact with you.

Pregnancy and birth are normally very social and cultural events and thus tied to many specific beliefs and practices. In order to better support a pregnant woman and her family, it is important to know these beliefs and practices. Some may be very good for the woman and her baby, others may not be beneficial but also do no harm; you can build upon these beliefs and practices, and try to incorporate them into your practice and service. Other beliefs and practices may cause harm. You will need to discuss these with the women and her family and the broader community to see how they can be changed.

Activity 1

1 to 2 hours

To assess whether local practices in your community are helpful, harmful or harmless for maternal and newborn health.

Note to facilitator: You can divide the group into 3 smaller groups and have each group look at a different aspects, e.g., one group looks at antenatal, another group looks at childbirth and the third group looks at postnatal practices. Then bring them back together as one larger group to discuss their findings.

Within different cultures or social systems there can be ceremonies or ways to mark important events such as childbirth. For example, pregnant women may be expected to act or behave in certain ways. They may be given medicines or special foods. There may be ceremonies or activities to mark the arrival of the new baby, or practices carried out during labour and birth.

Understanding the context in which you are working and counselling is very important. This activity looks at local practices to help you to assess some important aspects of your context. Consider talking to women and community groups to help you answer these questions.

  1. Write down in your notebook all the local practices and beliefs that you have come across regarding pregnancy, childbirth and the postpartum/postnatal period. Ask women or groups if there are any other practices and beliefs you should add.

  2. For each one of the practices you have identified, consider whether it is good for the health of the woman and/or baby, if it is harmless or harmful. Organize your list of practices under the three headings:

    You may need to find out more information to be able to make your classification. A helpful practice is one that supports the advice and information that you give to women (for example, exclusive breastfeeding), a harmless practice is one that does not contribute to improving the health status of the mother or newborn but also does not have a damaging effect (for example, beliefs/rituals surrounding the care of the placenta after birth). Harmful practices cover anything which might carry a risk of infection, loss of blood, transmission of an STI or make the mother or newborn weak. Harmful practices may also delay the woman's access to appropriate care (for example, beliefs that announcing the onset of labour will result in an evil spell being cast). The following questions may help you as you think about this.

    1. Does the practice involve animal or human waste? For example, a common practice of rubbing manure onto the baby's umbilical cord can cause dangerous infections.

    2. Does the practice involve allocating different amounts of food, work or rest? For example, some cultures routinely give women less to eat than men. This could be potentially harmful to a pregnant or breastfeeding woman. But a cultural practice which encourages a woman who recently gave birth to rest in bed can be helpful.

    3. Does the practice involve sexual intercourse? For example, sexual cleansing where a woman with STIs has sex with a traditional medicine practitioner is unlikely to do any good, and can transmit STIs/HIV if condoms are not used. However, sexual intercourse between a woman and her husband during pregnancy is harmless, unless one or both of the couple are HIV-positive and are not using condoms.

    4. Does the practice involve taking blood from the woman outside of the health service? For example, taking blood from pregnant women to cleanse her of demons could be harmful as there is risk of infection and too much blood could be taken.

    5. Does the practice involve local herbs, remedies or medications? For example, taking local remedies to stimulate contractions could be harmful, but other herbs or foods to promote better nutrition might be harmless or helpful depending on the ingredients.

    6. Does the practice involve delays in reaching a skilled attendant? For example, the belief that infidelity causes obstructed labour may result in reluctance to give birth in a health facility.

  3. Think about how you might incorporate some of the helpful and harmless practices into your advice and counselling with pregnant women and their families. Think about how you will discuss the harmful practices with women, their partners and their families and the community so you can improve your mutual understanding.

Our View

Your list will be divided into those practices which are helpful, for example, a pregnant woman should be given an additional portion of meat or fish to help her stay strong. They could be harmless practices, such as the placenta after birth should be buried. Or they could be harmful, such as putting cow dung on the umbilical cord. Whether helpful, harmless or harmful, you should try to better understand the practice and belief. Where practices are helpful, they should be encouraged. Where harmless, there is no point in discouraging them. You may find you get more respect and better support from the community if you respect their harmless practices which may have great significance to them and their cultural and social context.

Discuss with women, their families and others in the community those practices which are harmful or which could endanger the health of the mother or newborn. Listen to their explanations about the practice and discuss the reasons why the practice is harmful. In many situations a replacement harmless practice can be substituted, instead of the harmful practice. In the case of female genital mutilation, for example, you could still conduct a “passage of rites” ceremony but simply replace the words in the traditional song used during the ceremony and provide a beaded necklace or some culturally suitable symbol instead of performing the cutting ceremony.


Many practices are deep rooted in social and cultural norms and gender roles and perceptions. However, health workers can play an important role in stimulating discussions on these issues in the community.

Gender roles

Two of the differences between men and women are sex and gender. Sex is the physical, biological difference between women and men. It refers to whether people are born female or male. Gender, is not physical like sex. Gender refers to the expectations people have from someone or a community because they are female or male. Gender attitudes and behaviours are learned and the concept can change over time. Sex is biologically determined while gender is socially determined in terms of the roles and responsibilities that society or family assigns to women and men.

Men and women usually accept the roles defined and perpetuated by their community which can have both advantages and disadvantages for them. There are many factors that influence gender roles. These include: age, culture, marital status, education, economics, profession, and the country or society itself. Understanding the gender roles in the community can help you to better understand the situation of the women and men you counsel, and thus improve your counselling interactions.

Understanding local gender roles and how they affect men and women in your community can improve your counselling interactions


  • Women should stay at home and look after the home or family.

  • Men should not do housework.

  • Men should not cry.

  • Women should not disagree with their husbands.

  • Women should keep their bodies covered.

  • Women should not drink alcohol.

How are women and men expected to think, feel and act in your community? How do they learn to do this? Gender roles are learned from a young age as parents may treat girls and boys differently. In addition, children often copy the behaviour of their parents.

Many women find the gender role of wife, mother and housekeeper very satisfying, providing them with status in the community. However, it can be a disadvantage to other women who want to have only a few children or want to pursue a career or other interests. Some women manage to combine a number of different roles. For the family and the community it can be beneficial for women to look after the children and remain at home, but it could also be a disadvantage as women who have paid employment could bring other benefits to the family and community.

Gender roles also teach men and women to express themselves differently. Women are often allowed to be more emotional whereas men are taught to keep their feelings inside. Men may get less support when they have problems due to expected gender roles. Sometimes it will be important for you to counsel men and it will be particularly important to take into account the community's norms for gender roles as you do so. For example, a woman may want her partner or husband to be present when she gives birth but the man may feel pressure from others in the community or fear the reaction of others in a community where this is not usual practice.

Similarly we can see examples of gender roles in the community. In some communities the opinions of men may be valued more highly than women's opinions. Women may not be encouraged to speak or participate in discussions. This means that the community hears more about what men think about problems and issues. The community or family may not benefit in this situation as women's knowledge and experience are undervalued or overlooked. You may need to be aware of this when you work with communities, in order to support women to share information, and discuss their knowledge.


  • Women make up two-thirds of the illiterate population in the world, and in many countries, there exists a gender gap in education - far fewer women than men are educated.

  • Women carry out two-thirds of the world's work, but earn only one-tenth of the world's income.

  • Maternal mortality in developing countries is 22 times greater as an average than in developed countries.

  • In many places, women are twice as likely to work for nothing as men.

Think about these statements. You may like to use them as a discussion point with the community when you discuss gender roles and inequality.

Source: Population Council. A client-centered approach to reproductive health. A trainer's manual. Islamabad, Pakistan: 2005. .

The impact of gender roles on health

Gender roles have an impact on beliefs, attitudes and values. Gender roles can also greatly affect health behaviour and the sexual and reproductive health of men and women in your community. For example, in some communities adolescents are encouraged to have sex with older men; thus gender roles can effect the transmission of STIs including HIV/AIDS and can also lead to unwanted pregnancies. Gender roles can lead to other undesirable sexual behaviours such as women having sex when they do not want to, and even rape and violence against women. Alternatively gender roles may prohibit women from expressing their own sexual needs or desires. Gender roles can have an impact on decision-making. For example, in some societies where there is a female hierarchy, young mothers will not be allowed to take decisions about seeking care on their own. This may not always be negative. In certain cases, adolescent girls may want support from older women in taking decisions.

Household decision-making processes

People do not make decisions in isolation from the context of their lives, and this includes asking advice from other family members and even the wider community. Research has shown that both the context in which decision-making occurs and the social influences such as those of a partner or the family, often have more effect on decision-making than merely information and education or the provision of communication materials.

You may need to facilitate the decision-making process among all those in the household who have important contributions to make. Cultural practices and gender roles often heavily influence the decision-making process. A woman may be unwilling to commit to a plan of action or take a decision until she has discussed the issues with her partner or other family members such as her mother or mother-in-law. You can support women in these discussions by reviewing the advantages and disadvantages of different options and her needs in that situation.


Situation: Counselling a woman about the need to exclusively breastfeed her baby up to six months.

Problem: Her mother is encouraging her to introduce porridge at three months.


  1. Establish with the woman what she wants to do through open questioning and active listening.

  2. Review the advantages and disadvantages with her to help her make her decision.

  3. If she wants to continue breastfeeding exclusively then facilitate the process of generating options of how she can address this subject with her mother. She might want information from you to give to her mother; she may want her mother to join you in a discussion; she may want to practise different scenarios with you.

Activity 2

45 minutes

To assess how gender roles and household decision-making contribute to the health of the women you see.

This activity explores the context of gender roles and household decision-making and how these impact on maternal and newborn health.

Note to facilitator: consider splitting the group up into smaller groups and give them different parts of the activity to complete, which they can then share with the whole group.

  1. Are there different ways in which women and men are expected to behave in the community?

  2. Do these different patterns of behaviour depend on the age or marital status of women?

  3. What impact might these behaviours have on MNH?

  4. What other reproductive health problems might these roles contribute to?

  5. What can you as a health worker do, in a counselling session or during your interactions with the community, to have an impact on gender roles so that women can better care for themselves and their babies?

  6. In general, in your community, how are decisions in the household made regarding the care of a pregnant woman?

  7. How does this affect MNH?

  8. How might you support women in the decision-making process in their homes about MNH?

  9. How might you include other key family or community members in the counselling and decision-making processes?

Our View

Some gender roles are influenced by religious beliefs while other gender roles are based on traditions or culture. Social norms and gender roles can lead to women not valuing their own bodies, or not understanding how their bodies work. This means they do not know what to expect or what is “normal”. Sometimes gender roles can lead to women paying more attention to the sexual needs and desires of men than to their own needs. This can lead to unwanted sex or having sex by force or to women not using contraceptives because of pressure from men. Other reproductive health problems may arise such as STIs.

You can play an important role in teaching women about the different parts of their bodies and the role that they play in sex and reproduction. Discuss with women what is normal (for example, routine vaginal discharge) and when they need to seek care (in cases of abnormal or infected vaginal discharge). You can also support women to take more control over their lives so that they can negotiate safer sex practices and contraception and participate in decision-making, especially where it concerns their sexual health, or the health of their baby.

Some communities have negative views about women's bodies. For individual women this can lead to feelings of shame and a lack of knowledge of their own body. Problems can arise because:

  • Women are embarrassed.

  • They do not know how to protect themselves from STIs or unwanted pregnancy.

  • They are not in control of their own sexual health decisions.

Help women to understand how their bodies work in relation to sexual and reproductive health. If it is socially and culturally appropriate, help them to explore their sexuality which includes their feelings and attitudes towards sexual relations.

Recognize when it is important to include partners and other family members in counselling for MNH. Also support women in how to deal with family involvement in their decisions. Do this through interactive discussions with the women. Sometimes you may need to work with partners or other family members in the absence of the woman (for example, when she is too ill to take decisions on her own). Your skill is in supporting her in determining who should be involved in the decision-making process. But remember to respect confidentiality in terms of the woman's wishes.


Involving the partner and other family members in counselling may require additional time and resources. However, if you only counsel a woman, the decisions she makes may be overruled later by her family.

Activity 3

3-4 hours

To explore the counselling context in your community.

Before moving on to Part 3 of this Handbook where you will examine topics and practice skills, you may benefit from a more in-depth exploration of the counselling context in your community.

Note to facilitator: divide the work of this activity among the group. Get them to plan and decide who will interview each different community group (as outlined in number 1), and to agree how the interviews should be conducted and which questions to ask.

  1. Set up interviews, meetings or informal discussions with religious leaders, traditional healers, chiefs, and political leaders, in addition to other health providers and members of the community.

  2. Make a guide of some of the questions and topic areas you would like to discuss in advance. The topics you explore might include areas such as:

    1. Local culture and social systems

    2. Politics and religion

    3. Poverty

    4. Gender roles

    5. Family structure and household decision-making

    6. Women with special needs

    7. Local beliefs and practices related to maternal and newborn health

    8. Opinions about the health service.

  3. Take notes of the discussion and share them with your colleagues – imagine you are trying to explain the context to someone new that has never been to your community before.

  4. Discuss how your findings might have an impact on maternal and newborn health.

Our View

You may find that you are working with a community where the context is the same for the majority of the population. Or you might find that you work in a community where there are lots of differences; for example, a community where there is more than one dominant religion, tribe or ethnic group. Different groups in the community will view maternal and newborn health and reproductive health in different ways. It is important to understand all the different factors and views that contribute to the social and cultural context of the area where you work. Understanding the context that communities live in can help you to counsel more effectively as you will understand the context in which decisions have to be taken and how the context may affect maternal and newborn health.

With this understanding, you can better facilitate processes for women and their families to find culturally and socially acceptable solutions for their problems. By doing this they are more likely to be able to follow the action and decisions they have taken.

Couple counselling

Just as it is important to consider the household decision-making processes, there are many times during counselling for maternal and newborn health where you will need to work with couples - the woman and her partner/husband. There are some obvious instances such as counselling about family planning where you could work with a couple, but there are other times also such as when you counsel about care during pregnancy, discuss support during labour or following birth.

When counselling a couple it is important to acknowledge that they may not have the same attitudes, beliefs and values. They may not even have the same perception of the problem or need that you are discussing. They may have different educational, social and literacy levels, and this is particularly true if culture gender roles in your community do not support women's education. Therefore you cannot treat them as a couple, but rather you must tailor your counselling skills to two individuals who need to reach a mutual decision.

You may find that you want to agree or disagree more strongly with one of the couple compared to the other. This is where the principles of self-reflection, and empathy and respect come in. You need to be aware of how your own attitudes, values and beliefs (which are shaped by the cultural, socio-economic and gender context that you live in) affect the way you think. Even if you disagree with one of the couple, you must maintain your respect for that person's point of view. It is not your role to support either the man or the woman in the argument.

It may be important to include her husband/partner in the counselling process

If you can form an alliance with both partners, it allows for a situation of trust and mutual respect. You can then follow the steps in the counselling process, making sure you give them both an equal chance to participate in the discussion. It is possible that sometimes when you counsel a couple, the situation may become heated with one person becoming abusive or aggressive. It can be a good idea in these situations to spend time with each person individually before bringing them together so that they both have a chance to talk freely. When you bring them together you can take some time to agree upon some ground rules for your discussion.


  • No interrupting one another

  • No shouting or aggressive behaviour

  • Mutual respect

  • Consider all options before discarding them.

In deciding upon these ground rules together you also have to take into account what is appropriate socially and culturally in terms of how men and women behave.

Counselling on issues of sexuality

For most health care providers, sexuality will probably be the most difficult and challenging area of counselling during pregnancy and the postpartum period. We are all reasonably comfortable talking about STIs and family planning methods, but discussing and counselling for other sexuality issues and in particular sexual intercourse is more challenging and as a result often avoided. There are many priorities in the provision of good health care to women during pregnancy and childbirth such as preparing for the birth, learning what danger signs to look for, all aimed at reducing morbidity and mortality from pregnancy and childbirth and providing women with good care. It is easy for issues of sexuality to be put to one side. In comparison to other clinical conditions, they are not as high on the priority list for providing good care.

However, sexuality issues do contribute to anxiety for many women in pregnancy and after birth.There is often little opportunity for these anxieties to be allayed or even discussed. This is mostly due to our own limitations in discussing matters of sexuality frankly and openly. There is also a lack of evidence in this area, which means that, there is little clear guidance.

Many women will not need extensive counselling around sexuality issues. It is useful for the health care provider to give women an opportunity to discuss sexuality issues when appropriate. Giving women the opportunity to discuss sexuality can be done simply by quietly saying to a woman that if she has any problems or questions of any kind during her pregnancy or after birth, including things that she may not feel able to talk about to other people, she can discuss them with the counsellor.

We have already mentioned the importance of the cultural and social context in counselling. This is particularly important regarding sexuality issues. Most cultures and societies have well-defined attitudes about sexuality, and also well-defined ideas as to what sexual practices are acceptable. Many of these social attitudes or morals are closely linked to the religious practices within a community. Many religious texts provide clear guidance on sexuality issues during pregnancy. Counselling around sexuality issues should always start with you familiarizing yourself with the cultural and religious context and the specific information needed around the sexuality practices of each community. If you are from the community in which you are counselling then you may already be familiar with many of the local practices. If you are not from the community then this information can sometimes be learnt from other health care providers, from the elder women, or other respected people in the community. In some communities sexuality is not an open subject and even gathering information about sexual practices needs to be done respectfully and sensitively.

Different communities use different terms for sexual intercourse. For example, some communities would not be comfortable with the term ‘sexual intercourse’ or ‘sex’ and may prefer to say ‘sleeping together’. Using the same terms and names that are acceptable in a community demonstrates respect for the community and may be a useful tool to paving the way for open discussion. It would be appropriate for you to support local sexual practices that are not harmful. For example, many communities prohibit sexual intercourse at different times during pregnancy. While there is little evidence to prohibit sexual intercourse in an uncomplicated pregnancy, it would not be harmful for couples to follow their community sexual practice in this instance and therefore you can support this practice. However, it would be inappropriate for you to actively support harmful sexual practices such as Female Genital Mutilation (FGM).

Many of the questions and concerns that women have related to sexuality issues during pregnancy are related to the physiological changes of pregnancy. For example, women may think that the normal increase in vaginal discharge that happens during pregnancy (leucorrhoea) is a sign of an STI. Providing this information as well as screening and testing for STIs is important. Women are also often unprepared for the changes in their sexual desire during pregnancy. This changes as pregnancy progresses: during the first part of pregnancy when women are often feeling nauseated and sick their desire is typically reduced; in the middle part of pregnancy women often feel much better and therefore their desire returns to normal; in the last part of pregnancy women feel very uncomfortable due to the size of the baby they are carrying, they are tired and their interest in sex decreases. These changes are all related to the body processes in pregnancy and are normal. They also may vary greatly from woman to woman.

Counselling during pregnancy is limited by time and sometimes the environment may not enable you to speak to a woman about sensitive or private topics. Sometimes the barriers of language, culture or age may become a barrier between you and the woman, particularly in discussing sexuality issues. In such instances it would be appropriate for you to encourage the woman to open up perhaps to another health care provider or community leader.

In talking about sexuality issues you may encounter a situation when a woman discloses a sexual problem that you feel unable to deal with. Examples of this may be a woman who discloses abuse or incest or a couple who have a long-standing sexual dysfunction. In this situation it would be appropriate for you to seek help from another more experienced counsellor or someone with special experience in these matters.

Note for working group facilitator

The key issue is to try to prevent the working group from totally dismissing any need for counselling around sexuality issues because they have been offended by some of the suggestions in the Handbook. The role of the facilitator is to encourage the working group to voice their concerns on this topic, demonstrate that these concerns are respected and that local custom will guide the counselling. At the same time the facilitators should try to ensure that counselling around issues of sexuality is considered to be valuable and not abandoned. It is useful for the facilitator to acknowledge the importance of counselling on issues of sexuality and the potential benefits to pregnant women as outlined in the handbook and to consider that local custom and taboos, sometimes influenced by gender discrimination may be a potential barrier to providing women with important counselling.

What did I learn?

After completing this session you should be more aware of the wider context of counselling and key factors that can affect it. These include: socio-economic status, culture, gender roles, traditional practices, and the wider support and decision-making network from the partner, family and community. You have also considered how to improve your skills in couple counselling and counselling on sensitive issues around sexuality.

Progress check

  • Do I understand the influence gender, the socio-economic system and culture have on maternal and newborn health in my community?

  • How can I discuss practices and beliefs which are not harmful?

  • How can I discuss practices and beliefs which are harmful?

  • What are the different ways I can facilitate the decision-making process with couples and other family members?

  • How can I address sexuality concerns of women during pregnancy or after birth?

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