1. Journal Entry The attached (BUROS Center for Testing).docx

1. Journal Entry:
The attached (BUROS Center for Testing) website link presents
and explained the
seven assessment competencies needed by teachers in detail:
http://buros.org/standards-teacher-competence-educational-
assessment-
students (Links to an external site.)Links to an external site. .
Read the information provided on this site and in your Journal
self-reflect on the
following question: What is my current level of understanding
and skill in these
competencies? In your self-reflection be sure to address EACH
of the seven
competencies.
NOTE: It is a self-reflection, so you can NOT use any sources
other than the
attached website.
DUE: in 24 hours
How nondirective therapy directs: The power of empathy in the
context

of unconditional positive regard
Marvin Frankela*, Howard Rachlinb and Marika Yip-Bannicqc
aSarah Lawrence College, New York, USA; bStony Brook
University, New York, USA; cNew
York University, New York, USA
(Received 26 November 2011; final version received 16 May
2012)
This paper explains how acceptance and empathy are vehicles
for psychothe-
rapeutic change by showing how these factors function in
nondirective client-
centered therapy. The paper argues that because the
nondirective client-centered
therapist’s unconditional positive regard may conflict with the
client’s conditional
self-regard, the therapy cultivates a novel restructuring of the
client’s narrative.
By revealing how positive therapeutic change can result from
the interplay of
unconditional positive regard and empathy, the article explains
the effectiveness
of classical client-centered therapy in particular and accounts at
least in part for
the effectiveness of other therapies that stress the healing
properties of the
psychotherapeutic relationship.
Keywords: empathy; unconditional positive regard; Gestalt
figure/ground
relationships
Wie nicht-direktive Therapie dirigiert

Dieser Artikel erklärt, wie Akzeptanz und Empathie das Agens
therapeutischer
Veränderung sind, indem er zeigt, wie diese Faktoren in der
nicht-direktiven
klient-zentrierten Therapie funktionieren. Gerade weil das
bedingungslose
positive Beachten des nicht-direktiven klientzentrierten
Therapeuten im Konflikt
liegen kann mit der Sicht des Klienten auf sich selbst, die voller
Bedingungen
steckt, gerade deshalb kultiviert die Therapie eine neuartige
Restrukturierung des
Klienten-Narrativs. Positive therapeutische Veränderung
resultiert aus dem
Zusammenspiel zwischen bedingungsloser positiver Beachtung
und Empathie.
Die Effektivität der klassischen Klientzentrierten Therapie ist
zumindest teilweise
die Ursache, wenn es um die Wirksamkeit anderer Therapien
geht, die die
heilende Dimension der psychotherapeutischen Beziehung
betonen.
Cómo dirige la terapia no directiva
Este escrito explica cómo la aceptación y la empatı́a son
vehı́culos de cambio
psicoterapéutico, mostrando cómo funcionan estos factores en la
terapia no
directiva centrada en el cliente. El escrito argumenta que al
entrar en conflicto la
consideración positiva incondicional de un terapeuta no
directivo centrado en el
cliente con la auto consideración positiva condicionada del
cliente, la terapia

cultiva una nueva reestructuración de la narrativa del cliente. Al
revelar cómo los
*Corresponding author. Email: [email protected]
Person-Centered & Experiential Psychotherapies
Vol. 11, No. 3, September 2012, 205–214
ISSN 1477-9757 print/ISSN 1752-9182 online
� 2012 World Association for Person-Centered & Experiential
Psychotherapy & Counseling
http://dx.doi.org/10.1080/14779757.2012.695292
http://www.tandfonline.com
cambios terapéuticos positivos pueden ser resultado de la
interacción de la
consideración positiva incondicional y la empatı́a, este escrito
explica la eficacia
de la terapia clásica centrada en el cliente y explica, al menos
parcialmente, la
eficacia de otras terapias que hacen hincapié en las propiedades
curativas de la
relación psicoterapéutica.
La manière dont la thérapie non-directive est directive
Cet article explique la manière dont l’acceptation et l’empathie
sont porteuses de
changement dans la thérapie non-directive centrée sur le client,
en démontrant la
façon dont ces facteurs fonctionnent. Il argumente que le regard
positif

inconditionnel du thérapeute non-directif centré sur le client
peut entrer en
conflit avec le regard conditionnel sur soi du client, et que pour
cette raison, la
thérapie facilite une restructuration nouvelle du narratif du
client. En démontrant
la manière dont le changement thérapeutique positif peut
résulter des interactions
entre le regard positif inconditionnel et l’empathie, l’article
explique l’efficacité de
la thérapie centrée sur le client classique et explique, du moins
en partie,
l’efficacité d’autres thérapies qui mettent l’accent sur les
propriétés guérissantes de
la relation thérapeutique.
Como a terapia não-diretiva dirige
Este artigo explica de que modo a aceitação e a empatia são
veı́culos de mudança
psicoterapêutica, demonstrando como estes fatores funcionam
no seio da terapia
não-diretiva centrada no cliente. O artigo defende que, uma vez
que o olhar
incondicional positivo do terapeuta não-diretivo pode colidir
com o olhar
condicionado que o cliente tem sobre si mesmo, a terapia
cultiva uma
reestruturação original da narrativa do cliente. Ao revelar como
a mudança
terapêutica positiva pode resultar da interligação entre o olhar
incondicional
positivo e a empatia, o artigo explica a eficácia da terapia
centrada no cliente
clássica e justifica, pelo menos parcialmente, a eficácia de
outras terapias que dão

ênfase às propriedades curativas da relação psicoterapêutica.
Introduction
The following story highlights the major feature of this article:
the directive role of
empathy in the context of unconditional positive regard. A few
months ago the
daughter of a friend of mine informed her father of an insight
her client-centered
therapist had given her that day. My friend was taken aback. He
protested, ‘‘But I said
that so many, many times to you to no avail.’’ His daughter
insisted that he hadn’t.
Then my friend reviewed the last time he had an argument with
his daughter and
206 M. Frankel et al.
reminded her of what he had said. ‘‘Now, wasn’t this what your
therapist said?’’ he
asked. His daughter replied, ‘‘It’s amazing, I wonder why I
forgot!’’ He said, ‘‘You
didn’t remember because you hate to give me credit!’’ But the
reason why the daughter
didn’t remember what the father said was because he did not in
fact say the same thing
as the therapist. The father offered his insight in the context of
anger, criticism, and
rejection, or in a word, blame, thus negating the daughter’s
openness to critical
feedback. In contrast, by offering his insight in the context of
acceptance, in other
words, without blame, the therapist encouraged the daughter’s

self-critical attitude. The
insights of the father and therapist were no more the same than
gray looks the same on
black or on white. Unconscious defense mechanisms such as
denial and distortion are
not required to explain the daughter’s ‘‘forgetfulness’’ (Rogers,
1959). Therapeutic
empathy in the context of unconditional positive regard
necessarily provides a novel
context for self-criticism. Classical client-centered therapy
(CCCT) is thus nondirective
with respect to the content of the narrative but directive with
respect to the attitude that
the client brings to the narrative, which in turn transforms the
content.
We agree with Barbara Brodley that it is mistaken to view the
nondirective model as
merely one that influences the client. As Brodley (2005) aptly
stated, ‘‘. . . all therapies
influence . . . clients towards growth and healing. A
therapymust influence in order to be
effective . . .. The non-directive issue exists at a different level
from the discourse on
therapy as influencing clients’’ (p. 1). We disagree, however,
with her about the nature
of this difference. Whereas she argued that ‘‘[e]mpathic
understanding, unconditional
positive regard and congruence are all non-directive with
respect to the client’’ (p. 1), we
maintain that the therapist’s communication of unconditional
positive regard is
directive in cultivating the client’s unconditional positive self-
regard and enabling the
client to view his/her narrative through this lens. This directive
component is too

systematically employed to be regarded as a mere influential
agent. We also consider
the model directive rather than influential in the sense that the
CCC therapist is going
beyond the client’s frame of reference and is thus inconsistent
with the alleged essence
of nondirective therapy which was to empathically and
exclusively respond to the
client’s internal frame of reference (Rogers, 1951).
As described by Rogers (1951) in Client-Centered Therapy, one
major aim of the
CCC therapist is to:
perceive as sensitively and accurately as possible all of the
perceptual field as it is being
experienced by the client, with the same figure-ground
relationships, to the full degree
that the client is willing to communicate that perceptual field;
and having thus perceived
this internal frame of reference of the other as completely as
possible, to indicate to the
client the extent to which he is seeing through the client’s eyes.
(p. 34)
This is, in effect, our operational definition of empathy. We
will show, however, that
in fact Rogers never empathically reflected ‘‘the same figure-
ground relationships’’ as
those of the client. Instead he provided a direction by changing
the context of the
client’s narrative which then transformed the meaning of the
client’s experience.
The directivity we will be discussing is different from that of
other person-

centered therapies (Cain, 2010), such as those that validate or
reassure the client’s
experience (Bohart, Elliott, Greenberg, & Watson, 2002; Brink
& Farber, 1996),
offer evocative reflections (Rice, 1974), or empathic responses
that attempt to target
the client’s ‘‘edge of awareness’’ (Mearns & Thorne, 1999).
Some later forms of
person-centered therapy (process directive therapy and
relational depth therapy, for
example) also tend to introduce various directive elements
during the course of
Person-Centered & Experiential Psychotherapies 207
therapy (process guiding techniques, therapist self-disclosures,
etc.) that might
obscure the subtle kind of continuous directivity that takes
place in CCCT. While
this analysis focuses on CCCT, it is relevant to all
psychotherapies that emphasize
the importance of acceptance and empathy as a necessary if not
a sufficient condition
for effective treatment (Farber, 2007); this would include multi-
modal therapy
(Lazarus, 2005) or any form of cognitive-behavioral therapy.
A novel background creates a novel client narrative
How do unconditional positive regard and empathy contribute to
therapeutic
change? After all, empathic reflection does not bring anything
new by way of meaning
into the client’s frame of reference; instead, it captures, as

accurately as possible,
what is already there in the client’s current frame of reference
(Rogers, 1951, 1959).
The often-heard client response to an accurate empathic
reflection, ‘‘Yes, that’s
precisely it,’’ demonstrates this. Rogers’s filmed therapeutic
encounter with Gloria
(Shostrom, 1965) provides an example of such a response:
Rogers: And you feel, this is a conflict and it’s just insoluble
and therefore it’s hopeless
and here you’ve looked up to me and I don’t seem to give you
any help, to . . .
This empathic reflection lifts any burden of responsibility and
blame from Gloria’s
shoulders for her predicament, but just as importantly Rogers
openly accepts
Gloria’s perception that he was of no help without blaming
himself, thus modeling a
blameless attitude.
Gloria: Right . . .
Gloria’s despair when she utters that single word ‘‘Right’’ was
not only a
confirmation of Rogers’s empathic reflection but a novel
expression of her sense
of hopelessness. The written word fails to do justice to her
troubled expression when
she agrees with Rogers. But how did this come about?
The noted historian and existential phenomenologist van den
Berg (1974)
captured the point that an accurate empathic reflection, apart
from the communica-

tion of unconditional positive regard, brings nothing novel to
the client’s narrative
when he characterized nondirective therapy as one in which the
counselor does
‘‘nothing.’’ Of course, van den Berg was not suggesting that
Rogers was truly doing
nothing, but only that, unlike directive therapies of that time,
Rogers did not offer
novel interpretations that went beyond or contradicted the
phenomenal field of the
client. Van den Berg was not suggesting that nondirective
therapy was ineffective but
only that Rogers was taking an original psychotherapeutic
approach by attempting to
offer only nondirective reflections of the client’s frame of
reference, offering nothing
whatsoever from his own frame of reference. Rogers viewed
interpretations, self-
disclosures, advice and even commendation as reinforcing the
undesirable power
relations between therapist and client (Rogers, 1942). However,
a closer examination
will show that Rogers was not offering a purely nondirective
response.
Consider the following dialogue between Rogers and a client
(Kirshenbaum,
1979, p. 248):
Client: (. . . begins to talk in hard flat voice, quite unlike her
usual tone. Does not look at
counselor . . .) You feel I want to come, but I don’t! I’m not
coming anymore. It doesn’t
do any good. I don’t like you. I hate you! I wish you were never
born.

Rogers: You just hate me very bitterly.
Client: I think I’ll throw you in the lake. I’ll cut you up! You
think people like you, but
they don’t . . . You think you can attract women but you can’t .
. . I wish you were dead.
Rogers: You detest me and you’d really like to get rid of me.
Client: You think my father did bad things with me, but he
didn’t! You think he wasn’t
a good man, but he was. You think I want intercourse but I
don’t.
Rogers: You feel that I absolutely misrepresent all your
thoughts.
Client: . . . You think you can get people to come in and tell
you everything, and they’ll
think they’re being helped, but they’re not. You just like to
make ’em suffer. You think
you can hypnotize them, but you can’t! You think you’re good,
but you ain’t. I hate
you. I hate you.
Rogers: You feel I really like to make ’em suffer, but I don’t
help them.
Client: You think I haven’t been straight, but I have. I hate you.
All I’ve had is pain,
pain, pain. You think I can’t direct my own life, but I can. You
think I can’t get well,

but I can. You think I had hallucinations, but I didn’t. I hate
you. (Long pause, leans on
desk in strained, exhausted pose.) You think I’m crazy but I’m
not.
Rogers: You’re sure I think you’re crazy.
Client: (Pause) I’m tired, and I just can’t get loose! (Despairing
tone of voice and tears.
Pause) I had a hallucination and I’ve got to get it out! . . . (Goes
on about her deep
conflicts, and tells of her hallucination she has experienced with
terrific tension in her
voice, but with an attitude very different from that at the
beginning of the interview.)
(Later in interview)
Client: I knew at the office I had to get rid of this somewhere. I
felt I could come down
and tell you. I knew you’d understand. I couldn’t say I hated
myself. That’s true but I
couldn’t say it. So I just thought of all the ugly things I could
say to you instead.
Rogers: The things you felt about yourself you couldn’t say, but
you could say them to me.
Client: I know we’re coming to rock bottom.
In a footnote, Rogers wrote: ‘‘Just as it is impossible to convey
on paper the venom
and hatred in the client’s voice, so it is utterly impossible to
convey the depth of
empathy in the counselor’s responses. The counselor states, ‘I
tried to enter into and

to express in my voice the full degree of soul-consuming anger
which she was pouring
out. The written words look incredibly pale, but in the situation
they were full of the
same feeling she was so coldly and deeply expressing’’’ (italics
added). But if Rogers’s
version of what he did is true, if he is merely providing an
empathic understanding
that remains entirely within the phenomenal field of the client,
then why doesn’t the
client simply say to each and every one of the empathic
reflections: ‘‘But you are
simply repeating the meaning of what I just said’’?
The answer is that although Rogers is repeating the words, he is
not repeating the
context of the words and hence the meaning of the words. The
client’s assertions are
contextualized by her contempt for herself (‘‘I couldn’t say I
hated myself’’).
Rogers’s statements are contextualized by his compassionate
acceptance (uncondi-
tional positive regard) of the client. The client was in effect
saying: ‘‘I hate you Carl
Rogers!’’ In response Rogers asserted, ‘‘I appreciate but do not
blame you for the
extent of your contempt of me.’’ Indeed, each of Rogers’s
empathic reflections could
be preceded with the statement, ‘‘I appreciate but do not
blame.’’ For this reason, the
client did not say to Rogers, ‘‘That is what I just said,’’ since
Rogers is never just
repeating the meaning (I hate you, Carl Rogers) of the client’s
assertions but

conveying his unconditional positive regard for them. When
Rogers wrote that ‘‘it is
utterly impossible to convey the depth of empathy in the
counselor’s [Rogers’s]
responses,’’ he was, in our terms, referring to his unconditional
positive regard for the
client, which frames his empathic response, rather than just his
empathic response.
Consequently, the client does not understand Rogers as giving a
redundant response.
On a more clinical level, the client is expressing her feelings of
self-contempt and in
return is finding herself not only understood but prized by
Rogers.
Conceptually, empathy and unconditional positive regard are
independent of
each other (Rogers, 1957; Shlien, 1997). In fact, a person may
be empathic and
rejecting at the same time. The journalist Gita Sereny was
mainly empathic with the
former commandant of a death camp, Franz Stangl, over a
period of months but had
to excuse herself from one particular interview in utter disgust
when confronted with
the moral perversity of the commandant (Sereny, 1995). Shlien
was so critical of the
tendency to blur the distinction between empathy and
unconditional positive regard
among contemporary person-centered therapists that he
highlighted how empathy
can ‘‘be a weapon of war, an advantage in every form of
competition as well as in

cooperation’’ (Shlien, 1997, p. 64).
But a person can mistakenly feel accepted and safe when being
empathically
understood. In her book, The Journalist and the Murderer, Janet
Malcolm
commented on the moral dilemma journalists face when they
win the confidence
of an alleged criminal simply by understanding them in an
empathic way. The
alleged criminal feels so accepted that he lets his guard down
only to discover, when
he reads the journalist’s negative written account, that he was
betrayed (Malcolm,
1990). Like Malcolm, existential therapists use empathy to
establish rapport and
allow clients to be feel accepted when they are lying (to
themselves) only at a later
time to express their criticism of the clients’ moral position.
Prochaska and Norcross
(2003), summed up this approach in contrast to the approach of
CCC therapy by
offering the following description:
Existentialists do not agree, however, that a therapist must
maintain unconditional positive
regard toward the patient. In order to be authentic, the therapist
can respond with positive
regard only toward honesty and authenticity but never toward
lying and pathology. That
the therapist at first allows the patient to lie and objectify
without overt judgment is
accepted in order for the therapist to experience the patient’s
phenomenal world. But an
authentic therapist can hold no positive regard for a patient’s
lying. (p. 124)

For Rogers, the client’s perception of the CCC therapist’s
unconditional positive
regard is accurate and not illusory since Rogers has no ulterior
motive (writing an
article, making an evaluation, inducing a change in a specific
direction, etc.) in his
relationship with the client. The client is thus justified in
feeling unconditionally
accepted.
By changing the meaning of the client’s narrative through
his/her unconditional
positive regard, the CCC therapist is introducing a novel feature
to the therapeutic
discourse and in this significant sense CCCT is directive. The
novel context
(unconditional positive regard) dramatically alters the text
(empathic understand-
ing). Thus, in the above dialogue, the client is liberated from
her self-protective
strategy when she states: ‘‘I couldn’t say I hated myself. That’s
true, but I couldn’t
say it.’’ In other words, the client offered her narrative with
conditional self-regard
but received the meanings and feelings of her narrative with
regard. In offering his words with a tone of compassion and
acceptance, it is as
though Rogers is saying in each exchange: ‘‘Here is what you
might say if you did

not blame yourself but had instead unconditional positive self-
regard.’’
The power of empathy in the context of unconditional positive
regard should
come as no surprise since Gestalt psychologists have
demonstrated that figure-
ground relationships govern all perception. Thus a gray circle
on a black background
will be seen as white while the same gray circle on a white
background will be seen as
black. As Rachlin (1994) described this phenomenon:
The two spots differ in brightness not because the different
backgrounds fool the
observer creating an illusion . . . but because of a fundamental
fact about phenomenal
experience; what you perceive in the first place . . . is the
relationship between the spot
(gray figure) and its background. . . . [Consequently] on the
most fundamental level of
perception the two gray spots differ in brightness. Context is
thus not a correction to
perception or a distorter of perception but a vital component of
the fundamental
perceptual process. (pp. 7–8)
For example, the client offered her narrative, ‘‘You think I had
hallucinations, but I
didn’t. I hate you’’ (the figure) against the implicit background
of her conditional self-
worth: ‘‘maybe as much as I hate myself.’’ And so to carry the
analogy one step
further, the narrative figure is black indeed. The client, if alone
at home, may not even
be able to experience hostility towards Rogers lest she think

less of herself (lowered
conditions of self-regard) for attacking her therapist. However,
in the context of the
therapy, Rogers offered an empathic and compassionate
reflection, ‘‘You’re sure I
think you’re crazy’’ (the figure) against the background of
regard, rendering the narrative figure white. In effect, then, the
narrative the client
initially authored is not the same narrative that is expressed by
the therapist. The
client’s attack on Rogers resulted in her being accepted by
Rogers in no less a way
than she was prior to the attack. Indeed, Rogers embraced her
rage. Consequently, in
listening to Rogers’s response, the client is directed to reflect
on a novel meaning of
her narrative, and re-view her hatred of Rogers without adding
the insult of
conditional self-acceptance. In this formulation, Rogers’s
regard encouraged the client’s hopes that despite her rage she is
beyond blame or
praise and thus broadened her perceptual field. In this case, the
broadened perception
includes the fact that the client hates herself rather than Carl
Rogers.
Yet, why do clients so often say, ‘‘Yes, you understand me
perfectly,’’ when, in
fact, their conditional self-regard (implicit or explicit) goes
counter to the therapist’s
unconditional positive regard? For example, a client who is
familiar with Rogers’s
vocabulary (Rogers, 1959) might say, ‘‘It is evident that you
have unconditional

positive regard for me, but I have only conditional positive self-
regard. Your
empathic reflection captures the essence of my feelings
perfectly but your total
acceptance of me is contrary to the way I feel about myself.’’
Clients do not say this
but instead more often than not claim that they feel understood.
How then can we
make sense of the client’s subjective experience of being so
understood? We suggest
that it is not entirely accurate to describe clients as simply
having conditional
positive self-regard (Rogers, 1959). It would be more correct to
say that clients are
ambivalent about their conditional worth and may hope that
their narrative will be
utterly acceptable (unconditionally) and even prized by the
therapist even as they
may fear their narrative will only be conditionally accepted or
in fact rejected.
Clients often reveal this ambivalence when they express the
wish to see themselves in
the same benevolent way as their therapists do. One of the
authors (MF) recalls from
his internship at the Counseling Center of the University of
Chicago, one client
saying in so many words: ‘‘If I saw myself as you see me I
would have little need of
you, right?’’
In effect, then, we are suggesting that the unconditional positive

regard of the
therapist fulfills the client’s hopes of acceptance while the
empathic reflection illumi-
nates the content of the narrative which often expresses shame,
guilt, and fears of
rejection. The subtext of ‘‘Yes, that’s exactly what I mean,’’
could be understood to
mean: ‘‘Yes, you have understood my unspoken hopes to be
accepted as well as what I
have said.’’ It is true that the CCC therapist will empathically
communicate the client’s
ambivalence about her self-worth when this is the explicit
subject matter of the client’s
narrative (the figure), but even then the CCC therapist’s
unconditional positive regard
conveys a more positive view of the client than the client’s view
of herself.
Whence the power of unconditional positive regard?
Why does the client care at all about being accepted by the
therapist? So far as the
client is concerned the therapist may be a perfect jerk in his/her
own personal and
professional life. The therapist does not possess a Ph.D. in
maturity or wisdom. Is
the unconditional positive regard of the therapist important
because of the client’s
misperception and overvaluation of the therapist’s character
(sensibility, wisdom,
expertise)? Freud certainly thought so. The power of the
analyst, psychoanalysts
argue, resides in the childhood wishes of the client to have a
powerful ally. Without
the preservation of these wishes, the analyst would be powerless
(Freud, 1966). This

is the essence of positive transference which was itself viewed
as a neurosis that
eventually had to be extinguished. From this perspective, then,
it is only because of
‘‘a positive transference neurosis’’ that the interpretations of
the analyst or the
explicit empathy and unconditional positive regard of the client-
centered therapist
are seriously entertained by the client.
Rogers eschewed transference and instead stated that people
have a need for
positive regard that may either be innate or quickly learned and
is an expression of
the actualizing tendency (Bozarth & Wang, 2008; Rogers,
1959). But to say the client
desires the positive regard of the therapist because the client
has a need for positive
regard and to define the need for positive regard in terms of the
client’s desire for it is
circular. In any case, we do not seek the positive regard of
everyone but only of those
we respect. We propose instead, that the CCC therapist’s
empathic communications
and unconditional positive regard earn the trust and respect of
the client. While all
therapists may sincerely claim to have a nonjudgmental attitude
towards the client,
only CCC therapists refrain from offering any comments from
the therapist’s frame
of reference and in so doing demonstrate a singular openness to
the client’s narrative.
In this way, the CCC therapist is offering a relationship
different from other
therapeutic relationships. For example, CCC therapy goes
contrary to the current

practice of personal self-disclosure by therapists to influence
their clients to live more
optimally (Hill & Knox, 2002, pp. 255–266). In brief, the CCC
therapist is providing
a unique experience for the client; therein may reside the power
of his/her
unconditional positive regard.
Summary and conclusions
This paper offers an alternative to Rogers’s understanding of
the effects of uncon-
ditional positive regard and empathy by explaining how they
work in conjunction with
one another. In his introductory comments to the interview with
Gloria, Rogers
discussed the probable consequences of his empathic and
accepting attitude:
She’ll explore some of her feelings more and attitudes more
deeply. She is likely to
discover some hidden aspects of herself that she wasn’t aware
of previously. Feeling
herself prized by me, it is quite possible she’ll come to prize
herself more. Feeling that
some of her meanings are understood by me, then she can more
readily perhaps listen to
herself, listen to what is going on within her own experience.
(Shostrum, 1965)
In his description, Rogers isolated the effects of his

unconditional positive regard (his
prizing of her will result in her prizing herself) from the effects
of his empathic
understanding (‘‘. . . feeling that some of her meanings are
understood by me then she
can more readily listen to herself’’) (Shostrum, 1965). Bohart,
Elliott, Greenberg and
Watson (2002) offered a similar explanation for the positive
therapeutic effects of
empathy. Our view differs in two ways. First, we suggest that
the unconditional
positive regard of the therapist will be effective only if it
triggers the client’s hopes
that indeed she is acceptable. The client does not see herself
solely through Rogers’s
eyes but through the lens of her own hopes. Second, we argue
that the effects of
unconditional positive regard and empathy cannot be isolated
from one another in
the therapeutic encounter, since the client only values
acceptance when understood.
If the client felt unconditionally accepted but utterly
misunderstood, CCCT would
likely have a very different effect than it does.
In a review of studies on positive regard, Farber and Lane
(2002, p. 177) offered
considerable documentation that ‘‘. . . there has been a
historical confounding in
Rogers’s (and his followers) writings among the concepts of
‘warmth,’ ‘respect,’
‘acceptance,’ ‘openness,’ ‘genuineness,’ and empathy.’’
Bozarth exemplified this
tendency when he stated, ‘‘Rogerian empathy is, in fact,
inseparable from
unconditional positive regard and, ultimately . . . they are the

same condition’’
(Bozarth, 1998, p. 52). In this paper we have argued that such
confabulation is more
apparent than real. Empathy in the context of a respectful,
genuine unconditional
positive regard is not a confabulation of these conditions but a
novel gestalt that is
different from its parts.
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Patient Education and Counseling 81 (2010) 362–367
Structured contraceptive counseling—A randomized controlled
trial
Aileen M. Langston *, Linette Rosario, Carolyn L. Westhoff

Division of Family Planning and Preventive Services,
Department of Obstetrics and Gynecology, Columbia University
Medical Center, New York, USA
A R T I C L E I N F O
Article history:
Received 10 February 2010
Received in revised form 30 July 2010
Accepted 4 August 2010
Keywords:
Contraceptive counseling
Unintended pregnancy
Abortion
Contraception
Birth control
Structured counseling
A B S T R A C T
Objective: To evaluate the addition of structured contraceptive
counseling to usual care on choice,
initiation, and continuation of very effective contraception after
uterine aspiration.

Methods: We conducted a RCT of a version of the WHO
Decision-Making Tool for Family Planning Clients
and Providers with women having a procedure for a spontaneous
or induced abortion. Our intervention
provided structured, standardized counseling. We randomized
women to usual care or usual care with
structured counseling. Our outcomes included choosing a very
effective contraceptive method and 3
months continuation.
Results: Fifty-four percent of all participants chose a very
effective method. Women in the intervention
group were no more likely to choose a very effective method
(OR 0.74, 95% CI 0.44, 1.26) or to initiate
their method compared to the usual care group (OR 0.65, 95%
CI 0.31, 1.34). In multivariate models,
structured counseling was not associated with using a very
effective method at 3 months (AOR 1.06, 95%
CI 0.53, 2.14).
Conclusion: In this setting, structured counseling had little
impact on contraceptive method choice,
initiation, or continuation.
Practice implications: Adding structured counseling did not
increase the proportion choosing or

initiating very effective contraception in a practice setting
where physicians already provide
individualized counseling.
� 2010 Elsevier Ireland Ltd. All rights reserved.
Contents lists available at ScienceDirect
Patient Education and Counseling
journa l homepage: www.e lsev ier .com/ locate /pateducou
1. Introduction
Despite the availability of very effective contraceptive methods,
the rate of unintended pregnancy in the United States (US)
remained stagnant at 49% from 1995 to 2001 [1]. Most women
in
the US have not used the most effective methods available [2],
and
47% have had a repeat abortion [3]. Women’s health
professionals
have regarded counseling as an important component of improv-
ing contraceptive use [4], and access to counseling services has
been considered an integral part of informed choice [5]. The
World
Health Organization (WHO) has supported the practice of
contraceptive counseling so that patients can make informed
decisions in conjunction with their provider [6].
Accepted practice within contemporary healthcare has been to
offer patients information regarding diagnoses and proposed
treatment options. Contraceptive counseling, where options are
presented with mechanisms of action, efficacy, risks and
benefits,

has been a challenge due to the limited resources in the clinical
* Corresponding author at: Division of Family Planning and
Preventive Services,
Columbia University Medical Center, 622 West 168th Street,
PH 1669, New York,
NY 10032, USA. Tel.: +1 212 305 4805; fax: +1 212 305 6438.
E-mail address: [email protected] (A.M. Langston).
0738-3991/$ – see front matter � 2010 Elsevier Ireland Ltd. All
rights reserved.
doi:10.1016/j.pec.2010.08.006
setting and the ability of any person to receive and comprehend
a
large amount of information.
A recent Cochrane Review found that ‘‘little evidence from
randomized controlled trials supports the hypothesis that
counseling improves contraceptive use,’’ and a systematic
review
of the literature on counseling to prevent unintended pregnancy
also [7] found limited evidence regarding its effectiveness [8].
In
1996 the US Preventive Services Task Force (USPSTF) recom-
mended contraceptive counseling, but the 2002 USPSTF
withdrew
this recommendation due to insufficient evidence [9,10].
Limited data has suggested a possible benefit to using
structured counseling—consisting of audio–visual materials
with
standardized information—for contraceptive counseling. Two
randomized controlled trials (RCTs) utilized structured audio–
visual educational material with standardized information about

contraceptive methods. The results from both studies showed
increased contraceptive use or continuation of effective
contracep-
tive methods (pill and injection) 1 year later [11,12].
In a post-abortion population, one RCT of counseling performed
by a contraceptive specialist along with advanced provision of
contraceptive methods compared to routine counseling found
increased uptake of long acting reversible contraceptives and
increased continuation at 4 months but no difference in repeat
abortion rates at 2 years [13]. The information given by the
http://dx.doi.org/10.1016/j.pec.2010.08.006
mailto:[email protected]
http://www.sciencedirect.com/science/journal/07383991
http://dx.doi.org/10.1016/j.pec.2010.08.006
A.M. Langston et al. / Patient Education and Counseling 81
(2010) 362–367 363
specialist counselor in this study was not standardized or given
in a
structured audio-visual format.
In an attempt to meet family planning counseling needs, the
WHO developed a series of family planning guidelines and
tools,
including the Decision-Making Tool for Family Planning
Clients
and Providers (DMT) [14]. A double-sided flipchart with one
side
for the client to aid in decision-making and the other side for
the
provider to aid in the counseling process by giving information
and
guidance, this tool was studied for improving communication

with
clients in limited resource settings [15,16]. The DMT was found
to
improve communication, particularly with clients choosing a
new
contraceptive method [15].
Given the need for resource efficiency in health care, the belief
by many providers and organizations that contraceptive counsel-
ing is necessary and worthwhile, and the limited literature [7–
10,17], we aimed to study this topic using a structured and
standardized counseling intervention based on the DMT in a
post-
abortion setting with most modern methods available for
immediate initiation. Our study evaluated structured, standard-
ized contraceptive counseling for its influence on participants
choosing a very effective contraceptive method at the time of
first
trimester vacuum aspiration, method initiation, and 3 months
and
6 months method continuation.
2. Methods
2.1. Setting and participants
From December 2008 to July 2009, we enrolled participants
from a family planning referral clinic to a private practice
setting
serving a predominantly Hispanic (Dominican) population with
Medicaid coverage in New York City. Providers at the practice
were
all physicians: faculty, fellows, and residents at Columbia
University Medical Center (CUMC). Vacuum aspiration
procedures
were offered 1 day per week, and on a given day, 3–4

physicians
each cared for 6–8 patients.
The study population consisted of women seeking a first
trimester
procedure for a spontaneous or induced abortion. Inclusion
criteria
were (1) age� 18 years, (2) no desire to become pregnant right
away,
(3) fluency in Spanish or English, and (4) access to a telephone.
The
CUMC Institutional Review Board approved this study.
2.2. Structured contraceptive counseling intervention
In this study we sought to address whether structured,
standardized, non-directive counseling (the intervention) in the
setting where contraceptive methods are immediately available
and
the women have confirmed fertility, will result in increased
choosing
of very effective contraceptive methods, method initiation, and
method continuation at 3 months. Structured counseling
consisted
of the trained research coordinator reading and displaying a
contraceptive flipchart in its entirety to the participant in a
private
office with samples of each method available for patients to see
and
touch. The counseling was structured in that the format included
visual and audio components allowing the participant to both
visualize and hear the information. The counseling was
standardized
in that the same information was presented every time the
counseling was performed. Participants were encouraged to ask
questions and to write down questions for their physician on

supplied note cards. The research assistants were trained to
answer
questions using only the information from the flipchart. If a
question
was not able to be answered by the information on the flipchart,
the
research assistant was instructed to request the participant ask
her
provider this question during usual care.
The flipchart was a version of the WHO 2005 Decision-Making
Tool for Family Planning Clients and Providers (DMT) [14]. We
did
not intend the intervention to provide tailored counseling,
though
that is one of the common uses of the DMT. We chose to use the
format of the DMT for its ready-made structure, simple
language
and images to create our structured and standardized
intervention.
We utilized the portion of the DMT focused on choosing a
method
and the method tabs (overview and information for choice,
medical eligibility criteria, possible side effects, how to use,
when
to start, and what to remember). We modified this portion of the
DMT to add methods available in the US (patch, ring,
levonorges-
trel IUD, and etonogestrel implant) and to remove information
about methods not available in the US (NET-EN injections,
monthly
injections, and Norplant) or not appropriate for post procedure
patients (lactational amenorrhea and fertility awareness). Thus
the
flipchart administered by a research coordinator gave our
intervention a structured format with visual and audio compo-

nents. The research coordinators gave standardized information
using this structured tool. The simple language and images in
the
flipchart, as well as reading the pages aloud as they were
viewed,
mitigated any effects of low literacy. Information on
contraceptive
methods (female sterilization, male sterilization, copper IUD,
levonorgestrel IUD, etonogestrel implant, depo provera
injection,
ring, patch, pill, and condom) was presented on 5–7 double-
sided
pages per method with patient and counselor focused content on
the front and back, respectively. We used flipcharts printed in
English for our participants who preferred English and
flipcharts
translated and printed in Spanish for our participants who
preferred Spanish. The flipchart included information on con-
traceptive effectiveness, how to use each method, possible side
effects, and when to seek help.
Usual care consisted of a single physician performing the
medical history, physical exam, ultrasound, obtaining informed
consent for the suction aspiration procedure, and carrying out
this
procedure for each patient. This visit required about one hour to
complete. Contraceptive counseling was routinely offered by the
physician as well and was embedded in the visit. As part of
usual
care, the content and duration of contraceptive counseling
performed by the provider was left to their discretion.
2.3. Study procedures
Two research coordinators fluent in English and Spanish
performed enrollment and follow-up. We used training scripts

and role play to standardize interactions with participants.
Questionnaires were piloted and adjusted based on responses
prior to enrollment.
We assessed all women aged 18 or older registered in the clinic
for eligibility. To ease anxiety, the coordinator first gave each
patient basic information about routine clinic procedures before
discussing the study. Interested and eligible women were
consented. A baseline questionnaire was administered to collect
demographic characteristics as well as partnership,
reproductive,
and contraceptive histories. Participants were then randomized
to
usual care with intervention versus usual care alone. Those
randomized to the intervention group received structured
counseling by a coordinator immediately prior to usual care
during the same visit. Attention was paid to minimize delay for
women in the intervention group.
Using a random-number table, we determined the sequence for
1:1 allocation constrained by blocks of 10. Randomization
assignments were sealed inside numbered, opaque envelopes.
The coordinator opened the next sequentially numbered
envelope
after completing informed consent. No blinding of participants
or
coordinators was feasible due to the nature of the intervention.
Physician-providers did not know the participant’s allocation
group, did not discuss the study with patients, and were asked
not
to change their counseling.
(2010) 362–367364

Contraceptive methods available to participants immediately
following their procedure included intrauterine devices (IUDs),
implants, injections, rings, and pills. The IUDs and implants
were
donated and available at no cost to all clinic patients. All
participants had either New York State Medicaid coverage for
prescription contraceptives or access to additional free supplies
at
a safety net clinic so all contraceptives offered were available
free
of charge. The patch was available by prescription only and
sterilization by referral only. Those who chose pill or ring
received
either a prescription or a 1-month supply and prescription. All
participants received condoms with handouts on emergency
contraception and condom use.
After each enrollment day, we reviewed charts to confirm that a
procedure was performed and to identify the contraceptive
method chosen as well as whether initiation was immediate or
delayed. Coordinators called participants 3 months after enroll-
ment to assess contraceptive use. A subset of patients received 6
months follow-up phone calls. Initial analysis of the first 101
participants to complete both 3 and 6 months data found no
significant differences, so 6 months follow-up was stopped to
focus
on maximizing 3 months follow-up.
2.4. Outcomes and analysis
The primary outcome of this study was proportion of
participants choosing a very effective contraceptive method.
Secondary outcomes were method initiation on the day of the
procedure and method continuation of very effective and/or
effective methods at 3 months, and at 6 months for the sub-
group

for whom we collected data.
The WHO defined very effective contraceptive methods as those
with 1 year typical use pregnancy rates of <1% (sterilization,
IUDs,
and implants) [6]. Effective methods have typical use pregnancy
rates of 1–9% (pills, rings, patches, and injections). The WHO
defined additional categories for methods with �10% and >25%
typical use pregnancy rates. In this study, we used the WHO
[(Fig._1)TD$FIG]
Fig. 1. Participant enrollment and follow-up in a randomized
con
definition for very effective and effective methods and defined
less
effective methods as those with �10% pregnancy rate
(condoms,
withdrawal, periodic abstinence, and no method).
We defined initiation of effective and very effective methods as
leaving the clinic with a method requiring no healthcare
provider
contact to begin use. If a participant requested pills and left
clinic
with a pill pack and a prescription, this was coded as immediate
initiation. If she left with a prescription only, this was
considered
delayed initiation because she needed to go to a pharmacy to
begin
using the method. Less effective contraceptive methods
(condoms,
withdrawal, and periodic abstinence) were coitally dependent
and,
therefore, were not able to be initiated in the clinic.

We defined continuation as using a contraceptive method at 3
or 6 months that was in the same effectiveness group as the
method requested at enrollment. For example, two patients
requested sterilization and were using an IUD at the 3 months
follow-up interview. Both these participants were counted as
‘continuers’ for the very effective group.
In this clinic in 2003–2004, 29% of patients chose the most
effective available methods (injection, copper IUD, or
sterilization)
following a first trimester aspiration procedure [18]. We
designed
our study to identify an increase from 30% to 50% of women
requesting a very effective method in the intervention arm. With
up to 20% loss due to exclusion after randomization, a two-
sided
alpha of .05, and power of .80, we needed 125 women in each
arm.
We used SAS, version 9.2 (SAS Institute, Cary, NC) for
statistical
analyses to compare the intervention and control groups. We
performed Chi-square analyses to assess differences between
allocation groups. We calculated two-sided p-values and 95%
confidence intervals. We performed logistic regression analyses
with two dependent outcomes: very effective method use at 3
months; or very effective or effective method use at 3 months.
The
8 participants who reported sexual abstinence since enrollment
due to no partner were excluded from these analyses. We
performed univariate logistic regression with (1) intervention,
(2) immediate initiation, (3) age, (4) education, (5) ethnicity,
(6)
trolled trial of structured contraceptive counseling, NY 2009.

Table 2
Structured contraceptive counseling versus usual care:
contraceptive method
chosen and 3 months continuation.
Intervention
(N = 114)
Usual care
(N = 108)
Total
(N = 222)
p-Value*
Contraceptive method chosen
Very effective methodsa 57 (50%) 62 (58%) 119 (54%) 0.27
Effective methodsa 48 (42%) 37 (34%) 85 (38%) 0.27
Less effective methodsa 9 (8%) 9 (8%) 18 (8%) 1.0
(N = 89) (N = 83) (N = 172b)
3 months continuation
Very effective methodsc 41/48 (85%) 40/52 (77%) 81/100
(81%) 0.28

Effective methodsc 28/41 (68%) 21/31 (68%) 49/72 (68%) 0.96
* Chi-square p-value.
a Very effective methods—copper IUD, levonorgestrel IUD,
etonogestrel implant,
sterilization. Effective methods—DMPA, ring, patch, pill. Less
effective methods—
intervention group: 1 undecided, 2 abstinence, 2 declined
contraception, 4
condoms. Control group: 3 undecided, 1 natural family
planning, 1 coitus
interruptus, 1 declined contraception, 3 condoms.
b Less effective methods are not represented in this total.
c Numerators are continuers and denominators are those who
chose this method
group and completed 3 months follow-up.
(2010) 362–367 365
parity, (7) prior abortion, (8) stable relationship status, (9)
provider
and (10) current smoking. Variables were chosen for
multivariate
logistic regression based upon univariate results and overall
importance to the clinical outcome. We constructed the final
model using the likelihood ratio test as variables were added
sequentially to determine the most parsimonious model. The
Hosmer–Lemeshow statistic was calculated to test the goodness-
of-fit of the final model.

3. Results
3.1. Enrollment
We screened 380 women and enrolled 250 women (Fig. 1). We
excluded 28 women after randomization because they did not
have a procedure that day primarily due to pregnancies in the
second trimester, completed spontaneous abortions, and ectopic
pregnancies. The remaining 222 women were eligible for
analysis
and follow-up.
The groups were well balanced with regard to baseline
characteristics (Table 1). They were mainly Hispanic and in
stable
relationships, defined as a relationship the participant reported
will continue for >1 year. Participants’ ages ranged from 18 to
45
years with a mean age of 26.2 years. Participants were seeking
induced abortion (94%) or spontaneous abortion management
(6%). The time used to conduct the structured counseling
intervention was, on average, 20 min (standard deviation �8
min).
3.2. Methods requested
The intervention and control groups were similar in the
methods requested (Table 2). Participants in the intervention
group were similar to the usual care group in often choosing a
very
effective method (OR 0.74, 95% CI 0.44, 1.26). Most women
requested very effective methods (levonorgestrel IUD (27%),
copper IUD (15%), implant (9%) and sterilization (2%)). Many
women requested effective methods (oral contraceptive pills
(18%), vaginal ring (9%), injection (7%), and patch (5%)).
Fewer

women requested less effective methods (undecided/declined
(n = 7), condoms (n = 7), abstinence (n = 2), withdrawal (n = 1)
and
periodic abstinence (n = 1)).
Comparing the demographics of participants who chose very
effective methods to those who did not, parous women and
women
in a stable relationship were more likely to choose a very
effective
method (OR 2.51, 95% CI 1.35, 4.67 and OR 1.98, 95% CI 1.11,
3.54,
Table 1
Demographics and reproductive history—structured
contraceptive counseling
versus usual care (N = 222).
Intervention (N = 114)
N (%)
Usual care (N = 108)
N (%)
Age (SD) 25.6 (5.7) 26.8 (6.7)
Age<25 years 59 (52%) 49 (45%)
Hispanica 98 (87%) 97 (90%)
Education�12th grade 74 (65%) 77 (71%)
Birthplace
United States 47 (41%) 43 (40%)

Dominican Republic 50 (44%) 53 (49%)
Other 17 (15%) 12 (11%)
Current smokersb 20 (18%) 20 (19%)
Gravida>1 98 (86%) 96 (89%)
Parous 84 (74%) 81 (75%)
Ever had a prior abortion 57 (50%) 58 (54%)
Ever used contraception 109 (96%) 104 (96%)
Current stable relationship 78 (68%) 77 (71%)
a One missing value from intervention group.
b One missing value from intervention group.
respectively). Six providers saw the majority (91%) of the
participants. No differences were seen in the methods requested
(p = 0.44) or the proportion of methods initiated immediately
(p = 0.83) among these providers. There was no difference
between
the intervention and control groups in the physician-providers
from whom they received usual care (p = .59).
3.3. Immediate versus delayed initiation
Participants in the intervention group were not more likely to
initiate the requested method immediately compared to those in
the usual care group (OR 0.65, 95% CI 0.31, 1.34) (Table 2).
Only 15
percent of participants chose a method that could not be
initiated
the same day (18 less effective methods, 10 patches, and 5

sterilizations). The other 189 participants selected a method that
could be initiated the same day; 80% of these women initiated
their
method the same day (80 IUDs, 28 pills, 19 implants, 15
injections,
and 10 rings). The remaining 20% of participants had delayed
initiation of their method (14 IUDs, 11 pills, 10 rings, 1
injection,
and 1 implant). Of these, 3 women preferred to delay IUD
insertion,
and 1 woman wanted to obtain her pill prescription from her
personal physician. The physician-providers delayed 9
initiations
due to infection, 2 due to bleeding, and 1 due to lack of
confirmatory products of conception at the time of the
procedure.
Twenty-one women were given prescriptions only (10 rings, and
11 pills).
3.4. Follow-up and continuation
Of 222 participants, 186 (84%) completed 3 months follow-up
(Fig. 1). Loss to follow-up was equal between the intervention
and
control group. The baseline characteristics and requested
methods
of the women who completed 3 months follow-up and those who
did not were similar (data not shown). Those in the intervention
group who completed 3 months follow-up had chosen similar
methods compared to those in the control group (p = 0.51). No
participants reported a repeat pregnancy at 3 months.
For those who chose a very effective or effective method, 3
months continuation of the requested method and 3 months
continuation of immediately initiated methods were not signifi-
cantly different comparing the intervention group to the usual

care
group (OR 1.24, 95% CI 0.62, 2.50 and OR 1.43, 95% CI 0.58,
3.52,
respectively) (Table 2). Fourteen (78%) participants who chose
a
less effective method completed 3 months follow-up; 13
reported
being sexually active; and only 2 reported adopting an effective
Table 3B
Predictors of contraceptive method use at 3 months,
multivariate model (N = 186).
Very effective method
use
Very effective or ef-
fective method use
AOR 95% CI AOR 95% CI
Structured counseling 1.06 (0.53, 2.14) 1.59 (0.77, 3.28)
Immediate initiation 15.5 (6.02, 39.7) 4.26 (2.05, 8.87)
Age 0.91 (0.43, 1.89) 1.67 (0.81, 3.47)
Education – – – –
Prior abortion – – – –
Parous 3.17 (1.37, 7.32) – –

Hispanic – – – –
Relationship – – – –
Smoking – – – –
*Excluded participants abstinent since enrollment from the
analysis (N = 8). **The
reference group is ‘no’ and the comparison group is ‘yes’
except for age where
reference group is <25 years and comparison group is �25
years.
(2010) 362–367366
method (pills). In a sub-group analysis of those who initiated a
very
effective method on the day of enrollment (n = 83), the
interven-
tion group trended towards increased 3 months continuation
compared to the usual care group (98% versus 83%; p = .06).
With the initial participants at the start of the study, we took
the opportunity to conduct 6 months follow-up interviews. We
completed 6 months follow-up with 131 (59%) participants. For
these participants, 6 months continuation between the inter-
vention group (67%) and the usual care group (68%) was similar
(OR 0.95, 95% CI 0.45, 2.02). Two participants reported a
repeat
pregnancy at 6 months, one from each randomization group.
3.5. Predictors of using a very effective and/or effective method
at 3

months
When limiting our outcome to using a very effective method at
3 months, the counseling intervention did not have a strong
effect
in univariate or multivariate models (Tables 3A and 3B). In
univariate analyses, completing at least the 12th grade in school
and immediate initiation of a requested contraceptive method
had
the strongest associations with using a very effective or
effective
method at 3 months (Table 3A). In a multivariate model, the
counseling intervention did not have a strong association with
using a very effective or effective method at 3 months (AOR
1.59,
95% CI 0.77, 3.28).
4. Discussion and conclusion
4.1. Discussion
We sought to address whether structured, standardized, non-
directive counseling (the intervention) in the setting where
contraceptive methods are immediately available and the women
have confirmed fertility, will result in increased choosing of
very
effective contraceptive methods. We specifically chose a
counsel-
ing format that would not be performed by a physician to reflect
the reality of limited health resources and the common practice
of
family planning clinics in the US to utilize non-physicians to
perform counseling. We chose standardized counseling in
contrast
to tailored counseling to ensure that participants in the interven-

tion group received the same information to minimize bias from
the counselor. Minority women have been shown to be more
likely
to receive contraceptive and sterilization counseling compared
to
white women [19], and our clinic serves a predominantly
minority
population.
We performed a RCT of an intervention utilizing a modified
version of a readily reproducible counseling intervention (DMT)
Table 3A
Predictors of method use at 3 months, univariate analyses (N =
186).
Very effective method
use
Very effective or
effective method
use
OR 95% CI OR 95% CI
Structured counseling 0.97 (0.53, 1.74) 1.35 (0.68, 2.68)
Immediate initiation 14.02 (5.58, 35.22) 3.87 (1.90, 7.89)
Age 1.05 (0.58, 1.89) 1.44 (0.73, 2.86)
Education 1.65 (0.87, 3.14) 2.11 (1.04, 4.25)
Prior abortion 0.91 (0.50, 1.64) 1.62 (0.82, 3.22)

Parous 2.43 (1.19, 4.95) 1.37 (0.65, 2.89)
Hispanic 0.86 (0.33, 2.24) 1.46 (0.52, 4.10)
Relationship 1.38 (0.72, 2.65) 1.10 (0.53, 2.29)
Smoking 0.77 (0.35, 1.69) 1.12 (0.46, 2.74)
*Excluded participants abstinent since enrollment from the
analysis (N = 8). **The
reference group is ‘no’ and the comparison group is ‘yes’
except for age where
reference group is <25 years and comparison group is �25
years.
that is available online and developed by experts. Our
structured
and standardized counseling intervention did not result in more
women choosing a very effective contraceptive method,
immedi-
ately initiating more methods, or significantly increasing 3
months
continuation of their chosen method in our setting. In our clinic,
physicians who specialize in family planning are providing
contraceptive counseling with the patients as an integrated part
of their visit for a first trimester uterine aspiration. Additional
counseling may have been unnecessary in this setting.
Our study had several limitations. Our clinic setting had
specialized providers as well as a specific ethnic demographic
that
limited the generalizability of our study’s findings. We utilized
the
DMT for structured, standardized counseling, and it was

designed
for tailored counseling. This approach may have affected the
effectiveness of the intervention. Our 3 months contraceptive
data
was self-reported and vulnerable to social desirability bias. We
made an effort to reduce patients’ anxiety but could not
eliminate
it before the intervention. This anxiety could have lessened the
effects of the structured counseling intervention. A further
limitation was that the providers in our setting were aware of
the study and could have altered their counseling during the
study,
minimizing the effect of the intervention, though they were
asked
not to do so. We also did not collect data on participant
satisfaction
specifically with the contraceptive counseling or detailed data
on
participants’ desires for future pregnancy beyond whether they
desired contraception.
One further limitation of our study was that it was powered for
the outcome of choosing a very effective contraceptive method;
however, it was not powered for the other outcomes collected—
initiation and continuation. The initiation outcome for very
effective methods was so similar between the intervention and
control groups (84% versus 82%, respectively) that, though
underpowered, the trend showed no difference. The continuation
outcome for very effective methods was less similar between
the
two groups (85% versus 77%, respectively). A larger sample
size
could have benefited this outcome in our study.
We had a very high proportion of patients in both the
intervention and control group who chose IUDs (42%) compared

to the 2% of contracepting women using IUDs in the US in 2002
[20]. Hispanic women in the US have been found to have higher
ever-use of IUDs (10.0%) and implants (4.0%) compared to
non-
Hispanic White (4.7% and 1.4%) and non-Hispanic Black (5.5%
and
3.2%) women [20]. The community served by our practice is
predominantly Hispanic, and greater baseline usage of these
long-
acting methods among Hispanic women could partially explain
the
high proportion of women choosing an IUD. In one study of
post-
abortion contraception, 53% chose the pill, 11% chose the IUD,
8%
chose DMPA and 17% declined or were undecided on the day of
(2010) 362–367 367
their procedure so our findings were not typical though the
literature is limited on post-abortion contraceptive use [21]. The
proportion of our participants selecting very effective methods
was
also higher than found in the same population and setting in
2003–
2004—54% compared to 29% [18]. The larger than expected
proportion of women in the control group who chose a very
effective method was an unexpected outcome and decreased the
power for our sample size.
The physicians and patients participating in this study may
have been further motivated by the fact that these very effective
contraceptive methods were available for insertion on the same
day as the procedure. Previously in this same clinic, patients

who
chose a very effective method had to make an additional visit on
a
different day to have the method initiated. Immediate access to
very effective contraceptives following an abortion has been
shown to decrease repeat abortion [22,23]. The intervention to
increase uptake of very effective post-abortion contraception
may
be to provide increased access to contraceptives while the
specific
counseling methods may be less significant as long as
contracep-
tive counseling is provided. Interventions to improve contracep-
tive uptake and use to better meet family planning needs
deserve
continued study.
4.2. Conclusion
Contraceptive counseling is valuable. The exact amount and
extent of counseling appropriate for each patient likely varies
though a common minimum should be standard to give patients
the opportunity to make an informed choice. All our patients
received contraceptive counseling by the physician doing their
procedure with the structured counseling done in addition if
they were part of the intervention group. Due to a higher than
expected proportion choosing a very effective method in the
control group, our power was less than planned and needs to be
considered in the interpretation of our outcomes. Structured
contraceptive counseling in our setting did not have a
significant
impact on method choice, method initiation, or 3 months
continuation. Interventions to improve contraceptive use
deserve continued study.
4.3. Practice implications

Adding structured contraceptive counseling did not increase
the proportion choosing or initiating a very effective
contraceptive
method in a practice setting where specially trained physicians
already provide informal individualized counseling.
Conflict of interest
None.
Acknowledgements
The authors acknowledge Heidi Jones and Sara Fuentes,
Division of Family Planning and Preventive Services, Columbia
University and Sarah Johnson, Department of Reproductive
Health
and Research, WHO.
Financial support provided by a grant from an anonymous
foundation. This foundation approved the study design. It did
not
have a direct role in the collection, analysis and interpretation
of
data; the writing of the manuscript; or the decision to submit
the
manuscript for publication.
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Structured contraceptive counseling-A randomized controlled
trialIntroductionMethodsSetting and participantsStructured
contraceptive counseling interventionStudy
proceduresOutcomes and analysisResultsEnrollmentMethods
requestedImmediate versus delayed initiationFollow-up and
continuationPredictors of using a very effective and/or effective
method at 3 monthsDiscussion and
conclusionDiscussionConclusionPractice implicationsConflict
of interestAcknowledgementsReferences

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