Miscarriage: An Ecological Examination

Jennifer L. Rogers, Jamie E. Crockett, Esther Suess


About one in four women will experience miscarriage of pregnancy, which can be the impetus for significant and persistent psychological distress. Because of cultural norms of silence and minimization around pregnancy loss, as well as a notable lack of scholarship on the topic, counselors may neglect this area in their clinical work. This article describes the relevance of Bronfenbrenner’s ecological systems theory for counselors seeking to account for the numerous variables that may be at play when working with clients who have lost a pregnancy. Using a detailed case example to demonstrate ecologically informed case conceptualization, the authors draw upon practically applicable clinical literature to highlight the possible developmental, relational, cultural, political, and economic impacts of miscarriage.

Keywords: miscarriage, pregnancy loss, Bronfenbrenner, ecological systems, case conceptualization


Miscarriage is defined as the premature loss of pregnancy occurring so early that the embryo or fetus is not viable outside the womb, up to about 23 weeks’ gestation (Mutiso, Murage, & Mukaindo, 2018). Miscarriage is the most common early pregnancy complication, occurring in approximately 15%–20% of known pregnancies, and is usually caused by chromosomal abnormalities in the embryo or fetus (Bardos, Hercz, Friedenthal, Missmer, & Williams, 2015). The estimated rate of loss for both known and unknown pregnancies is 20%–50% (Markin, 2017). Risk of miscarriage declines as a pregnancy progresses, with most occurring in the first 13 weeks of gestation, and 75% occurring in the first 17 weeks (Mutiso et al., 2018). Many women and couples are unaware of the high incidence of miscarriage until, or even after, they experience one (Bardos et al., 2015). In a recent survey assessing public perception of miscarriage in the United States, most participants were mistaken in their beliefs about both the prevalence and causes of miscarriage (Bardos et al., 2015). This widespread misinformation is related, at least in part, to powerful cultural norms of silence around the premature loss of a pregnancy (Markin & Zilcha-Mano, 2018). Despite societal taboo and minimization obscuring both prevalence and impact, approximately one out of every four women will experience a first trimester miscarriage (Wallace, Goodman, Freedman, Dalton, & Harris, 2010). As such, counselors are likely to work with clients who have encountered this specific type of loss.

Women vary in their responses to miscarriage (Trepal, Semivan, & Caley-Bruce, 2005). Some women feel relief upon learning that an unplanned pregnancy will not continue (Wallace et al., 2010), and others consider miscarriage a minimal obstacle to overcome (Engelhard, 2004). Bardos and colleagues (2015) reported that women who had personally experienced miscarriage and men whose partners had one endorsed feelings of guilt (47%), having done something wrong (41%), isolation (41%), and shame (28%), as well as a belief they could have done something to prevent the loss (38%).

Multiple factors influence a woman’s reactions to miscarriage, including how she experienced and ascribed meaning to the loss, her level of psychological distress prior and subsequent to the event, and variables within her environment (deMontigny, Verdon, Meunier, & Dubeau, 2017; Engelhard, 2004; Engelhard, van den Hout, & Arntz, 2001; Shreffler, Greil, & McQuillan, 2011). Many women experience grief after miscarriage (deMontigny et al., 2017; Randolph, Hruby, & Sharif, 2015; Trepal et al., 2005). Half of women grieving after pregnancy loss report clinically significant psychological distress, most commonly manifested as anxiety or depression (Randolph et al., 2015). Of the 30%–50% of women who experience severe symptoms in the 6 months after a pregnancy loss, most can still be described as grieving, and their symptoms often decrease over time (Engelhard, 2004). Identifying those women who are at high risk for intense psychological distress is important in order to facilitate assessment and treatment (Hutti et al., 2018). Predictors of acute and persistent symptoms of depression and anxiety after an early pregnancy loss include pre-existing mental health diagnoses, childlessness, and dissatisfaction with health care received (deMontigny et al., 2017). Given the prevalence of miscarriage and associated risks to psychological well-being, as well as the cultural norms that may influence both clients’ and counselors’ willingness to acknowledge this type of loss as significant enough to warrant assessment and intervention, mental health professionals are advised to seek out knowledge and strategies to inform their work when they encounter clients who are struggling after the loss of a pregnancy (Markin & Zilcha-Mano, 2018).

The aim of this article is to provide a clinically salient and practical overview of the current literature for practitioners, educators, and researchers, as well as to suggest a conceptual lens that may counter counselors’ own assumptions about miscarriage and through which multiple germane variables influencing the client can be seen. In the following sections, we: (1) highlight the dearth of counseling-specific scholarship focused upon early pregnancy loss, (2) briefly review recent practically applicable clinical literature, and (3) describe the relevance of Bronfenbrenner’s ecological model (1979, 1994) as a conceptual tool for counselors seeking to account for multiple systemic factors that may be at play when working with clients who are experiencing psychological distress after miscarriage. We then (4) apply this ecological conceptualization strategy to a case example, demonstrating how one woman’s miscarriage is an important life span event influenced by numerous variables—developmental, relational, cultural, political, and economic.


Miscarriage: Missing in the Counseling Literature

Cultural silence regarding pregnancy loss is noted by multiple authors (e.g., Engelhard, 2004; Markin & Zilcha-Mano, 2018; Randolph et al., 2015; Trepal et al., 2005), and this reticence extends to the counseling literature as well. Our search for the word “miscarriage” in 25 peer-reviewed journals specific to the counseling profession revealed only six articles published in the last 20 years (from January 1, 1998, to August 7, 2018) in which there was more than an incidental mention of the term. A recent qualitative study examined fathers’ lived experiences of miscarriage (Wagner, Vaughn, & Tuazon, 2018). Randolph and colleagues’ (2015) review focused on counseling women who had experienced pregnancy loss; they identified six themes in the literature (silence, grief, psychological distress, the role of social support, satisfaction with health care, and coping strategies) and noted the paucity of counseling scholarship on this topic. Another article discussed grief associated with pregnancy loss, particularly as related to work with infertile couples who had experienced recurrent miscarriages (Stark, Keathley, & Nelson, 2011). Betz and Thorngren (2006) explored family grief around ambiguous losses, with miscarriage mentioned multiple times as an example of such; they described a family counseling model that includes defining the loss, accessing coping resources, and creating a meaningful narrative of the event. Trepal and colleagues (2005) offered an empathy-infused overview of the topic, including conceptual and developmental perspectives and case-specific examples of diverse reactions to this type of loss. Sperry and Sperry (2004) presented a brief review of the literature as related to medical and psychological aspects of miscarriage and ectopic pregnancy, as well as a case example illustrating a therapeutic approach with a married, heterosexual couple who had experienced early pregnancy loss. It is noteworthy that four of the six miscarriage manuscripts that were selected for publication by counseling journals did not focus specifically on women clients, instead examining families (Betz & Thorngren, 2006), heterosexual couples (Sperry & Sperry, 2004; Stark et al., 2011), and male partners’ experiences as part of such a couple (Wagner et al., 2018). Only three of the six focused on miscarriage specifically (Randolph et al., 2015; Trepal et al., 2005; Wagner et al., 2018). The limited literature on this topic can be viewed as a systemic barrier to the development of clinical competence related to pregnancy loss—an isomorphic reflection of the lack of awareness, customs, conversations, and resources related to the experience of miscarriage in our culture. In the next section, we seek to begin to address this gap in the counseling literature by offering a brief review of empirical and conceptual scholarship relevant to counselors working with clients who are struggling after pregnancy loss.


What Counselors Need to Know: Women’s Reponses to Miscarriage

As previously mentioned, women vary in their responses to miscarriage, which may include relief that an unwanted pregnancy is over, resilience in the face of a setback, or deep sadness at the loss of a child (Engelhard, 2004; Trepal et al., 2005; Wallace et al., 2010). Although grief following early pregnancy loss mirrors other grief responses in intensity and duration, it is unique in its focus on the demise of an anticipated future rather than on memories of the past, leaving the griever to create a narrative of this ambiguous loss (Betz & Thorngren, 2006). Feelings of guilt, isolation, and shame are common (Bardos et al., 2015), exacerbated by cultural taboos regarding the expression of perinatal grief and related responses of minimization and dismissal by others (Markin & Zilcha-Mano, 2018). Such taboos and responses are reflected in multiple ecological systems. Historically, the ability to reproduce has been a measure of women’s worth; this, along with the fact that pregnancy loss can be a physically and psychologically disturbing event, may contribute to the long-standing taboo, silence, and a lack of scripts around miscarriage in many cultures and settings (Burnett, 2009; Engelhard, 2004). In light of this, women and couples may struggle to find both outlets to process their stories and resources for coping with the physical, mental, relational, and spiritual dimensions of their loss (Betz & Thorngren, 2006; Randolph et al., 2015; Trepal et al., 2005), highlighting the need for counselor competence in this domain.

Findings from Shreffler and colleagues (2011) support a “social constructionist approach” (p. 353) to understanding the psychological impact of pregnancy loss. Their research showed that women’s beliefs about motherhood, their fertility, and loss; their current desire for a baby; whether or not their lost pregnancy was planned; whether or not they subsequently gave birth to a child; and time since the loss were significant predictors of distress—in other words, a woman’s experience and understanding of her miscarriage within her unique environment is related to her ability to cope with her loss.


Serious and Persistent Responses to Miscarriage

There are subsets of women for whom miscarriage is the catalyst for serious and persistent mental health symptoms (deMontigny et al., 2017; Engelhard et al., 2001; Hutti et al., 2018; Shreffler et al., 2011). Markin (2017) reported that 15%–30% of women have major psychological difficulties after losing a pregnancy and that 10% of these reactions may be classified as diagnosable, including anxiety disorders, depressive disorders, acute stress disorder, substance use disorders, and post-traumatic stress disorder (PTSD). Women already struggling with mental health concerns before their miscarriage, women without living children, women who were dissatisfied with the health care they received related to their pregnancy loss, and women who were traumatized by their miscarriage can be more vulnerable to persistent symptoms (deMontigny et al., 2017; Engelhard, 2004; Engelhard et al., 2001; Shreffler et al., 2011).

The primary foci of most investigations of the psychological impact of miscarriage are depression and anxiety, and studies often do not include trauma-specific assessments (deMontigny et al., 2017; Hutti et al., 2018; Shreffler et al., 2011). Some women, however, are traumatized by the experience of miscarriage: physical pain, distressing amounts of blood and tissue, emergency medical interventions, doubts about future fertility, insufficient support within their microsystem, and the unexpected and unexplained loss of a future child (Engelhard, 2004). The experience of pregnancy loss can represent the devastating demise of a nascent primary relationship with associated destabilizing effects (Markin & Zilcha-Mano, 2018). Some women who have a miscarriage—especially those with higher neuroticism, lower emotional regulation, more negative life events, and who experience dissociative reactions to the event—may meet criteria for PTSD (Engelhard, 2004). In a prospective longitudinal study of PTSD and depression after loss in any stage of pregnancy (including both miscarriages and stillbirths, the latter of which is much rarer and holds a much greater risk for trauma), 25% of participants met criteria for PTSD one month after pregnancy loss, dropping to 7% after four months (Engelhard et al., 2001).

A study by Engelhard and colleagues (2001) is particularly noteworthy for its inclusion of qualitative, first-person participant accounts of both miscarriage and stillbirth. These descriptions offer a window into the potential traumatic nature of such experiences—shedding light on both the stories themselves and the possible origins of cultural taboos around this topic. Such stories underscore the need for timely, sensitive interventions for some women, perhaps similar to work done with individuals who have closely experienced disaster or assault. Meeting diagnostic criteria for PTSD was associated with persistent depressive symptoms after pregnancy loss (Engelhard et al., 2001). This result raises questions as to whether women who were identified as having higher than average levels of depression and anxiety in other studies were experiencing a post-traumatic response. Even when not meeting the diagnostic threshold for PTSD, women may experience trauma-specific symptoms such as re-experiencing, hyperarousal, and intrusive recollections (Engelhard et al., 2001). Diagnosis and treatment planning for women experiencing severe distress can be improved by pushing through cultural norms of silence and minimization and fully assessing clients for trauma responses.


Health Care Experiences During and After Miscarriage

The amorphous psychological vulnerabilities associated with miscarriage exist alongside concrete biological ones; the loss of a pregnancy is, at least in part, a medical event. When appropriately managed, the physical risks of miscarriage are relatively low (Wallace et al., 2010). The first stages occur inside a woman’s body without her immediate knowledge. Quickly, however, there are interpersonal and ecological variables that begin to influence a woman’s experience (Trepal et al., 2005). Bleeding or pain may be the first sign; some women present in the emergency room with these symptoms and find out about both their pregnancy and impending miscarriage at the same time (Wallace et al., 2010). Women may learn that a pregnancy is non-viable at a prenatal medical appointment, based upon routine bloodwork or ultrasound scans. Medical professionals may not receive adequate training about working with patients who are experiencing pregnancy loss. Among a sample of third-year medical students, less than 25% had observed a physician deliver news about a miscarriage during their obstetrics and gynecology rotation (Marko et al., 2015). The high cost of medical care, particularly when not openly discussed with patients, might be another source of marked distress (Ubel, Abernethy, & Zafar, 2013). Culturally condoned minimization of miscarriage can manifest in multiple interpersonal interactions, including those with health care providers, and leave women isolated and disenfranchised in efforts to cope with their loss (Markin & Zilcha-Mano, 2018).

Satisfaction with health care was identified as a theme in the literature on early pregnancy loss (Randolph et al., 2015), and dissatisfaction with the health care received during and immediately after a miscarriage predicted atypically persistent psychological distress more than 2 years after the event (deMontigny et al., 2017). This finding is particularly important for counselors, as the nature of clients’ previous interactions with health care providers may not emerge or be noticed as potentially pertinent in standard biopsychosocial assessments. Dissatisfied patients cite providers’ attitudes and failure to convey awareness, empathy, compassion, information, and suggestions for follow-up related to the emotional impact of the loss (Geller, Psaros, & Kornfield, 2010).

Despite the large number of women impacted by miscarriage and its effects, a shortage of published clinical research in this domain across disciplines has been noted (e.g., Markin, 2017; Randolph et al., 2015). Many existing studies lack empirical or theoretical rigor (e.g., exclusive focus on only certain symptoms, use of very brief interventions that may or may not be performed by trained mental health clinicians, lack of longitudinal follow-up). Our societal classification of miscarriage as primarily a medical matter contributes to a scarcity of psychologically focused scholarship regarding how to fully support women during and after the multi-faceted experience of losing a pregnancy (Markin, 2017).


Understanding Miscarriage: Clinical Application of the Ecological Model

Counselors without specific training focused on awareness of miscarriage and ways to intervene with clients experiencing distress related to it can inadvertently neglect this area in their psychotherapeutic work (Markin, 2017). Engaging in a systemically informed approach to learning about and conceptualizing this highly prevalent life span event is one way to combat cultural silence regarding pregnancy loss. Bronfenbrenner’s (1979, 1994) ecological systems model is firmly situated within the psychological and developmental canon and is a powerful foundation from which to explore and develop systemic thinking skills in students, professionals, and clients. In it, a series of ever-broadening environmental systems influence the development and functioning of individuals (see Figure 1). Some factors related to resilience and distress originate in or are exacerbated by variables in distal systems (meso-, exo-, macro-, and chronosystems); counselors who share these complexities with their clients may help lessen self-directed attribution leading to blame, shame, and guilt (Rogers, Gilbride, & Dew, 2018). Counselors who utilize an ecological approach to understanding clients are less likely to ignore or minimize the many complex and nuanced variables that may influence clients’ experiences related to miscarriage.

During a time in which she may have just begun to grapple with the physical, emotional, and existential ramifications of her pregnancy (e.g., wanting or not wanting the pregnancy, nausea, soreness, fear, joy, what it means to become a mother, plans for the future), a woman who is miscarrying is suddenly beset with biopsychosocial ramifications of loss (Engelhard et al., 2001; Trepal et al., 2005). Awareness, understanding, and exploration of the multiple systemic influences in women’s stories of miscarriage are inherent in an ecological conceptualization of this topic. Williams, McMahon, and Goodman (2015) used ecological systems (Bronfenbrenner, 1979) as the foundation for a pedagogical intervention called eco-webbing, which is intended to develop counseling students’ critical consciousness through the creation of a visual representation of systemic influences in their clients’ lives. Resilience researchers Ungar, Ghazinour, and Richter (2013) expanded upon the traditional nested ecological model through the introduction of the idea of differential impact. This concept suggests that the importance of a given variable is not predicted by its closeness to the individual at the center of Bronfenbrenner’s model; rather, variables existing in the outer levels of the ecosystem may be extremely significant to a specific person in a specific context. Drawing upon this, Rogers and colleagues (2018) proposed the use of an eco-map, a visual representation of environmental variables organized both by systemic level and current salience to the client. Clinical relevance is noted by distance to the client at the center of the map and by the size and ordering of variables within each level. The eco-map for a particular client will change over time, with different variables gaining salience while others recede. This strategy for organizing client information may be of particular use to counselors, educators, and supervisors in search of clinical and teaching tools that counter biased assumptions and capture the complexities of current environments (Rogers et al., 2018).

Figure 1. Bronfenbrenner’s Ecological Model.


Ecologically Informed Clinical Encounters

During clinical encounters with women who have experienced miscarriage, the importance of acknowledgment and validation is emphasized by authors working from a variety of disparate theoretical vantages (Diamond & Diamond, 2017; Markin & Zilcha-Mano, 2018; Wenzel, 2017). Narrative therapy is one recommended approach (Betz & Thorngren, 2006; Stark et al., 2011), with particular focus on clients’ reproductive story (Diamond & Diamond, 2017; Jaffe, 2017). This conceptual construct integrates exploration of the past, present, and future into work with clients who have experienced a reproductive loss, normalizing and validating both acknowledged and unacknowledged reactions to the loss, as well as making space for the client to create a hopeful narrative about the future. Therapeutic exploration of the meaning of the loss, both to the individual client and within broader relational and cultural contexts, is encouraged in order to facilitate client understanding and growth (Diamond & Diamond, 2017; Markin & Zilcha-Mano, 2018; Wenzel, 2017), supporting the utility of the ecological model as a conceptual frame. Ecological conceptualization pairs easily with a wide variety of theoretical approaches to clinical work. It can be used to facilitate a more deeply person-centered encounter, to provide context for adaptive and maladaptive relational strategies at play both in and out of the therapy room, to facilitate existential exploration, and to co-create goals and strategies tied to specific variables. Counselors can infuse ecological conceptualizations and observations into the therapeutic encounter, providing rich opportunities for reflections of meaning, re-framing, and narrative restructuring.

Following a detailed case example describing a client who has recently experienced a miscarriage, the next sections progress through each level of the ecological model (Bronfenbrenner, 1994). After explicating the level, we identify clinically relevant variables from both the literature and the case example and offer clinical implications for counselors working within an ecological framework. An eco-map summarizing ecological variables from the case example can be found in Figure 2.


Figure 2. Eco-map of Michelle.



Case Study: Michelle

Michelle is a 27-year-old woman who lives in a mid-sized East Coast city. She resides with her boyfriend of 3 years, Jon, and is employed as a server at a high-end restaurant. She is currently 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 friends about her situation, but they are confused about why she is not simply relieved to have the unplanned pregnancy no longer be a hindrance to her educational and professional aspirations. She reports that she is close with her parents but has not told them anything. They already disapprove of Michelle and Jon living together because of their religious beliefs, and she does not want to further complicate her relationship with them.


Ecological Conceptualization of Michelle

Individual. At the center of Bronfenbrenner’s model is the individual (see Figure 1). There is a great amount of variability among individual women’s experiences of miscarriage. Baseline physical and mental health, presence or absence of physical and psychological symptoms, the length of the pregnancy, whether or not the pregnancy was wanted, number of prior pregnancies, plans for the future, and the physical experience of the miscarriage are just some of the many variables that counselors should be aware of when working with clients (deMontigny et al., 2017; Shreffler et al., 2011).

Though Michelle’s pregnancy was unplanned, she demonstrated resilience and flexibility regarding the news and had begun planning for her future as a mother. She may be mourning the loss of this new life and identity (Betz & Thorngren, 2006). Her pregnancy symptoms were caused by shifting hormones; her current physical and psychological symptoms may be influenced by her hormonal levels returning to a non-pregnant state. She has a history of panic attacks from 10 years prior, and this pattern reemerged upon learning that her pregnancy was non-viable. She has undergone a series of invasive medical procedures, including transvaginal ultrasound, dilation of her cervix, and surgical removal of tissue from her uterus, as well as unexpected pain. Michelle’s surprise over her pregnancy, her adaptive response to it, the unanticipated miscarriage, and her resultant novel physiological and medical experiences have coalesced into an overwhelming intrapersonal incident. Conveyance of a caring and nonjudgmental stance around these variables, as well as normalizing her reaction to a series of physically and existentially significant life span events, is essential to creating a clinical space where she can freely explore her unique experience (Trepal et al., 2005). Knowledge on the part of the counselor around what many find to be a taboo topic may serve to both normalize the experience and highlight its uniqueness to this client at this moment in her life.

Microsystem. Per Bronfenbrenner (1979, 1994), the microsystem is made up of the person-to-person engagement that an individual experiences in their immediate environment. These interactions, and the relationships associated with them, hold tremendous sway through encouraging or discouraging an individual’s behaviors. There is a deep body of research examining the influence of relational patterns on human development and psychological functioning (Bronfenbrenner, 1994). It is within our relationships that we learn whether it is safe or unsafe to be unguarded and authentic in our environment (Ainsworth, Bell, & Stayton, 1972; Miller, 1986). As such, variables in the micro-level are of utmost importance when assessing, conceptualizing, and working with clients who have lost a pregnancy. Counselors should be aware that some clients do not tell anyone about the pregnancy, tell only a select few people in their microsystem, or share the news more broadly. Although women experience more support when loss is public (Betz & Thorngren, 2006), many are dissatisfied and distressed by others’ response to their loss (Geller et al., 2010; Randolph et al., 2015). Medical professionals may inadvertently minimize the experience (deMontigny et al., 2017; Geller et al., 2010). They and others in the client’s microsystem may project their own emotional reactions (e.g., grief, relief) or processes (e.g., minimization, spiritual bypass) onto the client.

Over the last 2 months, there has been much clinically noteworthy activity within Michelle’s microsystem. There were marked shifts in her relationship with her romantic partner: a growing intimacy with energy focused on a long-term future together, followed by a distancing that includes new behavior patterns that did not exist before her pregnancy. Though she reports closeness with her parents, she has chosen not to disclose news of her pregnancy or miscarriage to them because of her predictions regarding their reaction, suggesting a current lack of transparency in relationships that had previously been a source of support. Michelle reports a perceived lack of empathy from her close friends, who do not understand her response to the miscarriage. Similarly, her experience of pain during her surgery was not the response predicted by her physician.

Michelle’s sense of disconnection in her microsystem may be related to feelings of shame. Shame is a documented reaction to losing a pregnancy (Bardos et al., 2015). Women may feel ashamed that their body did not carry the pregnancy to term or that they are responding differently than they imagine others have responded to such a loss. Shame has been described as a sense of unworthiness to be in authentic connection with others, based upon previous experiences of disconnection or hurt in relationships (Miller, 1986), such as those that Michelle has recently experienced. Her growing sense of isolation within her microsystem is of utmost clinical importance. Her request for an older woman therapist can be understood as evidence of her resilience and ability to care for herself—she is seeking to enrich her microsystem via connection with a new person who is more likely to be empathic and validating than those currently within this sphere.

Mesosystem. The mesosystem is the system of microsystems in an individual’s life, describing interactions between environments (Bronfenbrenner 1979, 1994). Michelle describes her relationship with her parents as close, but the interactions between the system she currently lives in (Michelle and her boyfriend) and her family of origin are not without tension. She reports that her parents disapprove of her living with Jon. Based upon this, she has not told them about her pregnancy or miscarriage. Is this an example of healthy boundaries between the couple and Michelle’s parents, or are there other aspects of this system-to-system relationship in which Michelle feels torn between the norms of one system versus the other?

Questions also arise regarding the communication with and between her medical providers. Her physician minimized her concerns, and his prediction about the amount of pain she would experience during the procedure proved inaccurate. Assuming the surgical center has greater knowledge about the variability of patient responses to such procedures, could better channels of communication between the center and offices of referring physicians promote increased patient understanding regarding what they might expect? Was Michelle’s doctor aware of her history of anxiety, and was this communicated to the surgical center? If so, in what way? An ecologically informed counselor might request permission to facilitate communication between Michelle’s health care providers, so as to best serve the client and to model how advocating for such interactions might be helpful to her in the future.

Exosystem. Bronfenbrenner’s exosystem (1979, 1994) is similar to the mesosystem in that it describes interactions between two or more environments, except that the individual of interest is not present in at least one of them. This construct captures how a setting or system can have observable influence over an individual’s experience, even though a person may not ever have direct contact with it. There are multiple exosystem variables evident in Michelle’s story at intake, and more would likely emerge during the course of clinical work. For example, her current economic challenges are having a profound effect on her well-being. Michelle’s removal from her parents’ health insurance plan, her medical providers’ fees for services, and her employer’s guidelines (backed by federal and state law) regarding lack of health insurance and medical leave options for hourly employees are all examples of how the policies and actions of a seemingly distant entity can have profound consequences for an individual.

It is possible that Michelle’s physician did not receive specific training regarding communication with patients about miscarriage (Marko et al., 2015). In the absence of training and protocols that acknowledge the great variability in women’s responses to pregnancy loss, including the individual variables that influence reactions and preferences for the type of care received, medical providers may make incorrect assumptions regarding their patients’ needs and experiences. Furthermore, given the current economics of the U.S. health care system, even those providers who might like to offer a more patient-centered approach to care are pressed for both time and resources. In Michelle’s case, the information she received from her physician was likely informed by his training and the norms of the clinic where he is employed, but she experienced more physical pain during her procedure than she had been told to anticipate, exacerbating her feelings of fear and powerlessness.

Michelle is an uninsured patient who has experienced both an unplanned pregnancy and an unexpected loss; the medical organizations that have been involved in her care have not expressed awareness or concern regarding the health ramifications of their fiscal policies and procedures, a common practice in the U.S. health care system (Ubel et al., 2013). Michelle’s current distress is largely focused on her fears around her growing medical debt, which she conceptualizes as a problem that is hers alone. Sharing an ecologically informed conceptualization of this issue during the course of counseling, including the complex influence of systems on her current situation, may help broaden her view regarding both her level of personal responsibility and possible avenues for solving the problem. For instance, she may recognize that the billing department’s processes are likely automatic and choose to contact them (thus bringing them into her microsystem) in order to explain her situation and inquire about manageable payment plans and possible bill adjustments for uninsured patients.

Macrosystem. The macrosystem encompasses the societal context in which an individual exists, including elements such as laws, economics, and social norms (Bronfenbrenner 1979, 1994). The cultural environment is rich with variables that affect intra- and interpersonal experiences, and the macrosystem can hold much influence over how situations in a person’s life are understood and acted upon—even though individuals may not be aware of its effect. There are multiple influential macrosystem-level factors at play in Michelle’s situation. The cultural taboo around miscarriage—including the lack of general knowledge around causes and prevalence (Bardos et al., 2015) and the lack of traditional behaviors for both women experiencing miscarriage and those whom they tell about the loss (Trepal et al., 2005)—are woven throughout her story. Jon’s need for distance in their relationship may be a manifestation of a number of macro-level factors, including the taboo around the topic and the more general cultural expectations regarding masculine avoidance of painful emotions and the imperative for men to disguise a lack of knowing what to do in a given situation. Religion, another pervasive cultural force, influences Michelle’s parents’ conceptualization of her decision to live with her romantic partner, thus affecting microsystem relationships and the mesosystem interactions between those systems. Religious and other deeply held personal beliefs (e.g., how miscarriage should be addressed—or not addressed—per the norms of a specific culture) were likely at play in many of the interactions Michelle has experienced since the loss of her pregnancy.

Michelle’s removal from her parents’ health insurance plan upon turning 27 is deeply influential; this occurrence is one based upon laws that were enacted amidst a complex economic and political environment. Through a systemic lens, the quality and cost of her health care without insurance, as well as the cost of her upcoming graduate education, can be conceptualized not merely as facts, but rather as products of a dynamic and complex ecology. In this way, Michelle’s difficulties are not hers alone, but those of a much larger system. When ecologically framed, questions arise regarding the expectation that an individual should or even could be able to grapple with such situations in a vacuum. Through this lens, her economic anxiety may be seen as a normative and appropriate response, rather than as a symptom to overcome.

Research indicating the importance of patients’ perceptions of their health care and its relationship to ongoing distress after miscarriage (deMontigny et al., 2017) supports the notion that Michelle’s dissatisfaction with some elements of her medical care and her current mental health symptoms are not unrelated. These micro- and macrosystem interactions also occurred within a broader cultural context. In a recent exploration of the status of women physicians within the field of obstetrics and gynecology, Hughes and Bernstein (2018) noted:

Physicians are social creatures raised within a society with historical roots founded on patriarchy and a system in which men, particularly white men, have disproportionate power. People living today did not create this system, but all of us perpetuate it to some degree, usually without realizing it. (p. 365)

In Michelle’s case, the minimization of her miscarriage—including her doctor’s incorrect predictions about her pain level and a lack of assessment related to her emotional response to her pregnancy loss and related procedures—seems to have exacerbated her distress. Michelle may have benefited from expressed empathy and discussion both normalizing and educating her about the wide variety of biopsychosocial reactions to miscarriage (e.g., pain, relief, grief, guilt, anxiety, depression, trauma), as well as a collaborative conversation about her choices and the risks and benefits of her options, including costs. The lack of such discussions stems at least in part from macrosystem-level sexism that silently minimizes women’s experiences, thus placing the responsibility for the distress on the individual rather than spreading it throughout the system.

Chronosystem. The chronosystem in Bronfenbrenner’s (1994) ecological systems theory captures the role of time within environments. Specific events and developmental transitions that occur over the course of an individual’s life span and the parallel unfolding of sociocultural history are included in this level. Women’s personal histories of trauma, previous pregnancy losses, and concerns about future fertility (Engelhard, 2004; Shreffler et al., 2011) are significant variables identified in the miscarriage literature that may be understood more deeply when placed within the time-dependent chronosphere. For Michelle, her pregnancy and subsequent miscarriage occurred at a time in her life when her focus was on plans for furthering her education, not on having children. However, she quickly found herself developing a new facet of her identity—that of a future mother. This unexpected life span event may have triggered changes in her concept of self, including her assumptions about how, when, and if she might become a parent. This transition, followed by the existentially activating event of the miscarriage, has caused Michelle to question many other of her previous assumptions; she feels unable to simply return to her original plans.

Michelle’s personal experience is unfolding during a time of burgeoning national awareness regarding multiple areas of instability and injustice in our culture. Specific to Michelle at this point in both her individual life and in history are concerns about the present and future as related to economics (medical bills, upcoming costs of graduate school), health care (availability, quality, cost; her chosen future career in the health care field), and gender (her experiences of becoming pregnant, miscarrying, and exploring what it might mean to become a mother; awareness of how sexism and gender stereotypes may have influenced these experiences). An ecologically attuned counselor can utilize the construct of the chronosystem to highlight Michelle’s development as a person within the context of historic developments. Framing of her self-concerns (e.g., debt, lack of empathic responses) alongside societal-level concerns (e.g., economic instability, hostile and benevolent sexism) suggests a universality in her individual experiences and offers an explanation for the depth of her responses—her problems are not just significant within the arc of her own life, but are examples of significant events within the arc of history as well.



Miscarriage is a highly common life span event that is shrouded by misinformation and silence regarding its prevalence, causes, and associated outcomes (Bardos et al., 2015; Wallace et al., 2010). This opacity also is evidenced in the paucity of counseling scholarship that includes mention of miscarriage, much of which focuses on the early loss of a pregnancy as a challenge experienced by heterosexual couples en route to parenthood (Sperry & Sperry, 2004; Stark et al., 2011; Wagner et al., 2018). Women’s reactions to miscarriage are varied and unique, influenced by a multitude of variables (deMontigny et al., 2017; Engelhard, 2004; Engelhard et al., 2001; Shreffler et al., 2011). Some women experience clinically significant and persistent psychological distress subsequent to miscarriage (deMontigny et al., 2017; Hutti et al., 2018). Dissatisfaction with health care among women is widely reported, and research indicates a need for improved biopsychosocial care for women after miscarriage, which would fulfill women’s stated needs regarding acknowledgment, validation, education, and resources (Geller et al., 2010). The necessity of system-to-system communication between medical and mental health services, as well as for emotional support provided by clinicians who have knowledge of the complex potential ramifications of miscarriage, is evident. Such care could improve outcomes for many women, particularly those who are vulnerable to clinically severe and persistent distress.

Counselors’ education, theoretical leanings, cultural beliefs, and personal experiences influence their understanding of clients. A lack of both societal norms and clinical training regarding helpful ways to intervene with women who have experienced miscarriage may lead to challenges for clinicians. Clients with a history of miscarriage may or may not view the experience as important in their own story, but—particularly given the documented prevalence of silence, distress, and dissatisfaction around responses to this common life span event (Randolph et al., 2015; Trepal, 2005)—its possible clinical salience for individual clients warrants both inclusion in standard counseling assessments and therapeutic attention, according to the goals and needs of the client. It is important for counselors to: (a) be aware of the possibility of serious and persistent distress related to miscarriage; (b) thoroughly assess clients around this topic, despite cultural norms of not mentioning or minimizing pregnancy loss; and (c) have knowledge of the myriad of risk and protective factors around this issue, as well as recommended strategies for working with such clients.

The counseling profession has recognized that advocacy to diminish systemic impediments to our clients’ growth is an ethical and clinical imperative (Ratts, Toporek, & Lewis, 2010). When viewed through an ecological lens, the current literature on pregnancy loss describes the influence not just of individual- and microsystem-level variables (e.g., premorbid anxiety disorder, unsatisfying interactions with medical professionals), but also the influence of distal system interactions (e.g., health care policy, cultural norms). Politics and economics are inherent in health care, both of which are deeply influenced by cultural beliefs and historical context. Awareness of ecological variables when understanding a woman’s reaction to her miscarriage—the attitudes conveyed by the individuals in her immediate sphere, as well as the practices and policies enacted by those outside it—may provide the foundation for a more complex and deeply person-centered approach to counseling.

Although the complex definitions of Bronfenbrenner’s levels (1994) may not be of use or interest to many clients, learning to think about oneself and one’s experiences as occurring within a nuanced ecology is a valuable skill. The ability to self-conceptualize ecologically can transfer to multiple domains beyond the counseling office. Counselors may choose to share elements from their ecological conceptualizations with clients directly, both to check in regarding possible salience to the client and to demonstrate systemic thinking as useful cognitive strategy.

As people become more aware of the complexity of the systems in which all experiences are embedded, issues related to social justice and advocacy will naturally emerge (Rogers et al., 2018). Ecologically attuned counselors may feel called upon to seize opportunities for systemic-level interventions, using their awareness of complex systems and relational expertise as a foundation for actions that extend beyond their work with individual clients. In turn, as clients experience authentic connection based upon being deeply understood by their counselors, they may reap therapeutic benefits by using their growing awareness of the interplay between experience, relationships, and systems to take action outside the therapy room (Miller, 1986).



Miscarriage is a common life span event that can be the impetus for persistent mental health concerns. Distress may be exacerbated by non-supportive cultural norms that are both internalized by the client and systemically manifested. By utilizing established models that account for the influence of variables throughout the environment in which a person exists, counselors are more likely to consider the wide variety of factors that may be affecting an individual client. Bronfenbrenner’s bioecological model (1979, 1994) places individuals within complex ecosystems and posits that even interactions between system-level variables not directly connected to a person still influence their experience and development. We propose that an ecological assessment of the variables impacting the client as related to her miscarriage can counter culturally learned avoidance and facilitate complex, nuanced conceptualizations and interventions around the unique biopsychosocial issues that may emerge related to pregnancy loss. Research is needed to further examine women’s experiences of miscarriage and the processes and outcomes of miscarriage-specific counseling interventions. An investigation of the validity and the utility of the proposed conceptual model is just one example of the many areas rich with potential for further inquiry. Future scholarly endeavors on this important topic may ultimately improve awareness, visibility, knowledge, resources, and care for the many women who endure miscarriages during their lifetimes.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Jennifer L. Rogers, NCC, is an assistant professor at Wake Forest University. Jamie E. Crockett, NCC, is an assistant professor at Wake Forest University. Esther Suess, NCC, is a counselor at the Mood Treatment Center in Winston-Salem, NC. Correspondence can be addressed to Jennifer Rogers, P.O. Box 7406, Winston-Salem, NC 27109, rogersjl@wfu.edu.

Resolving Value Conflicts With Physician-Assisted Death: A Systemic Application of the Counselor Values-Based Conflict Model

Nancy E. Thacker, Jillian M. Blueford

Counselors are becoming more involved with clients pursuing physician-assisted death (PAD) as legislation for legalization increases. PAD may present complex values-based conflicts that can challenge counselors to maintain ethical practice in counseling. When conflicts arise, counselors must engage in ethical decision making that considers systemic influences on personally held beliefs and values. The authors merge ecological systems theory with the counselor values-based conflict model to offer a holistic approach to resolving values-based conflicts surrounding PAD. In this article, the authors review PAD and counselors’ roles in the hastened death process, discuss sources and impacts of personal and professional values through an ecological systems lens, and provide an applied method of managing values-based conflicts with PAD through a case illustration.

Keywords: physician-assisted death, hastened death, values-based conflict, ethical decision making, ecological systems

Individuals with terminal illnesses encounter difficult end-of-life decisions amidst experiencing physical and emotional distress (Daneker, 2006). Currently in six U.S. states and Washington, DC, terminally ill individuals have a legal right to end their lives via physician-assisted death (PAD). As legislation for legalization of PAD increases, more terminally ill patients can consider PAD as an option (Miller, Hedlund, & Soule, 2006). As a result, the need for mental health professionals to assist individuals dealing with these end-of-life decisions is on the rise.

The topic of death presents complex questions about the meaning of life and death and evokes reflections on one’s personal beliefs and values surrounding death and dying (Yalom, 2009). Terminally ill individuals may confront their personal beliefs about a morally just or good death, explore feelings about the process of dying, and consider their levels of personal control or power in their processes of dying (Laakkonen, Pitkala, & Strandberg, 2004; Yalom, 2008). Religion and spirituality often contribute to terminally ill individuals’ beliefs and values surrounding death and dying and can influence end-of-life decisions (Reiner, 2007). Each personal belief and value is influenced by systemic factors, cultural experiences, and cultural customs or expectations that play a role in end-of-life decision making (Laakkonen et al., 2004; Neimeyer, Klass, & Dennis, 2014).

Counselors will confront their beliefs and values about death and dying as terminally ill individuals who are contemplating PAD (PAD clients) seek counseling to explore end-of-life decisions (Werth & Crow, 2009). If counselors’ beliefs and values conflict with PAD clients’ beliefs and values, or PAD itself, then it may present an ethical dilemma that challenges the quality of care counselors provide (Heller Levitt & Hartwig Moorhead, 2013). Although not all counselors may experience a value conflict related to PAD, those who do experience a conflict may look to the American Counseling Association’s (ACA) Code of Ethics (2014) and an ethical decision-making model that accurately addresses the values-based nature of the ethical dilemma at hand.

Multiple scholars have discussed the need to explore values related to personal conflicts to maintain ethical practice in counseling (Cottone & Tarvydas, 2016). However, few sources have yet to provide direction for counselors on how to resolve personal values-based conflicts regarding PAD. There is an added layer of difficulty with PAD clients because of the multifaceted nature of personal and professional values at play. Counselors are grounded on the ethical principles of promoting client autonomy and respecting cultural differences in decisions (ACA, 2014), but hastening death conflicts with the counseling profession’s inherent stance to “first do no harm” and to maintain client safety and preserve life when clients desire to end their lives (Cohen, 2001). Even though hastening death is legal in certain states, values surrounding the decision to end life do not simply cease because there is justified reasoning for a decision. Thus, counselors face a challenging dichotomy between law and values in their practice with PAD clients.

Recent changes in the counseling profession’s ethical code also contribute to the potential challenge of maintaining ethical practice with PAD clients. The ACA Code of Ethics (2005) included codes that addressed counseling practice with clients considering end-of-life options. Section A.9 in the ACA Code of Ethics (2005) provided guidelines about the quality of care counselors should uphold for clients facing the end of their life, including the counselor’s role in assisting clients with end-of-life decisions. Counselors were tasked with the responsibility to reflect upon personal values and morals regarding end-of-life to ensure competent and ethical care. Although the revised ACA Code of Ethics (2014) includes considerations for confidentiality, legal concerns, and client safety during end-of-life care, there is no longer a designated section for the end-of-life care of terminally ill clients, and explicit codes regarding PAD are absent. The ACA Code of Ethics (2014) included guidelines for counselors regarding methods to maintain client autonomy and seek continuing education to address the holistic needs of clients, along with giving clients the tools necessary to make the most appropriate decisions for their care. However, lack of explicit codes about PAD and few guidelines related to end-of-life care might cause ambiguity when values-based ethical dilemmas about PAD arise.

In summary, consideration for counselors’ personal and professional values, along with the ethical and legal implications at hand, creates unique potential for a values-based conflict surrounding PAD unlike other sources of values-based conflicts. Values are influenced by numerous factors in multiple settings and contexts (Heller Levitt & Hartwig Moorhead, 2013). Therefore, resolving value conflicts related to PAD warrants a unique systemic perspective that considers the multiple influential sources that shape values about death and grief in personal and professional realms (Neimeyer et al., 2014).

The authors of this article review PAD, counselors’ roles in the hastened death process, and an applied method of managing values-based conflicts with PAD through a values-based ethical decision-making model and ethical bracketing. The impacts of personal and professional values will be described through an ecological systems lens. It is important for counselors to understand PAD in the context of various systems, as individuals’ decisions concerning PAD are influenced by multiple sources that contribute to their beliefs and values related to death and dying.

Physician-Assisted Death

PAD is currently legal in six U.S. states: California, Colorado, Montana (by court ruling), Oregon, Vermont, and Washington, as well as Washington, DC (Death with Dignity, 2018). Hawaii will become the seventh state to legalize PAD when their legal statute takes effect in January 2019 (Death with Dignity, 2018). PAD has been a topic of debate throughout American society and health care for decades (Werth & Holdwick, 2000). Many have voiced opposition to PAD as a legalized option (Werth & Holdwick, 2000), and previous “standards of mental health practice [have treated] all suicides as products of mental illness” (Cohen, 2001, p. 279). However, health care advocates of PAD, such as Dr. Jack Kevorkian, have fought for individual rights to choose dignified death when faced with terminal illness (Kevorkian, 1991). As the legalization of PAD emerged in the aforementioned states, the topic of debate shifted from the right to choose hastened death toward the policies that guide health care professionals to assist terminally ill individuals in hastening their deaths (Werth & Holdwick, 2000).

Language within each state statute slightly varies, but requirements to legally hasten death are similar across states. There are no formal requirements for PAD in Montana, because a law permitting PAD does not exist in that state; however, there is a legal precedent that protects physicians from prosecution as long as there is written consent from the patient (Baxter v. Montana, 2009). For all other states, patients must be over the age of 18, permanent residents of the state, have been determined by an attending and consulting physician to be suffering from a terminal illness, and carry a life expectancy of under 6 months to be eligible to legally hasten their deaths. Patients must voluntarily express their wishes to die orally, make a written request for medication to end their lives in a humane and dignified manner, and be deemed mentally competent to make end-of-life decisions by a licensed psychiatrist or psychologist. In addition, there is typically a 15-day waiting period between the initial request and when the physician provides a written prescription for medication to end life (Death with Dignity, 2018).

In the legal requirements of each state and district statute, there is no mandate for counseling services beyond an assessment of competency. However, PAD clients and their families often work with mental health professionals throughout the process of considering hastened death and implementing PAD (Fulmer, 2014). As more states move toward legislation to legalize PAD, counselors are becoming more involved in the interdisciplinary teams of health professionals working to meet the needs of this population. Interdisciplinary teams may be comprised of medical physicians, psychiatrists, psychologists, social workers, palliative care nurses and specialists, occupational therapists, and mental health counselors (O’Connor & Fisher, 2011). Clients pursuing PAD have physical, social, emotional, spiritual, and practical needs as they deal with the process and experience of dying (Daneker, 2006). Helping professionals’ roles can be blurred as the interdisciplinary team works together to meet PAD clients’ needs (O’Connor & Fisher, 2011). Physical needs include keeping clients comfortable in their final months of life when all other treatment options are exhausted. Practical needs include making arrangements for after death and navigating the legal processes to hasten death, including the competency assessment a psychiatrist or psychologist must conduct to ensure that PAD clients are stable and well-informed enough to decide to hasten their death (O’Connor & Fisher, 2011). Clients’ social, emotional, and spiritual needs will vary depending on the nature of the terminal illness, individual contexts, and familial and cultural contexts; counselors are trained to address such biopsychosocial needs within clients’ individual and cultural contexts (Peruzzi, Canapary, & Bongar, 1996; Werth & Crow, 2009).

A counselor’s primary role is to address how clients’ medical diagnoses are impacting their biopsychosocial well-being, including their decision-making processes to hasten death (O’Connor & Fisher, 2011; Peruzzi et al., 1996; Werth & Crow, 2009). Counselors build a unique therapeutic relationship that provides professional emotional support, and they help clients reflect on the factors that have led them to make this life-ending decision. They may explore what hastened death means to clients’ families or communities. Counselors also seek to understand how clients’ spiritual beliefs and emotional needs influence their well-being and decision making. Counselors recognize that spirituality and religious practices can be significant to clients when discussing dying, death, and grief (Altmaier, 2011). Addressing these factors allows counselors to be intentional in creating a safe setting for difficult discussions.

Standards of Counseling Practice With Dying Clients

The ACA Code of Ethics (2014) not only serves as a guide to ethical practice in counseling, but also provides an understanding of the goals and mission of the counseling profession. Counselors are committed to engaging in “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health [and] wellness” (ACA, 2014, p. 3). In order to engage in such a relationship with ethical integrity, counselors consider the six principles of ethical behavior: autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity (ACA, 2014). These principles are foundational to the ways in which counselors practice ethically across diverse client groups and settings. Counselors working with PAD clients should review relevant ethical codes concerning end-of-life issues, personal value conflicts, and confidentiality concerns pertinent to fulfilling the needs of terminally ill clients. Of these relevant issues, one specific code includes guidance in managing personal values in counseling:

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors.
Counselors respect the diversity of clients . . . and seek training in areas in which they are at risk
of imposing their values onto clients, especially when the counselor’s values are inconsistent with
the client’s goals or are discriminatory in nature. (ACA, 2014, A.4.b)

As counselors confront the socioemotional and spiritual needs of PAD clients, regulating personal values related to PAD is of utmost importance for the well-being of a dying client (Werth, 1999).

Values and PAD

Personal values exist at individual, professional, and societal levels. Counselors develop and mold their values in multiple contexts and through various experiences in their lifetime. Thus, counselors’ values surrounding death, dying, and PAD are multifaceted and influenced by multiple factors. Counselors’ views and values surrounding death may be impacted by age, race, gender, religion or spiritual beliefs, phase of life, family structure and influence, cultural identity (e.g., individualistic vs. collectivistic), and education (Bevacqua & Kurpius, 2013; Harrawood, Doughty, & Wilde, 2011; Kemmelmeier, Wieczorkowska, Erb, & Burnstein, 2002). How these factors are interwoven into personal views and values depends on counselors’ perceptions of their experiences and influences from their surrounding environments.

Because personal values are constructed and influenced by a multitude of factors and environments (Heller Levitt & Hartwig Moorhead, 2013), a systemic perspective can be used to appropriately explore and understand how personal values may form and influence counselors. Bronfenbrenner (1979) established the ecological model to describe an individual’s development within four ecosystems: the microsystem, mesosystem, exosystem, and macrosystem. In 1994, Bronfenbrenner revised the ecological model to include the chronosystem, which considers the influence of time and history as individuals develop. Each ecosystem interacts with the others and influences how each ecosystem forms and impacts the developing individual. The ecosystems can be understood as “a set of nested structures, each inside the next, like a set of Russian dolls” (Bronfenbrenner, 1979, p. 3). Next to the chronosystem, the outermost system, the macrosystem encompasses one’s culture, societal norms, and traditions. The exosystem lies within the macrosystem and represents the interactions between environments that may or may not directly affect an individual’s daily interactions. An example of this system would be a parent having trouble at work, and that stressor then affecting the relationship with the child. Within the exosystem is the mesosystem. The mesosystem includes the interactions between the individual’s microsystem and has direct effects on the individual. Lastly, the microsystem involves the individual’s immediate settings and relationships. Relationships can include family and caregivers among others in the environment. Each of these ecosystems and the interactions between them impact the developing individual’s behaviors (Bronfenbrenner, 1979).

Within a systemic ecological perspective, beliefs and values can be viewed as forming and ensuing through layers of influence first from the macrosystem and filtered down through the exosystem, mesosystem, and microsystem (Bronfenbrenner, 1979). The chronosystem includes a history of culture that influences development over time, but the cultural expressions of such influence play out in the macrosystem (Bronfenbrenner, 1994). The macrosystem, the most external of systemic influence, can include societal norms of death and dying and a religious or spiritual belief system. These norms and belief systems influence the exosystem, where laws and regulations exist (e.g., the right for individuals to hasten death in legalized states). Events that occur in the exosystem might not directly include counselors, but they impact the ways in which counselors interact with their lower systems (e.g., news reports of terminally ill patients miraculously overcoming illness).

Through the mesosystem structure, counselors directly engage with multiple settings that influence their beliefs surrounding death and dying (e.g., work and family). Counselors’ interactions with two settings, such as workplace and family, will shed light onto how beliefs, values, and behaviors about death and dying are experienced in each setting. Counselors’ values are subsequently influenced by the interactions between the two settings. Finally, direct experiences in counselors’ immediate settings, the microsystem, impact the unique views and values counselors espouse. Although values filter through larger systems with influence from external factors that impact multiple people, counselors will form distinct perceptions of their experiences that inform their intrapersonal reactions to death and dying (Werth & Crow, 2009).

As counselors consider each layer of the surrounding environment that informs their personal values, they face the values of the counseling profession in the mesosystem. The ACA Code of Ethics (2014) highlighted five fundamental professional values:


  1. enhancing human development throughout the lifespan;
  2. honoring diversity and embracing a multicultural approach in support of the worth, dignity,
    potential, and uniqueness of people within their social and cultural contexts;
  3. promoting social justice;
  4. safeguarding the integrity of the counselor–client relationship; and
  5. practicing in a competent and ethical manner. (p. 3)


These values provide a foundation for counselors’ ethical behaviors and decisions and inform the collective identity of the counseling profession.

Counselors first encounter professional values in their training programs and are continually exposed to new expressions of professional values throughout their careers. Counselors are nurtured throughout their development to integrate their personal attributes with professional factors as they form an identity congruent with the counseling profession (D. M. Gibson, Dollarhide, & Moss, 2010; Post & Wade, 2009). The ways in which counselors integrate professional values and develop their identities depends on the culture of their training programs, professional work settings, experiences in those settings, and individual perceptions that form from those experiences (Francis & Dugger, 2014). As a result, counselors may vary in their level of support for PAD, personal conflicts related to PAD, and general beliefs and values about death and dying. Therefore, counselors must evaluate their values at a personal and professional level as they work through value conflicts and ethical dilemmas with PAD clients (Johnson, Hayes, & Wade, 2007).

Ethical Decision Making and Bracketing

Counselors’ abilities to resolve value conflicts are determined through ethical decision making (Cottone & Tarvydas, 2016; Kocet & Herlihy, 2014). The ACA Code of Ethics (2014) serves as a guide to counselors to uphold equitable standards of care across client populations when ethical dilemmas and value conflicts arise. According to ACA:

When counselors are faced with ethical dilemmas that are difficult to resolve, they are expected to
engage in a carefully considered ethical decision-making process, consulting available resources as
needed. Counselors acknowledge that resolving ethical issues is a process; ethical reasoning
includes consideration of professional values, professional ethical principles, and ethical
standards. (ACA, 2014, p. 3)

Becoming an ethical decision maker is most effectively done through practice in intentional decision-making processes (P. A. Gibson, 2008). There are many ethical decision-making models that are relevant to maintaining ethical integrity during a variety of dilemmas (Cottone & Tarvydas, 2016). Counselors most often use practice-derived models that are produced from counselors’ experiences and are intended to provide a step-by-step guide for practice (Cottone & Tarvydas, 2016). Although each model is distinct in its step-by-step process, there are common elements throughout them that highlight a standard of practice for ethical decision making. Significant commonalities include gathering information; considering the context of the situation; reviewing codes, standards, and laws; evaluating the counselor’s values or biases; consultation; developing a plan; and executing the plan. For counselors working with PAD clients, their decision-making processes will require a more in-depth exploration of the context of the situation, counselors’ values and biases, and the counseling profession’s values (Heller Levitt & Hartwig Moorhead, 2013; Kurt & Piazza, 2012). Thus, a decision-making model that carefully considers values-based conflicts is needed.

Using a practice-derived framework, Kocet and Herlihy (2014) developed the counselor values-based conflict model (CVCM) to specifically address ethical dilemmas stemming from value conflicts. The model includes five steps: (1) determine nature of values-based conflict (personal or professional); (2) explore core issues and potential barriers to providing appropriate standard of care; (3) seek assistance/remediation for providing appropriate standard of care; (4) determine and evaluate possible courses of action; and (5) ensure that proposed actions promote client welfare (Kocet & Herlihy, 2014). Each step includes consideration for potential personal and professional values that may arise for counselors.

A key part of resolving values-based conflicts is avoiding imposing one’s values onto the client. To address this key issue, Kocet and Herlihy (2014) also introduced the term ethical bracketing. Ethical bracketing in qualitative research is “a reflexive process [that] enables [researchers] to bracket or set aside their own experiences and assumptions when they interact with their participants and thus accurately capture their participants’ voices” (Kocet & Herlihy, 2014, p. 182). To apply this concept to counseling, Kocet and Herlihy stated that ethical bracketing

is defined as the intentional separating of a counselor’s personal values from his or her
professional values or the intentional setting aside of the counselor’s personal values in order to
provide ethical and appropriate counseling to all clients, especially those whose worldviews,
values, belief systems, and decisions differ significantly from those of the counselor. (p. 182)

Counselors can engage in ethical bracketing by seeking supervision, consultation, continuing education, and personal counseling (Kocet & Herlihy, 2014). This bracketing technique allows counselors to confront their values and establish awareness of how their values may be impacting their views and interactions with clients. Counselors may more easily recognize the unique worldviews of clients through this process, thereby respecting the diversity of clients in their cultural contexts. Such recognition protects the welfare of clients as counselors strive to work from the client’s worldview rather than their own (ACA, 2014). The CVCM, along with ethical bracketing, can be used as a guiding ethical decision-making framework for counselors to explore the systemic nature of their values and resolve values-based conflicts with PAD.

Values-Based Ethical Decisions and Bracketing With PAD

The CVCM is designed to assist counselors in managing personal conflicts related to values that may arise when working with clients (Kocet & Herlihy, 2014). The model begins with a prompt for counselors to determine if the nature of the conflict is personal or professional and ensues with steps that align with the nature of the conflict. However, considering the systemic makeup of individual values, particularly related to PAD, counselors must be mindful of the influences that stem from the profession’s values in the formation and modification of their personal values. Personal and professional values are interwoven and will consequently impact the ethical decision-making process related to values-based conflicts with PAD (Heller Levitt & Hartwig Moorhead, 2013). As a result, adding a systemic lens to the process of resolving values-based conflicts using the CVCM and ethical bracketing is important to maintaining ethical practice with PAD clients.

The systemic sources of values related to PAD are important to consider in the second step of the CVCM; this step includes a prompt for counselors to “explore core issues and potential barriers to providing appropriate standard[s] of care” (Kocet & Herlihy, 2014, p. 184). Gathering awareness about counselors’ personal views related to death, dying, and PAD is the crux of working through this step in the model. As previously discussed, counselors must engage in reflective practice to examine influential factors throughout each ecosystem. Each system contributes to counselors’ personal views and beliefs, and reflecting will bring awareness to not only the sources of counselors’ values, but also potential barriers to overcoming values-based conflicts (Bronfenbrenner, 1979; Cottone & Tarvydas, 2016; Kocet & Herlihy, 2014).

Beginning with the macrosystem, societal norms and religious and spiritual views of death and dying will influence the exosystem. Legislation that gives clients legal freedom in certain states to decide to end their lives is situated in the exosystem. As the decision to engage in PAD is legalized, it then trickles down into the mesosystem where groups, such as work colleagues and family, hold beliefs and values about PAD. These beliefs and values influence counselors in new ways and impact the intrapersonal reactions counselors have in their microsystem of experience. Counselors must examine the interactions between settings and the messages they receive in those settings. Then, they may more readily discover how their values and beliefs about PAD are formed and either reinforced or undermined. Increased awareness will help counselors identify the ecosystem that is the most salient source of their value conflict with PAD (Bronfenbrenner, 1979). Identifying the salient source may then lead to increased potential for counselors to be more specific in the ways they strategize to bracket their values.

As counselors foster awareness about the sources of their value conflicts, they can move into the third step and engage in ethical bracketing as a strategy to seek necessary assistance to resolve value conflicts. In addition to referring to the ACA Code of Ethics (2014), counselors may consult with other counselors to explore individualized strategies to engage with PAD clients without imposing personal beliefs and value systems. Consultation with other professionals will shed light onto professional standards of care for PAD clients, while also serving as a mirror for further self-exploration about the sources and nature of value conflicts with PAD. It is important to note that counselors should “identify ways to maintain personal/religious/moral beliefs while still providing effective counseling” (Kocet & Herlihy, 2014, p. 184). Ethical bracketing is not designed to push counselors to give up their beliefs or values; rather, counselors simply “set aside their own experiences and assumptions” to effectively step into the client’s worldview (Kocet & Herlihy, 2014, p. 182). Seeking supervision, consultation, and personal counseling can provide guidance for counselors to determine their needs to maintain their personal beliefs and deliver ethical care for PAD clients (Cottone & Tarvydas, 2016; Kocet & Herlihy, 2014).

Next, counselors shift into the fourth step to “determine and evaluate possible courses of action” (Kocet & Herlihy, 2014, p. 184). Using ethical bracketing as a strategy may provide distinct options to consider in this step. Once counselors are aware of the intricacies of their values-based conflict with PAD, they may be more readily able to bracket their values. The guidelines for use of the CVCM in the fourth step note client referral; however, counselors may only refer when they “lack the competence to be of professional assistance to clients,” and their rationale is not the result of personal bias (ACA, 2014, A.11.a.). If counselors lack competence, they may seek appropriate continuing education and supervision to expand their competency in the future. However, in the case of personal value conflicts, referral is not ethical. There is no statement in the ACA Code of Ethics (2014) “that [indicates] referral can be made on the basis of counselor values” (Kaplan, 2014, p. 144). Self-evaluation and consultation is essential to maintain ethical practice surrounding this topic. Once a course of action has been determined as ethical and effective, counselors engage in the fifth step to “ensure that proposed actions promote client welfare” (Kocet & Herlihy, 2014, p. 184). In order to more fully conceptualize resolving values-based conflicts with PAD through this model, a specific example is provided in the following section.

Case Study Application

The following case study explores a counselor’s values-based conflict related to PAD for illustrative purposes. Although many sources may contribute to potential values-based conflicts, personally held religious beliefs are often influential to views and values about PAD (Bevacqua & Kurpius, 2013; Burdette, Hill, & Moulton, 2005; Reiner, 2007). Therefore, personal religious beliefs are explored for the purposes of this case study. Considering a systemic view of counselors’ values, the CVCM and ethical bracketing are used to generate potential conflict resolutions that ensure ethical practice and protect the welfare of the client.


Amy is a licensed professional counselor in the state of Washington. She works for an agency that receives referrals from a local hospital. Amy identifies as a religious person and has connections and support through her religious community. Her personal religious views do not endorse hastening one’s death, even under extreme circumstances like a terminal illness. Amy also has two young children.

Amy has been meeting with Frankie, a 40-year-old woman, for about four months. Frankie was diagnosed with leukemia about six months ago and began treatment shortly thereafter. Frankie recently found out that the leukemia is not responding to treatment and her treatment options are exhausted. Frankie’s oncologist has estimated a five- to six-month life expectancy. Frankie has expressed to Amy that she wants to pursue PAD so that she does not have to be in pain for 6 more months. Frankie has a husband and 6-year-old daughter.

Amy is initially shocked to hear Frankie’s desire to hasten her death. Amy is unsure how to proceed in her work with Frankie because she feels Frankie’s decision conflicts with her religious beliefs. Amy also is wondering if Frankie has considered how her family feels and if they would be okay with Frankie’s decision. Recognizing she needs to process her thoughts and feelings, Amy seeks out a helpful colleague in order to proceed in her work with Frankie.


Beginning with the first step of the CVCM, Amy appears to be dealing with a complex values-based conflict. The nature of Amy’s conflict is primarily personal, but she is faced with some professional conflicts as well. Amy’s religious beliefs and values are personally driven, but the countertransference she is experiencing related to Frankie’s seeming lack of concern for her family can become a professional issue if Amy considers making professional decisions that emphasize family values over Frankie’s requests (Heller Levitt & Hartwig Moorhead, 2013). Furthermore, Amy’s personal religiously driven value conflict intertwines with the counseling profession’s value and ethical standard to respect clients’ worldviews and not impose personal beliefs onto clients (ACA, 2014, A.4.b). Understanding both personal and professional implications allows counselors to move into the second step of the CVCM.

The development and context of Amy’s values may be explored through a systemic ecological lens in the second step. Beginning with the macrosystem, Amy may consider how her religious culture views death and what messages she has internalized to form her understanding of morality and autonomy (Burdette et al., 2005; Johnson et al., 2007). She also could explore how society at large influences her religious beliefs and practices and subsequently how she believes her religion views the practice of hastened death. The interaction between Amy’s religious culture and society is situated in the exosystem. Amy’s interactions with her religious community, which are a part of her mesosystem, also will play a role in her beliefs and actions. She might think about how her immediate community impacts her beliefs and influences her perceptions of hastened death; Amy’s individual perceptions and direct engagement with her religious practices play out in her microsystem. As each ecosystem is explored, Amy can develop a clear understanding of the sources of her value conflict. The same process should be repeated for her values-based conflict about Frankie’s family. Amy may value collective family decisions and could potentially struggle to meet Frankie with acceptance if she believes an isolated decision is improper.

Once Amy has explored the systemic sources of her values, she is ready to seek assistance to ethically move forward with Frankie in the third step of the CVCM. Using ethical bracketing, Amy can reach out to her colleagues to consult about the issues at hand. Exploring her values with a trusted professional may enable her to bracket her values to approach Frankie’s differing beliefs and values. Amy must review the ACA Code of Ethics (2014) before creating a plan of action. Again, Code A.4.b, regarding personal values and biases, is central to an ethical course of action; the profession’s value of client autonomy and Code A.1.a, to protect the welfare of the client, also are important to consider here (ACA, 2014). Attending to legal implications, Amy should keep in mind that Frankie has a legal right in the state of Washington to decide to hasten her death. Lastly, Amy should consider ways she can maintain her own values without compromise while still providing effective care and assistance to Frankie in her decision-making process (Kocet & Herlihy, 2014). Amy may pursue personal counseling or supervision and connect with trusted individuals in her religious community to maintain her personal beliefs and values while providing ethical care (Cottone & Tarvydas, 2016; Johnson et al., 2007).

Moving into the fourth step of the CVCM, referral is an option only if Amy lacks competence to provide Frankie with effective care. According to the CVCM, when a counselor is determining action plans, the choice to refer a client is decided after careful consideration of ethical guidelines, rationale for the referral, and in-depth consultation (Kocet & Herlihy, 2014). Referral based on personal values is not ethical according to the ACA Code of Ethics (2014); therefore, Amy cannot ethically refer Frankie, considering the source of her conflict is related to personal values.

Finally, in the fifth step, Amy can ensure her constructed course of action considers both legal and ethical implications. The rationale for Amy’s action plan should be based on professional competency, not personal bias (ACA, 2014, A.11.a). Amy’s ability to effectively bracket her values will be dependent on her depth of self-exploration, understanding of ethical practice in counseling, willingness to consult and seek appropriate resources, and ability to ensure client welfare as the priority. It is essential for Amy to seek consultation from her professional peers, who can provide insight into maintaining ethical boundaries with clients. Also, Amy can receive permission to speak with Frankie’s lawyer and the primary doctors involved with her decision to hasten her death. By increasing involvement with Frankie’s interdisciplinary team, Amy is ensuring holistic care and attending to the systemic nature of end-of-life decision making surrounding PAD.

Implications for Counseling Practice

The interplay between PAD and the values of counselors and the counseling profession is complex and warrants depth of exploration for counselors to effectively meet the needs of this population. Values-based conflicts do not occur in isolation; instead, multiple systems that impact individuals in varying ways influence the formation and expression of such conflicts (Heller Levitt & Hartwig Moorhead, 2013). No one specific cultural identity, belief, or value can predict a counselor’s conflicts with PAD, but it is crucial to explore values through a systemic lens to successfully manage values-based conflicts with PAD. The CVCM, along with ethical bracketing, can serve as an appropriate framework to confront and resolve values-based conflicts with PAD. Counselors will be better equipped to provide care to PAD clients as they willingly and openly explore their values related to death, dying, and hastening death through an ethical decision-making model (ACA, 2014). Counselors’ effectiveness in self-reflection and ethical practice is reliant in part on counselor education.

Counselor Education

As state laws change, counselor educators need to recognize that counselors will play a larger role in caring for potential PAD clients. It can be beneficial to learn about the role of value bracketing in regard to discussing the possibility of a client exploring the option of PAD. It is difficult for counselor educators to prepare counselors-in-training (CITs) for every potential ethical dilemma. However, with a better understanding of PAD, novice counselors can feel more equipped to effectively address concerns their clients may have without interference of their personal beliefs and values. PAD is a topic that will continue to expand. Introducing PAD during training may allow counselors to feel more prepared should a value conflict arise. As counselor educators facilitate conversations with CITs about their personal and professional beliefs toward PAD, CITs can implement their value bracketing skills under the supervision of their faculty. Being in a safe environment can encourage CITs to explore their authentic feelings concerning PAD and evaluate their value bracketing skillset. Addressing concerns and potential red flags during training can prevent harm to future clients and unethical clinical judgment and behaviors.

There is a potential challenge in maintaining consistency in training about end-of-life issues, including PAD, because of the nature of accreditation standards for counseling programs. There is no specific standard of learning in the 2016 Council for Accreditation of Counseling and Related Educational Programs (CACREP) standards regarding end-of-life counseling issues (CACREP, 2016). Counselor educators are tasked to meet learning standards related to human growth and development “across the lifespan,” but they have discretion over what they include and highlight throughout their curriculum (CACREP, 2016, p. 10). Counselor educators should consider the importance and advantages of including specific instruction on end-of-life issues in their curriculum (Servaty-Seib & Tedrick Parikh, 2014).

In addition to educating CITs, more research is needed to further understand counselors’ developing roles with clients pursuing PAD. With more states legalizing this procedure, it is only a matter of time before counselors are face-to-face with a client that needs a counselor’s experience and competency to assist with this life-changing decision. Although data is available concerning grief and loss counseling, literature directly related to counselors’ roles in working with PAD is sparse. Future research should incorporate counselors’ emerging roles with PAD clients and needs for training to prepare CITs. With stronger research in this area, counselor educators may feel more equipped to teach and support CITs
to become aware of and potentially bracket their values about death, dying, and PAD.


Counselors must be knowledgeable about the legal and ethical standards surrounding PAD in order to work effectively and ethically with PAD clients. Counselors also need to be aware of their personal beliefs and values about death and dying and be able to manage values-based conflicts. This article highlighted personal and professional values relevant to counselors working with PAD clients through an ecological systems lens. Considering the values at play, counselors can use the CVCM with ethical bracketing as an integrated method to resolve value conflicts with PAD (Kocet & Herlihy, 2014). Increased knowledge regarding ethical decision making surrounding PAD can encourage counselors to provide care for PAD clients with competence and confidence. Further research on counselors’ roles with PAD clients and needs for training may enhance counselors’ knowledge and competency with this client population.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.



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Nancy E. Thacker, NCC, is a doctoral candidate at the University of Tennessee, Knoxville. Jillian M. Blueford, NCC, is a doctoral candidate at the University of Tennessee, Knoxville. Correspondence can be addressed to Nancy Thacker, 501 BEC, 1122 Volunteer Blvd, Knoxville, TN 37996-3452, nthacke2@vols.utk.edu.