Objectives

Training frontline providers to effectively:

  • Be introduced to pregnancy options counseling techniques, including validating, seeking understanding, reframing, and referring
  • Review the options for patients/clients with an unintended pregnancy

Duration

55 minutes, including:

  • 10 minutes: Introduction to the Module
  • 25 minutes: Activity: Validate, Understand, Reframe, and Refer
  • 15 minutes: Reviewing the Options: PowerPoint
  • 5 minutes: Closing Discussion

Materials Needed

Introduction to the Module

(10 minutes)

Materials: Flipchart and markers.

After welcoming the group and introducing yourself explain that this is a module about pregnancy options counseling. There may be a broad range of experience with pregnancy options counseling in the room, including some participants who have already had training in options counseling and some who have not. This module is intended to introduce trainees to some of the skills used in pregnancy options counseling, but the module is not intended to be a comprehensive training on full pregnancy options counseling. Trainers can refer participants to other organizations that do full pregnancy options counseling trainings or suggest follow up from Provide’s Technical Assistance Coordinator.

Begin the module.

  1. Ask participants to raise their hand if they’ve sat with a client/patient in the following circumstances: (1) that was facing an unintended pregnancy, (2) decided to continue the pregnancy and place the child for adoption, (3) decided to end the pregnancy, and (4) decided to continue the pregnancy and parent. Recognize the diverse experiences in the room and note that these experiences will enrich the work you all will do today. [There may be support staff in the room who have not had direct experience with clients or patients facing unintended pregnancy. Acknowledge that they may wish to think back to someone they know from their personal lives who faced an unintended pregnancy.]
  2. On a flipchart, write “Client/Patient who is Unexpectedly Pregnant.” Below, in bullets, write:
  • Feelings the Client/Patient Expressed
  • How YOU Felt Interacting with the Client
  1. Ask participants to recall or imagine an interaction with a client/patient who was unexpectedly pregnant and was ambivalent about what to do. [Allow them a few moments to remember/imagine.]
  2. Referring the flipchart, ask them—without necessarily disclosing the outcome of the pregnancy—to describe the feelings the client/patient expressed, using emotion words. Write the words on a flipchart.
  3. Ask them—without necessarily disclosing the outcome of the pregnancy—if the patient/client could have felt something internally that was different than what they expressed. Ask trainees to use emotion words. Write the words on a flipchart.
  4. Ask them—without necessarily disclosing the outcome of the pregnancy—to say how they felt while interacting with the client, using emotion words. Write the words on a flipchart.
  5. Note that an unexpected pregnancy can bring up a range of feelings, both in the client/patient and in the person providing care.
  6. Introduce the module. Explain that because of the range of feelings just explored, reflective listening is key for providing support to the client/patient. Explain that this module gives an overview of three counseling strategies or techniques—Validating, Seeking Understanding, and Referring—and applies them to patients/clients with an unintended pregnancy. This session will offer practice in these skills, as well as provide some basic information about options a client/patient facing an unexpected pregnancy may ultimately pursue.
  7. Ask participants to raise their hands if they have completed training in counseling before. Acknowledge that counseling, regardless of the context, takes skill and experience, both of which are difficult to develop in an hour session. Remind participants that this session is a brief introduction to these skills, and an exploration of how such an approach can be valuable even in a brief interaction with a client/patient who is ambivalent about a pregnancy.

Note

This exercise may feel repetitive when participants are being trained on the entire curriculum in one day. If that is the case, trainers should modify accordingly.

Validate, Understand, Reframe, Refer

(25 minutes)

Materials: Flipchart and markers, Handouts for Fishbowl Exercise and Leads for Empathetic Responses

  1. Remind participants that they have discussed the values we bring to the work they do. Our values as providers help us support our patients and clients who are exploring their options when faced with an unintended pregnancy. [Display PowerPoint slide or flip chart sheet with goals].
  2. Our goals as providers are:
  1. To create a space where the patient or client feels it is safe to ask questions, it is critical to listen without an agenda.
  2. To be a person whom the patient or client trusts, you must be known as someone who will give them accurate information.
  3. To establish an environment free of stigma around pregnancy decisions, you should use unbiased language.
  1. Propose to the participants that there are four key ingredients to creating a space where patients/clients can discuss their options: Validation, Seeking Understanding, Reframing, and Referring.
  2. Explain that the fundamental principle of options counseling is that the patient has the answer.

Validate

  1. Explain that this exercise starts with exploring how to Validate patients/clients. Explain that we validate each other to show that we understand and support the other person. Part of validating patients/clients is to normalize what they are going through so that they do not feel alone.
  2. Use an example of Validating someone’s feelings:
  1. Imagine someone tells you that their dog is sick and they are feeling sad.
  2. If you say: “Oh, that’s really hard,” You are validating.
  3. If you say: “Oh, don’t feel sad, he’ll be fine,” you might be providing words of encouragement, but you are not valid. Validating is about hearing what the other person is saying.
  4. If you say: “Well, let’s go to the movies so you don’t think about it.” Are you validating? Not really. You are distracting them.
  5. If you say: “Oh, gosh, of course you feel sad.” Are you validating? (pause to allow participants time to respond.) Yes, and normalizing.
  1. Remember that the tone of voice you use when Validating can make a big difference.
  1. If I say, “You’re really sad about your dog” I am validating. But if I say [trainer uses a tone that sounds incredulous] “You’re really sad about your dog???” That’s not validating.
  1. Ask participants to brainstorm phrases to validate verbally. On a flipchart write Verbal Validation and record phrases participants suggest. Probe for phrases such as:
  • “That makes sense.”
  • “I see what you are saying.”
  • “Lots of people feel that way.”
  • “I hear you.”
  1. Note that much of how we validate is both verbal and nonverbal. Let’s take a moment to think about how to non-verbally validate someone’s feelings, imagine our dog scenario ago:
  1. If I say, “You’re really sad about your dog,” but I do not make eye contact, instead I’m looking at my phone while I say it [trainer should demonstrate this] is that validating?
  2. Ask participants to name a few ways we can validate non-verbally. [On a flipchart write Non-Verbal Validation and record phrases participants suggest.] Probe for phrases such as:
  1. Nodding
  2. Looking interested
  3. Not interrupting
  1. Let’s put all of this together in an example about validating a woman with an unintended pregnancy. [Trainer or a pair of trainers should demonstrate]:
  1. Patient/Client: “I just had a positive pregnancy test.”
  2. Provider (looking directly at patient): “Ok. How does that make you feel?”
  3. Patient/Client: “I don’t know what to feel. I’m so confused and scared.”
  4. Provider nods while Patient speaks.
  5. Provider: “That makes sense. A lot of people feel that way.”
  1. Explain to participants that we will now explore how to Seek Understanding.

Seeking Understanding

  1. Explain to participants that we will now explore how to Seek Understanding with patients/clients.
  2. Seeking understanding is often something we do intuitively. Let’s go back to our example of the sick dog.
  1. If someone says, “My dog is sick and I feel really sad,” and we want to be supportive. One thing we might do is ask open and non-judgmental questions about the dog such as “What’s going on with your dog?” or “What happened?” We are trying to learn more about the situation.
  2. But if we start asking questions such as, “Did you take him to the vet? You should call someone. It sounds like he has what my uncle’s dog had,” then we might be helpful, but we’re not seeking deeper understanding of the situation or the speaker’s feelings.
  1. We need to seek understanding because our response to our patient/client will change based on how they answer open, non-judgmental questions. Let’s go back to our friend with the dog.
  1. The person might respond to our open-ended questions by saying, “Well, the dog’s going to be fine, but I spent the money I was going to use to go to a concert on the vet, so now I can’t go see my favorite band in concert.”
  2. Or, she could answer: “Well, the vet says there’s not really anything we can do to help.”
  3. Our response varies dramatically based on the answer to the open-ended, non-judgmental questions we ask. That’s why we need to seek understanding before we dive into providing resources or referrals.
  1. Prepare and post a flipchart with the heading “Seeking Understanding” on the top and have participants identify phrases that seek understanding. Probe for phrases such as:
  1. “Tell me more about that.”
  2. “What makes you think that?”
  3. “How does that work for you?”
  4. “Help me understand that.”
  5. “Are you saying . . . ?”
  6. “It sounds like you mean . . . is that right?”
  1. Let’s apply this again to an example about validating a woman with an unintended pregnancy. [Trainer or a pair of trainers should demonstrate]:
  1. Patient/Client: “I just had a positive pregnancy test.”
  2. Provider (looking directly at patient): “Ok. How does that make you feel?”
  3. Patient/Client: “I don’t know what to feel. I’m so confused and scared.”
  4. Provider nods while Patient speaks.
  5. Provider: “That makes sense. A lot of people feel that way.”
  6. Patient/Client: “I know I can’t have a baby right now. There is too much going on in my life.”
  7. Provider: “Tell me more about that.”
  8. Patient/Client: “Well, I’m in school, I have a full time job and I am working so hard right now to make ends meet for my family and we are barely scraping by.”
  9. Provider: “It sounds like you are considering your options. Is that right?”

Reframing

  1. Introduce the value of Reframing, a tool to support a client/patient facing a difficult situation. Explain that reframing is giving a different perspective—a different frame for the picture, a different slant, shifting the perspective.
  2. Let’s move away from our example with the dog and dive more deeply into our example of a patients/ clients facing an unintended pregnancy. You may have encountered patients/clients who are angry, scared, sad, confused, or overwhelmed by the fact that they are pregnant.
  3. [Put up the slide “Reframing”]. Explain that the goal of reframing is to help the client move from a place of fear, confusion, or shame and allow them to see another side of their story in order to help them make a decision about their pregnancy (or, for that matter, any difficult issue they are facing. Here are some examples of reframing:
  1. “Yes, that is hard, and you have some real strengths, some things in your favor, some assets you’re not thinking about.”
  2. “I know it feels hopeless, but I’m wondering if you’re missing part of the picture. It seems like . . .”
  3. “It seems like you’re being really hard on yourself, what would you say to a friend in this situation?”
  4. “This is a tough situation, but it sounds like you’re trying to make the best decision for your whole family.”
  5. “It seems like you’re being selfish, but I see it differently.”
  6. “It sounds like you’ve been through a lot. It must have taken a lot of strength and courage to get to this point.”

Discuss these examples of reframing with participants.

  1. Let’s apply this again to an example about validating a woman with an unintended pregnancy. [Trainer or a pair of trainers should demonstrate]:
  1. Patient/Client: “I just had a positive pregnancy test.”
  2. Provider (looking directly at patient): “Ok. How does that make you feel?”
  3. Patient/Client: “I don’t know what to feel. I’m so confused and scared.”
  4. Provider nods while Patient speaks.
  5. Provider: “That makes sense. A lot of people feel that way.”
  6. Patient/Client: “I know I can’t have a baby right now. There is too much going on in my life.”
  7. Provider: “Tell me more about that.”
  8. Patient/Client: “Well, I’m in school, I have a full time job and I am working so hard right now to make ends meet for my family and we are barely scraping by.”
  9. Provider: “It sounds like you are considering your options. Is that right?”
  10. Patient/Client: “I just feel so stupid. How could this have happened to me?”
  11. Provider: “It seems like you’re being really hard on yourself, what would you say to a friend in this situation?”
  12. Patient/Client: “I would probably tell her that these things happen to lots of people and she shouldn’t be so hard on herself.”
  1. Give participants the handout “Leads for Empathetic Responses.” Explain to participants that this handout helps them think of other ways to reframe difficult statements from patients/clients. Ask participants to respond to a series of statements, using those leads as a start, that invite the client/patient to a more neutral place.
  1. “I know you want to help me, but you should know that I’ve been one big screw-up my whole life.”
    • Sample response: “It sounds as though you have struggled in the past. But you are here now and I’m observing you to be both thoughtful and ready to the take the steps that you need to take.”
  2. “I don’t think I can handle this. I’m just going to pretend like I never found out that I’m pregnant.”
    • Sample response: “Listening to you, it seems as if you are feeling pretty overwhelmed. But I see you as facing this situation with courage. For example, you came in for a pregnancy test.”
  3. “I have friends who did all the same stuff I did, and they didn’t get pregnant. It’s not fair that this happened to me.”
    • Sample response: “Tell me if I’m wrong, but I sense that you’re feeling angry and asking, ‘Why me?’ While you can learn from the past, let’s focus now on taking good care of yourself in this situation.”
  4. “I feel like I can’t think straight. I have no idea what I’m going to do and I don’t know how I’m going to decide.”
    • Sample response: “I hear you saying that you are struggling to process this information. It’s okay to feel overwhelmed. I can offer some tools to help you think this over and am confident you are able to figure out the best path for you.”

Role Play

  1. Explain to participants that they are now going to practice the skills we have gone over.
  1. If two trainers are presenting the curriculum, one trainer should be the patient/client and the participants should take turns being her provider who is offering her options counseling for an unintended pregnancy. Have an object ready to be the talking stick. Explain that when someone has the talking stick, they are the counselor. When they are stuck or ready to hand off the counseling, they can hand it to someone else. Assure them that the trainer who is observing will also help them with the counselor role if they get stuck.
  2. If there is one trainer presenting the curriculum, ask for two training participants to do a role play in front of the room. Have an object ready to be the talking stick. Explain that when someone has the talking stick, they are the counselor. When they are stuck or ready to hand off the counseling, they can hand it to someone else. Assure them the trainer will also help them with the counselor role if they get stuck.
  3. Start the role play by giving participants a scenario to work with. Scenarios can be tailored to the site where the training is taking place. In all scenarios, explain that the patient/client coming to the providers is unexpectedly pregnant and wants more information about her options. Examples include:
  1. A client at a domestic violence shelter who has two children and is trying to leave an abusive relationship.
  2. A patient in a substance abuse treatment program focused on sobriety.
  3. A patient at a local health department who is juggling college and a full time job.
  1. Ask the first 2-3 role play participants to spend time solely validating and normalizing. [Display corresponding PowerPoint slide.]
  2. Ask the next 2-3 role play participants to seek understanding. [Display corresponding PowerPoint slide.]
  3. Ask the next 2-3 role play participants to reframe and refer.
  4. With two trainers, the trainer who is not participating in the role play can point out the skills being demonstrated by participants during the role play.
  5. The role play usually ends when everyone who is willing has participated. It can also end when Trainer 1 closes by using a phrase that wraps up the role play, e.g. “Well, this has been helpful. I’m going to think about it and let you know what I decide.”
  6. After the role play ends, trainers should discuss between themselves what it was like – how she felt – doing the role play. Did she feel supported, validated, understood? Then ask the participants what it was like for them.
  7. Congratulate participants for their work. Remind them that validating, creating a deeper understanding, reframing, and referring are all skills that take practice.

Reviewing the Options: Power Point

(15 min)

Materials: PowerPoint Presentation

  1. Show PowerPoint slide outlining basic information about adoption, abortion, and parenting and reinforcing the STAR model’s application to referrals for all services.

Note

Reviewing the STAR model may feel repetitive when participants are being trained on the entire curriculum in one day. If that is the case, trainers should modify accordingly.

Wrap-up: Grounding in Self-Efficacy

(5 minutes)

  1. Close by acknowledging: “Ambivalence is a difficult place to sit, both for a client/patient and for a provider trying to support them. It asks us to really listen to our client/patient and support them to hear themselves. I hope this session has supported you to feel [insert positive words from reflection above] as you do your good work.”