The issues female clients bring to the counseling session are as unique as the individuals who come to counseling in pursuit of personal growth, wellness or answers to life’s problems. But Cecelia Hope Manley, an American Counseling Association member who estimates that 90 percent of her client base is female, says she sees a common thread running through many of the issues.

“I noticed over time that many women lack the training that was so ubiquitous in the 1970s women’s movement — assertiveness,” says Manley, who runs a private practice in Westport, Conn. “I work with my clients to ‘find their voice’ and often role-play how to stand up for themselves and ask for what they want in relationships. We often work on values clarification — what do they believe their purpose in life is and how do they use free will to set a course and make decisions that create the life they want?”

Manley says the issues themselves run the gamut: women grieving the loss of a spouse or partner and struggling with identity issues; women whose fear of being alone is greater than their desire for a relationship in which their love is reciprocated; women healing from childhood sexual abuse and/or neglect; and female caregivers in danger of burning out. Her female clients have also struggled with, among other things, negative body image, a lack of boundaries in relationships, overvaluing the approval of others, accepting abuse (whether physical, verbal or emotional) and avoiding confrontation at all costs.

Self-care is another common topic among female clients, says Manley, who previously worked in hospice care, an environment in which the importance of self-care is emphasized for those caring for a loved one. “It’s not really possible to do well at caregiving unless you care for yourself,” she says.

Manley takes a holistic perspective with her clients, emphasizing the importance of exercise, good nutrition, meditation and making time for enjoyable relationships. She offers the following pieces of advice to other counselors working with women:

  • “Recognize that while addressing the personal issues that women clients bring into counseling — internal, individual concerns, relationship concerns, workplace concerns, physical health concerns — that as a society and across cultures, we continue to emerge from a long-standing patriarchal system … in which women have been devalued, considered inferior and expected to be submissive,” Manley says.
  • “Women and men are exploring new ways to balance the masculine and feminine within and how to create equitable, respectful relationships,” she says. “It can be helpful to provide this context for our clients and to reframe what may seem to be solely personal struggles as issues that arise from societal expectations and traditions. In the ’60s and ’70s, the women’s movement slogan ‘the personal is political’ reflected this.”
  • “Help empower women and help them understand that others may resist the change to varying degrees,” Manley says. “Help women understand that overgiving in relationships is not a gift to others; it’s enabling and is detrimental to both self and other. Give permission to women to value themselves, to exercise their right to put themselves first according to their values and to say ‘no’ to what they do not want. Teach women skills to relate to themselves and others from a powerful, self-respecting place.”

To explore some of the unique needs and circumstances that female clients bring to the counseling table, Counseling Today spoke with four other ACA members who have worked in specific areas serving women.

‘The country of Motherhood’

Terre Grable compares embarking on motherhood with moving to a new country where you don’t speak the language and no one tells you the rules of the road. “You have to figure out how to function on a daily basis knowing there are social norms but not [being] sure what they are. It is just you and your kids. As you go along on this new journey, your former friends who did not move with you wish you well but still cannot identify with your experiences. When you accidently walk on the wrong side of the street, you notice a small group of others looking at you in an odd sort of way, and you just somehow know you have failed and messed up. Feelings of anxiety, fear and just wanting to get it right consume you,” says Grable, who regularly works with moms as part of her private practice in Brentwood, Tenn. “A few years later, you think that you have figured it all out, but then you accidentally send your kid to the wrong school and on the wrong bus. And the feelings of self-doubt creep back in again. That is what it feels like sometimes to live in the country of Motherhood.”

Grable, herself a mother who juggles her counseling practice and raising children, says society’s views on motherhood can leave moms feeling unsure, afraid, criticized and not good enough. Grable and a colleague, Susan Douglas, collaborate on a blog called No Mommy’s Perfect ( Grable says the blog aims to provide a support forum where women can discuss the realities of modern motherhood without guilt and find encouragement instead of criticism.

“I have seen a lot of moms trying to balance motherhood, specifically as it relates to the pressure of measuring up to societal standards, concerns of doing the right thing for their kids, and the countless expected and unexpected physical and emotional costs that result from becoming and just being a mom,” Grable says. “Motherhood is a great thing, yet I think it blindsides many unsuspecting women in so many ways that they are afraid to talk about openly. Or if they do, they feel criticized and [don’t want] to get in the middle of a ‘mommy war.’ I have found this to be true not only in my practice but [also in] other mom groups I have been in — church groups, school activities, kids’ birthday parties, etc. There is such relief when one mom is brave enough to speak openly [in a way] that the others can relate to, which is a sad reality actually.”

The pressures on moms that Grable sees reflected in her clients are wide ranging. Many are trying incredibly hard to do everything possible for their kids, as if an unwritten understanding exists that how a child turns out is wholly dependent on the actions of the mother, Grable says. Many moms get stuck comparing themselves to others and harboring unrealistic expectations, which causes feelings of guilt and stress, she adds.

Technology provides yet another source of pressure, Grable says. “Technology creates parenting issues with cyberbullying, creating another distraction for our kids, and it keeps us plugged in all the time,” she explains. “With the information superhighway, there is a lot of information hitting us at once, and sometimes it can be overwhelming. Instead of walking into a bookstore, grabbing a latte and perusing the parenting section, we now grab some coffee, sit down to the computer, do a search on ‘parenting resources’ and are bombarded with pages of articles that have a lot of information.”

The goal is to control technology rather than let it control you, Grable tells her clients. “Use it to your advantage,” she says. “Find some apps that will be helpful and encouraging to you as a mother. Any bad day can be brightened up with a picture of our little ones on our phones. Use social media to connect with old friends. Follow blogs that will be helpful for you as a mom.”

However, Grable also encourages her mom-clients to take some time to unplug each day. “Avoid allowing technology to steal away the fleeting moments we have with our kids,” she says.

Of course, many women balance their jobs as mothers with another job outside of the home, which can provide endless challenges. Grable tries to help these clients overcome any guilt associated with not being able to be a full-time, stay-at-home mom or not having the desire to be a stay-at-home mom. She also works with them to alleviate the anxieties that stem from juggling a crazy schedule and from wondering whether working outside the home will have a negative impact on their kids. “Help them stop getting caught up in the ‘comparison game,’” Grable advises her fellow counselors. “Reframe their anxieties to the positive opportunities that [working outside the home] provides for themselves and their children. Working allows many moms to cherish the opportunity to spend [time] with their kids. Working outside the home models so many positive things that kids can learn from, such as the power of a positive work ethic and the fulfillment [that comes] from doing a job that you enjoy.”

Motherhood is filled with many expectations, both spoken and unspoken, Grable points out. “There is the fear of what others will think if she deviates from such expectations,” she says. “Or, she may just find it difficult to find a group of friends that embraces her and their differences and may feel displaced.”

For example, Grable says, a mom who enjoys her job and finds her work more fulfilling than staying at home with her child might feel reluctant to express that to others. “Often, if she voices her preference, in some circles, it may lead to criticism and accusations of selfishness and indirect messages of displeasure and even of ‘not measuring up,’” Grable says. “Why risk that?”

In doing research for a book she’s co-authoring with Douglas, Grable came to the conclusion that the precepts on which motherhood is based are outdated. “We need a new concept of motherhood,” she says, “one that states the realities without demanding perfection, because that will never happen.” Grable sees one of her tasks as a counselor as assisting clients to create their own understanding of what defines a “good mother.”

“With any mom, I would hope that I bring a sense of what I call ‘leveling the playing field’ — [an understanding] that we are all in this together,” Grable says. “We all make mistakes and worry about [whether we are] doing the best thing for our kids.” Grable tells her clients who are mothers to focus their energy on their own definition of motherhood instead of getting stuck on the what-ifs, if-onlys and I-shoulds. Counselors can “help them to redefine what motherhood really is and separate the realities from the myths,” she says. “And help them let go of the expectations that are discouraging to them and their growth as moms. My understanding of what motherhood is must be congruent to my reality.”

Helping these clients plug into available support is also key, Grable says. “I try to connect them with local resources that are a match for their needs, whether they need career coaches, psychiatrists, pastoral counseling, weight-loss coaches or just getting connected to other moms through moms groups. I also send them to [our] blog for a sense of global community to motherhood. I also constantly need to check my countertransference and avoid disrupting their process of growth with my own agenda or perception of motherhood.”

And it doesn’t hurt for counselors to remind downtrodden mom-clients just how important and wonderful they are, Grable says. “Remind them of the significance of motherhood. Without [them], all humanity would stop,” she says. “Motherhood is not based on the clothes we wear, the cars we drive or the schools [our children] attend. Rather, it is based on the love we have for our kids and how we show it to them in a healthy manner. Help them to identify the life lessons they want their kids to know and help them achieve their goals. Just the fact that moms are brave enough to get up each day, try to do the best for their kids, even if not perfectly, and not give up makes them rock stars.”

A life-changing diagnosis with a dose of counseling

When Tamara Williams-Reding was 43, she was diagnosed with breast cancer and underwent surgery, chemotherapy and radiation to treat it. She’s a cancer survivor now, and like many cancer survivors, Williams-Reding took a long look at her life and reassessed what she wanted out of it.

Williams-Reding had worked as a counselor before her cancer diagnosis, and after taking some time off during her cancer treatments, she returned with a new vision for her professional life, opening a practice focused on psycho-oncology. Approximately 90 percent of her clients are women, all of whom are at some stage of battling or surviving cancer. Her office is located within the office building of an oncology practice in St. Louis, and Williams-Reding says the neighboring oncologists refer a majority of her counseling clients to her.

When Williams-Reding was going through cancer treatment, she saw a counselor to help her work through the anxiety she was experiencing. “I met with the counselor at the place [where] I was to receive chemo, and he helped me by employing behavioral approaches, such as sitting in the chemo chair, talking with the nurses [and] learning what to expect,” Williams-Reding says. “At the time of my cancer diagnosis, my children were 11 and 15 and, like my husband, were deeply affected by the cancer experience. After regaining my health, both physically and emotionally, I knew that I could bring my own experience, and that of my family, to helping others face the same events.”

The National Cancer Institute estimates that in 2012, more than 226,000 women will be diagnosed with breast cancer, making it one of the most commonly diagnosed cancers among American women.

On the basis of what she has learned both from research and from her own experience, Williams-Reding says women and men generally deal with a cancer diagnosis differently. “Women react to the stress of cancer by internalizing it and becoming anxious and depressed,” she says. “Men tend to rely heavily on their partners and tend to feel more anger.” Women also tend to use language and seek human connection in addressing that anxiety and depression more so than do men, Williams-Reding says, which might support why so many of her clients are women. “I think women respond to stress by talking — with friends, family and sometimes a professional,” she says. “Men still seem to want to work through stress by doing.”

The clients with whom Williams-Reding works are divided roughly into two phases: those who are newly diagnosed and evaluating treatment options, and those who are in the post-treatment phase and dealing with survivorship issues.

Clients who are newly diagnosed have an enormous host of issues with which to deal, Williams-Reding says. They might need assistance making decisions regarding treatment, navigating and managing relationships with health care providers, learning how to communicate the diagnosis to their families and managing how the cancer experience affects their families. “Cancer reminds each person that they are not in control,” Williams-Reding says. “Many have no symptoms. The cancer [might be] discovered during a scan, so there is a sense of betrayal by one’s body. Then there are life-altering decisions to make — surgery, treatment options, side effects, the financial issues — all under the stress of a life-threatening illness.”

As Williams-Reding herself experienced, a high level of anxiety can manifest over the cancer treatment itself. Clients may also experience some depression related to “whether they can see the end of the tunnel,” she says. To address those issues, Williams-Reding uses desensitizing techniques, such as having the client sit in the chemo chair, as well as cognitive behavioral techniques to help the client deal with depression.

Education is another element that Williams-Reding provides to her clients who are undergoing cancer treatment. “I am constantly educating clients about the emotional impact of treatment options, side effects and healing options,” she says. “My office is located within the office of a very comprehensive oncology practice, so I have resources available at all times. I can help my clients in learning how to express themselves to the physicians and nurses, how to ask for care, how to find the resources in the community, which are extensive. I do a lot of education about sexuality and treatment options for those issues. I also educate those who are facing end-of-life decision-making on how palliative and hospice care is handled. Finally, I try to educate my clients on self-care, on taking care of their emotional, physical and spiritual needs.”

Her clients going through treatment also deal with relationship issues, Williams-Reding says. Some clients’ partners and families withdraw to protect themselves from the frightening situation, while others, fearing loss, become overly involved and clingy, Williams-Reding says. Because a cancer diagnosis is a systemic issue that disrupts partnerships and entire families, Williams-Reding works with her clients’ partners or families as needed. “Women [diagnosed with cancer] are usually trying to care for their loved ones at the same time as [they are caring for themselves], so they often worry about those around them more [than they worry about] themselves,” she says.

Williams-Reding helps her clients examine concerns related to their loved ones and find resolutions for those concerns. Some concerns are more concrete, such as helping clients arrange for dinner on nights when they have treatments. In other instances, clients worry that they won’t be around as their children grow up. In those cases, Williams-Reding might encourage them to start a scrapbook for their children.

Clients in the cancer survivor stage deal with a wide variety of challenges as well, Williams-Reding says, including adapting to an altered body image, exploring how their life meaning or purpose has changed, determining what they want from the rest of their life and encouraging others to see them as the “normal” version of themselves rather than the “cancer” version.

Although no individual can guarantee that he or she is going to wake up tomorrow, with cancer survivors, “there is more of an urgency in making sure that you are maximizing your experiences and decisions, more awareness that time is limited for all of us,” Williams-Reding says. Many cancer survivors start making changes and different decisions in relation to their careers, relationships, health and how they spend their free time, she says. Women, oftentimes more so than men, seek to maximize their relationships, making different decisions about how they spend their time and with whom, Williams-Reding says. “It really becomes a transformative period of their lives,” she says. “I support them in trying to make those changes in their lives.”

Williams-Reding has developed an interest in female sexuality as it relates to cancer survivorship, saying it’s an area of study that hasn’t received much attention. “Treatment of cancers of the breast or reproductive organs can use methods focused on stopping the cancer but can create all kinds of sexual side effects that clients don’t expect,” she says. “Surgery, chemo and radiation can have devastating effects on libido, tissue and future fertility.”

The topic of sexual health tends to come up in sessions when her clients are at the survivorship stage, Williams-Reding says. They want to resume their lives, she notes, but often realize the experience of cancer has altered them physically and emotionally. Clients who are feeling less sexual than they did before their cancer diagnosis or treatment worry about how that might affect their relationship with a spouse or partner moving forward and wonder whether they will ever feel the same again, Williams-Reding says. Clients sometimes also struggle with psychological issues such as an altered body image or physical issues such as vaginal pain, she says.

“[Clients] are looking for a more in-depth discussion about the sexual issues than they can have with their oncologists,” Williams-Reding says. “I remind clients that sexuality is complex and involves many, many ways of expression. We might talk about alternative ways to be sexual, the importance of self-stimulation and the use of appliances, etc., that can help ease the way back to a sexual life. Clients are often conflicted about their sexual needs, feeling that they should just be happy to be alive, and [they] feel guilty about wanting to feel good in all areas of their lives.”

Williams-Reding encourages all counselors to understand the issues that accompany cancer diagnoses and survivorship. According to the American Cancer Society and the National Cancer Institute, the number of cancer survivors in the United States is expected to increase by almost one-third to nearly 18 million people by 2022. “The odds are that in working with families and clients, you’re going to come across people who have had cancer,” Williams-Reding says. “It’s something to be aware of. It will shape how they view the world, how they view relationships and how they view themselves going forward. Even if the outcome is good, it still has a profound effect.”

A system geared toward men

The number of women in U.S. prisons has risen sharply during the past few decades. That’s a well-documented fact, but one that more counselors need to be aware of, says Cindy Miller, an assistant professor of counseling at South University in Richmond, Va., and a member of the International Association of Addictions and Offender Counselors, a division of ACA.

Counselors, especially those working in community agencies, are more likely than ever to encounter women released from prison and needing assistance, says Miller, who has worked as a counselor in two prisons in Virginia. According to the Women’s Prison Association (WPA), the number of women in prison grew by 832 percent between 1977 and 2007.

Speaking to why more women are being incarcerated, Miller points to the “war on drugs” as one root cause. “It has led to a lot of women getting incarcerated for nonviolent drug offenses,” she says. Another factor, according to Miller, was an effort in the 1960s and ’70s to move people out of state psychiatric hospitals and back into the community. The drug Thorazine was developed during that time and reduced some patients’ symptoms enough that they could function outside of a hospital setting, Miller says. There was also a movement to revolutionize mental health treatment by getting people out of hospitals, many of which “weren’t great places to be,” Miller says. As state psychiatric beds decreased, the number of mentally ill people in prisons increased, she points out. Many of those released from the psychiatric hospitals, including a substantial number of women, returned to the community, struggled and were arrested, Miller says. She adds that after John Hinckley was found not guilty by reason of insanity for shooting President Ronald Reagan, laws were tightened to make it more difficult to obtain those verdicts.

At the first prison at which she worked, Miller provided treatment to women with chronic mental illness. “Most of the time, their mental illness directly contributed to their arrest, and it was usually because they stopped taking their medication in the community or couldn’t get access to services and returned to substance use to treat their symptoms,” Miller says.

At the second prison, Miller provided individual therapy, crisis intervention and assessments for psychiatric referrals. “Almost all of [these individuals] had some kind of history of physical or sexual abuse, violent relationships and substance dependence,” Miller says. “Once they get incarcerated, they often try to substitute psychiatric medications for their drugs of choice. The need for services, especially individual treatment, far surpassed the level of staffing and resources allotted.”

By and large, Miller says, prison systems across the country haven’t adapted to accommodate the increasing number of female inmates. “Many of the programs and policies were designed by and for men and are being used with females without any evidence to support their effectiveness,” she says. “Unfortunately, there isn’t a lot of good research on what works for female offenders because they are still a small percentage of the larger prison-industrial complex.”

Part of Miller’s responsibilities in both prisons included helping with release planning for women who were completing their sentences. “The challenges were huge,” she says. “Just trying to get a woman a follow-up appointment at her local mental health center so she could continue to receive her psychiatric medications was difficult because of all the funding cutbacks.” Depending on the amount of effort each individual state puts into offender re-entry, that’s oftentimes still the case today, according to Miller.

Miller suggests that counselors working with former inmates take into account how much power and control has been exerted over these women in a prison setting. “Women in prison live in a very structured, militarized setting that is full of rules and regulations,” she says. “The routine choices that the unincarcerated make every day — what to eat, when to eat, what to wear, when to use the phone and for how long, etc. — are predetermined for a woman who is incarcerated. On the one hand, the rules and regulations exist to maintain safety and security within the facility and keep operations running smoothly. In addition, many women whose lives were chaotic before their incarceration benefit from having the structure of the institution.

“But on the other hand, the rules and regulations perpetuate a problem many incarcerated women have struggled with their whole lives — being controlled by someone else. The number of incarcerated women who have experienced sexual abuse and/or domestic violence in the course of their lives is estimated to be around 60 to 80 percent. When women with a history of abuse are placed into a highly controlled setting like a prison, it can perpetuate their victimization by forcing them to submit to control and authority all over again. I’m not saying we shouldn’t be incarcerating women with trauma histories, but I do think we have to make sure that rules, regulations and interventions inside a prison are informed by best practices in trauma treatment.”

What counselors need to know when seeing a woman who has just been released from prison is that she is going to experience an adjustment period, Miller says. “She will need to get used to having choices again and to making her own decisions. She will also need to figure out how to transfer some of the positive structure the prison provided into her daily free life. Counselors could really focus on using interventions that empower a woman to make her own choices. At the same time, they can assist her in identifying ways to create structure in her life that will help her be successful. They can also invite her to talk about what her experience was while incarcerated and ask about her experiences with power, control and victimization.”

Working with these clients to develop coping skills is another priority, Miller says. “One of the misconceptions is that people in jail are bad people who have done bad things,” she says. “Many people who are in jail are folks who were never taught the coping skills that we need to be successful. They’re not fundamentally bad people. Many times, [being arrested is] a direct result of the traumas they’ve had, the upbringing they’ve had and their efforts to try to cope.” In her work with inmates, Miller found dialectical behavior therapy to be effective, in part because it taught coping skills.

Women recently released from prison are often scared and facing a number of hurdles, Miller says. Oftentimes, they are returning to families and communities where rates of violence, substance abuse and crime run high, she says. “It’s a lot harder for a woman with a felony charge to get housing [and] nearly impossible to find someone to hire her. She’s often going back into a home environment that hasn’t been healthy, and she needs to re-establish bonds with her children if they’re still in her custody or be a part of their lives if they’re not [in her custody],” Miller says. According to the WPA, nearly two-thirds of women in prison are mothers.

“They may want to get out of their living environment, but they have no money of their own and no realistic means of doing so for the immediate future,” Miller continues. “So, they need help with developing a plan that will allow them to move forward and avoid getting caught back up in the cycle of their family and environment.”

Of course, some counselors may never work with an inmate or former inmate. Even so, Miller says the involvement of these counselors is necessary on the advocacy front. Incarcerated women, especially those with significant mental illness, have little ability to advocate for themselves and very few people advocating for them, she says. “We need stronger advocacy for a better mental health system which does not consider the incarceration of the seriously mentally ill an acceptable solution to the lack of psychiatric beds and services in the community,” Miller says. “We also need to advocate for better services for women in prison. Women need staff trained in trauma and co-occurring disorders and programs developed specifically for women.”

Counselors seeking to help this population of women can get involved by volunteering at their local prisons, talking with prison administrators and local probation and parole offices, and contacting legislators, Miller says. “Remember that most women who have been incarcerated are not going to show up at a private practice,” she says. “They are going to be presenting for services at community agencies that serve uninsured populations. So, consider reserving a pro bono slot for a woman who has just been released from prison. Offer to run a Seeking Safety or other trauma-recovery group at a local jail. Consider running a parenting group for incarcerated women who are pregnant or those who are trying to parent while incarcerated. Offer a mindfulness group for female inmates or those on probation. Those are just a few ideas. The reason we should do this, aside from social justice, is that it is simply good common sense from a taxpayer perspective. If we provide adequate treatment, then we can reduce recidivism and the amount of money we spend incarcerating people.”

Miller doesn’t want to paint a picture that casts all prisons in a negative light. That would be much too simplistic, she says. Prisons run the gamut from good to bad, and many prisons offer good treatment services for female inmates, she says. “But at the same time,” she adds, “there is a tremendous need for more programs, more staff and more recognition of the unique needs of female offenders.”

A space without judgment

Since placing more focus on fertility and infertility issues in her private practice the past few years, Ulash Thakore-Dunlap hasn’t had much trouble finding clients who want counseling connected to those topics. About half of her client base consists of women seeking counseling support as they consider starting or struggle to start a family, says Thakore-Dunlap, whose practice is located in San Francisco.

Fertility is seemingly discussed more in today’s society than ever before, Thakore-Dunlap says. She theorizes that’s because couples are delaying having children in favor of focusing on their careers for a longer time or because the topic of infertility has become less stigmatized.

Thakore-Dunlap became interested in the topic as she was starting her own family about five years ago. She says working with clients in the area of fertility might mean counseling women who are single and choosing to start a family on their own or counseling women who are in relationships and possibly struggling to get pregnant. With clients in relationships, Thakore-Dunlap asks about the strength of the relationship and the communication they have with their partner because both are crucial elements when starting a family, she says. When couples face infertility issues, they can sometimes experience a breakdown in communication, Thakore-Dunlap adds. “It is essential that couples communicate their needs, wants and feelings during the infertility process so they can understand and support each other. For couples seeking infertility treatment, I usually recommend couples counseling — or meeting [together at least one time] with a counselor or their fertility specialist/doctor — so they can explore their fears, hopes and plans. This will hopefully give them a space to communicate their ideas and feelings directly at each other.”

Among women struggling to get pregnant and considering treatment for infertility, feelings of anxiety and even depression can arise, says Thakore-Dunlap, who has undergone training and consultation on the topic of infertility. The anxiety can be related to deciding whether to initiate treatment, the cost of the treatment or the actual process of the treatment itself, she says.

In many cases, a substantial amount of sadness emerges over repeatedly trying to conceive and not being successful, Thakore-Dunlap says. “There’s a lot of self-blame,” she adds. “‘Why me? Why am I broken?’” Clients might also feel resentful that friends or family members seemingly experienced little trouble conceiving and now have children of their own — living, breathing reminders of what these clients are missing and seem unable to have.

“I help women by giving them space in the counseling room to verbalize their feelings of sadness, shame, resentment, etc., and ways they can verbalize this to their partner and family without feeling shameful and broken,” she says. “Many women report that counseling gives them the space to explore their feelings without being judged. In sessions, we explore the sadness in depth, letting them tell their story and being empathic.”

Self-esteem and self-confidence can also take a hit among clients who are undergoing fertility treatments, Thakore-Dunlap says. “Many of [these clients] are very successful women,” she says. “They’re very confident and established in their lives, but they have no control over their fertility, so that creates some anxiety and sadness for them.”

Finding out they’re not pregnant after a fertility treatment can be devastating news to receive, Thakore-Dunlap says. “I give them space to grieve. I take the client’s lead in her next step. Some clients come up with a plan to start treatment again; others take a break.”Thakore-Dunlap says she takes a relational counseling approach with her clients. At the beginning, she might offer a good deal of supportive counseling. Further into their work together, she might introduce some cognitive behavioral techniques to address disordered thinking. “When they think, ‘I can’t do it; I’m not able to,’ especially after they’ve failed at a cycle, I challenge those automatic thoughts and ask them, ‘How can you change those thoughts and turn them around? So the treatment didn’t work. How can I help you, and how can you help yourself?’”Connecting clients with local resources such as support groups and offering them ideas such as stress-reduction techniques can also be helpful, Thakore-Dunlap says. Stress, she says, can affect fertility; for that reason, she also encourages clients to focus on self-care. “It’s so important because if you don’t take care of yourself, you’re not able to reduce the stress and cope,” she says. “Take part in pleasurable activities. You need to if you’re having treatment. It adds a bit of balance.”

Interested in learning more? Click here to read a Counseling Today online exclusive focused on meeting female clients’ needs at midlife and beyond.

To contact the individuals interviewed for this article, email:

Lynne Shallcross is a senior writer for Counseling Today. Contact her at

Letters to the editor: