TPC Journal-Vol 9- Issue 1

58 The Professional Counselor | Volume 9, Issue 1 applying to graduate school to be an occupational therapist. She presents for counseling at a large clinic, asks about sliding scale fees for uninsured clients, and states on her paperwork that she would prefer to see a female clinician, “middle aged or older if possible.” Intake assessments suggest mild to moderate symptoms of depression and anxiety. During the first session, Michelle discloses that she experienced a miscarriage 4 weeks ago. She learned she was pregnant from a home pregnancy test at approximately five weeks gestation, after her menstrual period did not arrive on time. She began experiencing pregnancy symptoms (sore breasts, sensitivity to smells) the next week. When she visited a medical clinic at 9 weeks gestation, pregnancy hormone levels in her blood did not align with the dates of her last period. A transvaginal ultrasound was ordered, and results showed that the embryo had stopped developing at approximately seven weeks, with no visible heartbeat. She was told that the pregnancy was not viable, that she should prepare for “nature to take its course,” and that she should expect to begin bleeding in the coming days. She was told that if she did not spontaneously miscarry in the next week, she would need to undergo a procedure called a dilation and curettage (D&C), during which her cervix would be partially dilated and the pregnancy-related tissue would be surgically removed from her uterus in order to avoid infection and other complications. Michelle described a growing sense of anxiety and sadness upon hearing the news that her pregnancy was not viable. Though she was initially shocked and upset about her unplanned pregnancy, she and Jon had begun to plan for their new identity as a family of three. In the days after her doctor’s appointment, Michelle had two panic attacks—something that had not happened to her since high school. Michelle experienced some painful cramping and spotting one week after her appointment. She called and reported her symptoms, and the nurse scheduled her for a D&C at an outpatient surgery center. She asked what would happen if she did not get the D&C, what to expect from the procedure, and if the D&C posed any risks for future fertility. Her male doctor offered minimal information, stating that the D&C was necessary, that she should not worry, and that the procedure would be “quick, with only mild cramping, if anything.” Jon accompanied her to the surgery center, though per facility’s policies he was not allowed to be in the room during the procedure. She experienced panic symptoms prior to and during the D&C as well as moderately severe pain, and she was reminded of the time in college when she accompanied a friend who got an abortion. In the month since the procedure, Michelle reports a variety of distressing symptoms and situations. Though they were planning a long-term future just weeks ago, she describes a growing distance between her and Jon. He is spending more time going out with friends and does not want to talk about the pregnancy or their relationship. Michelle was unable to work for a week after the surgery, and the missed income is creating short-term financial strain. She reports this would be manageable if not for the multiple medical bills for appointments, labs, scans, and the D&C that are starting to arrive in the mail. Michelle does not currently have health insurance: She was removed from her parents’ plan on her birthday, her employer does not offer benefits, and she has been trying to save money for a few months before starting graduate school and getting a new plan through the university. So far, the bills from the surgery center alone total over $5,000. When the largest of these bills arrived in the mail, Michelle had a panic attack that included chest pain and shortness of breath. During this episode, she convinced Jon not to call an ambulance because of the cost, even though he feared she was having a heart attack. She has also been experiencing inability to sleep, loss of appetite, nightmares, and ruminations focused upon the state of her relationship with Jon, whether she still wants to go to graduate school, whether she could have done anything to prevent the miscarriage, and whether she will be able to have children in the future. She has told a few close