Jacki Witt, MSN, WHNP-BC, SANE-A
Advisory Board Member:
Agile Therapeutics, Watson Pharmaceuticals and Afaxys Pharmaceuticals
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Discuss counseling vs education in a family
planning context
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Compare three methods/frameworks for
effective contraceptive counseling (RLP, MI and
Tiered Counseling)
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Delineate at least three evidence-based
principles for counseling in a family planning
setting
Guidance of the individual by use of
standard psychological methods.
 The counselor's goal is generally to orient
the individual toward opportunities that
can best guarantee fulfillment of his
personal needs and aspirations. The
counselor usually attempts to clarify the
client's own thinking rather than to solve
his problems.
(Merriam-Webster)
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To instruct or provide with information
(Merriam-Webster)
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Patient-centered, shared decision making
and patient engagement in a
nonjudgmental manner
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A self-assessment of life goals
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Goals in several broad categories (based on
the social determinants of health)
 Education
 Work/Career
 Family Planning
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We assist or guide as needed
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To reveal patient’s genuine intentions
regarding reproduction
Individual absorbs what is most important
to her/him
So that she/he can:
 obtain necessary information
 make choices
 adhere to her plan
 fulfill her own goals.
 Ambivalence is expected
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It shows how motivated someone is to
become pregnant or prevent pregnancy
Once this is clarified we can begin the
process of offering appropriate
interventions
Contraception or not
Highly effective or not
Preconception Care
Life goals prior to planned pregnancy
Do you want to have (more) children?
(Someday?)
If so:
When? (Or how old would you like to be?)
How many children would you like to have?
How long do you want to wait between
pregnancies?
 How would you feel if you were to become pregnant
over the next few months?
 What are you hoping to accomplish before then?
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The point of a RLP is to get substantive
information from our clients about what
is motivating them so we can help them
make better choices
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The client is the one who will make the
choices
 Saves time
 Effective
 Client centered
A patient says:
“Give me the most
effective
method you’ve
got!”
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Addiction counseling and treatment
Contraception counseling
Behavior change
Diabetes self management
Weight loss
Medication adherence
Start from a place of respect
Guiding not directing
Not “me vs. you” rather…“us together on the same
side”
 Help patients feel motivated by having them
verbalize their own reproductive and life goals
 Identify what is personally meaningful or of value to
the patient rather than those things that we think are
most important
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Reduces frustration with the patient and
subsequently ourselves
Removes our ego…
 “I need to make this patient do what’s good for
her.”
 “I want to protect her from an unnecessary
unplanned pregnancy!”
 “If I can’t get through to my patient, I fail.”
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Our morale will be exhausted without success
Taking sides in the patients ambivalence
 Threatening bad outcomes;
 “You’ll get pregnant if you don’t ...”
 This gets their attention but doesn’t work for
behavior change
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Giving advice assumes this person simply
doesn’t know enough.
To offer one idea after another =
exhaustion
MI elicits behavior change by helping
clients explore and resolve ambivalence.
 Expect, find, accept and show
ambivalence
 Also called developing discrepancy
 Just showing the discrepancy is a powerful
way to help patients make better choices
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We want to accomplish our goals
OBSTACLES
REWARDS
There may be many obstacles
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With PERFECT use of contraception
 1 year,
 3 years,
 5-10 years,
 20+ years…what will happen??
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The best case scenario...
NOTHING!
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All contraceptive methods have potential
side effects
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Fear of negative health effects
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Risk for unplanned pregnancy is theoretical
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Perception of risk is not fully rational and is
based on past life experience---ask
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Contraceptive sabotage by a partner
Logistical constraints
 Cost
 Wait times
 Work schedule
 Transportation
 Childcare
Intermittent/inconsistent sexual partnering
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Believes she doesn’t need contraception (today)
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Ask specific details of what she did and when
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Ask if she intends or would like to be sexual with
someone in the next month, year… two years
RLP:
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Wants to get pregnant now
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Ask about her life goals
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Find something about her behavior that is “mature” and
refer to it
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Review PCC (insert reality)
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Demonstrate that you believe she is in charge of her own life
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“You will be a wonderful mother some
day…and to be an even better mother,
what would you like to accomplish before
you have a baby? (or in addition) ”
“Sounds like you’ve given this some
thought (or “you are obviously smart”),
what are some ways you see yourself
handling this?”
RLP:
 Wants children one day. At least 3 years from
now. Wants to be married, finish school.
She’s clear that she is not willing to have
another abortion
 Prior DMPA (gained weight), very concerned
that hormones cause weight gain. Mostly has
used withdrawal and doesn’t believe she has
ever gotten pregnant that way
“You said that you are using the pull out
method now. And on the one hand you
feel that if you get pregnant you would
continue the pregnancy, yet you also are
pretty sure you don’t want to have a
baby right now. Do I have that right?”
 “What would you like to accomplish
before you have a baby? And what
else?” (Refer to RLP life goals)
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“If delaying pregnancy until you finish
school is very important to you, would you
be interested in using one of the top tier
methods?”
“Since a lot of women who rely on their
partner to “pull out” get pregnant, would
you like to talk about pre-natal vitamins
and other things that are important to do
to prepare for pregnancy?”
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If we listen well enough to where the
resistance has come from we can develop
discrepancy (describe the ambivalence)
Confidence Ruler
QUANTITATIVE APPROACH: ‘the ruler’
Melanie Gold DO
0
Least
2
4
6
8
10
Most
“Think of how you feel about getting pregnant right
now and then see if you can tell me where you fall on a
scale of 1-10. 1 being that it would be the worst thing
you can imagine, and 10 being that it would make you
the happiest you could possibly be.”
“a 2”
“Why would you say you aren’t you a lower #?”
“I’m not ready for a baby but I know that I won’t
have another abortion because I am an adult and
having a baby wouldn’t be the absolute worst
thing in the world”
 “Why do you think the # might not be higher?”
 “I really want to wait a few more years!”
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“How would you feel if you got pregnant
now?”
“How ready are you for pregnancy?”
“How important is it to you to avoid
pregnancy?”
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….”Let me make sure I understand….”
“So on one hand you don’t want to get
pregnant…do I have this right? Yet, you are
not using birth control. How does this fit in
with your not wanting to get pregnant?”
Her reply uncovers the ambivalence
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“On one hand you really want to get
pregnant in the future, but not right now,
and on the other hand, it sounds like a part
of you would like to have a baby now? Do I
have that right?”
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“Have you discussed this with your
partner? Do you plan to tell him? How do
you think he would react?”
What do you think you will do?
What birth control are you thinking can help
you... (fill in with her stated goal)?
 What do you see as your options?
 Where do we go from here?
 What happens next?
Rather than:
 Do you have any questions?
 Do you understand?
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Plan for obstacles; they have great intentions
but they return to their lives once they leave
the office (it’s a long way from the exam
room to the bedroom)
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Close the deal
 Operationalize same day LARC placement
 Ask “How do you feel about this”
 Plan concrete next steps
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Based on Jaccard and Levitz – Adolescent Counseling
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Principle 1: Demonstrate the “key three”
attributes of effective counselors -- expertise,
trustworthiness, and accessibility
Principle 2: Address issues of confidentiality
and the role of parents in contraceptive
decision-making
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Principle 3: Use skills-based strategies to actively
engage the client in learning and remembering
important points and provide them with easily
accessible and reliable information sources
Principle 4: Address all four facets of
contraception – method choice, correct use,
consistent use, and method switching
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Principle 5: Make choosing a method manageable
and give priority to more effective methods
Principle 6: Consider how the method fits the
lifestyle of the client by raising other key socialbehavioral factors
Principle 7: If the client is at risk of contracting a
STI, which is almost always the case for
adolescents, recommend dual protection-condoms plus a more effective contraceptive
method
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Principle 8: Give the client practical strategies
to ensure accurate and consistent use of the
chosen method of contraception
Principle 9: Address the issue of side effects
ahead of time
Principle 10: If a client decides to change her
method of birth control, encourage her to
switch to an equally or more effective method
and try to ensure that there are no gaps in
protection
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Principle 11: Be sure a staff member follows
up with the client to see how things are going
Principle 12: Use quick-start options for any
method that has such an option unless it is
medically inappropriate to do so
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ACOG Committee Opinion: Motivational Interviewing: A Tool for behavior
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Barnet B et al. Cost-effectiveness of a Motivational Intervention to Reduce
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Dehlendorf, C et al. Women’s preferences for contraceptive counseling and
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Egarter, C et al. Contraceptive counselling and factors affecting women’s
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