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Contents
Introduction Acknowledgements 1. What is counselling? Introduction Advice-giving counselling The background to counselling Things that can be seen and those that cant Other promoters of change Components of the counselling relationship A dose of reality 2. What kind of person makes a good counsellor? Introduction A good counsellor has exceptional character A good counsellor is specially trained A good counsellor has compassion A good counsellor treats the client as an equal A good counsellor is competent Balancing compassion and competence The counsellor as human being How does a counsellor benet from counselling? 3. Understanding HIV and AIDS as biological, emotional, social and spiritual conditions Introduction BESS How this model helps 20 19 19 16 16 iv vi 1 1 1 2 3 6 7 10
Interaction between people and their environments Global perspective Psychological and emotional issues Defences Cultural issues Gender issues Older clients HIV-specic issues Difcult clients These are the symptoms 5. First meeting: assessment and planning Introduction The counselling environment The rst meeting 12 12 13 14 15 6. A counselling model Introduction A combination of counselling models for Africa Think for the year Practise by the hour Making a necklace The relationship ends How an organisation or group could say goodbye 7. Counselling techniques Introduction Preparation Attentive listening Reecting emotions 21 21 22 23 Skilful and purposeful inquiry Asking open-ended questions Talking about the elephant in the room Recognising and responding to invisible interactions
31 31 32 34 35 36 37 37 39 41
43 43 44 44 56 56 56 57 62 63 64 67 69 69 69 70 70 72 74 74 75 76
Creating your own assessment checklist 25 4. The client with HIV or AIDS Introduction Who is a client? Obvious needs Understanding the clients situation 28 28 28 29 30
Comment on the big picture Using the counselling relationship to understand the clients usual behaviour Responding to your own anxiety
77 77
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8. Special HIV and AIDS issues Introduction Voluntary counselling and testing Anonymous or condential? The HIV test Relationships VCT counselling procedures Assisting with medicines HIV prevention Current prevention strategies The issues of youth HIV and AIDS and violence Reasons for domestic violence The counsellors issues Signs of problems Interventions with individuals Community-level interventions 9. Mental health Introduction What are mental health problems? The BESS model helps Who treats mental health problems? Symptoms do not necessarily mean a problem The common use of mental health terms The counsellor is observant The counsellor enquires about symptoms Physical complaints Symptoms that may indicate depression Anxiety Symptoms that may indicate emotional trauma Symptoms of severe mental illness Symptoms of brain impairment 10. Substance abuse Introduction
80 80 80 81 82 83 83 87 90 92 94 100 101 101 102 104 105 106 106 106 107 109 109 109 110 111 111 112 114
Use, abuse and addiction What causes substance use? Results of substance use No substance abuse counselling in your community? Tools for substance use counselling Understanding and dealing with the clients needs The Transtheoretical Model Making community connections 11. Loss and grief Introduction The sense of loss begins with an HIV diagnosis Reactions to dying Surviving a loss Grieving in children Other counselling issues 12. Caring for yourself as the counsellor Introduction Many caregivers neglect themselves HIV and AIDS impose extra burdens What is wrong with this picture? A modest proposal The We cant do that! response
123 124 125 126 126 128 130 132 133 133 134 135 136 137 138
Strategies to keep yourself emotionally healthy 143 Organisational strategies to keep staff emotionally healthy 148 13. More information 150 150 151 151 153
More basic information Information for advanced readers Accessing information on the Internet Reference information for books and articles mentioned in this text
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Introduction
This book is written for men and women who have had no formal training in counselling, but feel called to help their neighbours respond to the HIV and AIDS epidemic. It can also inform psychologists, teachers, social workers and other people working in Africa who want to know more about HIV and AIDS counselling issues. In different countries, and even in different organisations within a country, those people who provide counselling to people living with HIV and AIDS are called by different titles. There are some standard titles for people with university degrees. People with advanced training in psychology may be called psychologists. A person with a medical degree and specialised mental health training may be called a psychiatrist. But what title is best for people who dont have a university education? There is no agreement on this. Some people prefer the term lay counsellor. Others dislike it. This book acknowledges that many titles may be used throughout Africa for those people who provide care to people with HIV and AIDS. For the sake of simplicity and consistency, this book will use the title counsellor. Despite the fact that almost everyone in Africa is touched by the epidemic in some way, it is moving to know that people still feel they have the time and energy to help others. I have witnessed inspiring acts of caring-love, the term this book uses to describe the essential ingredient in the counselling relationship. For many of you, this book will be a beginning. I hope that it will provide a secure rst stepping stone on your pilgrimage as a counsellor. I trust that those who feel called to counselling will add their own experiences and stories to the conversations along the way, helping to create a truly Afrocentric way of counselling. Skilful counselling is desperately needed as the continent waits for science and governments to respond meaningfully to the epidemic. While there is no cure as yet for a body infected with HIV, the skilful counsellor can encourage a person with HIV to have a meaningful and loving life. Counsellors can also remind governments, agencies, hospitals, clinics, international organisations and other groups that they have a responsibility to help. Our task in this epidemic is to comfort the aficted and afict the comfortable. Readers will encounter several themes in this book: caring-love, which is the ingredient in the relationship that heals the need for both compassion and competence the importance of courage the understanding of HIV and AIDS as biomedical, emotional, social and spiritual conditions
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the concept that counselling is not advice-giving thinking long-term about counselling but practising by the hour.
These themes are based on my experience working with people with HIV and AIDS, and the experience and teachings of many wise and loving people Ive had the privilege of knowing. When referring to the counsellor or to the client, I sometimes use he and sometimes she. This helped me avoid the awkward use of he and she or him and her as far as possible. In appreciation In writing this book, I have stood on the shoulders of many people whose compassion and competence are unparalleled. These are Namibians who have responded courageously to the epidemic in a country where people with HIV and AIDS are still seriously stigmatised. My colleagues at the University of Namibia and Catholic AIDS Action live in a country where a national sample of pregnant women seeking antenatal care found that 23% were HIV infected. During the writing of this book, I was a Fulbright Scholar at the University of Namibia. There I worked closely with Barnabas Otaala, Ed.D., who headed the HIV/AIDS Unit. I also had the honour of working with Dr Theres Schiwow, a Swiss psychiatrist, and Dr Itah Kandjii-Murangi, now dean of students. This book would not have been possible without Lucy Steinitz, Ph.D., Senior Advisor of Catholic AIDS Action (CAA), who suggested its creation. She and Father Rick Bauer, MM, CAAs chief executive ofcer, provided support and assistance. They enlisted Caroline Cohrssen. Ms Cohrssen and I became partners in the books development, and her contribution in producing a book that is appropriate to its readers is immeasurable. I am grateful to T. Byram Karasu, MD, Chairman of the Department of Psychiatry and Behavioral Sciences, Monteore Medical Center/Albert Einstein College of Medicine, Bronx, NY, who supported my Fulbright application and the year of leave in Namibia. My wife, Diane Sturm Winiarski, and my son, Alex Winiarski, shared the Fulbright year with me in Windhoek and were tolerant of my many moods. My wife, who volunteered with CAA, shared observations that helped me focus the book. Sister Pascal Conforti of St Vincents Hospital Midtown, formerly St Clares Hospital and Health Center, provided support and permission to quote her loving advice. Aline Amutenya provided valuable assistance at the University of Namibia. Peter Arno, Ph.D. and Maite Villanueva, MPA gave valuable support from the Bronx. Mark G. Winiarski, Ph.D. Windhoek, NAMIBIA June 2004 v
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Acknowledgements
Many people know how important counselling is and want to help. But they feel uncertain or afraid to provide counselling, because they feel they have not been properly trained. This book is designed to help you counsel people in your community. It will also help you identify those people who need special help and should be referred to medical practitioners or psychologists. Catholic AIDS Action was very fortunate to have the assistance of author Dr Mark Winiarski, a visiting Fulbright Scholar who was based at the University of Namibia. We are extremely grateful to the University for its support and consider ourselves privileged to have beneted from Dr Winiarskis experience and insight. Dr Mark Winiarski spent the better part of a year writing this book, which included interviewing practitioners and travelling all across the country in order to ensure that the material here is culturally relevant and meets the needs of counsellors in the eld. His collaborative approach made the development of this book into a wonderful learning process for colleagues at Catholic AIDS Action and elsewhere. In addition, he volunteered many additional hours checking and re-checking the manuscript in order to make sure that it is accurate and reader-friendly. We appreciate his going the extra mile over and over again. Similarly, Caroline Cohrssen, as the books editor, has been terric. She worked closely with Dr Winiarski to allow the book to have as wide an appeal as possible. Caroline Cohrssens dedication to this project has set the standard for editors everywhere, and we are deeply appreciative. A SUPER BIG THANK YOU goes to Amanda Kruger and the staff and volunteers at Lifeline/Childline for their input as counselling experts in Namibia. We are also grateful to the members of the Editorial Review Committee who were generous with their time and advice. These committee members helped to make the book practical: Father Rick Bauer, Cecil John Clarke, Efraim Iipinge, Paulina Lukileni, Geraldine Muteka, Tua Nghixulifwa, Marianne Olivier, Paul Pope, Tinah Rajaal, Monika Schwab Zimmer, and Francis van Rooi. Thank you also to all the rest of the staff of Catholic AIDS Action for their input and assistance. This book is the second of a three-part series, co-produced by Catholic AIDS Action and Maskew Miller Longman. The rst book, Building Resilience for Children Affected by HIV & AIDS, was written by Sr Silke-Andrea Mallmann and published in 2003. Complementing this book on counselling will be a third book on home-based care. Tentatively called Community Mobilisation and Support for People Affected by HIV & AIDS, it is being written by Caroline Cohrssen for publication in late 2004 or early 2005. A book like this costs time, and it also costs money. Catholic AIDS Action appreciates the generous support it has received for this project from the European Union and its partners, Kindernothilfe and Misereor, as well as from the United States Government through its partners, USAID and Family Health International. Many thanks also to Maskew Miller Longman and to John Meinert Printing for their efforts in the printing and distribution of this book. Now one thing remains: for you, the reader, to apply what you have learned in this book to the counselling you do in the community, whether as a volunteer or a professional. All of us at Catholic AIDS Action wish you well in this endeavour. May God be with you.
Lucy Y. Steinitz, Ph.D. Senior Adviser Catholic AIDS Action Windhoek, NAMIBIA June 2004
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1
What is counselling?
Introduction
As a counsellor working with people affected by HIV and AIDS, you will experience relationships with people unlike any other relationships you have known. You will comfort and support people in great need. You will help people with HIV and AIDS to feel accepted and valued. You will help such people as they learn to accept themselves. You will comfort and support people as they are dying. You will hold children who have lost their parents and touch parents who are burying their children. Your capacity to experience emotional pain and caring will increase. You will discover courage and an ability to love that you never knew you had.
Advice-giving counselling
Counselling is usually understood to mean offering words of advice. Elders, headmen, chiefs, traditional healers and pastors may counsel people. Lawyers are sometimes known as legal counsel. School guidance counsellors advise students about what subjects to take, what careers to follow and other personal matters. Debt counsellors teach people to use their money wisely and to repay loans. One problem with advice-giving counselling is that it is often taken as criticism and so it may be resented and rejected. The person offering advice may be offended if the advice is not followed and this may affect the relationship
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between the two people. There may be a feeling that the person who offers the advice is more clever and more powerful than the person who receives the advice. The person who receives the advice may feel inferior. There is a sense of inequality in advice-giving counselling. Another problem with giving advice is that it does not promote learning. People learn by making their own decisions. They may make mistakes, suffer the consequences and make changes based on those experiences, or they may make wonderful decisions which are their own and from which they benet.
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The study of feelings and behaviours has become complex. Professions have emerged, such as psychology, psychiatry and social work, each with specialised training. The person asking for help has been called a patient, a client or a consumer. Relationships between counsellors and clients now come with a set of rules that protect everyones interests. Because much of this occurred in Western countries, much of what is thought and written about counselling is based on Western cultures. How Western counselling methods can be successfully adapted to African people is not known, although it is often discussed. Adaptations of Western counselling to African cultures, as well as the creation of an Afrocentric (Africa-based) model of counselling, are currently underway. Counsellors are part of that work. This book is part of that work. It is based on a theory that emphasises the importance of relationships. As a result, the quality of the counselling relationship is referred to many times in this book. Your job is to read the book, decide what you think about the contents, use ideas that you think are wise, and then help your clients with competence and compassion.
Many aspects of counselling the ground rules which are understood by counsellor and client, the talking and the silences, the common experiences of pain and joy, the anger with one another and the work to understand it all exist, and are understood, in the context of the relationship.
Counselling is about starting and keeping a relationship that is centred on the welfare of the client.
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Client:
Yes, sometimes he hits me, but I know he loves me. Those violent outbreaks must cause you great emotional pain as well as physical pain.
Counsellor:
Or the discussion may go like this: Client: Yes, sometimes he hits me, but I know he loves me. Is hitting part of loving?
Counsellor:
Because the meeting is seen and heard, we understand counselling to be meeting and talking these are the observable parts of counselling. Other aspects of counselling that we can see include: Showing respect for the clients spiritual beliefs, even if they are different from your own. Showing understanding and acceptance of the clients culture. For example, a client may expect several exchanges of greetings before a session begins. Sitting together in silence. Being on time for meetings.
Many counselling books focus on the talking that takes place during counselling and do not talk about respect and culture issues. This makes it seem that if the counsellor just says the right thing at the right time, the client will somehow change. Thinking along these lines is like thinking that to be a successful farmer you only need to learn how to plant seeds and harvest crops, whereas a good farmer has many other skills and understands the land and the progress of seasons.
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Less obvious than the words is the way that the counselling relationship slowly develops. This is hard to describe in a book and difcult to teach. For these reasons, teachers of counselling often neglect it. Not so in this book! The counselling relationship develops feelings and attitudes that go beyond words and actions. Sometimes, the counsellor and the client may not have much time together for example, when the counsellor is working with a person living with HIV and AIDS. Still, good feelings such as trust may come quickly and so a relationship develops. In other circumstances, a relationship that is built and reinforced over time has a special value because it allows the client to return over and over again for support and to work with new issues. Whether counselling is just one or two visits, or many more, the counsellor communicates acceptance and regard for the client, and the client feels valued.
The concept of caring-love for others is based on universal traditions of spirituality and religious beliefs. Obviously, we are not speaking of love that is romantic or sexual. Rather, we express the love of the Creator, God, Creative Force, Higher Power, or however we choose to think of a force that is beyond understanding. The challenge to demonstrate caring-love is expressed in many faiths. We do not have to be religious to understand the concept of caring-love. Regardless of religious belief, the spiritual person acknowledges her connection to the energy of the universe, whatever name she may give to that energy. She believes that this energy lls her life or has the potential to ll her life. The communication of caring-love through the counselling relationship seems very obvious, although it is seldom talked about. Many mental health professionals will admit that their work is based on a belief that little is more important than this unrestricted love. In Africa, the expression of love is obvious when one sees volunteers walk kilometres to visit and comfort the sick.
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It is the relationship that heals. If the counsellor communicates caring-love to the client, the healing of emotional wounds can occur. The counsellors communication of caring-love leads to self-acceptance and a sense of worth that helps the client nd the desire to change.
How does the process work? The counsellor communicates love. The client feels valued and accepted. Accepted by the counsellor, the client begins to accept himself. In accepting himself as worthy, he realises he is worth improving. He decides to make changes that improve his life.
These changes may be obvious, like seeking medical care for symptoms that were previously ignored, or cutting down on drinking alcohol. But the changes may be internal: the client may be able to accept himself or to forgive other people who have done him harm; the client may come to terms with death, feeling at peace.
Expressing feelings
Some people believe that depression is anger turned inwards. They believe that people become depressed when they dont express their anger. Other people believe that feelings are expressed in physical complaints like stomach pains and headaches. Often, a client will say, I feel better after just one session with a counsellor. This is just because the person talked. It helps to express feelings.
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Empowerment
By getting to know herself through counselling, the client discovers the strength to confront and resolve problems.
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A non-judgmental presence
As we go about our lives, our heads are lled with judgments: my neighbour talks too much, or, my wife isnt fair to me. As we start learning how to counsel, these judgments often enter our thoughts. The task of a counsellor is not to let them leak into the relationship. As a counsellor gains experience, it gets easier not to be judgmental. When a counsellor nds herself being judgmental, she should ask herself, What is making me judge this client? She may have a deeply personal reason that is not obvious. For example, an angry reaction to a client may be because the clients behaviour or comments provoke a memory for the counsellor.
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The role of the counsellor is not to judge. Critical judgments never help.
Skilful listening
Becoming a good listener takes some practice. You need to focus entirely on your clients speech, expressions and mannerisms. Taking note of the subjects that your client does not want to talk about will also tell you something about the person. Skilful listening leads to skilful replies that probe and challenge. These are important in helping a client to explore her feelings, understand problems and emotions, and come to terms with her situation. There are specic techniques for listening, especially for listening to anxiety-causing stories, which will be described in Chapter 7.
Safety
The counsellor is responsible for the emotional and physical safety of the client. This involves acting ethically and taking steps that involve the following: Ensuring condentiality Because so much stigma and discrimination surround HIV and AIDS, you may only tell another person that your client is receiving counselling if you have your clients written consent. One exception to this rule is that you will discuss your client with your supervisor, who may know your clients identity. Another exception is that you may have to report the client to government authorities if she threatens or harms someone. Never make promises that cannot be kept It is human nature to say things like, Everything will be all right. We may do this automatically in an attempt to make the other person feel better. Try to avoid saying this because it ignores the reality of the clients situation and is probably not true. Sometimes the things we say as counsellors are really to make us feel better as counsellors, rather than to reassure the client. No sexual contact Any contact between counsellor and client that can be interpreted (or misinterpreted) as sexual is not allowed. 9
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A dose of reality
Sometimes, the reality of our own lives may wear us down. But trying to nurture supportive relationships with clients and to love them despite our pain and weariness continues to motivate us. We persevere because a force inside us calls us to act with love.
Extra information
By the late 20th century, Western countries had psychoanalysts, psychiatrists, psychotherapists, psychologists and counsellors all of whom thought there were better ways to help people than just to give advice. Although many people believe that understanding ourselves helps us to improve our lives, not everyone agrees on how to help people understand themselves. Theories were developed to explain what causes emotional (the way we feel) and behavioural (the way we act) problems. Based on their explanations, specic approaches to counselling were developed. For example: Psychodynamic theory, developed by Sigmund Freud, says that people have an unconscious mind (a part of the mind that we dont think about) that inuences their behaviour, and that a persons childhood greatly inuences that persons later years. Practitioners who believe in the behavioural theory look at a persons behaviour and try to nd out what happened in that persons environment to cause certain behaviour. Behavioural psychologists dont consider things that cant be seen or measured they are only concerned with behaviour that can be seen. The cognitive theory suggests that feelings and behaviours are mainly inuenced by what a person thinks. If people change what they think, they can change their feelings. Social learning theory suggests that behaviours are learned by watching and copying the behaviour of other people. Another group believes that all behaviours and feelings have biological and medical causes, and that problems disappear if you change a persons brain chemistry with the proper medicine.
There are many more theories. Most specialists agree that no theory is perfect and that none apply to everyone with emotional and HIV and AIDS-related problems. In fact, some practitioners now combine different theories. For example, some practitioners are cognitive-behavioural, combining the cognitive approach and the behavioural approach.
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2
What kind of person makes a good counsellor?
Introduction
In the introduction to this book, we have explained that people who do counselling are called different things according to local rules and customs. In this book, we refer to counsellors and counselling.
When a person goes for counselling, the counsellor must be able to show that he cares for the client. It is this caring relationship between a counsellor and a client that helps the client to heal. This means that the counsellor must be a person who can express caring-love and be comfortable in a relationship. This is not a loving relationship like the relationships between couples a counsellors care for his client shows the Creators love for all humanity. In the Bible we read that Jesus urged his follows to love your neighbour as yourself (Mark 12:29). Remember that neighbours arent only the people who live next door to you. They are also the people who you see or talk to every day. You may know them, or you may not know them. This does not make any difference. Sometimes we dont love our neighbours. Why? Perhaps we dont feel loved at the moment. Perhaps we dont think that we are worth loving. We may have emotional pain. We may be too busy just trying to survive. Perhaps we mistake sex or romance for love. All day long, things happen that stop us from thinking about loving or being loved. Take a few moments to think about being a counsellor. This will help you to focus. Ask yourself these questions: What is my purpose here? Am I called to be a counsellor? Do I believe that earthly existence is all there is? What do I owe others? Who am I to judge other people?
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Far too few people even try to answer these questions. Just thinking about being a counsellor can put you on the road to a more meaningful life. As you work with a person who has HIV, you will learn more about yourself. If you have always thought of yourself as compassionate, you may discover that you have limitations. You may nd that you are judgmental. But remember that learning about yourself, however painful it may be, is good and will help you to relate better to other people in your life. Relating to your client as a counsellor will encourage you to be in a healthy relationship with yourself, and with the members of your family and community. Becoming a counsellor is not like reading a book or attending a training workshop. It is a lifelong process of personal growth.
Maturity
Maturity includes awareness of other people, awareness of what each of us contributes to relationships, and sound judgment. A mature counsellor has earned wisdom through having experienced his or her own difculties in life.
Courage
A counsellor must have extraordinary courage. Counsellors often act in the face of community pressure. People with HIV and AIDS, and the people who work with them, are often faced with discrimination and stigmatisation.
Patience
A counsellor must have extraordinary patience, knowing that the battle against HIV will not be won in a month or a year, and perhaps not even in your lifetime.
Commitment to learning
A counsellor is committed to knowing about himself or herself, about other people and about HIV and AIDS.
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Authenticity
Authentic is another word for being genuine, being real.
Authenticity means not putting on airs and graces, or pretending to be someone you are not. Authentic people are happy as they are and dont try to act differently.
Humility
People are called to counselling to serve other people, not to feel better than the people they help. Their rewards are knowing that they did what needed to be done. If there should be other rewards (like a certicate or a mention on a television show or in a newspaper), that is something to be proud of. But it may not happen often.
Emotional strength
A counsellor needs to have a lot of emotional strength to share the clients pain and the pain that the counsellor may feel while working with a client.
Flexibility
There are two kinds of exibility that are important. The rst kind of exibility is practical: coping with limited space or unexpected problems. The second kind of exibility has to do with the way the counsellor thinks about life and the world. It is important for a counsellor to understand that everyone sees things differently.
Introduction to training
During the introduction, a counsellor learns basic information about counselling. This includes counselling theory, practice and HIV-related facts. This book is an introductory text that provides many of these basic facts. However, reading this book alone does not qualify you to be a counsellor. Classroom education and clinical supervision are also required for competence. Attitudes to people with HIV and AIDS and alternative lifestyles must be included in the training.
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Middle period
At this stage, a counsellor usually begins to feel a bit more condent. The counsellor works with clients and reports his experiences to a supervisor. Most counselling students take careful notes of their time with clients. They also make comments about how they felt during the sessions. A skilful supervisor will discuss the contents of the sessions, including the emotions that arise. This period is when a counselling student learns that his own feelings may have an effect on the relationship with his client. During this stage, many counselling students feel inadequate. Sometimes this makes them feel defensive and so they dont share all of this information with their supervisors. This is a problem, because these are normal feelings and a supervisor can help the counsellor to overcome negative feelings. Overcoming these feelings is part of the personal growth that a counsellor experiences.
Defensive means that a person feels under pressure and tries to defend himself or herself.
Later period
By this time, a counsellor feels that he is working effectively. The counsellor is aware of his feelings towards a client and how those feelings may affect the relationship with the client. This period never ends the counsellor continues to read about HIV and counselling, and tries to attend conferences. The advanced counsellor may teach and supervise others, while still discussing his own work with colleagues (or a supervisor). Counsellors continue to experience personal growth as they respond to injustice and suffering.
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It takes a lot of emotional strength and willingness to share the pain a client feels, but a counsellor who is emotionally distant is of no use to a client. A counsellor who is too emotionally close to a client can, however, also be ineffective. Compassion, that is, co-suffering, implies equality. Some people become counsellors because they need to feel superior compared to others (even if they dont admit this). Inside they may think, This person has problems, but I am better than he is because I dont have these problems. Or, This person is immoral, but I have morals. Or, I am so wise, compared to this person. I can give him advice. These are all indications that the counsellor is ghting her own feelings of inferiority and insecurity.
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Acting ethically
There are rules about how a counsellor should behave with a client. The box (which follows below and continues on pages 18 and 19) summarises key ethical considerations.
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Knowing governmental rules. National and local governments have laws and rules that govern the behaviour of people who work as counsellors, and there are special rules about HIV and AIDS care. For example, various countries have laws that govern a counsellors responsibility when a person with HIV fails to warn a sexual partner of his condition. A counsellors training should include a review of such laws and rules.
Work rules. Usually there are rules about duties, being on time for work,
holiday and sick leave, accounting for funds and food available for clients, and attendance at staff meetings and training. Volunteers may have to follow certain rules to make sure that their organisation maintains standards of care.
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Supervisor: You seem very worked up about her drinking, very angry. Didnt you once tell me that your father drank a lot? Could that be affecting your response to the client?
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understand the feelings of people who are scared, embarrassed or ashamed, or have other feelings that keep them away from counselling. One can also better understand the courage of those who come.
Counselling may look simple, but working with people affected by HIV and AIDS is very difcult. In return, your compassion and competence will grow and ll your life. You will become a deeper person, with more self-knowledge and better able to care for others. You will have the privilege of accompanying your neighbours on their most important journey. You will witness and experience pain, joy, suffering and, in some cases, salvation. You will educate yourself about medical, emotional, social and spiritual aspects of life. You will learn about your inner self; you will discover thoughts and feelings that you didnt know existed.
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3
Understanding HIV and AIDS as biological, emotional, social and spiritual conditions
Introduction
Understanding exactly what HIV and AIDS are is the rst step towards helping people living with HIV or AIDS. Most people think of HIV and AIDS as medical conditions and life-threatening diseases. When someone mentions health care in terms of AIDS, people usually think about medical care pills, hospitals, doctors and nurses. However, skilful counsellors think of HIV and AIDS differently. They take into account the whole person as well as the community in which that person lives. Such a counsellor understands that: A virus is the biological (to do with the body) cause of infection, but the virus doesnt jump from person to person. Usually infection occurs in social situations. Psychological or emotional issues are often involved, such as when a depressed man drinks too much and then nds someone who will have unsafe sex with him. His emotional situation places him, his sex partner and others at risk. Poverty, a social condition, makes children vulnerable. Many orphans live in extreme poverty, in households headed by other children.
Social situations are situations in which people interact with one another.
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Spirituality comes into the picture. A deeply religious man may think that God has abandoned him because of his HIV status. The man may benet from spiritual counselling that reconnects him to his Creator.
BESS
These are just a few examples of situations in which HIV may be more usefully understood as a condition that has biological, emotional, social and spiritual aspects. To help you remember the four aspects, think of the word BESS:
B E S S
stands for Biological or biomedical (biology + medical = biomedical). This includes the medical and physical parts of HIV and AIDS. It refers to esh, blood and bone, and such things as viruses and germs.
is for Emotional. This has to do with the inner life of the person, including emotions and feelings for other people. Emotions have to do with why we think and act. Another word for this is psychological. is for Social. This refers to a persons participation or lack of participation as a member of a family, a community and a society, and the effects of family, community and society on the person. Culture falls into this category, although the way a person reacts to his or her culture may be psychological. stands for Spiritual. For many African people, religious generally refers to our relationship to a higher power which some people call God and others may call Allah. It also gives meaning to experiences that cant be explained by logic or science. Spirituality has to do with the way we explain the wonderful world around us. It may be expressed by participation in organised churches, synagogues or mosques, or may be a highly private matter.
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When this way of understanding HIV and AIDS is drawn as a diagram, it looks like this: Think of each circle as a container. The Biomedical circle contains all the aspects of HIV and AIDS that are medical or physical.
Biomedical
The Emotional circle contains all the emotional causes and responses to infection. The Social circle contains everything to do with our relationships with other people. The Spiritual circle contains everything to do with spirituality.
Psychological HIVpositive client Social
Spiritual
The area where all the circles overlap is the HIV-positive client. The person is where the biomedical, emotional, social and spiritual parts of a person all come together.
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A good assessment will help the counsellor to anticipate and head off problems before they start. For example, if the client is uncomfortable with doctors and hospitals, the counsellor can anticipate that during a medical crisis, the client may not seek emergency help. He will stay at home even though he may be very sick. Having anticipated this, the skilful counsellor should: Find out if the clients feelings are due to an emotional disorder (such as undue suspicion of strangers, or depression). Discuss the clients feelings about doctors and hospitals, trying to correct any wrong ideas, before an emergency arises. Help the person to understand the consequences of not seeking help in a medical emergency. Help the client to weigh up his negative feelings about hospitals with the fact that his life may be in danger if he doesnt get help in an emergency.
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category a question should be in. This isnt a test. Just place it in a category that makes sense to you. This list should change over time. As you gain experience, you will add to the list and it will be uniquely yours. It will help you make a skilful assessment.
Assessment Checklist
Biomedical
Does the client know whether he or she has HIV or AIDS? Does the client understand what that means? Does he or she accept the diagnosis? How does the client feel? Does the client have any physical problems at the moment? Breathing Skin Headaches Trouble holding urine or bowels What medicines is the client taking? Ask to see them. Ask how often and when each medicine is taken. Compare the instructions with the clients report. Are they taken properly? How is the clients thinking? Slow Confused How is the clients memory? Can the client walk? Does the client leave his/her house? Does the client have enough food? Enough clean water? Does the client have any illnesses other than HIV? High blood pressure Diabetes (sugar) Tuberculosis (TB) Malaria Who provides medical care? When was the clients last visit? What did the client tell the health worker during the last visit? What did the health worker tell the client at the last visit? Does the client need help in talking to or understanding the health worker? If the client has a medical record, such as the medical passport used in Namibia, look at it. Add your own questions.
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Emotional
What is the clients current emotional condition? Is the client: Sad? Suicidal? Thinking about death? Having trouble sleeping? Having trouble with appetite if food is available? Able to enjoy things, such as food or children? Nervous? Add your own questions.
Social
Does the client have: A spouse/a partner available to help? Visitors? A family member or a friend to help? Friends? Transportation to a clinic? Does the client visit other people? Besides the clients health worker, who are other caregivers? Chemist? Traditional healer? Optician (eye doctor)? Is the client sexually active? Does he or she practise safer sex? Is there any violence in the home? If so, in what situations: Sex? Drinking? Or at unpredictable times? Add your own questions.
Spiritual
Does the client believe in God/Allah? Does the client belong to a church/synagogue/temple/mosque? Does the client attend services? Does the client pray? What is the clients current relationship with God? (Feeling condemned, abandoned, nurtured?) Does the client nd comfort in his or her beliefs? Does the client want additional religious materials, such as a Bible? Is there a member of the clergy available for the client to talk to? Add your own questions.
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4
The client with HIV or AIDS
Introduction
One Sunday morning in Windhoek, two volunteers from Catholic AIDS Action went to visit a client who lived in an informal settlement of makeshift housing. When they arrived, they discovered that the shack in which the client lived had burnt down the night before. A CAA staff member brought food and blankets. Volunteers and staff worked together to put up a basic shelter using the burnt corrugated iron sheets and assorted other items, such as metal rods and car parts, fastening the pieces with fencing wire and coat hangers. This is only for tonight, someone said, but we all believed the client was likely to live out her life in the shack, with no electricity or running water. In sub-Saharan Africa, HIV is tangled up with poverty, stigma, fear, shame, lack of medication and other issues. It is a knot of problems that cannot be easily undone. A client with HIV and AIDS poses extraordinary challenges for the counsellor. Chapter 3 provided a model for understanding HIV and AIDS. This chapter gives an overview of common difculties and issues in clients lives.
Who is a client?
A client is someone who agrees to counselling. The client brings all her problems, fears, suspicions and other emotions along to her counselling sessions. The counsellor makes only one request: the client must be willing to try the counselling process. The client doesnt have to be
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enthusiastic, and usually she isnt. There are messages of acceptance and care that counsellors can communicate and these messages can unravel knotted up hearts and souls. Sometimes the client isnt just one person. The client may be two people in a relationship, or even an entire family. In these cases, the skilful counsellor has a very clear idea of who the client is, and what his responsibilities are to each person.
Obvious needs
Most of us living in Africa understand the critical needs of people living with HIV and AIDS. Often, HIV and AIDS are not the most pressing issues, and not even close to what needs immediate attention. Often, a clients more critical problems include: Little or no money. Hunger, with little access to food. Illness. People with HIV or AIDS get what are called opportunistic infections. These occur because the bodys immune system is not able to ght off organisms that cause sickness. Also, people with HIV often have other illnesses, such as high blood pressure and malaria. Difcult access to health care. If care is available, it may be kilometres away and the client may not have transportation. Emotional troubles. Because of the lack of mental health care, many people have psychological difculties that are not recognised and treated. Overwhelming family responsibilities. Many single women or widows with children sacrice their own health and welfare for that of their children. Many have taken in the children of their deceased relatives, or care for relatives who have shown up at their doors. There are many
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Shame is when you feel you have broken a cultural or religious rule, and it makes you feel unworthy or bad.
child-headed households in which children are shouldering adult responsibilities. Shame, Discrimination, Stigmatisation (sometimes called SDS); see page 41. Homelessness or inadequate shelter.
Stigma is like a stain on someone, setting them apart as inferior and disgusting.
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Thinking about this model will help you to anticipate your clients needs. A person with many needs may (understandably) feel that nding food and shelter are far more important than counselling. A counsellor can acknowledge those needs and suggest that counselling may also help the client. While you cant promise to provide food and shelter, you can say that counselling may help.
Global perspective
HIV and AIDS tie all the people in the world together. The decisions of pharmaceutical companies to keep the prices of HIV drugs high, so that the company stockholders can make a lot of money, cost lives in Africa. Less expensive generic medicines imported from India or Brazil help Africans. African wars fought with guns produced by other nations have encouraged the spread of HIV, as many soldiers rape local women. Truck drivers who cross national borders also contribute to increasing HIV rates. HIV and AIDS truly tie all people together. HIV and AIDS are at the intersection of social injustice, gender inequality, poverty, hunger, lack of economic opportunities and unequal distribution of resources.
Global means around the whole world.
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Hunger 4
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going to jail or being punished, but when the threat of punishment disappears, so does she. A sense of oneself. While most people can get depressed or anxious, their behaviour over time shows that they have self-esteem and emotional strength. Some personality disorders make people feel insecure, empty and troubled. They may stay in hurtful relationships (or go from relationship to relationship) just to have company. Stability in mood, relationships, and life in general. Most people, during their adult lives, are stable in their moods, relationships and work habits, and their friends and associates generally know how they are likely to react to things. Some personality disorders make people very unpredictable, emotionally unstable and often full of rage. They may hurt themselves or try to commit suicide.
Stability is a state of being constant, hardly changing.
Counsellors are not trained to treat personality disorders. Treatment for such complex disorders lasts years and, sometimes, medication is recommended. But a counsellor should be able to recognise a problematic personality. This will enable him to: Anticipate behaviour in clients with character disorders. For example, if a man has regularly broken the law since he was a teenager, the counsellor should anticipate a lack of responsibility in relationships. Recognise that a positive HIV test result may severely upset a person who has a history of unstable behaviour. If someone has attempted suicide, an HIV test may create additional dangers for the client. Understand a clients personality. The counsellor can make comments that (a) show that he understands the pain the client feels and (b) starts the client thinking about how lifelong behaviours have harmed her. Anticipate how the client may react to things in counselling. 33
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As a counsellor you could say, I understand that you are terried and deeply hurt when someone you love leaves you. I am going on holiday for a month, and I wonder if you will feel abandoned by me. I also wonder if you will then engage in unsafe sex. Recognise that no matter how hard you try to counsel a person, personality disorders may undermine the best of counselling efforts and you should not feel defeated.
Learned helplessness
As you get to know your clients, you will nd they have great personal resources. So why did they seem so helpless in the beginning? An idea called learned helplessness might help to explain this. A psychologist found out that animals and people who tried to x their situations but kept failing nally gave up. It may be that a client tried many times to get maize meal from local party headquarters, but failed repeatedly. He then gave up and the counsellor met someone who had learned to be helpless.
Defences
Many people who study how our minds work think that defences are at work in the clients mind without the client being aware of them. They say that the defences are unconscious. According to one theory, defences protect the person from feelings that are too much to cope with. Not understanding a clients defences and responding wrongly could harm the client. Some defences that are useful when studying HIV and AIDS are explained below.
Denial
A person in denial rejects painful realities. Here is an example of denial: A woman who has had many sexual partners goes to a counselling and testing centre where she is told she has HIV. She says, This is impossible. I want another test. The second test has the same result.
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The client still doesnt believe the result. She is exhibiting denial. Her emotional functions have protected her from overwhelming feelings that result from testing positive.
Good denial
Because denial prevents emotional pain (at least in the short term), counsellors are usually advised not to attempt to burst the bubble of denial. The counsellor should invite the client in denial to begin counselling that would provide the security she needs to accept the test results. In the context of a caring relationship, the counsellor can gradually challenge denial.
Denial can interfere with responding to an emergency. If someone is having trouble breathing, it is important to act quickly, even if the client is in denial. In this case, psychological denial could be at work, but so could the effects of a shortage of oxygen to the brain. The client needs immediate help if she is to live.
Rationalisation
When a person gives an acceptable but wrong explanation (usually involving reasoning that can be shown to be wrong), we say that the client is rationalising the problem. A woman who is beaten repeatedly by her husband may rationalise staying with him. The counsellor deals with rationalisations by pointing out weaknesses in her story. Client: Staying with him is the only way I can survive. Counsellor: If you stay with him, you may not survive.
Cultural issues
Experts say that cultural beliefs and rituals were created to help ethnic groups survive. These days, people concerned with HIV and AIDS claim that some cultural beliefs endanger, rather than protect, ethnic communities. For example, how do health workers prevent sexually transmitted diseases (STDs) if young boys in a community believe an infection proves their manhood? What does a counsellor, working in a community that allows a man to take several wives, do when he knows the husband of three women is HIV-positive?
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The effects of cultural practices on the spread of HIV and AIDS are a major concern around the world. Unfortunately there are no easy answers. The counsellor should consider his work to have two levels:
Client level
People have different levels of commitment to, or rejection of, cultural beliefs. Assess your clients identication with her culture and nd out what aspects, if any, she rejects. If she rejects some, she may reject other aspects, provided their HIV-related dangers are brought to her attention. Ask your client to weigh up the benets and costs of certain beliefs (in terms of HIV, sickness and death). Help your client to determine whether the benets are worth the costs.
Community level
The real work regarding HIV and AIDS and the cultural practices that encourage the epidemic is likely to occur at the community level. Change needs to occur from within an ethnic group. Counsellors could create an organisation for mutual support to look at cultural behaviour in the context of HIV and AIDS, and to advocate for changes to stem the epidemic. Counsellors could think about what is necessary to create social changes to stop infection and never miss opportunities to inuence community leaders to address the epidemic.
Gender issues
Mutilation may include cutting marks on the face or genital cutting, where the labia (outer lips of the vagina) are cut off.
Gender issues usually intersect with cultural issues. Womens gender issues include their roles in a community, their independence and power relative to that of men, their ability to say no to sexually aggressive men, their childbearing and childrearing options (if any), and rites of passage that involve mutilation or sexual activity.
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Mens gender issues can include their treatment of women, hidden sexual activities with other men, rites of passage that may include victimisation of others and harming themselves, beliefs regarding womens roles and womens power, and roles regarding their children. While there is much sympathy for the often difcult situation of women, many counsellors are less sympathetic to mens issues. However, many men are afraid of abandonment, possibly caused by the early loss of a father. Many men have emotional problems (such as depression) that are not recognised or treated. Counsellors should examine their biases against men.
Older clients
Older clients have specic concerns, including: The loss of adult children to HIV and AIDS. Normally, parents die rst. With the AIDS epidemic, parents from older generations are living longer than their children. The emotional impact of these losses must be looked at. Grandparents caring for grandchildren. Counsellors should consider how communities could ease the burden of childrearing. For grandparents who raised their own children a long time ago, parenting training about new youth cultures and discipline issues may be a good idea.
HIV-specic issues
Counsellors should be aware of issues related to HIV infection. These include:
Loss
Many people who learn they have HIV feel they have lost their lives. By life, we mean not only physical existence, but also way of life. They expect sickness and a rapid death, as well as rejection, shame, discrimination and stigma.
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In Africa, HIV and AIDS are considered conditions of loss. People who get HIV have often suffered many other losses too.
Your client may ask, I cant be cured, so wouldnt it be better just to give up? What she is really asking is, Is my life worth living, despite the stress and discomfort and pain? Your client may be asking you to tell her that her life is of value.
Abandonment
People with HIV fear abandonment with good reason, because other people are afraid of infection and there is discrimination and stigma. They may be left without nancial support, housing and, especially, love and emotional support.
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Betrayal
One very difcult issue is being infected by someone who was trusted and who may have known his HIV status and lied about it. Counselling someone who feels betrayed is similar to working with other losses. In this case, there is a loss of trust that must be mourned.
Fear of dying
When someone begins to talk about death, it is helpful to ask if she is afraid of dying and what it is particularly that she fears. Fears may include that dying will be painful or difcult, that she will lose control of bodily functions and be embarrassed, or that it will come after a long period of mental problems (that she will be a vegetable). In some parts of Africa there are hospices where staff and volunteers care for people who are dying and provide a dignied departure from this earth. Talk to your client about dying and help her to talk about how she would like dying to be. In other words, help her to plan her death as much as possible. The discussion may include whether the client has things to say to people before she dies (such as asking for forgiveness), the names of people the client would like nearby, what she would like them to do (pray, sing, tell stories) and the memorial service. In discussions about dying and death, watch out for the clients discomfort. An uncomfortable counsellor often tries to calm the fears of the client (which may be your own fears) by saying things like, Everything will be all right, or, We dont need to talk about this yet. Some counsellors abandon their clients as they get sicker because of fear of death. A mature counsellor knows his own feelings about death.
Difcult clients
Some clients are easy to like, but others make counsellors feel nervous. Some make clear threats, but others communicate hostility without using words. While we must be loving towards these people, this does not mean we must ignore problems or put ourselves in danger.
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A director of the World Health Organization Global Programme on AIDS identied three phases of the HIV and AIDS epidemic: the epidemic of HIV, the epidemic of AIDS, and the epidemic of stigma, discrimination and denial. He noted that the third phase is as central to the global AIDS challenge as the disease itself. Counsellors of people living with HIV are on the frontline of the battle against shame, discrimination and stigma. They must have great courage. In this battle, counsellors will also be attacked. As people with HIV are stigmatised, so too are people who work with those who are affected by HIV. Counsellors must acknowledge what is real in the clients environment that people living with HIV are treated badly. The client must realise that this cruelty is based on fear rooted in ignorance. Ask about and explore the clients feelings of shame, with the goal of healing those feelings. When appropriate, encourage clients to disclose their HIV status to other people. The counsellors expressions of acceptance will help. SDS needs to be brought to everyones attention. There are several things counsellors can do to ght shame, discrimination and stigma: Advocate more open discussion of HIV and AIDS in your community. Be open and proud of your work. Ignore attacks. Advocate for policies and laws that prohibit discrimination on the basis of HIV status. Counsellors could consider starting and supporting campaigns against SDS. Local campaigns have included poster contests, beauty contests for HIV-positive women, and HIV-positive men and women forming organisations and speaking to groups. What could you do in your community?
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5
First meeting: assessment and planning
Introduction
Counselling is talking and acting with the aim of helping the client. To help the client, the counsellor has to know as much as possible about the clients situation. To nd out this information, the counsellor has to ask questions in an organised way, a process called doing an assessment. This takes place during the rst few meetings. It can take as long as the counsellor needs to get a good picture of the clients situation. Skilful counsellors have a list of questions available (Chapter 3, pages 26 and 27) that detail what information should be obtained during an assessment. Some of the information will be the same for men, women and adolescents, but other information will be different. This information helps the counsellor to draw up a counselling plan to address the clients needs. This plan is sometimes called a treatment plan. The best counsellors do not throw question after question at the client during the rst meeting. They allow the client to tell his story and then ask questions at the proper places in the storytelling to obtain more detail. If there is more to be learned after the client tells his story, then the counsellor goes to the list of questions to ll in the gaps. This chapter describes the rst meeting and the assessment and planning process.
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Introductions
Introduce yourself with your name and a few sentences about your training and other qualications. You may want to give the client a piece of paper with your name and contact information, such as a phone number.
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information about how you will conduct an assessment and create a plan together assurances regarding condentiality ground rules.
Counselling is a word that is confusing to a lot of people. It has been used to describe advice-giving. Im not likely to give you advice in our counselling visits. In our meetings, you will talk about problems and feelings that affect your life. Ill ask questions, helping you to explore how you feel about those issues and what you could do to feel better or nd solutions to problems. People believe that talking about problems can make them feel better and help to improve them. Over time well form a relationship, and I think that alone will help you. Do you have questions about counselling? (Give the person a chance to reply.) Before we can begin counselling, though, I would like you to tell me about your physical, emotional, social and spiritual life, so that I can understand your situation and be better able to help. Later on, we will work on a plan together that will help you. First, I want to explain about the condentiality of our work together and the ground rules. Then Ill give you a chance to ask questions. Everything we say during your visits is strictly condential. That means I will not tell anyone that you come here or that we meet. Our records are kept secret. There are a couple of exceptions: I will discuss our work together with a supervisor, who also has to keep information about you secret. I also have a legal responsibility to prevent you from harming yourself or other people. If you tell me that you are serious about harming yourself or anyone else, I may have to bring this to the attention of authorities. There are some basic rules to counselling. I have responsibilities not only to keep your visits a secret, but also to act according to rules. I promise I will be on time for our visits, that I will always tell you the truth and that I will act in your best interests.
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You then inform the client of his responsibilities, which may include: not disclosing to others the identities of people whom the client may see at the clinic payment (or barter) for services, if there are charges appearing on time for all appointments, or cancelling within a stated time, such as 24 hours in advance.
If appropriate, the counsellor may want to add that the ground rules include respect for all staff, no violence, and that the client may not come to sessions intoxicated (drunk or on drugs). Breaking these rules will result in a discussion and possibly the end of counselling.
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For example, the conversation may go like this: Counsellor: Sometimes men in our community are uncomfortable talking about HIV and AIDS with a woman. How do you feel? Client: It isnt a problem for me.
Counsellor: I just want to make sure, because it is a very understandable situation if you are reluctant to talk to a woman. Client: No, no, everything is okay.
Counsellor: Well, if you dont mind, if I begin to feel that you are uncomfortable but you arent saying so, Ill ask about it and well work on it together. This is the place to talk about your feelings. If my being a woman troubles you, mention it at any time. If I think it is becoming an issue, Ill bring it up again. Similarly, a woman may not want to discuss female matters with a male counsellor. If there is no female counsellor available, explain that to the client. Another way to overcome client discomfort based on gender is by attaining status in the community and getting the approval of a traditional leader. Age issues Older people are sometimes unwilling to speak to a younger counsellor, especially if the youthful counsellor is seen as unskilled or unwise. They may have a point: a younger counsellor may not appreciate the problems of older people. The counsellor and the counsellors supervisor should study the counsellors attitudes. Does the counsellor really appreciate and honour older clients? Is the counsellor aware of the issues that affect older people? Are there personal issues, such as a complicated relationship with an elderly parent or grandparent, that block the counsellors caring-love for elderly people? The counsellor may ask the client for a bit more time to prove her value.
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embarrassed. A skilful counsellor will note this (even though the client may not say it) and she will use it as an entry point into the counselling process. Counsellor: It seems to me that you are embarrassed to be here. I understand your feelings. Coming to counselling doesnt mean you are bad or awed. It means you are a member of the human race. Every person has problems. But youve shown the courage to do something about the things that are affecting your life.
Wrong expectations Some people see counselling as an easy means to food, clothing, money or other tangible benets. If the organisation for which you work has food available, your client should have access to it as any client of the organisation would. But you must make clear that counselling is about talking and solving problems, and does not necessarily provide any direct payments for participation. Should clients be given food or other benets for coming to counselling? There is no denite answer to this question. Perhaps it should be tried and evaluated in your community. Condentiality in a small community If you and your client live in a small community, it is likely that you will see each other on the street. This could make your client feel uncomfortable or even reveal your clients HIV status. During the initial session, you should ask how your client wants to handle that situation. Say, If we see each other on the street, do you want me to acknowledge you and say hello? Or would you prefer that we pretend we havent seen one another? If the client does not mind saying hello on the street, you may want to say something like, I will say hello but I am not likely to stop and talk, especially if I am with my family.
The assessment
Before counselling begins, explain to your client that you need to know a lot about him so that you can have a foundation for your work.
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Invitation to tell the story Just as you would with any new person in your life, you invite the client to tell his story. You could say something like, Why are you here today? followed later by, Tell me about your life. You could ask, Where did you grow up? or a culturally-acceptable version of What community did you grow up in? Your work during the storytelling While the client is telling his story, your task begins. During the storytelling, you have to do a number of things. First of all, watch the client. Secondly, ask questions at appropriate times to ll in any gaps in the story. Your goal is to understand the client. As the client speaks, you should accurately write down information if that is not threatening to the client. You could ask the client, Do you mind if I take notes? and see what the reaction is. Some clients may agree to note-taking but not mean it. You will have to decide whether note-taking is appropriate. If you cannot take notes, you will have to concentrate to remember the details and then write them down after the visit. Observations As your skills increase, you will notice more and be better able to understand how the things you notice contribute to an overall picture of your client. Your observations may include: State of clothing: Neat, dirty, mended, torn. This gives clues about how the client is functioning in daily life and his nancial situation. Physical appearance: Thin, well-fed, bruised, dirty hair. This gives clues about his nutrition, HIV status, injuries. Emotional appearance: Happy, sad, tearful, laughs at the wrong times. This gives clues about his emotional state; use these clues to ask questions. Relation to counsellor and environment: Are there culturally appropriate greetings, body language, eye contact? Does the client seem inattentive (as if he isnt concentrating on what you are talking about) or distracted? Is his thinking
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slow? These are clues for social appropriateness, or evidence of emotional or thinking problems. Was your client on time for his appointment? Does he have the correct paperwork with him? Does he seem prepared to talk? These suggest your clients attitude towards counselling and his ability to be in counselling. They also help you to anticipate similar problems. Note that no single observation or fact is enough for you to make up your mind about a client. All the puzzle pieces must be put together to make the nished picture. Questions A counsellor asks a lot of questions. But a counsellor doesnt ask questions just because this seems like the thing to do. The questions are also not asked just because the counsellor feels the urge to ask questions. The questions are used to ll in the gaps in the clients story and to help the counsellor understand the clients life. The story and the information obtained by the questions together help the counsellor to decide what issues should be addressed. The questions and the answers can be grouped according to the BESS model, so that the counsellor can understand the clients situation in terms of biomedical, emotional, social and spiritual aspects. The BESS model says that these four parts of us interact and affect each other. Understanding these parts and the interactions direct how the counsellor goes about counselling a client.
Extra information
An unskilful assessment, or the clients reluctance to speak truthfully, can lead to an incomplete and incorrect view of what problems exist and their causes. For example: A client complains that he is depressed. The counsellor fails to ask about how much beer the client drinks. The drinking problem is not addressed and the depression does not improve. A client is taking HIV medication but is feeling ill. A counsellor does not enquire about how the medication is being taken. The client is taking it incorrectly, but the problem is not taken up in counselling because of the omission.
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With the assessment, there is always some compromise between keeping the client comfortable and having a complete and accurate view of the clients situation. These guidelines may help: If a client is in crisis, conducting a full assessment without rst helping with the problem is insensitive to his need for immediate assistance. The counsellor should respond to the crisis and then conduct the full assessment in subsequent visits. It may be difcult to assess the client in one session (or even two) if there are many complicated issues. The assessment should take as long as is necessary.
An example of an assessment outline begins on page 26. You should add to, delete or change the questions to suit the needs of your community.
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With practice you will learn to ask certain questions, or groups of questions, during the rst few visits. You will also learn ways to obtain more information from your client. As you learn more about human nature, your explanations of clients problems will probably become more complex.
2.
3.
4.
Answers to these questions will lead to goals that may improve medication taking. For example, the client needs to tell his health worker that he doesnt understand the language on the instruction sheets.
Create a counselling plan with goals that address problems and their causes
The counsellor creates a work plan that responds to the clients problems and the preliminary explanations. The plan has long-term and short-term goals. The counsellor returns to the Assessment Summary Form on page 53. The counsellor reviews the problems she has recorded in the rst column. Then, understanding the causes of the problems, the counsellor writes the long-term goals in the second column and the short-term goals in the third column. The last column, with the heading How, provides space to describe what needs to be done to reach the goals.
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In addition to counselling, other activities may be required, like family training. The form also has space for a counsellor to ll in potential problems and responses.
Problems
Biomedical Getting thin. Poor nutrition, little access to good food. Emotional Seems sad, may be depressed.
Long-term goal
Weight gain.
Short-term goal
Find food. Go to soup kitchen.
How
I will show him soup kitchen.
Improved mood.
See if his doctor will consider medicine. Talk to him about sadness. Suggest more activities.
Social Isolated, family has rejected him. Only one friend. More social involvement. Family reconciliation? Get him out of house to visit people. Discuss if family reconciliation is wanted or possible. Encourage social activity. Spiritual Feels isolated from God. Review faith. Go to services. I will contact minister on his behalf and arrange meeting.
What to do Get Emergency Services phone number to client. Suggest friend calls. Neighbour has phone. Can friend help?
Who to contact Get Emergency Services phone number. Follow up to see if client contacted neighbour and friend.
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Supervisory review
Supervision is important for all counsellors, both experienced and new. Supervision means discussing the case with a more experienced counsellor. The supervisor reviews the counsellors notes and the completed Assessment Summary Form. Usually the counsellor will do the following with her supervisor: Describe the new client, including his age, ethnicity and family situation. List the problems that he seems to have. Describe her preliminary explanations for the problems. Explain how the client makes the counsellor feel. Describe the treatment plan she has in mind.
The supervisor will: point out missing information suggest other explanations suggest treatment goals and ways to approach counselling mention community resources that may be helpful ask about her feelings regarding the client.
Based on the supervisors comments, the counsellor may decide to ask the client more questions, rethink the explanations and goals, and change the plan.
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You could say: Counsellor: Weve talked about a lot of things. Clearly you are in a lot of emotional pain and your childrens health needs attention. Your family also needs more food. Which issue do you want to address rst? Client: We really need to eat.
Counsellor: So, lets start off by working out how more food can be obtained for your family. We then will talk about your childrens health needs and your sadness.
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6
A counselling model
Introduction
At rst, a new client may try to make a good impression on you. With time, the real person emerges: sad or joyful, open or guarded, suspicious or trusting, passive or active. However the client acts, the counsellor should respond with compassion and acceptance. The skilful counsellor and the client will have agreed on both long-term and short-term goals to deal with problem areas that were identied in an assessment. But how do you start to work towards the goals that you agreed on? What does a counsellor think and do during the counselling process? This chapter and the next will answer these questions.
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Another type of counselling, called crisis intervention, assumes that the client has an urgent problem and that the counsellor will see the client only once or twice to help with the problem. The counsellor must make a quick and accurate assessment of the situation and respond immediately in a helpful way. There are four types of clients who may seek HIV- and AIDS-related counselling: The usual type of client, who is in counselling for several sessions, but not for a long time. The client who looks for help with a problem and doesnt return unless she faces another crisis. The person in emotional pain who is open to the benets of counselling and who is likely to be seen over a long period of time. The person who has a few sessions, disappears for a time, and then reappears for more sessions, repeating this pattern over years. (Sickness, family problems, job hunting and other issues may contribute to the disappearances.)
A counselling model that combines the two approaches is needed. The model we use can be described by this phrase: Think for the year, but practise by the hour. By thinking for the year, but practising by the hour, the counsellor is using two strategies (plans) at the same time. These strategies, based on the BESS model, give direction to the counselling. Without direction, the counsellor is like a driver without a map, wondering which way to go.
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Thinking for the year includes these steps: After assessment, the counsellor draws up a statement of long-term and short-term counselling goals, as described in Chapter 5. Then he anticipates and lists problems that could emerge over the long-term and some solutions to these problems. For example, if a client seems to be getting weaker, will she have to be rushed to hospital at some time? The counsellor could ensure that someone is available to transport her. The anticipated problems could be written down on the Assessment Summary Form. The counsellor will act as though the client will remain with him so that the problems can be addressed.
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Flight into health. Suddenly the client may announce that all her problems have disappeared and there is no need for additional visits. This confuses new counsellors, who know the client has many complicated issues. But the experienced counsellor knows this is a ight into health an attempt to avoid the pain of dealing with the issues. The attempt is unconscious, that is, not deliberately planned. In this situation, the counsellor should gently go through the list of problems, suggesting that they are not resolved. The counsellor could then suggest, Counselling is bringing up a lot of painful thoughts for you. One way to make the pain go away is to say the problems have been xed. That is a good wish and I wish it for you too. But your problems remain. Facing the issues and the pain in here will help you with the problems. Appointments missed for good reasons. You will remember from Chapter 4 that clients rationalise pain away. If counselling raises painful issues, a client may stop coming for visits or come too late to do meaningful work. The client offers what seem like good reasons for the absences or lateness. The good reasons may very well be rationalisations. Client: I didnt come last week because I couldnt nd someone to take care of the children.
To rationalise means to offer what seems like good reasons for behaviour, even when these are not the real reasons.
Counsellor: I wonder if you would have found a babysitter if we werent talking about the rape. Client: No, I really tried and no one was around.
Counsellor: There was always someone to leave the children with before. I am wondering if the pain of talking about the memories kept you from doing what was needed to have the children watched.
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The client will not say, Yes, youre right! immediately. But the counsellor should strongly suggest that the client considers the comments. If absences continue and are explained in ways that are questionable, then the interpretation is repeated. It may be that the clients primary defence is rationalisation. Avoidance of important issues. The counsellor and the client have agreed on goals, but the client never seems to want to talk about painful topics. The client always raises other topics. In supportive counselling, the counsellor will go along with whatever the client wishes to discuss. But in more active counselling, the provider will try to help the client understand what is occurring in the relationship. The counsellor may want to bring the avoidance to the clients attention, perhaps like this: Client: Yesterday my sister just wouldnt leave the house, when I had so much to do. When we began meeting, we agreed that you were very depressed and wanted to get better. Although you still seem depressed to me, you talk about everything but your feelings. Could it be that you dont want to talk about the depression?
Counsellor:
Discouragement is felt
When you address problems that have taken years to build, that are slow to x, or for which there are no clear solutions, it is natural to feel discouraged at some stage. In counselling, discouragement is sometimes felt because the problems are being thought about, where previously they may have been ignored. By ignoring the problems, the client avoided the feelings. Discouragement also comes if the client thinks that counselling is only for solving problems.
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The client can see the problem but cant see a quick solution and becomes discouraged. Often there are no easy answers and there is no magic medicine to make HIV go away. Counselling, however, has another function. It helps a person come to terms emotionally with HIV and AIDS and other issues that are difcult or impossible to change. Coming to terms with something is an emotional healing. The counsellor, responding with understanding to discouragement, explains again that counselling offers emotional assistance, but not necessarily solutions to concrete problems.
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A skilful supervisor will note that there is no emotion in the counselling relationship and should suggest that the counsellor consider her own emotional issues.
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the name of someone at a local organisation who may help solve a problem, or the name of a pastor who can help with spiritual issues.
Making a necklace
Think of this counselling model as a bead necklace. Together, the counsellor and the client design the necklace. The long-term plan is the string that connects all the beads. The beads are the individual sessions; each one is unique and important. The strong connecting string of a year-long plan keeps the beads together in a good design.
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Client disappears
Few occurrences are as upsetting for the counsellor as when a client disappears. The counsellor sits in his ofce at the appointment time, waiting for the client, but she doesnt appear. He telephones (if she has a telephone) and nds the service disconnected. It is an emotional blow, especially if the counsellor feels that some relationship has been built. This happens to all counsellors and it raises various feelings and issues. Among the feelings are anger and a sense of abandonment. This is understandable. The feeling may be stronger in counsellors who have issues with abandonment themselves or who are feeling insecure in their positions. A case review with the counsellors supervisor is suggested to see whether the counsellor perhaps made mistakes. Perhaps the counsellor was judgmental or failed to be empathetic (to be emotionally connected to the clients pain). The counsellor should be open about his actions and his feelings, both before and after the disappearance. One way to anticipate disappearance is to ask a question during the assessment. The counsellor should ask whom he can contact for information if the client goes missing, saying, I hope it doesnt happen with us, but sometimes a client just disappears without notice. Can you give me several ways to try to contact you if that happens? Is there anyone I could contact if you miss an appointment without warning? If a client has been sick and has no one to watch over her, you could say, If you miss the visit and I am unable to reach you by telephone, and you dont contact me within ve hours, I will go to your house to see if you are all right. If necessary, Ill break down the door or climb through a window to check on you.
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Also, as health seems to be declining, the counsellor could mention other issues that may need the client to take action: Is the client interested in saying goodbye (or making apologies) to people in her life? A good dying includes a persons satisfaction that she has said everything that needed to be said. The writing of a will or, perhaps, giving away possessions during face-to-face visits with loved ones before death. A visit from a priest or other religious leader. Saying what she would like to happen regarding the welfare of her children, a spouse, or other family members. Leaving messages, perhaps dictated to the counsellor, for family members who cant visit.
Home or hospital visits need not be long and they dont have to be about accomplishing goals. Rather, the counsellor offers a few empathetic words, perhaps holds the clients hand for a few minutes and then leaves. For many counsellors, the most awkward times come when a client is clearly dying. Sometimes health workers, unable to deal with their own feelings of loss, stop visiting the dying client or come less often. They rationalise this, saying their schedule has become too full, but in fact they are avoiding pain. A counsellor should notice if this happens and ask for help or counselling from his supervisor, rather than hurt the client. What do you say or do? The counsellor should be authentic, saying what is on his mind, knowing that this might be the last meeting. The counsellor could talk about his affection for the client, about the things she has accomplished, and the love that she has given and received. Perhaps he could remind the client of her belief in an afterlife and her belief in God (or however the client expressed it). The counsellor could ask if his client wants to be visited by a clergy person. A client, when departing, once said to me, Ill see you when I see you.
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Death
The medical path of the HIV disease is lled with unexpected events. People who seem to be dying are hospitalised, recover and return to their homes. Individuals who dont seem so sick die unexpectedly. Even when anti-retroviral medicines are available, the unexpected can occur. If a counsellor opens his heart to a client and expresses caring-love, the loss of a client to death is painful, even when it is expected. When a counsellor meets an HIV-positive client for the rst time, the clients eventual death should be expected. However, often counsellors forget or deny that expectation, especially when the client looks healthy. The counsellor is then shocked when the death occurs. Even when the counsellor expects the death of a client, it is traumatic. How should a counsellor respond? The counsellor should allow himself to mourn, just as he encourages family members to mourn. If there are no condentiality issues, he should attend the memorial service, pray for the clients soul if appropriate, and take comfort in the knowledge that he helped the client acknowledge life and die a better death.
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A memorial book is placed in a quiet corner where everyone can reach it. In it are listed the names of all the clients who have died. Sometime a candle is left burning beside the book. People can sit silently with the book, remembering those they have known. The agency holds an annual memorial service, perhaps on World AIDS Day, which is 1 December. The names of deceased clients are read out and prayers are said. Educational and advocacy activities are held after the service. Organisations often provide refreshments at these activities, as a gesture of nurturing and acknowledging clients hunger and thirst. Memorial quilts are sometimes made by a group of people to commemorate the lives of those who have died of AIDS. A new panel is added to the many other pieces that make up the AIDS memorial quilt. There are more than 44 000 panels in the international project that commemorates lives lost to AIDS internationally.
The international AIDS quilt, seen here in Washington, DC, in the USA, travels on display to promote public awareness of AIDS. Each panel is individually designed and is dedicated to the memory of someone who has died of AIDS. (Photo: A. Reininger/ Woodn Camp & Associates, Inc)
Finally, when a client dies, especially if the death is a difcult one, the clients counsellor and other staff members should identify other clients who may suffer greatly and would benet from extra attention. These might be best friends, former or current partners, or others who were close to the deceased. The agency offers extra attention and, perhaps, invites them to enter into counselling.
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7
Counselling techniques
Introduction
The advice, Think for the year but practise by the hour, suggests how to plan and conduct counselling: by knowing the clients long-term issues and setting goals. Like the string on which the beads of a necklace are threaded, long-term themes and goals run through individual sessions. Each session is like a bead: each one has its own purpose and goal. The skills that a counsellor must have to work effectively with clients are just as important as the plan. The skills help the counsellor to listen to the client and to respond in an appropriate way. This chapter describes techniques that will help the counsellor to be effective.
Techniques are ways of doing things.
Preparation
The importance of being prepared for each clients visit may seem obvious to you, but some counsellors are very busy, take shortcuts or just try to take the lazy way out. Before meeting with a client, a counsellor should read through the clients record including the comments made after previous meetings. The counsellor should remind herself of both the long-term and short-term goals of the relationship, and of the major issues that have come up. Having refreshed her memory, she can encourage discussion or make better comments. This creates continuity between sessions. If there was an important subject discussed previously and the client 69
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doesnt raise it again, the preparation will remind the counsellor to ask, Last week we talked about your mothers heart attack, but todays visit is almost over and you didnt bring it up. Why is that? Also, in keeping with the practise by the hour advice, preparation should include creating a goal for the next visit and preparing the gift, the sharing of a word of wisdom or knowledge that may be helpful.
Attentive listening
Attentive listening means listening to the client without being distracted. When friends talk, minds usually wander. A comment by a wife may start a husbands mind on a journey of thought. Distracted by the thoughts, he may stop listening. Everybody gets distracted sometimes, but this is not helpful during counselling. When Buddhists teach meditation, they say our minds are like monkeys, always jumping around. A counsellor must learn to focus while listening to a client. The keys to attentive listening are awareness and determination. While sitting with a client, the counsellor is aware that he must focus on what the client is saying. When the counsellor becomes aware that his mind has drifted away, he should realise this and refocus on the client. When his mind drifts away again, the counsellor should once again refocus. This effort is repeated thousands of times until he is better able to remain undistracted. If the counsellors mind drifts away and he loses track of what the client has been saying, it is acceptable to say, Im sorry, I lost my concentration. Would you kindly repeat what you just said?
Reecting emotions
Helping a client talk about her feelings is a major part of counselling. Too often, counsellor and client are content to talk about events and ideas. This doesnt deal with the emotions that often are the motives for, or reactions to, thoughts and behaviours. However, if the client can
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understand and be open with her feelings, then she can appreciate how they affect the rest of her life. One of the best ways to help a client appreciate and understand feelings is to use a technique introduced by a psychologist called Carl Rogers. Rogers introduced an effective style of counselling that looks simple, but is actually very difcult. Using Rogers methods, the counsellor tries to understand the emotions that the client is experiencing and then acts like a mirror, reecting (repeating back) those feelings to the client. These reections make the client feel that she has been heard and understood. It also gives the client an opportunity to correct the counsellor when he doesnt understand the feelings. This is how the method works in practice: Client is crying but not saying anything. Counsellor: You are so hurt, so in pain. Client continues to cry and says nothing. Counsellor: You are so hurt. Client continues to cry silently. Counsellor: Your pain is so great; you just have to cry and cry. And: Client: I really want to kill my husband.
Counsellor: You are very angry with him. Client: Angry? Im more than angry with him.
Counsellor: You are feeling rage. Client: Yes, rage. Im burning up inside.
Counsellor: You are so full of rage; you are about to burst into ames. This technique requires undistracted listening, as well as skill in appreciating the clients emotions and nding the right words to reect those emotions back to the client.
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It is usually easier to discuss feelings in your mother-tongue. But even then, many people (especially men) are so unused to talking about feelings that they dont have the words to describe them. The counsellor may want to keep a list of feelings-words and use it to help the client describe emotions.
A hunch is a suspicion.
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Counsellor: I notice you are crying a lot. Id like to ask some questions that may help us understand the crying. Is that all right? Client: Yes, thats okay.
Counsellor: How are you feeling emotionally? Client: (a bit angry with the counsellor) Well, as you should be able to tell, Im pretty unhappy.
Counsellor: Yes, I see that you are unhappy. Im sorry to sound insensitive, but I want to get to the cause of the unhappiness. Client: (still angry, and not sure why the counsellor is asking what he should already know) I told you that Im unhappy because my son got his girlfriend pregnant.
Counsellor: Yes, thats a good reason to be unhappy. (Explaining and asking for patience.) But something else may be bothering you as well. Please, bear with my seemingly stupid questions. (The counsellor is trying a bit of humour.) They dont mean I havent been listening. Counsellor: (starts asking questions from a list of symptoms of depression) Do you feel depressed most of the time? Client: Yes, pretty much since I heard the news. I dont know what hes going to do.
Counsellor: You told me you really enjoyed your life before this bad news. Are you enjoying life now? Client: What do you mean?
Counsellor: You had activities that gave you pleasure, like sewing. How much enjoyment do you get from sewing now?
In this case, the counsellor is following a checklist for depression symptoms that he copied from Chapter 9 (page 113) of this book while he was preparing for the session. He then followed the checklist very purposefully to see if the client could be suffering from clinical depression.
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Other situations that require some structured questioning include: unexplained (or poorly explained) bruises on a person when you suspect violence a child who seems to be starving a person who is full of rage and you suspect the possibility of violence someone who denies drinking too much, but talks about behaviour that may be the result of intoxication.
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Most counsellors dont have a real elephant in the room! But communities and families sometimes have something like an elephant that no one talks about, and it probably sneaks into counselling visits. An elephant in the room means a situation or topic that everybody knows is present, but everyone pretends isnt there because they know it is difcult or embarrassing to talk about. While friends and family may avoid certain issues, counselling should confront those issues. If the counsellor accepts the silence about an elephant, she sends the message that some topics can be overlooked. This undermines the counselling process. These are some important problems that people often dont discuss, but which must be discussed in counselling: violence in the home or community alcohol abuse and abuse of other substances rape (of women and men) and incest.
Enquiries should also be made, where appropriate, about alternative sexual practices and lifestyles, which are often not openly discussed. The counsellor, recognising that a sensitive topic needs to be discussed, can soften its introduction by saying, I know this is a difcult topic to talk about. However, it is important that we discuss ...
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One example is counselling a client who claims she is independent-minded and truthful. But during counselling visits, she keeps her eyes down and her shoulders hunched. The counsellor sees a contradiction between the clients words and the way she holds her body. The counsellor watches the behaviour and may not believe the words. He comments, Maria, you say many good things, but your body is saying something different. While you talk about how strong and independent you are, with me you look like a nervous puppy. The skilful counsellor understands that many messages are silently delivered.
Counsellor:
It is important for the client to see the pattern. This is the rst step in changing it. If the client does not understand the connection between the two events, the counsellor should explain how he reached this view. Over time, with repeated connections made by the counsellor, the client may accept
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the view. A client who doesnt see emotional patterns is unlikely to make progress.
Counsellor: (Doesnt respond to transport excuse.) This looks a lot like what others say about you. Youve told me they say you dont want to get close. I think you are doing here what you do with other people. You do want to get close, but at the same time you use excuses to keep your distance, and then you feel lonely.
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That comment has no useful purpose in counselling. It pushes the clients worries aside, stopping the conversation. It only makes the counsellor feel better. Sometimes, to escape the anxiety, a counsellor will distance himself emotionally from the clients pain. Here is a simple technique that may help you to get through these difcult sessions: When you are feeling anxious, acknowledge the feeling. Admit to yourself that you are feeling anxious and recognise that your clients story is making you feel this way. Breathe deeply and think about your breaths. Count the breaths until you feel a bit more in control. During this time, just listen and say nothing. Gently ask questions. Steadied by the focus on breathing, ask about your clients feelings during (a) the original event and (b) now, while she is telling you about it. Reect back the feelings. Check yourself for accuracy. Based on your clients response, rene your understanding of the clients emotional experience.
Some people believe that bad feelings experienced by the counsellor during discussions about a terrible event are actually the feelings of the client. Without being aware of it, your client tries to relieve herself of the bad emotions by giving them to you. Another explanation of the bad emotions felt by the counsellor is that the counsellor is empathising deeply with the clients feelings, thereby better appreciating her experience.
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8
Special HIV and AIDS issues
Introduction
Counsellors may be employed to do special tasks, such as counselling people who want HIV tests at voluntary counselling and testing centres, helping people take their HIV medicine correctly, conducting HIV prevention programmes, or meeting the special counselling needs of children and adolescents. This chapter looks at issues for counsellors who take on these important functions.
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Counselling at VCT centres requires special training. Counsellors learn to use a standard list of questions and responses when working with people who want to be tested or who want to hear their test results. Because the need for VCT counsellors is so great and so urgent, training is usually done quickly. There is little time to practise counselling skills. Some VCT programmes focus on the biomedical and prevention aspects of HIV, giving little or no attention to emotional, social and spiritual issues. The neglected issues could include harmful emotional responses to news of infection, mental illness, alcohol abuse and the potential for family troubles. VCT centres could serve clients better with additional attention to the emotional needs of clients.
Anonymous or condential?
Testing is usually anonymous or condential. Everyone should be aware of the difference between the two. Anonymous testing means a test result is not attached to a persons name. At a test site, a person does not give his or her name. The person is given a code name or number to use when he or she returns for the result. Condential testing is different. It means that the test result is put into a le, such as a medical record, with the patients name. This is usually what happens at a medical clinic or hospital, so doctors and nurses can better treat their patients. In this case, condential means that only those who need to see the test result may read the clinics les. In some small communities, just being tested leads to stigma and discrimination. Some people are concerned that neighbours who work at VCT centres will gossip, or that people who work at clinics or hospitals will read les and learn of a persons infection. As a result, people sometimes travel for hours to be tested where no one knows them. VCT centres are now being located in buildings where many people do business, so no one can say that someone entering the building is going to the VCT centre.
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Tests at VCT centres and clinics determine if someone has an antibody to HIV, which is a product of the bodys response to the presence of HIV. You may hear that someone is antibody positive this means that the person is HIV infected. When someone is in medical care, the person may be given a viral load test that directly measures the amount of virus in the persons body. The actual HIV test given at VCT centres and clinics will differ depending on the methods available. With one test, a clinic staff member takes blood from the person being tested. The blood sample is sent to a laboratory for testing. The client returns for the test results a week or two later. Many people, made anxious by the testing and the possibility of infection, do not return for their results. Newer tests are available. One requires the client to provide just a few drops of blood. Another type of test asks the client to rub a small sponge on a stick (which looks like a toothbrush) between the gums and cheek. A third test being developed uses urine. Results of these newer tests are available within minutes, hours or days. Because the new tests provide faster results and dont require a lot of blood, people are more likely to be tested and less likely to be anxious. The VCT counsellors ofcial tasks fall into two general categories: Pre-test counselling, which includes educating the client about the test and screening the person for suitability for testing. Post-test counselling, which includes notifying the client of the test result. If the person is infected, the result is explained and instructions may be provided for medical assistance.
Both infected and non-infected people are counselled regarding prevention of infection.
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Relationships
Even clients who have the courage to be tested are likely to be very anxious and upset. A VCT counsellor may seem at a disadvantage in approaching someone who is stressed, especially if someone is found to be HIV infected. The compassionate and competent counsellor can provide important support.
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An excessively anxious person may be too distracted to understand the counsellors teaching. If a severely anxious client is tested, the wait between the test and the results may be too much to tolerate, resulting in a serious crisis.
Depression
If a person who comes for testing seems depressed, a counsellor may want to ask questions about the symptoms of depression (see Chapter 9). Depression may cause the client to react very negatively to news of infection, leading to despair, suicidal thinking or even suicide. In such cases, HIV testing should be postponed until the symptoms of depression disappear.
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the smell of alcohol on the breath, and red eyes. Sometimes the client may be hostile, too friendly, or the conversation just doesnt make sense. These symptoms should raise several concerns about having an HIV test or receiving results: Why is an intoxicated person at the clinic? The client should be completely sober so that she can make an informed decision to be tested. It is unlikely that an intoxicated client can fully understand the counsellors instructions. Did the client think intoxication was necessary to tolerate the anxiety? Is the clients condition masking depression or a serious mental disorder? Is the client treating this serious event as trivial? Is the client addicted?
Intoxicated individuals should be instructed to return when they are sober and are able to understand and work with the counsellor. The counsellor may give the person information about where to seek assistance, if any is available, for the alcohol or substance abuse problem.
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that counsellors in Western countries seek anonymous testing so that they can empathise with clients. Unfortunately, the personal price of being tested is much higher in Africa. What would happen if a group of people, such as counsellors, university faculty members, or members of a student group, went in together for anonymous testing? Could this be a powerful public gesture that confronts anxiety, stigma and silence?
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Is the client at peace with her Creator? What does the client think Gods reaction would be to a positive HIV test? Will news of infection cause a spiritual crisis? Does the client belong to a church community that will offer solace?
HAART is an abbreviation for Highly Active AntiRetroviral Therapies. The combination of medicines prescribed is called a regimen or a protocol. Taking medicines as a doctor prescribes them is called compliance or adherence.
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Counsellors can assist their clients with HIV medicines in the following ways:
Be a team member
The counsellor who deals with medication issues should think of himself as part of a team that includes the doctor, family members and other people. Dont be shy about calling other team members, seeking advice, or asking for assistance with the client. The relationships built on behalf of the client should be face-to-face, rather than at a distance. For example, the counsellor could accompany his client to the clinic and be introduced to the doctor. The counsellor could then explain that he is assisting with the medicines and suggest the doctor phone him if concerns emerge. On the same basis, he could phone the doctor. During a visit, the counsellor could listen to the doctors orders, take notes and request any pamphlets that may be available that explain about the medicines.
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First, the chart is divided into days. If the client can tell the time, clock faces can be used to indicate when pills should be taken. Otherwise, you could draw morning, midday and bedtime symbols. If the medicines must be taken with a meal, draw food. Draw a picture of each pill in the correct block. To check that your client understands your chart, ask her to place the pills onto the chart, so that you can make sure the drawings are clear and understood. Explain to your client that she should take each pill at the right time and then cross off the pill on the chart. Before the client leaves, ask her to explain the instructions and you can correct any errors.
Pillboxes
Pillboxes are becoming more available. Some have compartments for each day of the week, while others have three compartments for each day. The counsellor teaches the client to put the pills and capsules for each day or time period into the proper compartment.
The pills in the chart above represent specic drugs. The drugs prescribed to and taken by your client, and the number of pills, may be different. Draw the pills or capsules to represent the actual medicine and the amounts prescribed to your client.
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Counselling FA EV 89
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If pillboxes arent available, use envelopes, paper cups or cans, marking them with the days of the week and times of the day, such as morning, midday and night, or breakfast, lunch and dinner. Some clients may need the drawings, or other creative reminders, and the pillboxes.
HIV prevention
The effort to halt the spread of the virus that causes AIDS has become a whole new industry. Unfortunately, somewhere down the line, prevention efforts became separated from health care. Often doctors, nurses and other health workers focus on the medical aspects of HIV and rely on other people, including the media and NGOs, to provide HIV prevention messages.
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Counselling FA EV 90
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This is a pity because prevention and health care should work closely together. Other issues that make it difcult to prevent HIV infection include: Cultural values that suggest that getting infected with HIV is just bad luck and not much can be done about it. Cultural values that discourage open discussion of sexual activities. Counsellors who feel uncomfortable about discussing sex. This discomfort can be communicated without words to the client.
There are no easy solutions to these problems. In the United States, one group used the slogan silence = death. Perhaps we need to talk about how community silence threatens the survival of its people. People who would like to be HIV and AIDS counsellors should consider looking inside themselves to understand their feelings about sex. An NGO activity, perhaps, could be the distribution of messages regarding all types of prevention and sexuality, even those distasteful to governments and churches. The prevention messages could come with a label, as do alcohol and tobacco products in countries that allow and prot from their sale, that indicate some parties think the practices described are morally harmful.
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Counselling FA EV 91
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Counselling FA EV 92
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A sexual act is destructive if it can transmit HIV. This issue could be addressed in public forums or in counselling with individual clients.
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Counselling FA EV 93
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Children affected by HIV and AIDS also have a wide range of situations that can come to a counsellors attention. Some young children may be HIV-infected and, if medicines become available to them, they will live with the infection as they grow older. Others may not be infected, but they may lose their parents or other family members and suffer great emotional pain. No single chapter or book can describe all the situations and the possible counselling responses. Some issues can be highlighted, however, to prepare counsellors. This section will briey discuss counselling themes for children and adolescents, and then discuss some specic issues.
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Counselling children and teenagers is usually connected with play, rather than sitting in a room and talking. Young children are given toys to play with and the counsellor watches and tries to understand the messages in the play. Sometimes children are given dolls and encouraged to have the dolls interact and talk to each other. The counsellor may take a doll and join in the conversation. It is believed that playing and talking will reveal their thoughts and feelings. The counsellor can then respond through play with the children. Counsellors take older children and teenagers to such places as sports venues. A counsellor may kick a soccer ball around or play basketball with a teenage boy once or twice a week. The belief is that the counsellor-client relationship will build as they play together and, gradually, the teenager will begin to talk about feelings. The counsellor can then respond in a healing way. These methods take time and only work with one child at a time. Counsellors are taught a variety of techniques to help children improve behaviours and get over their fears and other problems. For example, counsellors may train parents or caregivers to reward good behaviours.
Building Resilience Among Children Affected by HIV/AIDS, another book in this Catholic AIDS Action series of publications, details many constructive games a counsellor can play with children.
Non-traditional counselling
In the African context, special efforts are being made to use various group activities for affected children. These include: Training and supporting older children who head households or have responsibilities for children in adult-headed households, to help them look after their siblings better. Creating clubs for children that combine fun with developing skills and looking after their emotional needs. Creating recreational leagues, such as soccer leagues, for affected children. In addition to playing sport, the children hear messages about self-esteem, discipline, building healthy bodies and caring for others.
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counsellors to be cool as well. A counsellor who wants to work with teenagers may need to increase his coolness! Watching television shows that local teenagers watch and reading publications will help the counsellor make conversations that are relevant to the client. Some cool clothing also helps. However, counsellors who are always going to be seen as uncool shouldnt embarrass themselves.
Organising services
The counsellor may have to take additional responsibilities when working with young clients. These may include: teaching parents or caregivers to care for the children better, including advising on matters of discipline ensuring that the child gets proper health care, including arranging transportation and reminding caregivers about appointments helping with paperwork for government payments.
Security
Children have a need for security and constancy (things that dont change a lot). They express this in several ways: Through rituals, which means a set way of doing something, such as dressing or eating. Any change in this ritual may create anxiety. Clinging, including tightly holding a caregivers hand, wanting to be carried, or refusing to leave a caregiver.
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Counselling FA EV 96
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Counsellor: Child: Counsellor: Child: Counsellor: Child: Counsellor: Child: Counsellor: Child: Counsellor:
In this scenario, the counsellor is encouraging the child to talk about her concerns. But, because the parent has forbidden the counsellor to reveal the secret, he does not conrm the childs suspicions.
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With the child saying it would be better to know, the counsellor could talk to the sick parent, encouraging her to disclose the secret of AIDS so that all family members can prepare for the future, both emotionally and in terms of child care and other arrangements.
Gang membership
Children without access to healthy love and affection nd alternatives. One alternative to a family is a gang. In gangs, teenagers support each other emotionally, but also engage in group misbehaviours, such as theft and violence, or even murder. These gangs are vulnerable to control by criminal adults.
Sexual issues
Children are becoming sexually aware at an early age. They may experiment during play when they are young. Later, they may become sexually active. Counsellors may be in the middle of several expectations. Parents or guardians may expect the counsellor to reinforce the parents sexual teachings. An organisation may expect the counsellor to provide information that conforms to their requirements, for example abstinence. The adolescent client will expect the counsellor to be honest and straightforward about sex, especially if the counsellor wants to encourage openness.
Extra information One solution may be a counselling process through which the adolescent decides on her own standards for sexual expression. The counsellor challenges the youth but does not impose his own beliefs. This may take many visits. Ultimately the standards are decided upon by the teenager and not imposed by the adult. This process can also be done in a group, with teenagers discussing sexuality, peer pressure and other issues, and each creating his or her own rules.
Orphans
Without HIV medicines, a parent infected with HIV when her child is one year old is not likely to see the child become a teenager. Many households have both parents infected with HIV. As the parents get sicker, the children begin to feel the loss of them as active participants in their lives.
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After the deaths of parents, other family members, including their grandparents, may care for children. These children may nd themselves alone, with the oldest child acting as head of the household. Or they may end up on the streets fending for themselves. New orphanages are being founded in countries where previously families always cared for children. Now there are either no families to care for the children or the families are overstressed and cannot provide care. Issues for orphans include: the failure of welfare systems to provide for children in child-headed households prostitution and theft for survival continuation in school emotional problems such as depression, trauma and the likelihood of these problems continuing into adulthood.
Only recently have governments begun to recognise the existence of orphans. The real test of a governments intention to care for children is whether resources are allocated for meaningful services. A failure to spend money now to help children is likely to have far greater costs for generations to come. Counsellors may consider the following activities: speaking out for children so their needs are not lost in the silence that surrounds HIV and AIDS in many ethnic groups calling for changes in welfare programmes so that children without parents can receive a fair share of government money getting legal assistance and working with ethnic leaders to ensure that children receive their legal share of parents estates creating trusts or guardianships for childrens funds, so relatives or others do not take money that should go to children.
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Scientists use surveys to nd out what a large group of people think or have experienced. But it is too difcult and expensive to ask everybody in a large community, so they try to identify a small number of people to question. This smaller group is selected because it is likely that the members have experiences and opinions that are similar to those of their larger community.
Girls and boys can also be victims of incest, rape and other physical violence. For example, in some communities, men rape girls, saying incorrectly that sex with a virgin cures HIV infection. There is no acceptable reason for rape. Physical abuse and psychological abuse go hand-in-hand. People who are physically abused will also have emotional difculties. Although this situation is frightening enough on its own, the HIV and AIDS epidemic makes it even more dangerous. Violence and threats result in many women being unable to: ask about their partners HIV status negotiate for condom use or safe sex refuse sex with men suspected of being infected with HIV confront sexual partners about risky sexual behaviour with other people.
This means that women are often left powerless in situations that can lead to HIV infection.
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relationship. A male counsellor should ask himself whether he has ever been violent towards a woman or girl, or has forced someone to have unsafe sex. He needs to understand why that happened. He needs to be emotionally touched by the victims situation and to promise himself and the woman in his life that such a thing will never happen again. A woman counsellor will not need to be reminded if she has been assaulted or forced to have sex, or has been unable to negotiate safe sex practices. She will know if she is currently in a violent relationship (except if her response to the trauma was to remove the event from her memory). A counsellor who has been a victim needs to understand her feelings, whether they are hatred or anger directed at the attacker (or at herself), or pain. She needs to work out how close she is to getting over the trauma. If she still feels very hurt, she may identify too closely with the woman she is counselling. If she is working with a victimiser, the counsellor may still be too angry to work effectively with the man. In either case, feelings will interfere with the work. Without being aware of your own feelings about violence either as the person who acted violently or as the victim you will not be working skilfully. For example, if a counsellor plays down the harm of her own violent relationship, she may make the big mistake of not taking her clients experience seriously. Or, if she blames herself for the abuse, she may also blame her client. She may ask accusingly, What did you do to get him angry? It is suggested that you discuss your experiences with your supervisor before it shows that you are uncomfortable or not skilful in working with victims of domestic violence. Hopefully, if you have been a victim or a victimiser, you will seek counselling for your own emotional well-being. There is nothing to stop a counsellor from receiving counselling.
Signs of problems
Intuition is a feeling of knowing without thinking something through.
Many people who have been victimised by a spouse dont discuss this with a counsellor. For this reason, a counsellor needs to develop intuition about the possibilities of domestic violence. Here is a list of signs that suggest but do not prove that there could be violence in your clients home:
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You often notice physical marks and signs which your client cant explain to your satisfaction, such as limps, bruises and complaints of injury-related pain that occur again and again. Often they come with explanations that may be believable once or twice, but not more than that. Is it likely that the woman keeps walking into doorways or keeps falling down, hitting her face? An assault on a child may include facial bruises, bruises on arms and legs, and scars or bruises on the back or buttocks. Active children usually have grazed knees and elbows, but few are so accident-prone that they have repeated bruising or scarring injuries elsewhere on their bodies. Sexual abuse of a child may show itself in vaginal or anal bleeding or bruising, or infection with a sexually transmitted disease (STD). Sores, discharge from sexual organs, painful urination or warts in genital areas are symptoms of STDs. A mother may indirectly raise this issue by asking a counsellor what one of these symptoms could mean, or a child may complain of such symptoms to a counsellor or a health worker. Boys are also victimised and should be listened to carefully. A woman or child may express excessive fear when discussing a husband or father. On the other hand, a woman or child may be silent or nervous when the father is present. A tense body, unusual silence, or refusing to say anything critical may be signs that your client is nervous or afraid. A woman may talk in counselling about being too dependent on a partner. A child victimised by a family member may say that her mother doesnt protect her. When you try to nd out more, the child may not want to be more specic. A child may ask questions about how other fathers or mothers treat their children physically or show their love.
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A woman or child shows signs of malnutrition when food is available. Alcohol is abused.
Counselling experts in Africa often warn counsellors, especially those in training, about being too direct with clients. A client may feel uncomfortable and stop coming for counselling if a counsellor says, You have come here for months with injuries; is your husband beating you? The question is asked too directly. Some experts suggest that the counsellor must be sure of a trusting relationship with the client before raising such an issue. Others experts suggest the counsellor should talk about domestic violence and possible remedies without actually naming the problem. Each situation needs to be given careful thought before dealing with domestic violence.
Counselling
Counselling tries to: develop the clients trust so that she talks about the problem of domestic violence build the clients strength and self-esteem so that she can develop a response.
This is the same relation-based strategy that has been discussed in this book in relation to all people affected by HIV and AIDS. When using counselling to try and help victims of violence, the same counselling methods are used and the same problems may arise.
Crisis centres
A crisis centre is a safe place where a woman and family members can get help during a crisis. Once the victim is away from the attacker, the next move can be planned. In towns and cities, the location may be secret and the woman gains access to the crisis centre by calling a phone number. She is then met or directed to the safe place. Her presence
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there is kept secret. Services such as short-term crisis counselling may be available.
One-stop shelters
One-stop shelters for victims of domestic and sexual abuse are places where victims can stay or visit, and where they can obtain medical care, legal advice, counselling and training.
Community-level interventions
As with so many issues, counsellors and organisations must consider interventions that deal with the community. Projects in Africa have looked into the following: questioning culturally accepted customs such as examination to determine if girls are still virgins, and cutting or total removal of female sex organs (female genital cutting or FGC) organising meetings and creating organisations that emphasise and support the role of men and boys against gender violence
A guide about mobilising communities to prevent domestic violence in East and southern Africa is available from Raising Voices, Kampala, Uganda. E-mail: lori.michau@raisingvoices.org or go to www.raisingvoices.org training men to be gender equality role models to boys facilitating educational meetings for men on issues of sexuality, reproductive health, safe sex and fatherhood offering high-quality counselling programmes for men who have harmed women and girls establishing counselling groups that combine men and women for very personal discussions about gender violence.
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Counselling FA EV 105
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9
Mental health
Introduction
A person affected by HIV can have many mental health problems. Some may be related to the HIV infection. Other problems may not be related to the infection. In some cases the client may have struggled with these problems before infection. When mental health problems are serious, they can interfere with work, social relationships and how a person cares for his or her health. The community-based counsellor should be able to recognise the signs and symptoms of these problems, and should help the client seek expert help. The aim of this chapter is to help counsellors recognise mental health problems. Becoming an expert, including being able to make correct diagnoses, takes a lot of additional training.
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By using the term mental health problem we dont make any suggestions about what caused the problem.
Extra information There are lots of ideas about what causes mental health problems. Some people believe that an adults emotional issues are caused by the way a person was treated while growing up, as well as life at the moment. Some people say that some children inherit the ability to thrive (grow and do well) in a difcult environment, while others do poorly in a good environment. Some people argue that all emotions are based in the chemicals of the brain. Some researchers think that many people may be genetically vulnerable to specic mental health problems, but only those who suffer sufcient stress actually experience the specic disorders. A new school of thought is that what some people call mental health problems are caused by not knowing how to control emotions or have relationships.
Other complicated issues exist. A client with HIV may appear to have mental health problems, but the cause may be the effects of medicines or an opportunistic infection. Many people with AIDS get a brain disorder called dementia, which shows itself in emotional, behavioural and thinking problems. Another condition, called delirium, may look like a mental disorder but is actually a health problem. Also, someone unfamiliar with a clients culture may interpret beliefs and behaviours as mental health problems. For example, in Culture and mental health, a southern African view, the author notes that spirit possession as a path to becoming a traditional healer has been viewed as pathological. These days, people agree that if the behaviour or beliefs are generally accepted in a persons culture, they are not caused by a mental disorder.
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Lets put nervousness in the white area, where all the circles overlap. A person may, by his physical nature, be more nervous or apprehensive than other people (biomedical).
Biomedical
Emotional
Nervousness
Social
Spiritual
The components of mental health issues Because of this, he reacts with fear to events that dont affect other people (emotional). This nervous reaction may have alienated people, who dont want to be around him (social). Now he lacks social support, which makes him feel more vulnerable. Not having a rm spiritual foundation that allows him to feel grounded in the universe may also contribute to his nervousness about HIV. Some people may argue that, when it comes to mental health, there should be one circle only the biomedical circle. Other people suggest that many factors interact, even in diseases that are caused by brain problems. An example is depression. Most people will agree that a major depression, in which a person nds it difcult to carry on with day-to-day living, is biological and should be treated with anti-depressants and psychotherapy. But major depression can have a psychological beginning, such as the loss of a relationship. The emotional response can affect a persons brain chemistry, resulting in a biologically based condition. In this matter and all others involving medication and questions about medication, the client should ask a health worker for help.
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Afterwards, the mental health specialist will decide if all the information ts the requirements for a mental health problem.
Extra information A counsellor who wants to learn more about causes of mental health problems can consult textbooks or attend psychological, psychiatric or neurological seminars on HIV and AIDS (see Chapter 13). Criteria for mental health diagnoses are published in the Diagnostic and Statistical Manual of Mental Disorders, (4th ed., Text revision) (referred to as DSM-IV-TR) published in 2000 by the American Psychiatric Association.
Counselling FA EV 109
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Extra information
Some people may argue that a mental health perspective on the behavioural and emotional issues of Africans is Western-based and not useful here. Western-based concepts certainly need cultural adaptation and some may not be applicable (or could be improved). Even in Western nations there is discussion about the validity and value of the psychiatric diagnoses in DSM-IV. Unfortunately, most people living in Africa who suffer from mental health problems get no help. The simple recognition that a mental health problem may exist could help someone realise that he or she isnt imagining the symptoms and that they indicate a real condition.
A skilled counsellor may be the only person in the clients life who recognises and responds to a mental health problem.
If the client shows any of these signs or symptoms, he or she should be referred to a doctor or a mental health professional.
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Extra information
With experience, a counsellor will learn to notice certain behaviours that make red ags pop up in her mind when a client talks about the following: A situation that could harm the client that doesnt change, despite a lot of counselling. For example, a client is not eating. Could it be that the client is depressed and unmotivated? Unreasonable suspicions that interfere with life. For example, if a client distrusts medical care and would rather be sick than get help. Out-of-control behaviour, such as sexual behaviour, that is unusual for the client. The client has very odd ideas, such as believing that the police are watching his house or that medicines prescribed by a doctor are poisonous. A client objects to medicines but abuses substances (takes drugs, uses alcohol). A client cant gure out cause-and-effect relationships, for example, realising that if I do this, then that will happen. A client preys on vulnerable people and avoids discussion in counselling, or continues with the behaviour even though he claims he will change. It is worth repeating that symptoms do not necessarily indicate that a client has a mental health problem, but they are still important. It is the responsibility of the counsellor to recognise symptoms.
Physical complaints
Some people are thought to express their feelings through physical complaints. They say they have headaches or a stomach ache, even though there are no physical causes for these pains. The pains are not made up; they are really felt. We say the pains are psychosomatic. Another approach is to say that talking about physical issues is a way of interacting with another person.
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A sudden complaint or increase in complaints about physical symptoms in someone who has AIDS may be a sign of a serious underlying problem. The client should be urged to visit his health worker.
When an HIV-infected person talks about pain, a counsellor must listen and take the complaint seriously. A headache can be a signal of a serious condition. But what can a counsellor do when a person who is HIV-positive seems to have physical problems just when they are going through a difcult emotional time and there is no health care easily available? Hearing complaints about headaches or stomach pains, the counsellor should consider the following: Is the person who is suddenly complaining of pain the type of person who doesnt usually complain? This is a sign that the complaint may require medical attention. Does the clients level of complaints and anxieties seem to be appropriate to having HIV in your community? Does the client often have lots of complaints? If so, the counsellor should anticipate conversations emphasising physical complaints. Has the client already discussed the discomfort with a health worker? What was the response?
Counselling FA EV 112
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A woman may no longer enjoy her children, or a man may no longer enjoy his card game or visiting friends. Telling a depressed person to get better is useless. For many people, depression may last as long as six months and then disappear, but for others the condition continues. If depression is suspected, counsellors should ask the following questions. They describe the symptoms of a major depression and have been adapted from the diagnostic manual published in 2000 by the American Psychiatric Association.
If someone is thinking about killing himself or herself, ask: Do you have a specic plan? Tell me what it is. Do you have the means to kill yourself? (Pills, a panga, a gun?) If the client has a specic plan and the means to end her life, you should not let the client leave the ofce. She is at risk of hurting herself. You need to take the person to a hospital or clinic, or have police or ambulance personnel take her to a place where she can be held safely and treated. It is not up to a counsellor to diagnose or treat depression, but you must recognise the signs. If the client is getting no pleasure from life, that in itself is a sign of depression. Also, if the client has some other symptoms described on the list above, you should refer the person to a doctor or mental health professional.
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The most effective treatment is a combination of an anti-depressant (a pill taken daily) plus psychotherapy. It is a mistake for anyone to think that a person is just depressed because she has HIV and then not treat the depression. Depression should always be treated.
What could you do as a counsellor if there is no health worker available? You could: Encourage the client to visit often and encourage her to talk during the visits about everything that is bothering her. Discourage the use of alcohol and drugs. Many people use these to take away bad feelings. However, they may make a person more depressed. Encourage exercise. A man could join a soccer game or a woman could walk vigorously around her community. A counsellor could walk with the client during the visit, if condentiality isnt a problem. Discourage social isolation and encourage being with people. A client could volunteer to watch or care for children at the local school, or help at the agency the counsellor works for. Encourage the client to try new activities, such as vegetable gardening. The counsellors organisation may be able to buy seeds for clients. Perhaps the counsellor could start a gardening class for clients. This may also generate income. Let the client know that depressed people sometimes have to push themselves a bit to become active. Praise the client for her efforts.
Anxiety
Another common symptom that indicates a mental health problem is anxiety. Many people think of anxiety as nervousness. It is that, but nervousness shows itself in many ways: It can show itself through worry that is excessive, as in a generalised anxiety disorder. It can show itself through a sudden overwhelming anxiety, which may be a sign of a panic disorder. A person may be unreasonably or excessively scared of a situation, such as being outdoors or in an enclosed space, or of certain things such as dogs or insects.
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Also, anxiety or nervousness can be a symptom of a number of disorders, including a lack of oxygen. Anxiety that comes on suddenly in a person who is not normally anxious requires a referral to the clients health worker.
Extra information
Some people, when anxious, begin breathing very rapidly. This is called hyperventilation. It can lead to a feeling of being light-headed and possibly fainting. If a client has episodes of hyperventilation, suggest this: Find a paper packet. When you begin to breathe rapidly, breathe into the bag, holding it close to your mouth so no air escapes. Usually the breathing will slow down and the light-headed feeling will not start.
These questions may reveal symptoms of generalised anxiety disorder: Do you worry a lot? Do you feel that you worry too much or that your worries are unreasonable? Can you control the worries? When you are worried, do you experience any of these: restlessness, becoming tired easily, difculty concentrating or suddenly going blank, feeling irritable, feeling tense or having difculty sleeping? Do these feelings make some part of your life very difcult?
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You could enquire about the symptoms of panic disorders by asking the following questions: Are there times when some of the following happen? Your heart pounds. You sweat, tremble, or shake. You feel you cant breathe properly. You feel as if you are choking. Your chest hurts or is uncomfortable. You feel sick to your stomach. You feel dizzy, light-headed, or as if you are going to faint. You feel as if the situation is unreal, or that you are outside yourself, detached somehow. You are afraid of losing control or going crazy. You feel as if you are dying. Your body feels numb in places, or there is a tingling feeling. You shiver or suddenly feel hot.
If some of these symptoms are troubling the client, you may want to refer the client to a health worker, if one is available. Severe anxiety can be treated with various medicines or with therapy.
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Ask the client to think of activities that are calming for her and encourage her to do some of these things every day. These activities may include gathering food, gardening, sewing, watching children play, praying, or even hard physical labour such as chopping wood. Ask if the anxieties have a spiritual basis. For example, is a man convinced that he has done such bad things that he will not go to heaven after he dies? Ask a client with AIDS if he or she is anxious about dying or death, and about what aspect of death specically. Some people are afraid of being in pain, dying alone, or dying shamefully because they may lose control over bodily functions.
Also ask, Have you experienced any other unusual event that caused emotional harm? If the person experienced one of these events, ask, Did the situation involve intense fear, helplessness or horror? If so, the person who experienced such an event may have lasting emotional difculties.
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Ask the client if any of these things happen: Memories of the trauma pop into his or her head. The client has frequent distressing dreams about the event. The client sometimes acts or feels as if the event is happening again. When the client sees things or experiences that make him recall the event, he has intense emotional distress or a signicant physical reaction. The client avoids thinking, feeling or talking about the trauma. The client avoids activities, places or people that make her recall the trauma. The client cannot remember an important part of the event. The client feels detached or emotionally separate from others. The client cannot experience emotions like other people. The client feels his life will be short or wont have normal events.
Other signals of emotional harm from a traumatic event include problems with sleep, irritability, angry outbursts, difculty concentrating, extreme jumpiness in response to loud noises or other events, and being highly aware of surroundings. As with depression, the person who has a number of these problems would benet from proper diagnosis and perhaps treatment, if it is available in your community.
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This seriously affects their ability to cope with life, let alone cope with HIV. Some symptoms of serious mental illness are: hearing things that other people do not hear, especially voices that urge you to harm yourself or other people feeling that you are being tormented, tricked, followed, spied on or ridiculed believing that TV and radio shows are targeting you believing that you are God, an historical gure or someone very important.
People with severe mental illnesses cannot benet from counselling without medical treatment.
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One (or even a few) of these symptoms does not automatically mean that a person has dementia. There could be other reasons for the symptoms. But one of these symptoms is a good enough reason to visit a doctor. When a health worker determines that a client has dementia, a counsellor could offer these suggestions to the clients caregivers: Maintain a consistent living situation for the client. Dont make changes in the clients routine or home. Create a care team to help the loved one cope. Create a reminder system to help the loved one take medicines and go to appointments. Help the client with reality. Remind the person about where he is, the date and day. Create a safe environment for the client, such as removing or locking up dangerous substances.
Opportunistic infections can also affect the brain, possibly leading to: headaches seizures reduced alertness problems with specic functions controlled by the brain changes in personality or behaviour disorientation.
A counsellor may also witness the effects of a condition called delirium that is caused by a medical condition, including opportunistic infections, tumours, substance intoxication or trauma. Unlike dementia, delirium occurs suddenly and its symptoms, that come and go during the course of a day, include: The clients mind wanders or his thinking is stuck on one issue. The client is easily distracted. The client has problems with remembering something that happened recently. 120
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Conversation is difcult or impossible. The clients speech is hard to follow, rambling or irrelevant, or he cant talk at all. The client doesnt know where he is or what time of the day it is. The client misinterprets events, such as thinking that a loud noise is a gunshot, or that the shadow of a tree is a person. The client sees things that are not there.
The symptoms of opportunistic infections or delirium appear suddenly. The client may not be thinking clearly and the counsellor must get the client medical attention immediately.
The bias against anti-depressants Medicines that reduce symptoms of depression can be amazingly effective. While they dont make a person feel happy, they can take away the feelings of hopelessness and lethargy that prevent normal functioning. Anti-depressants give extra biochemical support that makes it easier for a person to handle problems that come up. For example, a depressed person may react to a problem like this, I cant take this any more. I cant stand it or you. Stop bothering me. A person whose depression has improved through using anti-depressants may say, OK, I can handle this. Despite their effectiveness, counsellors and clients alike seem to have a bias against anti-depressants. Some people feel ashamed, thinking they are weak if they use medicines to help them with cope with symptoms of depression. Others use labels, such as mental illness, which can be stigmatising. Anti-depressants have drawbacks. Some can be expensive. Some have side-effects. These may include sleepiness or loss of sexual drive. A client may have to try several before getting one without problematic side-effects. However, the correct anti-depressant can give a depressed person a new life, and their use should be seriously considered in communities where they are available.
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10
Substance abuse
Introduction
Clients can be substance users, substance abusers,or dependent on (addicted to) alcohol or another substance. To make things clearer, this book will usually just refer to substance use.
When we talk about substance use, we mean the use of alcohol or other substances like dagga and tobacco. This is common in many communities. Using any amount of substances like these can have a serious effect on a person living with HIV or with mental illness. The effects include dangerous driving, loss of jobs, harm caused to relationships, increased violence in the home and on the street, sexual violence, precious money wasted and serious health problems. Substance abuse, which is the excessive use of substances, and mental health problems go hand-in-hand. Alcohol and other drugs can cause mental health problems. Mental health problems can lead to substance use problems for example, when someone with a mental health problem uses alcohol or drugs to improve his feelings. Even though substance abuse causes many problems, few communities and countries have made a commitment to reduce its human and economic costs. Tobacco is widely sold, although in some places the package has a warning about health risks. Commercially brewed beer is not expensive and home-brewed beer (tombo) is even cheaper. Venues for socialising promote drinking. Although there may be laws against the sale of dagga, it is easy to nd. Some people misuse medicines that are prescribed by a doctor. Even caffeine, the active ingredient in coffee, can be abused.
People can have both mental health problems and substance abuse or substance dependency (addiction) problems. These people have what is called a dual diagnosis a mental health diagnosis and a substance abuse diagnosis. Sometimes people with both problems are called mentally ill chemical abusers. Dual diagnosis is very complicated and difcult to treat.
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Although communities may ignore the negative effects of substance use, counsellors must not. Because of the relationship between substance use and mental health, and because both affect how people respond to HIV and AIDS, counsellors need to be informed and active when it comes to alcohol and other drugs.
Substance dependence This is also a formal diagnosis. According to the American Psychiatric Association, three of the following symptoms must be present:
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Tolerance This means that a person needs more and more of the substance to become intoxicated or to get the desired effect. (Or, if the person takes the same amount, he or she feels it less and less.) If the person stops taking the substance, he or she has a physical reaction that is called withdrawal. Even though the person didnt mean to end up like this, gradually he or she uses more of the substance or uses it more often. The person wants the substance all the time or nds it impossible to stop (or cut down) using it. The person spends a lot of time getting, using or recovering from the substance. Important activities are sacriced or cut down because of substance use. The person carries on using the substance despite knowing that it has probably caused physical or psychological problems, or made existing problems worse.
Withdrawal includes such physical reactions as trembling, seeing things that are not there, feeling sick to ones stomach and throwing up, and seizures.
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A client who is a substance user usually has problems taking care of himself. Because of the effects of the substances, these patients may miss appointments, have more accidents, be jailed, have no money for food, eat unhealthy food and take medicines without following the prescription. Apart from HIV and AIDS, alcohol and other drugs contribute to a number of problems. People may commit crimes in order to get the substance; jobs or relationships may be lost because of intoxication or addiction. Alcohol and other drugs may cause mental confusion, sleep problems, malnutrition, sexual problems, depression or agitation. Alcohol and drug use can lead to serious physical problems. Mixing alcohol and other drugs, including drugs that a doctor tells a client to use, can lead to a large increase in the effects of the substances, causing greater intoxication than one expects, psychiatric symptoms, or such a deep sleep that the drug user cant easily be woken up. Some home-brewed beers have been found to contain poisonous chemicals. Brain and liver disease occur in some heavy drinkers, lung disease in smokers, retarded growth in children who breathe in cigarette smoke, and heart disease and skin abscesses in injection drug users.
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Another debate
There is debate about whether a person with a serious alcohol or drug use problem should be in counselling for problems other than substance use. Some people think that the serious substance user is not likely to benet from counselling. Instead, he should be in a programme that treats the addiction. Other people argue that addressing a persons issues has to start somewhere and that a compassionate counsellor can have some effect.
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Counselling someone to change substance-using behaviour requires a lot of patience. Ultimately, the counsellor has to accept whatever the client decides. Many counsellors who work with substance users have feelings of incompetence because clients may not change. Remember that even if the substance use does not end, there may be other changes in the client just because you were there for him, unlike most other people.
Assessment
When conducting an assessment, all clients should be asked what substances they use and how much. The counsellor should not be surprised to hear a client say that he doesnt use substances this may be because he is ashamed or because he expects the counsellor to be critical. Confronting denial is not useful. The relationship has to be built rst and substance use raised again at a later stage. Assessment questions you could ask include: What substances are used? (Dont forget tobacco.) How much is used daily or weekly? If someone says three drinks, nd out how much is in a drink? Is it a litre per drink? How much is in a serving of dagga? Some counsellors suggest that, because clients typically under-report use, the counsellor should be wary of the amount stated. When are the substances used? With friends, family or alone? How much do friends use? Where does the use occur? Why is the substance used? For fun? To make an emotional or physical complaint go away for a while? To kill time? To gradually kill oneself? What are the physical effects? Has the substance caused any physical symptoms? What are the emotional effects of the substance? Can the client describe how the substance makes him feel? What are the social effects? How have family or friends reacted?
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How much does the client know about the relationship between substances and HIV care? What is the clients attitude? Does he think substance use is a problem? Does he want to do anything about it?
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The Transtheoretical Model created by DiClemente and Prochaska also had a large impact on the way counsellors approach counselling with substance users. This model suggests that a substance user, or someone else with a behavioural problem, can be understood to be in one of ve stages. When the counsellor recognises what stage the client is in, she can adjust the way she interacts with him accordingly. The table on page 130, from a chapter in Motivational Interviewing, offers counsellors an idea of what can be done with substance users, using the stages of change and motivational interviewing. It might inspire you to nd out more and to try using this model with your clients.
Goal setting
Having conducted a good assessment, the counsellor knows the extent of the problem and the clients attitude to it. According to the Transtheoretical Model, the attitudes express the stage the client is at. As discussed earlier in this book, the setting of goals is a mutual effort between counsellor and client. The counsellor, working with a substance user, makes a big mistake if she imposes her values on the client, expresses anger, is confrontational or impatient. For a person in the precontemplation stage, the goal may simply be to establish a relationship with trust, to discuss the issues and to build client condence. For a person in the contemplation stage, the counsellors goal is to help the client continue to explore the problem, including discussion of risks and benets.
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Precontemplation Reluctant Rebellious Resigned Rationalising Contemplation Acknowledges problem, seriously considers action, but not quite ready to make commitment. Commits to change and makes plans.
I dont have a problem. Explore situation, listen, feedback. Dont tell me what to do. Defuse resistance, offer options.
Theres nothing I can do. Instil hope, build condence. Theres little risk. Im thinking about it. Empathy, reective listening. Help client think through risks of behaviour and benets of change, instil hope that change is possible. Assess strength of commitment, help client develop most effective plan. Afrm client, help with plan and revisions. Reassure, motivate.
Preparation
Im ready.
Action Maintenance
Here goes.
Keeps new behaviour Still working at it. going, may try old behaviour (slip, relapse).
Compiled from DiClemente, C. & Velasquez, M.M. (2002). Motivational interviewing and the Stages of Change, in W.R. Miller and S. Rollnick (Eds) Motivational Interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Used with permission.
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If we accept that each of us has the right to make our own choices in life, then we stay at the side of the person who cannot alter his or her life. Start a 12-step programme. Another intervention used almost worldwide with substance users is called a 12-step model, because the programme has 12 parts through which a client has to progress. The most popular of the 12-step programmes is Alcoholics Anonymous (AA). Programmes can also be made available to partners (AlAnon) and children of alcoholics (AlaTeen). There also are variations for users of other substances. Participants in 12-step programmes are asked to admit that they are powerless in the face of their alcoholism or addiction, and then to ask for assistance from a higher power. Other steps include conducting a self-examination and making amends for damages to others. The 12-step programmes are run locally and the number of meetings held weekly is based on demand. Large cities may have daily meetings. Sometimes meetings are listed in a telephone directory or advertised in a local newspaper. Participants may not tell anyone about other people in the programme. Counsellors interested in starting a 12-step programme in their community should, if possible, seek information on the Internet at www.aa.org. By clicking on About A.A., then on Contact local A.A. General Service Ofce near you, you will get a list of country centres. You can then click on a country. Or contact the South Africa centre at gso@compute.co.za. To read The Big Book, the basic book about Alcoholics Anonymous, go to: www.aa.org/bigbookonline
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11
Loss and grief
Introduction
Loss and death are dominant themes of life in Africa. The continent has experienced loss and death to slavery, war, genocide, high infant mortality and fatal illnesses, including malaria and tuberculosis. Now HIV and AIDS have joined the continents killers, although too many communities have still not publicly acknowledged the death toll and the emotional trauma of so much dying and death. The depth of the loss and grief in Africa now caused by HIV and AIDS is ignored by the Developed World, where discussions about the effects of HIV and AIDS seem to be mainly about medicine and money. As for people living in Africa, it seems as though they need to push the pain deep down inside themselves in order to soldier on and survive. For a counsellor, comforting people who are dying and the survivors poses tremendous challenges. HIV and AIDS counsellors must be able to talk openly with clients about dying, death and grief. The goals and plans that they decided on together must fall by the wayside when the clients health takes a turn for the worse. Then it is time for one person to sit with another. But we are all just humans and this is not easy to do. A persons own history of loss has a great effect on the way that person deals with more loss. For example, if a woman hasnt nished mourning the loss of her own son, it would be difcult for her to face so many mothers and fathers grieving the losses
Developed World countries are economically well-developed. The term generally refers to Western European countries and countries in North America.
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of their sons and daughters. A counsellor may be tempted to help other parents avoid the pain if she has also handled pain that way. Counsellors also endure many losses and are just as vulnerable to bereavement overload as are all people who suffer many losses. The counsellor may shut down emotionally, which harms both her and her clients. Self-care, described in the next chapter, is very important for counsellors who are experiencing many losses. Although studies done about loss, grief, dying and death in other parts of the world have not necessarily been carried out in Africa, their ndings still apply.
African cultural issues of stigma and discrimination also contribute to the loss experienced by someone who is living with HIV. To reveal her illness, or even to be suspected of having HIV, a woman risks losing the love of her family, losing her job and her home, and being tormented by cruelty caused by ignorance and fear. Shame can lead to additional loss. The person who feels shame can get depressed and can isolate herself.
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Reactions to dying
In her book, On death and dying, Elisabeth Kbler-Ross created a useful way to understand a persons reactions to the news that he is dying. She identied ve stages of reaction: Denial. A person saying, No, not me, it cannot be true expresses this. The author suggests that this rst phase gives a person time to think about the news and then nd other ways to cope with the situation. Anger. This stage is expressed by saying, Why me? It includes anger, rage, and the envy and resentment of healthy people. Bargaining. The person tries to negotiate an agreement with God or a higher power in order to postpone death. The client may say to God, If Im nice? or, Can I live to see my grandchild born? Depression. This is when the dying person can no longer deny what is happening and has to face up to the great loss as the time draws nearer. The author says there are two kinds of depression: depression in reaction to the news and depression in anticipation of the losses to come (like a father knowing he wont see his son become an adult or a woman knowing shell never meet a grandchild). Acceptance. During this nal stage, the dying person is not depressed or angry. The person has mourned the losses that have already occurred and those still to come. This isnt a happy time its a time with no feelings. The person seems to be resting for the journey to come.
This book makes so much sense that some counsellors forget that people are different and each person has a unique reaction. The model describes the reactions of many people to impending loss very well, but it does not describe everyones reactions. Some people face death head-on and dont go through the stages. Other people stay in one stage or jump around through different stages.
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Surviving a loss
Concepts from J.W. Wordens Grief counseling and grief therapy (3rd ed.) are used with permission from Springer Publishing Company Inc, New York.
A different model describes four tasks of mourning in response to death. The author of this model, a psychologist named J. William Worden, says that each task must be completed so that the person can recover his emotional health and move on to further growth and development. The four tasks for clients are: to accept the reality of the loss to experience the pain of grief to adjust to an environment in which the deceased person is missing to help the survivor nd an appropriate place for the dead loved one in his or her emotional life a place that helps the survivor maintain an emotional connection, but doesnt hinder him or her from living effectively.
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Examine the clients defences and coping styles. If they are causing problems, help the client nd different ways to express grief. For example, if a widow wont discuss her husband, looking at his photograph or speaking to his relatives should be encouraged to actively deal with the memories and grief. The counsellor should spot emerging serious mental health problems and refer the client to a practitioner for treatment.
Grieving in children
Africa is trying to count its AIDS orphans and the number is in the hundreds of thousands. But are countries responding to their needs? The loss of a parent, let alone both parents, is one of the most terrible things that can happen to a child. But how many receive psychological care to help them cope? Losing a parent or both parents means that many stressful changes will follow: new caregivers (or often, no caregivers), being in a child-headed household, or being placed in an orphanage. A nurse and counsellor who specialises in children and grief, Dottie Ward-Wimmer, says that while all children grieve, young children see death as life continuing elsewhere. For these children, a mother going to heaven is no different from the mother going to Lusaka for the day. If the child is not told the truth, the child will wait for the dead person to return. Ward-Wimmer says that a childs grief seems to come and go. One minute the child will be extremely sad and the next minute the child will be playing quite happily. Older children are better able to work through the emotional pain. However, as the child grows older, the grief may return over and over again, triggered by birthdays, weddings and graduations. It is important for the counsellor not to ignore a loss that may have happened years earlier. Children usually dont have the words or the social skills that are needed to understand that death is forever and to mourn deeply. People avoid talking about death, so this also makes it more frightening. Some counsellors say that children
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feel survivor guilt: they feel guilty for being alive when the loved one has died. They need to be told over and over again that it is not their fault that the person died.
When working with grieving children, the counsellors role is to offer comfort, help nd clear answers (that are acceptable to the family) for the childs asked and unasked questions, invite and witness the experience and the expression of feelings, and nurture hope. Dottie Ward-Wimmer
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Rather, say something like, Im sorry for your loss and just be there for the grieving person.
Tell the client in your own words that the sense of loss the survivor feels is directly related to the love and joy experienced with the person who died. The more love and joy, the greater the pain of loss.
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12
Caring for yourself as the counsellor
Introduction
A man makes his living by carving wood. He sells his carved lions, rhinos, baboons and warthogs in the town market. He is very skilful and makes a good living. He has a set of carving knives, the instruments of his work. Without them he could not make a living. He looks after these tools because they are so important to him. Every night, he sharpens the blades and cleans the handles. He keeps these tools in a box lined with soft cloth. He hides the box away at night so that an intruder would not be able to nd it. Like this woodcarver, a counsellor also has a special tool: his or her self. The counsellor uses his self to reach out to a client, to establish trust, to understand the client, to feel the clients feelings, and to respond with compassion and competence. The counsellor learns about HIV and AIDS and teaches others. With a courageous self, a counsellor confronts the ignorance that creates stigma and discrimination, and becomes an advocate for the rights of people with HIV and AIDS.
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There is always someone needing help knocking on the door and they dont turn people away. They dont take time off to be with loved ones. They forget that there is a world out there, outside HIV and AIDS, which is gentle to body and soul. Why does this happen? It happens because people who are attracted to counselling are dedicated caregivers. These caregivers are focused on other people and not on themselves. All their attention and work is to make other people feel better. Some of them have always been like this. Or perhaps a mother or father was absent and they stepped in to help the family. By helping the family, they were rewarded and this gave them a feeling of importance and meaning. Others took religious messages to be seless to heart. Organisations and clients love these types of counsellors because they are dedicated to their clients welfare and they work extremely hard.
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Social isolation
The HIV-infected client is stigmatised and often the counsellor who works with this client is stigmatised too. In some communities, neighbours may back away. Counsellors often nd they cannot talk about their work with friends or new acquaintances. They nd that people change the subject abruptly or walk away because they feel uneasy about HIV and AIDS. The counsellor feels increasingly isolated.
Burnt-out counsellors are always exhausted, irritable, emotionally numb and joyless. They dont laugh, rarely have sex with their partners, and are cynical and despairing. A burnt-out counsellor is nihilistic. Thats a heavy emotional burden to carry. The burnt-out counsellor cannot work compassionately with a client and may infect the client with her pessimism. Some mental health professionals believe that burnout is a close relative of depression, or perhaps even depression itself.
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were burned alive. In the HIV and AIDS care context, we have counsellors burnt out alive. The seless, overworked counsellor pays a high emotional price: possible burnout and loss of effectiveness in about two years. The counsellor then needs to recover from the emotional trauma. It is a shame to lose such good people so soon.
A modest proposal
As counsellors we need to stop glorifying selessness and overwork, and begin to value a healthy lifestyle (in ourselves and our co-workers) that will ensure that counsellors are able to work with clients for many years. This requires counsellors to take their own advice: to focus and work on meeting their own emotional needs. It also means that organisations and institutions, however tight their nances may be, must be more sensitive to the needs of their employees and volunteers.
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changes means that you dont appreciate the effect that you have just by being there when no one else is. When you are feeling frustrated, focus on the fact that you are recognising and appreciating your clients humanity. Just being with the client is testimony to the power of love, which your presence represents. By being there, you are also bearing witness to the epidemic. Too many people have closed their eyes to it. Your presence shows that you know how serious it is. Some people wear red ribbons, and that is important. Your heart is your red ribbon.
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Just say no
In many organisations, a competent and responsible person is given more responsibilities to make up for lack of staff or for colleagues who dont pull their weight. This is how it happens. A supervisor says there are people who need care and there is no one else to do the job. The supervisor adds, If you dont do it, these people wont get help. The competent counsellor who gives her all to 50 clients is given 10 extra clients. Now her work begins to slide, but she still does better than a colleague who is incompetent. She is then given 10 more clients, but she cant keep up, which leaves her feeling incompetent and guilty. She is more stressed, works longer hours, loses sleep and feels exhausted at the end of the week.
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How does a counsellor avoid this situation? By realising that she isnt the only person responsible for the welfare of the client. The funders of the organisation are responsible, as are the organisation administrators and the government. The entire burden doesnt have to fall on her. She can decide to say no to additional responsibilities.
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Take time off and sit in a church, mosque or synagogue. Some religious traditions offer inexpensive retreats during weekends, which provide spiritual counselling, rituals and quiet time to pray. Is now the time to seek out meaningful spiritual counselling, which you can use to express your feelings and doubts about God and the epidemic?
Travel
When you travel, you nd that there are other places in the world where HIV and AIDS are not a constant theme. You nd new beauty and you may meet new people. Travellers return with stories that arent related to HIV and AIDS. Travel is renewing and replenishes the soul. You dont have to take a trip around the world take the bus to another town. Visit relatives you havent seen in a while, even if theyre only 25 km away. Ask your employers if they will help pay for a trip to attend a conference.
Many international conferences provide scholarships that pay for all or most of a trip. Other conferences cancel the registration fee for people making presentations. Check Internet websites to learn about these conferences, and e-mail the organisers to request a scholarship.
In addition, take time off from counselling, if possible. Now is your time to hurt and to work through pain. Care for yourself as you would care for your clients.
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Give rewards
Because working with people affected by HIV is so stressful, a exible manager should consider how she could reward responsible counsellors and keep them as staff members. Although managers may not be able to give pay increases as rewards, they could approve hours or days off, exible work schedules and in-service training that both educates and provides a break from client care. They could also: Reduce a counsellors responsibilities during a time of crisis or mourning. Reduce the number of hours that staff members have to be available on call after regular ofce hours. Budget sufcient funds so staff can attend conferences, or seek scholarships on their behalf.
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Ask each staff member to create a short- and long-term plan for educational advancement, and then put these plans into action. Encourage staff members to present descriptions of their work or programmes at conferences. Teach staff members to use the agencys Internet service and allow access to computers. Print out Internet-based HIV information and display it, making the notice board a real educational tool. Provide local experts to be supervisors, paid for by the agency, or allow time for counsellors to meet for peer supervision. Schedule regular training during ofce hours and bring in experts to teach. Provide refreshments. Subsidise costs when staff members need counselling. Recruit several clergy to act as organisation chaplains for staff. Invite them to hang around when employees arrive in the morning or depart for the day. Conduct agency memorial services so staff can grieve.
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13
More information
This chapter contains information under these headings: More basic information Information for advanced readers Accessing information on the Internet Reference information for books and articles mentioned in this text. Building resilience among children affected by HIV/AIDS, by Sister Silke-Andrea Mallmann, CPS Caring for ourselves in order to care for others. Conference Handbook Home-based family care in Namibia: A practical manual for trained volunteers To love my neighbour: A pastoral care handbook for Namibia, edited by Lucy Steinitz 12 steps to living positively with HIV, by Greg Satorie in cooperation with the staff, volunteers and clients of Catholic AIDS Action, Namibia
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Newsletter
SAfAIDS News, published by the Southern Africa HIV and AIDS Information Dissemination Service in Zimbabwe, is a useful quarterly newsletter. It is somewhat expensive but can be found in the HIV section of many libraries. The organisations website is www.safaids.org.zw.
Books
Barnett, T. & Whiteside, A. (2002). AIDS in the twenty-rst century. Disease and globalization. London: Palgrave Macmillan. Jackson, H. (2002). AIDS Africa continent in crisis. Harare, Zimbabwe: SAfAIDS. Jenkins, C.D. (2003). Building better health: A handbook of behavioral change. Washington, DC: Pan American Health Organisation. Sanders, P. (1998). First steps in counselling. A students companion for basic introductory courses (2nd ed.). Trowbridge, Wilshire, England: PCCS Books. Van Dyk, A. (2001). HIV/AIDS care & counselling: A multi-disciplinary approach (2nd ed.). Cape Town, South Africa: Pearson Education South Africa. Winiarski, M.G. (1991). AIDS-related psychotherapy. New York: Pergamon Press, now distributed by Allyn & Bacon, Needham Heights, MA USA. Winiarski, M.G. (Ed.) (1997). HIV mental health for the 21st century. New York: New York University Press.
Search engines
The web is vast, but you can search for specic information by using search engines. After youve connected your computer to your Internet Service Provider, click on your browser, which is likely to be Microsoft Explorer or Netscape Navigator. Then enter the name of one of these search engines into the correct area: www.google.com or www.google.co.uk www.yahoo.com www.metacrawler.com When the search engine pages comes up, type HIV and AIDS in the window, and click the button that starts the process, usually called Search. The search engine will report thousands of websites that refer to HIV and AIDS.
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Use additional words, such as opportunistic infection or grief to reduce the number of websites reported and focus in on your specic interest. When you see a web page that you are interested in, just click on the coloured title, and your computer will go to it.
Zimbabwe, South Africa, Tanzania and Zambia. http://www.repssi.org The website of the Regional Psychosocial Support Institute for Children Affected by AIDS. Click on portal for access to a wealth of information. http://www.raisingvoices.org An organisation based in Kampala, Uganda, concerned with domestic violence. http://www.aidsquilt.org For more details on memorial quilts.
Information sites
Many websites have extensive information on HIV and AIDS. Among them are: http://www.aegis.org and http://hivinsite.ucsf.edu US-based sites with a vast amount of HIV and AIDS information, including links to many sources of information. http://hopkins-aids.edu US-based medical information. http://www.safaids.org.zw Operated by the Southern Africa HIV and AIDS Information Dissemination Service. Check out the website to learn about the many information services the organisation provides. http://scienceinafrica.co.za Africanbased science news and articles. http://scidev.net/hiv African-based website of the Science and Development Network, contains information on HIV and AIDS, with updates on scientic ndings. http://www.unaids.org HIV and AIDS information from the United Nations, with regular statistical updates. http://www.fhssa.org The Foundation for Hospices in Sub-Saharan Africa supports African organisations that provide homebased care and palliative care for dying persons. There are hospice partners in
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Maslow, A.H. (1970). Motivation and personality (2nd ed.). New York: Harper and Row. Miller, W.R. & Rollnick, S. (Eds). (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Swartz, L. (1998). Culture and mental health. A southern African view. Cape Town, South Africa: Oxford University Press. Ward-Wimmer, D. (1997). Working with and for children. In M.G. Winiarski (Ed.) HIV mental health for the 21st century. New York: New York University Press. Worden, J. W. (2002). Grief counseling and grief therapy. A handbook for the mental health practitioner (3rd ed.). New York: Springer Publishing Company Inc. Yalom, I.D. (1980). Existential psychotherapy. New York: Basic Books. Zweben, J. (1998). The alcohol and drug wild card. Substance use and psychiatric problems in people with HIV. UCSF AIDS Health Project Monograph Series Number Two. San Francisco: University of California at San Francisco AIDS Health Project.
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Maskew Miller Longman Forest Drive, Pinelands, Cape Town Associated companies, branches and representatives throughout Africa and the world. Maskew Miller Longman and Catholic AIDS Action, Namibia 2004 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the copyright holder. First edition by Maskew Miller Longman 2004 ISBN 99916 1 314 5 Artwork by Gavin Thompson and Rassie Erasmus Cover artwork by Gavin Thompson Cover design by Flame Design Typesetting by Flame Design Printed by John Meinert Printers, Windhoek, Namibia For further information, contact: Catholic AIDS Action PO Box 11525 Windhoek NAMIBIA Phone: +264-61-27-6350 Fax: +264-61-27-6364 email: info@caa.org.na website: www.caa.org.na Maskew Miller Longman PO Box 396 Cape Town 8000 SOUTH AFRICA Phone: +27-21-531-7750 Fax: +27-21-532-2302
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