Creative providers: Counseling and counselors in family planning and reproductive health

Abstract This paper examines family planning and reproductive health counseling using qualitative data from four sites. Skillful counselors are creative. They improvise on counseling protocols that are never more than bare bones outlines. They also perform in a dual sense, carrying out a task and doing so in a way that engages their clients. To accomplish this, they draw on structuring resources from the wider society and culture as well as the settings in which they work. The implications of the creativity of counselors for the management and evaluation of counseling services are noted. 1. Introduction Counseling and counselors are regarded as key components of family planning and reproductive health services in developed as well as developing countries. Counseling is thought to provide clients with "new information in an interpersonal context that enables them to profit from it" (Frank and Frank 1991:145). It helps clients concerned with family planning to "make free and informed choices about [contraception] and to act on those choices" (Gallen, Lettenmaier and Green 1987:2). It enables those concerned with or suffering from HIV/AIDS "to cope with stress and take personal decisions" required to avoid or live with the condition (UNAIDS 1997). The role of the counselor is to make this happen, "giving and receiving relevant, accurate information to help clients make decisions" and creating the "trusting and caring relationship with clients" that makes this go smoothly and effectively (Gallen, Lettenmaier, and Green 1987:7). Though these appealing claims have led to a great deal of program effort, they have not been fully tested. None of the methodologies commonly used to assess the quality2 of counseling services or their outcomes - mystery client studies,3 situation analysis,4 quasi-experiments,5 randomized controlled trials,6 and transcript analysis7 - provide close-up, detailed views of the content of counseling sessions and the work counselors do to make them happen.8 Mystery-client studies and situation analyses include observation of provider-client interactions in family planning facilities - by a mock client in the former case and a third person in the latter - but the "indicators" observers are asked to record are "somewhat superficial gauges of the nature of the provider-client relationship" (Miller, Askew, Horn, and Miller 1998:249). Quasiexperiments and randomized controlled trials have used intention-to-treat analyses. That is to say, "[p]articipants [are] grouped according to the intervention assigned by randomization, regardless of whether they received or completed the assigned intervention ..." (Metcalf et al. 2005). Or precisely how. Transcript analysis comes closest to describing the conduct of counseling, but it begins by jettisoning the language in which counseling actually occurs.9 All of this research rests on two assumptions. The first is that models of counseling adequately specify the content of counseling sessions. The second is that counselors can and should reproduce prescribed forms of counseling without significant variation on all occasions, with all clients, and in all languages. This paper uses qualitative data from four sites to examine those assumptions. The next section introduces key concepts used in the analysis. The third section, based on fieldwork carried out in 1999, discusses the relationship between counseling guidelines and actual counseling talk at a clinic in downtown Rochester, NY, operated by Planned Parenthood of the Rochester/Syracuse Region. In the fourth section, I test my analysis of counseling in Rochester with material from published studies of counseling in three other sites. 2. Counseling as a form of verbal interaction In counseling, a client or clients and a counselor or counselors speak to one another.10 If we are to understand how counseling is accomplished we must set aside our ideas about what constitutes good counseling and about the effects of counseling and focus instead on the verbal interaction of which it consists. …