Caa Counselling 2 Redux

Community-Based Counselling for People Affected by HIV and AIDS
Mark G. Winiarski, Ph.D.

Caroline Cohrssen Editor
The download of this PDF version of the book is for individual, fair use only, and may not be sold or distributed as an alternative to purchasing the printed book from the publisher.

Catholic AIDS Action
Namibian Catholic Bishops Conference

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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 can’t 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 benefit 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-specific issues Difficult clients These are the symptoms 5. First meeting: assessment and planning Introduction The counselling environment The first 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 Reflecting 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 client’s situation 28 28 28 29 30

Comment on the big picture Using the counselling relationship to understand the client’s 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 confidential? 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 counsellor’s 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 client’s 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 can’t do that!” response

123 124 125 126 126 128 130 132 133 133 134 135 136 137 138

140 140 140 141 142 143 143

Strategies to keep yourself emotionally healthy 143 Organisational strategies to keep staff emotionally healthy 148 13. More information 150 150 151 151 153

117 118 119 122 122

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 don’t 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 first 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 afflicted and afflict 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 I’ve 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, CAA’s chief executive officer, provided support and assistance. They enlisted Caroline Cohrssen. Ms Cohrssen and I became partners in the book’s 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, Montefiore 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 Vincent’s Hospital – Midtown, formerly St Clare’s 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 benefited from Dr Winiarski’s 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 field. 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 book’s editor, has been terrific. She worked closely with Dr Winiarski to allow the book to have as wide an appeal as possible. Caroline Cohrssen’s 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, Tuafi 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 first 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 benefit.

The background to counselling
Over the past 100 years, particularly in Western countries, some people began to question the tradition of advicegiving. They believed that there were different ways of helping people to live better lives and to feel comfortable with themselves. Gradually, different approaches began to develop and are still used today: ᭜ Some people believe that understanding our feelings helps us to understand ourselves. When we understand ourselves, we are able to accept ourselves. When we accept ourselves, we value ourselves and we believe that we can change the way we are. Another approach is to say that our experiences as children have a profound effect on who we are as adults. Some people believe that behaviours that are sometimes thought to demonstrate a mental illness are really caused by a lack of skills in dealing with other people. Some people think that if we can change the way we think, then we will be able to change the way we feel. Some people believe that thinking and behaviour can be controlled by different medicines.

᭜
Profound means huge or significant.

᭜

᭜

᭜

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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 everyone’s 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.

Things that can be seen and those that can’t
Observable aspects of counselling
If you watch and listen to a counselling session, you will see and hear two people talking. Two people meet and talk together: the counsellor (who is specially trained) and the client (the person being counselled). These meetings and talks are necessary for communication, although they are not the only communication that takes place. Writing things down and body language are also ways of communicating.
Observable means something we can see.

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Counselling sessions may sound something like this:
In this book “he” and “she” are used alternately to refer to both sexes, and to distinguish between speakers in dialogue.

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 client’s spiritual beliefs, even if they are different from your own. Showing understanding and acceptance of the client’s 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.

Less observable processes
But, we have to ask ourselves, why choose certain words? And how are the words heard and taken to heart, resulting in changes?

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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 difficult 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 active ingredient in the counselling relationship that heals is caring-love.

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 fills her life or has the potential to fill 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 counsellor’s communication of caring-love leads to self-acceptance and a sense of worth that helps the client find 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.

Other promoters of change
In addition to the power of caring-love, other things that occur in counselling may promote change. These include:

Expressing feelings
Some people believe that depression is anger turned inwards. They believe that people become depressed when they don’t 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.

Components of the counselling relationship
Empathy
Sympathy means having feelings of regret about another person’s situation, but empathy is a feeling of emotional connection with the client and his problems, as if you have experienced them yourself. A sympathetic expression may be, “I’m so sorry for the loss of your mother.” An empathetic expression comes from a similar emotional experience, so you could say, “I’m so sorry for the loss of your mother. My mother has died as well and I have some idea of what you are going through.” By reflecting on your client’s experiences and trying to connect with what he must be feeling, you may have a heartfelt experience of your client’s pain. After greeting the client on his arrival, the counsellor may want to say something to show that she empathises with the client, based on what she knows about him. The counsellor will then see whether the client is guarded (unwilling to “open up”), hostile (resentful or angry towards the counsellor) or tearful (on the verge of tears). The counsellor could say to a guarded client, “Coming to counselling is very difficult and I really feel that you are very courageous to be here.” To a hostile client, she could say, “I can understand that you are upset to be here, and I appreciate your feelings about me and this situation. I hope that you will tell me all about your feelings and that you will feel that I am listening to you. I think you will begin to trust me in time and see that I am here to help, not to hurt you.” Later on, the counsellor could say, “Anger usually comes after hurt. I can see that you’ve been hurt very much.” To the tearful client, the counsellor could say, “I can see how much pain you are feeling. Please just let yourself cry and I will sit here with you.”

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Belief in the dignity of the client
This is more than just accepting or tolerating a person. It tells the person that she is worthy of love and that her HIV status makes no difference to you as a counsellor.

Respect for the client’s agenda
Never try to make the client into the person you think he should be. This attitude says: (1) ”I know what is best”, (2) “I’m more important than you”, and (3) “You don’t meet my standard.” It shows no respect for the client, which is not a good way to enter into a relationship. A good example of a counsellor without an agenda is a Catholic nun who worked in a hospital in New York City. The hospital had a unit for prisoners. The door to the unit was locked and there were guards everywhere. Sister Pascal Conforti would enter, greet a prisoner with AIDS and just talk. If a prisoner asked for a prayer, she would pray with him. She did not criticise, try to convert, or preach. She offered acceptance of the man who may have committed murder or rape. She believed that her acceptance of the man encouraged the prisoner’s acceptance of himself. In 1997, Sister Pascal wrote, “As mental health practitioners, we are present to our patients at some level, simply to receive them where they are in their journeys and to hear what they have to say.” She did not have to preach. Her actions expressed caring-love and her caring-love healed the prisoner spiritually.

A non-judgmental presence
As we go about our lives, our heads are filled with judgments: my neighbour talks too much, or, my wife isn’t 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 finds 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 client’s 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 client’s 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 specific 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 confidentiality 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 client’s written consent. One exception to this rule is that you will discuss your client with your supervisor, who may know your client’s 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 client’s 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, specific 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 don’t think about) that influences their behaviour, and that a person’s childhood greatly influences that person’s later years. Practitioners who believe in the “behavioural theory” look at a person’s behaviour and try to find out what happened in that person’s environment to cause certain behaviour. Behavioural psychologists don’t consider things that can’t be seen or measured – they are only concerned with behaviour that can be seen. The “cognitive theory” suggests that feelings and behaviours are mainly influenced 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 person’s brain chemistry with the proper medicine.

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᭜

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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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The importance of caring-love
In his book, Existential psychotherapy, Irvin D. Yalom spoke for many people who believe it is the relationship that heals. He wrote: “It is the relationship that heals … If any single fact has been established by psychotherapy research, it is that a positive relationship between patient and therapist is positively related to therapy outcome. Effective therapists respond to their patients in a genuine manner; they establish a relationship that a patient perceives as safe and accepting; they display a non-possessive warmth and a high degree of accurate empathy and are able to ‘be with’ or ‘grasp the meaning’ of a patient.”

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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 counsellor’s care for his client shows the Creator’s 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” aren’t 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 don’t love our neighbours. Why? Perhaps we don’t feel loved at the moment. Perhaps we don’t 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 find 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.

A good counsellor has exceptional character
If you needed help, what type of person would you want to help you? The person would probably have these characteristics:
Exceptional means different from the ordinary.

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 difficulties 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 don’t 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 certificate 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 client’s pain and the pain that the counsellor may feel while working with a client.

Flexibility
There are two kinds of flexibility that are important. The first kind of flexibility is practical: coping with limited space or unexpected problems. The second kind of flexibility 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.

A good counsellor is specially trained
By specially trained, we mean that the counsellor goes through training that has several phases but is never-ending.

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 confident. 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 don’t 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.

A good counsellor has compassion
Treating the client with compassion
Compassion goes beyond just sympathy. If you are compassionate, not only do you understand how that person feels, but you also feel their pain. Sister Pascal Conforti once wrote, “No quality, affection, or feeling comes closer to the heart of spirituality – both belief and practice – than compassion. Compassion is an emotion or quality of connection, rather than separation.” She continued, “Offering to our clients who are affected by HIV-related illness our compassionate, connected, loving presence is perhaps the greatest … gift we can give … ”

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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 don’t admit this). Inside they may think, “This person has problems, but I am better than he is because I don’t 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 fighting her own feelings of inferiority and insecurity.

A good counsellor treats the client as an equal
A good counsellor works with the client on these bases: With respect. All people, despite their circumstances, deserve respect. People who are poor, homeless, naked, dirty, or mentally or physically disabled deserve the same respect we would give anyone else. Not doing to, but doing with. Surgeons use scalpels to take out tumours and bullets. Doctors use little lights to look in our ears and stethoscopes to listen to our lungs. Counsellors don’t do things to clients but work together with clients. The client is an equal in the relationship. Not apart from or looking down on. A counsellor and a client are both human and so very similar to each other. A good counsellor understands this. A compassionate counsellor does not feel or act superior, or look down on a person with HIV or AIDS.

A good counsellor is competent
Compassion alone is not enough. Competence is also necessary. Competent counselling is not just two people talking like friends. A counsellor does not say whatever comes to mind. The counsellor’s actions and words are carefully chosen, based on important elements:

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Knowledge and understanding of HIV and AIDS
The competent counsellor understands that HIV and AIDS are complicated conditions that have physical, emotional, community/social and spiritual parts. This will be discussed in Chapter 3. In each of these areas, the counsellor has information and can teach clients effectively. For example, the counsellor must be familiar with the workings of the virus that causes AIDS, how HIV is transmitted from one person to another, how to prevent infection, and the medicines that can be used to treat HIV-related conditions. Also, the counsellor must be prepared to discuss clients’ beliefs about HIV that are factually incorrect and potentially harmful.

Understanding the client’s situation
From community to community, there are great differences in the resources available to people. The skilful counsellor will gradually expand his knowledge of what is available to people in a community. The counsellor will establish contact with people who are in charge of community services.

Competently assessing the client and conducting counselling
A skilful counsellor conducts a wide-ranging assessment before drawing up a treatment plan (see Chapter 5). Based on that plan, the counsellor uses counselling techniques, which are skills that have been learned (see Chapters 6 and 7).

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.

Key ethical considerations
᭜ Confidentiality. Confidentiality means that, except in extreme circumstances, the identity of the client is never revealed to any other person. The counsellor cannot discuss the client with his own partner, and cannot reveal the client’s identity to his family members. Apart from maintaining confidential records, confidentiality means sharing information about clients only with colleagues who need to have the information, such as a supervisor. Casual discussion of cases with people who have no need to know (such as office staff or your family members) is unethical, as are discussions or comments made about clients in public areas.

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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 counsellor’s responsibility when a person with HIV fails to warn a sexual partner of his condition. A counsellor’s training should include a review of such laws and rules.

Other ethical standards
᭜ Avoid causing physical (to the body) or psychological (to the mind) harm to others, and avoid the risk of harming clients, the community and society at large. Respect the fact that the client has the right to do whatever he or she wants as long as it doesn’t interfere with the welfare of other people. The counsellor should make sure that clients have all the necessary information they need to make good decisions. Improve and enhance the welfare of the client through counselling. Keep promises, tell the truth and be respectful to the client. Treat the client fairly. Know and obey the rules of the agency. Most counsellors work either as paid staff members or as volunteers for community agencies or nongovernmental organisations (NGOs). There will be certain rules that staff and volunteers must comply with. These rules include:

᭜

᭜ ᭜ ᭜ ᭜

• Record keeping. Counsellors are usually required to make notes about
all their contacts with clients and these records are generally kept in the main office.

• 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.

• Continuing to learn. The motivated counsellor never stops learning
by attending classes and seminars. Discussing a case with a supervisor and listening to suggestions is also a way of learning. An example of a conversation between a supervisor and a counsellor is: Counsellor: She just makes me so mad. She tells me that she is not going to drink, swears to it, and then she returns and says she was drunk three times.

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Supervisor: You seem very worked up about her drinking, very angry. Didn’t you once tell me that your father drank a lot? Could that be affecting your response to the client?

• Continuously monitoring feelings. An effective counsellor is one
whose own feelings, prejudices and judgments are not allowed to interfere with the counselling relationship. It is only human to have feelings, but a counsellor must control those feelings so that they don’t influence the relationship with a client. This is done by being very aware of feelings, studying and understanding their causes, and considering how they can be kept out of the counselling relationship. Some counsellors talk about these feelings with supervisors or their own counsellors, while others discuss them with other trusted individuals.

Balancing compassion and competence
Compassion is just as important as competence. Why? A person may know everything about HIV and community resources, but if he can’t get close to the client’s emotional life, then he will be a poor counsellor. A competent person who lacks compassion is no more than a person giving advice. The goal of counselling is to make the client feel resourceful, not stupid. Counselling is not an opportunity for a counsellor to show how clever he is.

The counsellor as a human being
When counsellors are found to have human weaknesses, some people express great disappointment. Some people need to see counsellors as perfect, so they can have faith in the effectiveness of counselling. However, if we understand that it is the relationship that heals, then our weaknesses are less important than the interactions we have with our clients. The importance of your role as the counsellor should be played down while you encourage the client’s contributions. You could say, “Thank you for your kind words. However, you have been working hard to understand yourself and change your life. I am so impressed by your courage and hard work. It is making such a difference in your life.” Counsellors also have human problems. How do we respond to our own problems and pain? Do we reject counselling for ourselves because we are ashamed? A counsellor who rejects counselling should be able to

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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.

How does a counsellor benefit from counselling?
“Salvation may be described as the moment … when we come to love and accept ourselves as God loves and accepts us – which is simply as we are.” Sister Pascal Conforti

Counselling may look simple, but working with people affected by HIV and AIDS is very difficult. In return, your compassion and competence will grow and fill 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 didn’t 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 first 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 doesn’t 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 finds 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 benefit 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 flesh, 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 person’s 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 can’t 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.

How this model helps
This view of HIV and AIDS is known as a model. A model is a way of thinking that helps our brains to organise a lot of facts. A model makes the facts easier to understand, to remember, and to respond to. This model can be used to:

Organise your thoughts about HIV and AIDS
If a counsellor did not have a model to organise her thoughts and actions, counselling sessions with clients would have no meaningful direction. It would be like belonging to a church that has no organised beliefs or rituals. What would you say or do? A model is like a belief system. It helps the counsellor to know what to say and do.

Help you to assess the client’s needs
If we know that HIV and AIDS have biomedical, emotional, social and spiritual parts, we can systematically ask the client how she is doing in each of these areas. This chapter provides a brief assessment form that has questions relating to each of these areas. You will need to add your own questions and use it during counselling sessions. See the assessment checklist on page 26. 23

Systematically means to do things step by step in a logical order.

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Direct your assistance, including organising other caregivers
After assessing a client, the counsellor will know the client’s strengths and problems in each of the four areas. For example, by assessing biomedical issues, the counsellor may learn that a client has not taken his TB medication for several weeks. The counsellor could ask follow-up questions to find out why. Has the client run out of pills? Can’t the client get more pills? Do the pills make him sick so he doesn’t want to take them? In the social section, the counsellor may learn that there are no family members to take the man to the clinic to get more pills. The counsellor can use all the information to formulate a counselling or treatment plan. The plan is a list of problems and solutions that the counsellor will now pay attention to.

Help you to anticipate problems
Anticipate means to predict what may happen in the future.

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 client’s feelings are due to an emotional disorder (such as undue suspicion of strangers, or depression). Discuss the client’s 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 doesn’t get help in an emergency.

᭜

᭜

᭜

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Provide an opportunity for various people to work together
Imagine a large umbrella under which people with different training backgrounds (health workers, counsellors, volunteers and others) can work together to help the client. The BESS model acts as an umbrella when all the members of an organisation or clinic understand that the client has biomedical, emotional, social and spiritual parts that combine to form her life. They then know that their clinic must respond to all the parts in an organised way. They understand that not everyone has expertise in each area, but by working together and telling the client about other experts in the community, they can respond to many needs.

Help you use knowledge from other disciplines
The model tells us we have more to learn from other fields of specialisation. When the counsellor sees all the other aspects of HIV care, she realises that she should learn about them too. A counsellor will be more aware of the medical aspects of care. A doctor will realise he should be more knowledgeable about the psychosocial parts of his patients’ lives. A priest will understand that he should learn more about the medical and psychological aspects of HIV infection. Everyone can cooperate to help the client. Now it is time to write a list of medical, emotional, social, and spiritual issues that your own clients may experience.

Creating your own assessment checklist
When a skilful counsellor assesses a client’s needs, she uses a list so that she doesn’t have to try to remember everything later. Without a list, a counsellor may forget to ask a crucial question. This exercise will help you start to develop your own checklist. On pages 26 and 27, we have started a list of questions using the BESS system, which organises the questions into biomedical, emotional, social, and spiritual areas. As noted in the text, many HIV-related conditions and situations do not fall neatly into one area. People may not agree, for instance, on whether depression should be emotional or medical. There is no need to worry about which

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category a question should be in. This isn’t 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 client’s report. Are they taken properly? How is the client’s thinking? Slow Confused How is the client’s 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 client’s 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 client’s 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 client’s 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 client’s current relationship with God? (Feeling condemned, abandoned, nurtured?) Does the client find 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 difficulties 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 doesn’t have to be

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enthusiastic, and usually she isn’t. There are messages of acceptance and care that counsellors can communicate and these messages can unravel knotted up hearts and souls. Sometimes the client isn’t 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 client’s 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 body’s immune system is not able to fight off organisms that cause sickness. Also, people with HIV often have other illnesses, such as high blood pressure and malaria. Difficult 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 difficulties that are not recognised and treated. Overwhelming family responsibilities. Many single women or widows with children sacrifice 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.

᭜
Discrimination is poor treatment based on HIV status or suspicion of HIV status.

Understanding the client’s situation
There are several models that help us understand the difficult situations some clients find themselves in. Below is one example of such a model.

Stigma is like a stain on someone, setting them apart as inferior and disgusting.

Maslow’s hierarchy of needs
Many years ago, a psychologist called Abraham Maslow created a model for understanding peoples’ needs. He suggested that people want to meet their needs in a certain order. Once one level of need has been met, people start to work towards meeting the next level of need. Some people stay at one level and never move up. Other people work their way through all the levels. These levels are: ᭜ ᭜ ᭜ ᭜ ᭜ first, physiological needs, including air to breathe, food, drink, sleep and sex second, safety needs, such as being safe from violence both in the home and in the community third, the need for belonging and love fourth, the need for esteem, including self-esteem and admiration by others finally, the need for self-actualisation – the need to be the best person you are capable of being. Self-actualisation Esteem needs Love and belonging needs Safety needs Physiological needs

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Thinking about this model will help you to anticipate your client’s needs. A person with many needs may (understandably) feel that finding 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 can’t promise to provide food and shelter, you can say that counselling may help.

Interaction between people and their environments
The BESS model shows how biomedical, emotional, spiritual and social aspects of HIV and AIDS infection all interact. Similarly, each of us interacts with one another and with the world around us. The environment affects the way a person thinks, feels and behaves, and each of us affect our environment. For example, a man in a relationship may complain that his wife is unkind to him. His counsellor may investigate whether the man, by being emotionally cold, discouraged his wife’s expressions of warmth and so she stopped trying.

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.

Pharmaceutical companies are companies that make medicines.

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Social injustice 4 3Poverty

Hunger 4

HIV and AIDS
3Unequal distribution of wealth

Lack of economic opportunities 4 3Gender inequality

Psychological and emotional issues
Character
Often, a counsellor will tell a supervisor that he has done everything he can think of to help a client and she still won’t change. Too often in counselling, people’s personalities (or characters) are overlooked. The skilful counsellor knows that understanding his client’s character is very important. Character shows itself in childhood and doesn’t change much during a person’s lifetime. If a client has a serious personality problem that interferes with his life, he is said to have a “personality disorder”. People with personality disorders can also have other emotional problems, such as depression. Emotional problems can be helped to improve. Aspects of character include: ᭜ The ability to connect emotionally to others. An emotionally healthy person will form good relationships, while someone with a personality disorder may be uncomfortable in relationships and avoids them. A person uncomfortable with relationships is not likely to go for, or remain in, counselling. A sense of responsibility to others. An emotionally healthy person can be trusted. Someone with a personality disorder may not care whether she infects someone with HIV. A person who lacks a sense of social responsibility may go for counselling to avoid

᭜

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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 client’s 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 terrified 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 find 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 fix their situations but kept failing finally 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 client’s 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 client’s 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 doesn’t 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 client’s identification with her culture and find 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 benefits and costs of certain beliefs (in terms of HIV, sickness and death). Help your client to determine whether the benefits 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 influence 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. Women’s 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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Men’s 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 women’s roles and women’s power, and roles regarding their children. While there is much sympathy for the often difficult situation of women, many counsellors are less sympathetic to men’s 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 specific concerns, including: ᭜ The loss of adult children to HIV and AIDS. Normally, parents die first. 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-specific 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.

Fear about rapid sickness and death
A common theme voiced by people with HIV is not knowing about the course of the illness, including when a crisis and maybe death will occur. A client may ask, “How soon will I die?” If the client has some resources, such as food, the answer may be, “I don’t know, but you may have some control.” Research studies show average times from infection to illness to death. They don’t look at the situation of each individual. Your client cannot know how soon she will become sick or die. Rather than worrying endlessly, a recently diagnosed person should be advised to: ᭜ Take anti-retroviral medication, if prescribed, according to doctor’s orders. Go to counselling sessions to talk about reactions to HIV infection, and to deal with old and new emotional issues. Look after her physical health, including improving nutrition, stopping smoking and drinking very little alcohol, if any. Practise safer sex, to avoid infection with other strains of HIV or other STDs.

᭜

᭜

᭜

Your client may ask, “I can’t be cured, so wouldn’t 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 financial support, housing and, especially, love and emotional support.

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Betrayal
One very difficult 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 difficult, 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 dignified 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 client’s 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 don’t 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.

Difficult 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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The violent client
Some clients may say things that make you nervous, while other clients may have histories of violence. Ideally, violent people should be in special programmes that are staffed by experts, but this is often impossible. ᭜ When a potentially violent person enters counselling, state clearly that no violence will be tolerated. If violence occurs, the person will no longer be welcome and she will be reported to the police. Say, “I want you to talk about these feelings, but you cannot act on these feelings.” Take special care to tell the client that threats to harm others receive special attention. First of all, you must decide if the threat is serious. A lot of people say, “I could kill him!” but they only use the words to express anger. Decide whether the client means what she says and if she is capable of acting on what she says. If a threat is serious (or if a child has been harmed) the confidentiality is ended. You must then take special steps. Warn the threatened person, and if the threat or harm is to a child, report the situation to the proper agency, such as the Woman and Child Protection Unit at your nearest police station. A counsellor must never see a potentially violent person without office staff being present outside the door. Office staff should be trained to respond quickly to a call for help. No home visits should be made to potentially violent clients. In the counselling room, the counsellor sits near the door, so he can make a quick exit. The counsellor’s supervisor should give the counsellor extra attention, discussing his feelings about the client. If the counsellor remains fearful or feels threatened and cannot resolve the feelings in supervision, another counsellor should see the client.

᭜

᭜

᭜

᭜

᭜

᭜

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These are the symptoms
When a client is difficult, makes significant mistakes or misbehaves, the counsellor should remember: These are the symptoms! Behaviour that frustrates the counsellor is a symptom of the problem that requires counselling. If she didn’t have the problematic behaviour, your client probably wouldn’t need counselling. Troublesome behaviour that provokes strong feelings in the counsellor is a gift from the client! It allows you to experience the client as others do. What angers you probably angers the client’s family and friends too. When the counsellor becomes angry, he can say something that relates his feelings to the feelings of other people in the client’s life. For example, “I’m beginning to understand why your mother is so upset with you!” or, “I can see why your husband gets angry with you.”

Shame, Discrimination, Stigma
In one sub-Saharan country, pregnant women are offered HIV tests and, if they test positive, they are offered drugs that cut in half their newborn baby’s risk of HIV infection. Few women take up the offer, fearing it will reveal their HIV infection. At a university, a young woman with repeated illnesses took an HIV test that revealed that she was not infected. Hearing that she took the test, her classmates shunned her, moving away when she sat nearby. Stigma, discrimination and shame (SDS) are powerful forces that get in the way of our response to HIV and AIDS. They are such powerful forces that people would rather suffer and die, and have their children suffer and die, than obtain medical treatment if it meant that people would find out about their HIV status. People hide their HIV status because they are afraid of losing friends, jobs, housing, or educational and other opportunities. “Each year, more and more people die from the [HIV] disease and it is the stigma and misinformation around HIV that is killing people,” said a president of the International Federation of Red Cross and Red Crescent Societies. “People place themselves at high risk from infection or refuse to access treatment rather than face the consequences of social stigma, such as losing their homes, businesses and even their families,“ he said.

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A director of the World Health Organization Global Programme on AIDS identified 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 client’s 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 client’s feelings of shame, with the goal of healing those feelings. When appropriate, encourage clients to disclose their HIV status to other people. The counsellor’s expressions of acceptance will help. SDS needs to be brought to everyone’s attention. There are several things counsellors can do to fight 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 client’s situation. To find out this information, the counsellor has to ask questions in an organised way, a process called “doing an assessment”. This takes place during the first few meetings. It can take as long as the counsellor needs to get a good picture of the client’s 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 client’s needs. This plan is sometimes called a treatment plan. The best counsellors do not throw question after question at the client during the first 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 fill in the gaps. This chapter describes the first meeting and the assessment and planning process.

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The counselling environment
Counselling should preferably take place in a room with a door that can be closed during visits. The room should have solid walls so that conversations inside the room can’t be overheard from outside. If possible, the counsellor and the client should face each other without a desk or any other furniture between them. You may need to move the furniture around before your client arrives! The counsellor could offer the client something to drink, if it is available. If the client has children old enough to understand the content of the discussion, they should stay outside the counselling room. Sometimes a private room is not available. If your client does not mind being seen with you, you could perhaps walk outside and talk. Counsellors have been known to use motorcars and empty churches for counselling.

The first meeting
Greetings
Counsellors should observe all traditional forms of greetings. Don’t share your own problems with your client. Unlike in a conversation between friends, the counsellor should not talk too much about her personal life. This is not to be unfriendly, but rather to give attention to the client.

Introductions
Introduce yourself with your name and a few sentences about your training and other qualifications. You may want to give the client a piece of paper with your name and contact information, such as a phone number.

Explanations about counselling
The client may not know what counselling is or how it works. That may make the client feel nervous. Spend as much time as necessary explaining what counselling is all about. Your explanation should include: ᭜ ᭜ acknowledgement of the client’s feelings information on counselling

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᭜

information about how you will conduct an assessment and create a plan together assurances regarding confidentiality ground rules.

᭜ ᭜

Your talk may be something like this:
Thank you for coming today. Most people are a bit nervous about starting counselling. If you are a bit nervous, that’s entirely normal and to be expected. After I explain what’s happening, you may feel less nervous or not nervous at all. I appreciate your being here.
Don’t memorise this explanation. Use your own words, but include all the points.

Counselling is a word that is confusing to a lot of people. It has been used to describe advice-giving. I’m not likely to give you advice in our counselling visits. In our meetings, you will talk about problems and feelings that affect your life. I’ll ask questions, helping you to explore how you feel about those issues and what you could do to feel better or find solutions to problems. People believe that talking about problems can make them feel better and help to improve them. Over time we’ll 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 confidentiality of our work together and the ground rules. Then I’ll give you a chance to ask questions. Everything we say during your visits is strictly confidential. 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.

Address potential barriers
The counsellor should anticipate potential barriers to counselling. What might be a barrier to counselling? It may be difficult for a man to talk to a female counsellor – this is one kind of barrier. Another example of a barrier might be an older person feeling uncomfortable talking to a younger counsellor. Language may also be a barrier. Even if you speak the same language, make sure your client understands the words you use. It is important to talk about such problems in the first or second session so that these barriers can be overcome. Here are some potential barriers: ᭜ Gender issues In many communities, a female counsellor can expect male clients to feel uncomfortable talking to her. This may even stop male clients from coming to counselling altogether. You could ask the male client what feelings he has about a female counsellor. The client may be polite and not tell the truth, but, if you can, persuade him to be honest about the problem. If the client is reluctant to talk about it, tell him he can always say what is on his mind, whenever he wants.

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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 isn’t 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 don’t mind, if I begin to feel that you are uncomfortable but you aren’t saying so, I’ll ask about it and we’ll 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, I’ll 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 counsellor’s supervisor should study the counsellor’s 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 counsellor’s caring-love for elderly people? The counsellor may ask the client for a bit more time to prove her value.

᭜ Feeling criticised or embarrassed
A client may see the suggestion that he come for counselling as criticism. He may see counselling as a sign that there is something wrong with him. He may be ashamed and

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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 doesn’t mean you are bad or flawed. It means you are a member of the human race. Every person has problems. But you’ve 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 benefits. 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 benefits for coming to counselling? There is no definite answer to this question. Perhaps it should be tried and evaluated in your community. ᭜ Confidentiality 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 client’s 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 haven’t 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 fill 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 financial 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 isn’t 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 client’s 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 finished picture. ᭜ Questions A counsellor asks a lot of questions. But a counsellor doesn’t 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 fill in the gaps in the client’s story and to help the counsellor understand the client’s 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 client’s 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 client’s 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 client’s situation. These guidelines may help: ᭜ If a client is in crisis, conducting a full assessment without first 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 difficult 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.

The planning process
After you have finished asking your questions, there are several things you need to do without the client knowing about them. These help you prepare for counselling. Using all the available information obtained from the assessment, the counsellor should take the following steps: ᭜ List the problems Read through the notes that you took and summarise them, using a form like the Assessment Summary Form on page 53. First of all, list the client’s problems in column one, under the headings “Biomedical”, “Emotional”, etc. ᭜ Try to understand the causes of the problems The counsellor’s explanations for the client’s problems are called “hypotheses” or “preliminary explanations” because the counsellor is never satisfied with them. As the client reveals more about himself, the counsellor will understand more about the client’s problems and change her hypotheses as she gets to know him better. Usually, after an assessment, the counsellor will find that more questions must be asked. As you think of possible explanations, write down the additional questions. At the next visit, explain, “I realised I needed to ask you some extra questions. May I ask them now?”

Preliminary means first, or early.

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Complex means more difficult or having more parts.

With practice you will learn to ask certain questions, or groups of questions, during the first 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.

Examples of trying to find explanations
Problem: The client does not take HIV medication according to the directions. The counsellor must determine why not by asking the following questions: 1. Does the client think he is taking the medication properly? Have him explain the directions as he understands them, so you can observe what errors he is making. Can the client read written instructions – for example, the medicine label? Ask him to read the label to you. If the client can read, does he understand the instructions? Ask him to explain the directions. If he knows he doesn’t understand, find out why he hasn’t asked for help. Does he have problems thinking? Is he shy about contacting the clinic? Is he unable to travel to the clinic? Is he uninvolved in his care because of depression or alcohol abuse?

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 doesn’t 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 client’s 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 first 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 fill in potential problems and responses.

ASSESSMENT SUMMARY FORM
Client: Contact information: .......Alfeus Mbende (this name has been made up)................... .......No phone. Go to his house ........................................

Date(s) of assessment: .......2/11/04..................................................

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.

Determine if he has clinical depression and seek appropriate treatment.

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.

Potential problems No transport if ill. No phone, so can’t call me if ill.

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 counsellor’s 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.

᭜ ᭜

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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.

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Based on the supervisor’s comments, the counsellor may decide to ask the client more questions, rethink the explanations and goals, and change the plan.

The plan is reviewed
After the counselling plan has been supervised and amended, the counsellor discusses both the plan and the goals with the client. The client may request changes. It is important to agree upon goals because then both the client and the counsellor understand the plan and can work together to reach the goals.

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You could say: Counsellor: We’ve talked about a lot of things. Clearly you are in a lot of emotional pain and your children’s health needs attention. Your family also needs more food. Which issue do you want to address first? Client: We really need to eat.

Counsellor: So, let’s start off by working out how more food can be obtained for your family. We then will talk about your children’s health needs and your sadness.

When the client is unwilling to cooperate
Some people may be unwilling to talk about personal problems or to accept what the counsellor offers. A client may tell you that he’ll come back when he is ready to talk. The counsellor could say, “I see you are feeling uncomfortable talking right now. Would you like to come back when you feel more comfortable?” Don’t be discouraged or angry. This is positive honesty. Instead, thank the client for his interest and for being honest. You could say, “If I see you on the street, can I ask about you and your family?”, “Can I telephone (if there is a telephone available) and check on you?”, or, “Would you drop in again and just tell me how you are doing?” These statements show that you are interested in continuing a relationship. You could suggest, “The door is always open. If you change your mind, I would be happy to see you.” If there are urgent problems, you could risk being a bit more forceful, saying something like, “You said that your children aren’t getting enough to eat. I know you love your children. But you say you are not coming back. Why is that?”

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6
A counselling model
Introduction
At first, 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 identified 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.

A combination of counselling models for Africa
Most people learn methods of counselling that assume the counsellor will meet with the client several times, perhaps even many times. This assumes that clients: ᭜ ᭜ ᭜ ᭜ understand and accept how counselling works have easy transportation to the counselling services are not overwhelmed with other problems to the point of being unable to do anything are willing to visit the counsellor often.

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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 doesn’t return unless she faces another crisis. The person in emotional pain who is open to the benefits 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.)

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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.

“Think for the year”
Thinking for the year means that the counsellor, based on a skilful assessment, considers the client’s biomedical, emotional, social and spiritual issues, and recognises it will take a long time to make things right. He recognises and understands the client’s long-term needs and creates a long-term plan – covering a year or more – to assist with them.

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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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Emerging issues in long-term counselling
As visits continue, the counsellor and the client work on both short-term and long-term issues. Other issues usually come up. Some organisations ask counsellors to revise the counselling plan every three to six months to include the new issues. It is unclear how many clients use long-term counselling. In countries where researchers count the number of sessions, most clients will have about seven or fewer sessions before ending counselling. Similar information for counselling clients with HIV in Africa does not seem to be available. Counsellors find that after several sessions, perhaps five or seven, several issues usually arise. These include:

Emotional discomfort increases
Effective counselling touches on painful areas – both past and present. No one likes feeling pain. However, counselling practice is based on the client talking about the pain and feeling it, rather than keeping it hidden away. For example, if a client has been abandoned because of her HIV infection, a skilful therapist makes the client talk about the loss in detail, expressing the pain. Strategies to avoid pain, the defences discussed in Chapter 4, reveal themselves in different ways during counselling:

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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 “flight 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 fixed. 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 didn’t come last week because I couldn’t find 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 weren’t 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, you’re 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 client’s 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 client’s attention, perhaps like this: Client: Yesterday my sister just wouldn’t 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 don’t want to talk about the depression?

Counsellor:

Discouragement is felt
When you address problems that have taken years to build, that are slow to fix, 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 can’t 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 difficult 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.

The counsellor is attacked
As counselling progresses and discouragement grows, the client may focus all her frustrations on the counsellor. She may say the following: How come you aren’t helping me? You don’t understand my feelings. I really need you in the evenings and you aren’t there. I came here with one problem and now I have five problems. The counsellor may feel attacked and defensive. But these comments are not criticisms. They are expressions of pain, frustration and other emotions. They must be understood as such. The counsellor is a convenient target simply because he is there with the client. Perhaps no one else in the client’s life will tolerate such an outburst. The counsellor’s task is to understand the expressions of pain and respond with caring-love. “You are so filled with hurt,” or “I am sorry you are so frustrated.”

The counsellor may be avoiding things
When painful feelings are not addressed in counselling, it is often because the counsellor is uncomfortable with intense emotion himself. The counsellor and the client, without actually agreeing out loud, ignore emotional issues and expressions like tears or shouting. The result is boring visits because they are emotionally empty and there is no possibility of growth. This is a counselling failure, caused by the caregiver.

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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.

“Practise by the hour”
HIV and AIDS teach us that life is short. HIV and AIDS counselling is a part of life. Clients suddenly disappear without warning. Clients stop counselling without saying goodbye, they leave town, get sick, or die. The counselling relationship is like any other relationship; we don’t know how much time we have together. The skilful counsellor doesn’t hope for sudden endings, but is prepared for them. He plans for a year of counselling in the hope that his client will stay healthy and committed to dealing with problems. At the same time, just in case, the counsellor also works as if each session is a complete “treatment” in itself. Each session has the following elements:

A goal for the visit
The counsellor works towards the long-term goal, session by session. At the same time, he wants each session to be valuable in itself. He has a goal for each session that is related to the long-term goals. For example, the counsellor may remind himself that a client is struggling to express her grief over the loss of her husband. At today’s session, the counsellor’s goal is that the client will move forward in her grief by talking about her husband. The counsellor will ask many questions about the husband, thereby encouraging the client to express her feelings. Another goal may be to encourage a client to visit a soup kitchen more regularly, to work towards the long-term goal of better nutrition.

A gift to the client
The gift is not an object, but some useful information or a message, prepared in advance and appropriate to what is likely to be discussed. For example, to the grieving widow, the message may be, “Crying alone is good, but it is better to cry with someone and receive support.” Other gifts may include a carefully chosen booklet about the topic being discussed, 62

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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.

An example of practising by the hour: Working with a dying client
Perhaps there is no more significant example of practising by the hour than working with a dying client. Sister Pascal Conforti once said that counsellors can do several things for clients who are facing death. These things include: ᭜ Helping the client deal with the fear of death by helping him or her accept death as another event in the process called “being” or “becoming”. Being truthful by acknowledging what the client already knows: “... that he or she is not getting better, that the body is weakening, and that he or she will die sooner rather than later”. Counselling the client to live in the present moment and to embrace whatever is happening. A friend who is trying to help may say, “You can beat this thing!”, but this is a battle that we cannot win and are not meant to win. Providing an atmosphere of love and encouragement. Sister Pascal wrote that the counsellor should remind the client “that we are more than bodies and that who we are is far greater than what is happening physically”.

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The relationship ends
The counselling relationship can end in several ways.

Counselling goals are met
The ideal ending (which is rare) is when the client has accepted herself, has come to terms with HIV infection and has overcome other problems as well. When the client has met most of her goals, it is time to start what is called the “termination process”, which means saying goodbye. It is a gift to be able to say goodbye to someone, whether it is a client or a loved one who is dying. The process is similar. The counsellor who is saying goodbye to a client guides a conversation that includes: ᭜ A review of the time spent together. This focuses on the client’s successes. The counsellor praises the client for what she has accomplished and takes no credit for the help he gave. Remember: the relationship was for the client’s benefit. This review takes as much time as it needs. ᭜ Expression of feelings for one another. In the safety of the counselling room, the client is encouraged to express her feelings for the counsellor. Sometimes these feelings have already been spoken about. Some clients wait until the end to say what is in their hearts. The counsellor can speak of his high regard for the client, his pride in what the client has accomplished, and his caring-love for the client. As when we say goodbye to a dying loved one, it would be best if both counsellor and client can feel that they have said everything they wanted to say, so that there are no regrets. Keeping the door open. The counsellor invites the client to return if she feels she needs to in the future.

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Client disappears
Few occurrences are as upsetting for the counsellor as when a client disappears. The counsellor sits in his office at the appointment time, waiting for the client, but she doesn’t appear. He telephones (if she has a telephone) and finds 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 counsellor’s 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 client’s 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 doesn’t 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 don’t contact me within five hours, I will go to your house to see if you are all right. If necessary, I’ll break down the door or climb through a window to check on you.”

Client is physically unable to come
Often a client gets sicker and is unable to make her appointment. In such cases, if it is safe and if the client agrees, a home or hospital visit is strongly suggested. Remember: home visits may violate the client’s confidentiality or reveal her HIV status. If the counsellor sees the client getting sicker, he could ask, “Would you mind if I visit you at home if you can’t come here?” Or, “If you get hospitalised, could I visit you there?”

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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 person’s 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 can’t visit.

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Home or hospital visits need not be long and they don’t have to be about accomplishing goals. Rather, the counsellor offers a few empathetic words, perhaps holds the client’s 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, “I’ll see you when I see you.”

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Death
The medical path of the HIV disease is filled with unexpected events. People who seem to be dying are hospitalised, recover and return to their homes. Individuals who don’t 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 first time, the client’s 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 confidentiality issues, he should attend the memorial service, pray for the client’s soul if appropriate, and take comfort in the knowledge that he helped the client acknowledge life and die a better death.

How an organisation or group could say goodbye
Some organisations that provide counselling services for people with HIV and AIDS understand that the death of a client affects staff members and other clients, especially when all the clients know each other and confidentiality is not an issue. Such organisations have developed activities to assist staff members and other clients to remember their neighbours and to mourn. ᭜ When there are no family members, the organisation or group conducts a memorial service for the late client. Other clients attend and are asked to speak about their colleague. If family members have refused to accept the person’s HIV status and have told organisation staff not to come to the family service, the organisation holds its own service.

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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.

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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/ Woodfin Camp & Associates, Inc)

᭜

Finally, when a client dies, especially if the death is a difficult one, the client’s counsellor and other staff members should identify other clients who may suffer greatly and would benefit 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 client’s 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 client’s 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 client’s 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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doesn’t raise it again, the preparation will remind the counsellor to ask, “Last week we talked about your mother’s heart attack, but today’s visit is almost over and you didn’t 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 husband’s 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 counsellor’s mind drifts away and he loses track of what the client has been saying, it is acceptable to say, “I’m sorry, I lost my concentration. Would you kindly repeat what you just said?”

Reflecting 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 doesn’t 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 difficult. Using Rogers’ methods, the counsellor tries to understand the emotions that the client is experiencing and then acts like a mirror, reflecting (repeating back) those feelings to the client. These reflections make the client feel that she has been heard and understood. It also gives the client an opportunity to correct the counsellor when he doesn’t 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? I’m more than angry with him.

Counsellor: You are feeling rage. Client: Yes, rage. I’m burning up inside.

Counsellor: You are so full of rage; you are about to burst into flames. This technique requires undistracted listening, as well as skill in appreciating the client’s emotions and finding the right words to reflect 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 don’t 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.

Skilful and purposeful inquiry
Because counselling is not a casual conversation, the counsellor does not ask a question just because it pops into his head or to satisfy his curiosity. When you are counselling a person, each question has a purpose. The counsellor should be able to tell his supervisor exactly why he asked each question.

Questions are good tools
Questions are one of the best tools a counsellor has. The reasons questions are asked include: ᭜ To find out what silence means. The counsellor asks, “You’ve been very quiet today and I can’t tell what’s going on. What are you feeling?” To help the client focus. The counsellor may say, “You’re talking very fast and I can’t quite understand what you are getting at. Is something going on that is upsetting you?” To encourage the client to do more self-examination. Unconvinced about some reason given, the counsellor says, “Your explanation isn’t very good and I don’t think you believe it either. Can you tell me the reason you refused to see the doctor?” To follow a hunch. The client cries a lot and the counsellor hasn’t yet seen a smile or even bright eyes. The counsellor suspects the client is seriously depressed. While the counsellor knows he cannot diagnose depression, he does know the symptoms and wants to find out if depression may be a possibility. If the client has symptoms of depression, the counsellor could send her to a doctor. But first he has to investigate, so that he doesn’t make an unnecessary referral.

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A hunch is a suspicion.

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Counsellor: I notice you are crying a lot. I’d like to ask some questions that may help us understand the crying. Is that all right? Client: Yes, that’s okay.

Counsellor: How are you feeling emotionally? Client: (a bit angry with the counsellor) Well, as you should be able to tell, I’m pretty unhappy.

Counsellor: Yes, I see that you are unhappy. I’m 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 I’m unhappy because my son got his girlfriend pregnant.

Counsellor: Yes, that’s 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 don’t mean I haven’t 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 don’t know what he’s 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.

᭜ ᭜

᭜

Asking open-ended questions
Some clients don’t talk much because of shyness, nervousness or discomfort when discussing personal information with a stranger. Rather than asking questions that can be answered with a “yes” or a “no”, ask open-ended questions. Open-ended questions require detail in the answers. Instead of asking, “And then you went to your mother’s house?” (to which your client will reply, “Yes”), rather ask, “And what happened after that?”

Talking about the elephant in the room
Look at the picture below.

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Most counsellors don’t 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 isn’t there because they know it is difficult 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 don’t 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 difficult topic to talk about. However, it is important that we discuss ...”

Recognising and responding to invisible interactions
Counsellors and clients interact and influence each other. A lot goes on that is visible and invisible. The client speaks and the counsellor might raise an eyebrow, causing the client to hold something back. The counsellor might say something that the client feels is critical. Her facial muscles tighten. The counsellor notices and considers what he has said. Gestures, eye and facial expressions, posture and other invisible signals all are forms of communication between client and counsellor. If a counsellor misses these, he will be overlooking many messages.
Posture is the way people sit or stand.

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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 client’s 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.

Comment on the big picture
Amid the details of daily life, it is easy to lose track of the long-term plan – the big picture – of the counselling relationship. The counsellor should always keep in mind the long-term goals and the themes that have emerged over time. When a recent incident is described, the skilful practitioner helps the client to see how the seemingly new situation relates to how the client lives his life and to their counselling goals. The counsellor may explain how the new situation (or the emotions created by the situation) is a repeat of a previous pattern in the client’s life. Client: My sister told me she was going to Gaborone and didn’t know when she was returning. I didn’t say anything, but I panicked. I cried. What will I do without her? I didn’t think I could live without her around. This sounds a lot like your reaction when your brother joined the army. You know we’ve been talking about how you panic when someone you depend on moves away. One of our goals has been to work on your feelings of emptiness and abandonment when someone leaves.

Counsellor:

It is important for the client to see the pattern. This is the first 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 doesn’t see emotional patterns is unlikely to make progress.

Using the counselling relationship to understand the client’s usual behaviour
A client will often be on her best behaviour for the counsellor, at least during initial visits. With time, personalities reveal themselves in the counselling room, showing the counsellor how a client behaves with her friends and family. The client’s behaviour that helps or harms the counselling relationship may be similar to behaviour that helps or harms other relationships. When the counsellor notices such behaviour, he could make a comment that connects her behaviour during counselling with her behaviour in other relationships. For example: Counsellor: I haven’t asked much from you in our relationship, but one thing I’ve asked is that you be on time. You are always very late, so we have no time to talk deeply. I think this is a way you stop me getting to know you. Client: No, no, I just have trouble with transport.

Counsellor: (Doesn’t respond to transport excuse.) This looks a lot like what others say about you. You’ve told me they say you don’t 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.

Responding to your own anxiety
Too often, a client with HIV will tell stories that make a counsellor very anxious. The story may be about impending disaster, such as the client getting sicker and sicker. Or it may be about a past event, such as a rape, or some disaster narrowly missed. The anxiety created in the counsellor can push him into saying the wrong thing, like, “Oh, don’t worry. Things will work out.”

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That comment has no useful purpose in counselling. It pushes the client’s 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 client’s pain. Here is a simple technique that may help you to get through these difficult sessions: ᭜ When you are feeling anxious, acknowledge the feeling. Admit to yourself that you are feeling anxious and recognise that your client’s 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 client’s feelings during (a) the original event and (b) now, while she is telling you about it. Reflect back the feelings. Check yourself for accuracy. Based on your client’s response, refine your understanding of the client’s 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 client’s feelings, thereby better appreciating her experience.

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Extra information: Alternative lifestyles
When a counsellor successfully encourages a client to be emotionally open and to talk intimately about her private life, issues of sexual behaviour should arise. If sexuality is not discussed, the counselling relationship has not yet matured. The counsellor must anticipate that explicit discussions of sexuality may occur and consider how he may feel before it happens, if he thinks that he may be uncomfortable talking about sexuality. The counsellor must be prepared to act carefully with the client, avoiding any harm to the client or to the relationship. For example, a client may reveal that she has same-sex relationships. Because some religious groups and cultures have negative views about homosexuality, some counsellors may have negative feelings about it themselves. A counsellor who is aware of himself and his beliefs knows these emotions might come out and should have already planned what to do and say. The counsellor’s responses may include: ᭜ Taking a few breaths before saying anything, as described earlier in this chapter. ᭜ Saying something like, “I’m not at all familiar with the experience of women having sex with women. Would you please tell me your story concerning this?” ᭜ Asking (of a male client), “What does your culture say about your feelings concerning men?” Then, if the culture is condemning, ask, “What effects has this had on you?” ᭜ Reflecting back the feelings, “You feel so rejected by your family. You are in such pain about this.” Working with a client with an alternative sexual lifestyle can provide a counsellor with opportunities to learn, understand and practise caring-love. However, some well-respected mental health supervisors believe that a counsellor should not work with a client who makes the counsellor feel very uncomfortable. A counsellor who condemns the client’s behaviour cannot offer caring-love. The client will once again feel rejected, this time by someone she has come to for help. If alternative lifestyles make a counsellor-in-training feel uncomfortable, it is important to give this some thought. What personal issues are coming into play, resulting in judgment and discomfort? Could these be discussed with a trusted colleague or supervisor and changed? Ultimately, however, if the feelings of disgust or repulsion are so strong as to interfere with the relationship, transferring the client to another counsellor would be recommended.

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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.

Voluntary counselling and testing
HIV testing plays an important role in the fight against HIV and AIDS. Special voluntary counselling and testing (VCT) centres have been set up in many countries, and hospitals and clinics may also do voluntary counselling and testing. Many governments, non-governmental organisations and donor organisations are urging people to be tested for HIV. People that support voluntary testing say being tested helps people focus on HIV issues, whether they are found to be infected or not. In areas that have HIV medicine available, you could seek medical care after finding out that you are infected. The care may include medicine that can lengthen your life if it is taken properly, called antiretroviral medicine. In countries without anti-retrovirals, a person who has been told he or she is infected can still take steps to live a healthier life. People who are tested are taught about ways to prevent HIV infection of themselves, if they are not infected, and of other people.

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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 confidential?
Testing is usually anonymous or confidential. Everyone should be aware of the difference between the two. Anonymous testing means a test result is not attached to a person’s 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. Confidential testing is different. It means that the test result is put into a file, such as a medical record, with the patient’s name. This is usually what happens at a medical clinic or hospital, so doctors and nurses can better treat their patients. In this case, “confidential” means that only those who need to see the test result may read the clinic’s files. 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 files and learn of a person’s 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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The HIV test
Antibodies are substances produced by the body in response to foreign substances, such as viruses or bacteria.

Tests at VCT centres and clinics determine if someone has an “antibody” to HIV, which is a product of the body’s 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 person’s 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 don’t require a lot of blood, people are more likely to be tested and less likely to be anxious. The VCT counsellor’s official 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.

VCT counselling procedures
VCT counselling procedures, also called protocols, differ from country to country and even from clinic to clinic (or counselling centre). Sometimes these procedures are deliberately ignored – for example, when no counselling is provided before or after an HIV test. Not providing counselling may be illegal and certainly is unethical. Counselling procedures usually emphasise a client’s biomedical or physical issues. Clinics and VCT centres require employees to work through the required checklists of questions and procedures. However, counsellors still need to find time for compassion. If time and the supervisors allow, the counsellor does more, asking questions and expressing concerns about the client’s emotional, social and spiritual aspects. These include:
Protocols are the counselling and testing procedures set up by a clinic.

The client’s emotional situation
Some checklists may not lead to a good assessment of the client’s emotional situation. It may be helpful to assess several issues: ᭜ Anxiety It is normal to be anxious when being tested for HIV and especially while you wait for the results. While it is normal to be anxious or nervous, if you should have a VCT client who is so anxious that he is having trouble functioning, you should be curious about why this is the case. It is possible that the client has a biomedical problem, such as lack of oxygen or an overdose of a medicine, a serious psychiatric condition, or a strong conviction that a positive test result means quick death.

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An excessively anxious person may be too distracted to understand the counsellor’s 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.

᭜ Severe mental disorders
People with serious mental disorders should not be tested for HIV without psychiatric support. Symptoms of severe mental disorders include: ᭜ ᭜ ᭜ problems recognising what is real and what is not speech that doesn’t make sense unshakeable beliefs (which are not culturally acceptable) about cures, aliens, strangers and other aspects of life a belief that the person himself is God or a public figure hearing voices that other people can’t hear, especially voices that give commands to hurt other people or herself believing that people are talking about them when they are not believing that people on television or radio are speaking directly to them.

᭜ ᭜

᭜ ᭜

᭜ Alcohol abuse and intoxication
The abuse of alcohol and other substances, such as dagga, is common enough that enquiries should be made about their use when someone comes for a test or for test results. An intoxicated client seems slowed down and a bit disoriented. Signs of intoxication include slurred or halting speech, slowed thinking and actions, unsteady walking,

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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 doesn’t 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 counsellor’s instructions. Did the client think intoxication was necessary to tolerate the anxiety? Is the client’s 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.

Wise words: “Come back anyway”
Father Rick Bauer, a psychotherapist, suggests that counsellors say this to clients who have just been tested for HIV infection: “Sometimes after someone has their blood drawn for an HIV test, he doesn’t want to return because he doesn’t want to know if he is HIV-positive. If that’s how you feel, that’s okay. But why don’t you come back anyway just to talk to me about those feelings?”

Facing the anxiety-causing HIV test
Being tested for HIV may make the person extremely anxious. Even people who have little or no chance of being infected get upset at the thought of being tested or waiting for the result. Imagine the anxiety of people who think they may have been infected! Added to this is the unfortunate situation that just being tested makes people vulnerable to stigma and discrimination in some communities. Counsellors may better appreciate their clients’ feelings if they have experienced the anxiety of being tested and considered the threat of stigma. It is recommended

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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?

The client’s social situation
A person may come alone to be tested and she may seem to be alone. But she is part of a larger system: a family. A counsellor may want to know how a test result showing infection will change the client’s relationship with her family. Will the family learn about the result and will the family members need support and guidance if the result is positive? The counsellor is encouraged to look at the big picture and help with all the consequences. Some questions, perhaps not on an official checklist, may include: ᭜ ᭜ ᭜ ᭜ Is the client currently in a sexual relationship? Is the partner’s HIV status known? Is safer sex being practised? Does she plan to tell her partner or other family members about the test result? If not, why? If the test is positive, and the partner learns about it, what are the predictable results? Will family members be supportive or rejecting? Is there a risk of violence? If the client is a parent, will her children learn about the result and what will the effects be? How can the counsellor be helpful in assisting the client with her family?

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᭜

᭜

The client’s spiritual situation
VCT protocols rarely suggest that counsellors ask about spiritual issues. Yet spirituality is very important to many people. Counsellors may ask about a VCT client’s feelings about spirituality:

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᭜ ᭜

Is the client at peace with her Creator? What does the client think God’s 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?

᭜ ᭜

Assisting with medicines
As countries begin to offer anti-retroviral medicines to people with HIV and AIDS, some counsellors will assist clients to take the medicines as prescribed. Some counsellors may join hospital staff and receive special training to counsel clients about their medicines. Increasingly, counsellors act as members of care teams that include the client’s doctor, family and others. Doctors often prescribe combinations of different types to attack the virus in different ways. These combinations are referred to as HAART (say “heart”). There are several important reasons why clients must take their medicines in the way they are prescribed. ᭜ This is the client’s best chance of improving quality of life and extending life. Taking medicines incorrectly (like stopping and starting the medicines when the client feels like it) may cause the virus to change. This creates what are called “new strains”. The new strains may be resistant to the medicines. A person may find there are no medicines that can fight the new HIV strain. An infected person can infect someone else with the new strain. A person who already has HIV can be “reinfected” with a different strain of HIV that is medicine-resistant. The worst nightmare of HIV care is the spread of HIV strains that cannot be treated with available medicines.
Anti-retrovirals (ARVs) are called anti-retrovirals because they attack retroviruses. HIV is a type of retrovirus. There are several different types of anti-retrovirals, each type attacking the virus differently.

᭜

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:

Know the medicines
In Namibia, for example, the Ministry of Health and Social Services has published an informative booklet that tells how these medicines should be prescribed. This book names the medicines, the amount to be taken, how often, and if they should be taken with or without food. Similar guides are available in other countries that provide ARVs and counsellors should read them. Sometimes colour photographs of different pills are available from pharmaceutical companies, chemists, or HIV and AIDS advocacy groups. Non-governmental organisations (NGOs) should request the local distributor of ARVs to make a presentation to the counselling staff, showing the colours and shapes of the pills and capsules, describing typical dosages and explaining possible side-effects that the medicines cause. A counsellor could introduce himself to a local hospital, chemist or clinic and ask if he can learn about the medications and contact them with questions. Having a relationship with a local chemist or doctor is important because prescribing guidelines may change, new medicines may become available (or old medicines be discontinued), or other news may emerge.

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. Don’t 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 doctor’s orders, take notes and request any pamphlets that may be available that explain about the medicines.

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Assist with daily medicine taking
Medicines for HIV and AIDS can be confusing, especially for people who have difficulty remembering or reading instructions. Assisting the client with this is an opportunity to be creative. Here are several suggestions, which you can adapt to suit yourself.

᭜ A weekly medicine chart
If you know what medicines your client needs to take and when, you could draw a chart for her:

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 specific 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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If pillboxes aren’t 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.

᭜ Training family members or friends
A counsellor can’t always be with his client, but family members or special friends are usually around. Using similar methods, the counsellor can train the family members to remind the client to take the correct pill at the right time. When the client is ill, family members should be asked to make sure that the client takes her medicines at the right time.

᭜ Checking up and retraining
Even if the counsellor is working with the client, family members, or both, from time to time he should make sure that the medicine is being taken properly. If a pillbox is being used, you could ask the client to bring the box to a counselling visit. Watch the client or a family member fill the compartments, to check for accuracy. You could also check the pillbox at the end of the week to see if any pills were not taken. If there is no pillbox, the client could be asked to bring her pill bottles to the counselling visits. Count the pills to see if the correct number has been taken. If you discover problems, re-educate the client about the importance of compliance. New types of reminders can be tested. For example, if a specific pill has to be taken with food, the client could leave her pill bottle next to the food.

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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This is a pity because prevention and health care should work closely together. Other issues that make it difficult 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 profit from their sale, that indicate some parties think the practices described are morally harmful.

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Current prevention strategies
The prevention strategy currently emphasised by many countries can be remembered by thinking “ABCD”. This stands for:

A Abstinence B Be faithful to one partner C Condom D Delay of first sexual encounter
The type of prevention programme used in a community usually depends on the amount of money available, and political and cultural mandates (permission). They are not always successful. Extra information In the absence of specific information, some people look to broad pictures of success or failure. For example, based on reported declines or stabilisation in infection rates, people will say that Uganda’s prevention efforts are working. Others may say that Namibia’s efforts are not working because of increases in infection rates. These “big picture” declarations unfortunately leave out the finer details, which are the population subgroups. A subgroup is a small group of similar people within a large group. Between subgroups there are likely to be wide variations. For example, prevention interventions, such as media messages, may be working well in a subgroup like teenage girls. But if researchers have not focused on this group, the success will not be discovered. Similarly, prevention messages may have failed with teenage boys, but this too is not reported. Because counsellors work with people one-on-one, the following is suggested:

Understand power issues
HIV and AIDS are at the intersection of poverty, lack of opportunity, hunger and other environmental issues (look at the diagram on page 32). In the same way, preventing the spread of infection intersects with power in a relationship. Much of this power is culturally determined, but with the HIV epidemic, it is now a good time to look at sexual violence that can result in HIV infection.

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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.

Offer prevention messages in every encounter
Because health care professionals and counsellors deal with intimate issues in people’s lives, they have opportunities to talk about HIV and AIDS prevention. Don’t leave prevention messages for another day. How can you bring them into the discussion?

᭜ Prevention message of the day
Tell clients that you believe HIV prevention is very important, and that you’ll mention it after each session. Take 90 seconds after the counselling has ended to deliver a very short prevention reminder. If the client wants to discuss it, you can make it the first thing you talk about at the next visit.

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The issues of youth

Children affected by HIV and AIDS also have a wide range of situations that can come to a counsellor’s 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 briefly discuss counselling themes for children and adolescents, and then discuss some specific issues.

Working with youth
Counselling children and teenagers is very different from working with adults. Talking techniques that are suitable for adults are not helpful to children. Very few children have the words to describe their feelings, the patience to sit and talk seriously with an adult, or the belief that an adult will understand them.

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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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The need to be cool
Teenagers, especially those who have received large doses of Western culture, have to be cool and expect their

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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 shouldn’t 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.

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᭜

Understanding children’s themes
Some themes in children’s lives are:

᭜ Security
Children have a need for security and constancy (things that don’t 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 caregiver’s hand, wanting to be carried, or refusing to leave a caregiver.

᭜

᭜ Dependence versus independence
A child of about 9 or 10 years old will want to be independent, but also needs to feel secure. So the child may sometimes act independently, for example by going to school alone, yet at other times may need to sit with a parent and cuddle, especially in times of family anxiety.

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᭜ Knowing something is wrong versus family silence
Children are usually very sensitive to the things that are going on at home. They know when a parent or other family member is ill. But if the family does not acknowledge the illness or openly denies it, the gap between the knowledge that something is wrong and the family’s silence can make a child feel like she’s going crazy or, at least, in a crazy situation. A family may forbid a counsellor to tell the family secret, but the counsellor should not lie either. The counsellor should then not directly answer a child’s question, and should chat in a way that doesn’t disclose the secret, but allows the child to discover that her observations (the things she has noticed) and her feelings are valid. For example: Child client: Counsellor: Child: Will Mummy die? Why do you think that? She is getting thinner and thinner, and sometimes she stays in bed for several days. I’ve heard that is part of a sickness. Where did you hear that? We read that at school. So you know getting thinner sometimes is part of a sickness. What is that sickness called? It is called AIDS. And what else do you know about AIDS? People die from AIDS. Have you asked Mummy about this? I’ve tried but she just tells me to be quiet, that there is no AIDS in our family. But you have good reasons to feel differently and so you worry a lot. Yes. In our culture, people don’t want to talk about AIDS. I cannot say whether your mother has AIDS or not. But I think the silence around this illness causes a lot of fear. If you think Mummy has AIDS, would it be better if she told you?

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 confirm the child’s 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 find 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 find 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 government’s 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 children’s funds, so relatives or others do not take money that should go to children.

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HIV and AIDS and violence
Sometimes harmful behaviours are so much a part of everyday life that people just overlook them. This seems to be the case with violence against women and girls in many parts of the world, including sub-Saharan Africa. According to a report issued by Johns Hopkins University in the United States, at least one woman in three has been beaten, forced into sex or otherwise abused. African-based studies have results that are even more worrying. For example: ᭜ A 2003 survey found that about 80% of Zambian wives questioned said it was acceptable to be beaten by their husbands as punishment for doing something wrong. The same survey found that 61% of the women interviewed (about 5 000 women were interviewed) said a beating was acceptable if they denied sex to their husbands. In Uganda, a survey found that 70% of the men who took part in the survey and 90% of the women who took part in the survey thought that beating a wife or a female partner was justifiable in some circumstances.

Scientists use surveys to find out what a large group of people think or have experienced. But it is too difficult 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.

᭜

Incest is sexual activity between family members.

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 difficulties. 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 partner’s 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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Reasons for domestic violence
Many reasons are given to explain violence against women and girls. One reason given is that the violence against women and girls is culturally based; that is, the community accepts that this type of violence happens. The survey results from Africa seem to illustrate this point. However, “cultural acceptance” of harmful acts is no excuse. Other practices have been obviously harmful, although they were “accepted” by large groups of people. These “accepted” practices included apartheid, slavery, human sacrifice, genocide, political oppression and economic exploitation. Many people believe that the low status of women and girls results in their being assaulted. In many countries around the world, women have unequal access to education, training and economic opportunities. As a result, they are economically dependent on their husbands. This makes it impossible for such women to protect themselves and their children by facing up to the man, getting help and ultimately leaving the abusive spouse. Men are being studied for their role in domestic violence. Some researchers are looking at the way boys are brought up and the attitudes boys learn about being men in society, and how they see women’s roles and sexuality. Others are looking at how men see force as proof of masculinity and how important sexual encounters are in showing the world (and themselves) that they are men. Researchers are looking at the influence that a man’s mother and father have. Another issue being studied is how men deal with their anger and hostility toward women. Some researchers are studying men who seem to lack relationship skills, and the effects of alcohol, substance abuse and violent pornography. One simple reason for violent behaviour is that the violent person cannot connect emotionally with the other person’s suffering and may have no conscience.

The counsellor’s issues
A theme repeated throughout this book is the responsibility of the counsellor to be aware of how personal issues may influence his or her own responses in the counselling

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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 victim’s 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 client’s 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 don’t 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 client’s home:

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᭜

You often notice physical marks and signs which your client can’t 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 doesn’t protect her. When you try to find out more, the child may not want to be more specific. 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.

Interventions with individuals
There are three common types of interventions generally used in cases involving domestic violence.

Counselling
Counselling tries to: ᭜ develop the client’s trust so that she talks about the problem of domestic violence build the client’s 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: [email protected] 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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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.

What are mental health problems?
In this chapter, the term “mental health problems” describes problems that are sometimes called emotional problems, psychological problems, psychiatric illness, mental illness or mental disorders. These terms may suggest a specific reason for what the client is experiencing. If you say that a certain group of symptoms is a psychiatric illness, you are suggesting that the problems have biomedical causes. If you say it is a psychological illness, you are suggesting that the problem is an emotional one.

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By using the term “mental health problem” we don’t 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 adult’s 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 difficult 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 specific mental health problems, but only those who suffer sufficient stress actually experience the specific 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 client’s 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 person’s culture, they are not caused by a mental disorder.

Pathological means having to do with disease or abnormality.

The BESS model helps
Avoiding the arguments, counsellors can think about mental health problems in the same way that they think of HIV and AIDS – as conditions that have biomedical, emotional, social and spiritual causes and effects, all of which interact with each other. Remember the BESS model in Chapter 3? Let’s look at the illustration again, this time for mental health problems.

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Let’s 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 don’t affect other people (emotional). This nervous reaction may have alienated people, who don’t want to be around him (social). Now he lacks social support, which makes him feel more vulnerable. Not having a firm 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 finds it difficult 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 person’s 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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Who treats mental health problems?
Usually a doctor, a psychologist or a psychiatrist will diagnose and treat most significant mental health problems. These professionals will interview a client, focusing particularly on: ᭜ the client’s experiences and complaints, called “symptoms” “signs”, which are what the counsellor sees.

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Afterwards, the mental health specialist will decide if all the information fits 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.

Symptoms do not necessarily mean a problem
Counsellors must understand that a client may have one, two or three symptoms of a mental health problem, but that doesn’t mean he has a disorder. Many mental health problems share symptoms. For instance, someone who is grieving may have some symptoms of depression but does not necessarily have a major depression. Making a diagnosis is based on many symptoms, observations and other pieces of information, interpreted by the trained professional.

The common use of mental health terms
Many mental health terms are often used wrongly. Feeling very sad and being depressed is not the same thing. Sometimes you hear the word “schizophrenic” used wrongly. Counsellors must learn the technical terms and use them correctly. This is important. 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 isn’t imagining the symptoms and that they indicate a real condition.

The counsellor is observant
In many African communities, mental health problems are not recognised. This is because many African cultures do not think of behavioural problems as mental health problems. This leads to suffering for the person who has the problem and difficulties for the person’s family and community. Even if problems are recognised, there is often a lack of trained health workers who could help. HIV and AIDS counsellors who are well-trained will be on the lookout for mental health problems that affect a client’s life. This is important because the client may not admit to problems or may not even know that anything is wrong. Observations that should cause concern include: ᭜ ᭜ ᭜ ᭜ speeded-up or slowed-down thinking confusion speech that is very fast or can’t be understood a person who has been emotionally stable but now seems to be very emotional a lack of emotional expression – for example never seeming to feel happy, sad, angry, etc.

A skilled counsellor may be the only person in the client’s 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 flags” pop up in her mind when a client talks about the following: ᭜ A situation that could harm the client that doesn’t 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 can’t figure 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.

The counsellor enquires at anytime
The assessment (see Chapter 5) should uncover existing problems. But other problems could emerge later in the relationship. The counsellor must stay alert and, if a red flag appears, ask questions at any point during the counselling relationship. With experience, a counsellor may become very good at picking up hints of 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 difficult 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 doesn’t usually complain? This is a sign that the complaint may require medical attention. Does the client’s 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?

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Symptoms that may indicate depression
During depression there is much emotional, and sometimes physical, suffering. Depression is a serious mental disorder. Depression is different from sadness. Sadness is an emotion that stays with a person for a while, but the person can still carry on with life. Depression knocks a person down and seems to take over. A person with depression feels as though all the joy and energy has been drained from him, leaving him to lie around the house, with no motivation to do anything. One common signal of depression is the complaint of feeling tired all the time, in combination with other symptoms. In some cases, a depressed person feels hopeless, thinks about death, and may even think about or try suicide. In men, depression may be signalled by increased anger or irritation. Even if these symptoms are not evident, a depressed person may say he does not enjoy anything in life. 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.

Checklist of symptoms of major depression
᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ Do you feel depressed (sad or empty) most of the time? Are you interested in your normal activities? Do you get pleasure from your normal activities? Have you lost a lot of weight, but not because of HIV? Has your sleeping changed? Are you sleeping too much or too little? Do you feel keyed up, very nervous? Do you feel slowed down? Do you feel tired or without energy? Have you had feelings that you are worthless? Do you feel very guilty about something? Do you have problems thinking, concentrating or making decisions? Are you thinking a lot about dying (not just fear of dying)? Are you thinking about killing yourself? Have you tried to kill yourself?

If someone is thinking about killing himself or herself, ask: ᭜ Do you have a specific plan? Tell me what it is. ᭜ Do you have the means to kill yourself? (Pills, a panga, a gun?) If the client has a specific plan and the means to end her life, you should not let the client leave the office. 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 confidentiality isn’t 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 counsellor’s 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 client’s 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.

Checklist for understanding anxiety
If a client is anxious or complains of anxiety, a counsellor could ask the following questions in order to understand what the client is feeling: ᭜ ᭜ ᭜ ᭜ You say you are nervous (anxious). What does that feel like emotionally? How does it make your body feel? How long has this been going on? If this is sudden, refer the client to a health worker. What is causing your nervous feelings? Are you scared of certain situations or things? Do you avoid these situations or things, or endure them? (This asks about symptoms of phobias.)

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, difficulty concentrating or suddenly “going blank”, feeling irritable, feeling tense or having difficulty sleeping? Do these feelings make some part of your life very difficult?

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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 can’t 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.

What could you do as a counsellor if there is no health worker available?
Anxiety can be a symptom of many conditions. If it is new and troubling for the client, a visit to a health worker is necessary. However, many clients will complain of experiencing anxiety for a long time. If you don’t have a health worker who can see the client, or if the client refuses to seek help, these suggestions may help. ᭜ Tell the client to gradually stop drinking tea, coffee or fizzy drinks, such as Coca Cola or Red Bull. These contain caffeine, which can make a person feel jittery or anxious. Someone who has a lot of caffeine and then stops can get headaches. Chocolate also contains caffeine. Encourage the client to drink teas, like Rooibos tea, that have a relaxing effect. Help the client talk about what makes her anxious and explore whether the anxieties are unrealistic. For example, some people think bad things are going to happen and this makes them anxious. These bad things may be very unlikely. You should point out thoughts that are not realistic and see if the client can stop thinking these thoughts. Encourage physical activities that will make the client feel tired and more likely to fall asleep instead of worrying.

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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 specifically. Some people are afraid of being in pain, dying alone, or dying shamefully because they may lose control over bodily functions.

Symptoms that may indicate emotional trauma
A surprising number of people have had severe emotional experiences, which left emotional scars. These experiences are called “traumatic”. Emotional symptoms may suggest that someone has a mental health problem that is called “post-traumatic stress disorder”. The counsellor should ask a new client whether she has experienced: ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ being in combat or witnessing warfare torture a severe car accident rape (ask both men and women) a crime such as being held at gunpoint, shot or cut witnessing a violent act against others, such as family members being driven from their home by force a difficult move from one region or country to another.
Trauma means physical or emotional injury.

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 difficulties.

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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 significant 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 won’t have normal events.

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Other signals of emotional harm from a traumatic event include problems with sleep, irritability, angry outbursts, difficulty 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 benefit from proper diagnosis and perhaps treatment, if it is available in your community.

Symptoms of severe mental illness
Some clients who are referred for HIV-related counselling will have serious mental illnesses.

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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 figure or someone very important.

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People with severe mental illnesses cannot benefit from counselling without medical treatment.

Symptoms of brain impairment
HIV and AIDS, and opportunistic infections that occur because of a weakened immune system, can affect the part of the body called the central nervous system. The brain is part of the central nervous system. In people with AIDS, the part of the brain that controls thinking, emotions and behaviour can be affected, resulting in problems in those areas. Other parts of the body can also be affected. This results in a condition called “dementia”. Dementia seems to creep up slowly on a person. Symptoms include: ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ problems concentrating forgetfulness confusion thinking becomes slower problems with balancing leg weakness behavioural changes apathy slowed speaking or inability to speak slowness in moving indifference to illness incontinence.
Brain impairment occurs when functions of the brain are affected by disease or injury.

Incontinence means that a person is unable to hold urine or faeces.

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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 client’s caregivers: ᭜ Maintain a consistent living situation for the client. Don’t make changes in the client’s 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.

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Opportunistic infections can also affect the brain, possibly leading to: ᭜ ᭜ ᭜ ᭜ ᭜ ᭜ headaches seizures reduced alertness problems with specific 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 client’s 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 difficult or impossible. The client’s speech is hard to follow, rambling or irrelevant, or he can’t talk at all. The client doesn’t 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.

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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 don’t 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 can’t take this any more. I can’t 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 find. 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 difficult 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.

Use, abuse and addiction
There is a lot of terminology used when discussing substance use and abuse: Alcohol – This is the active mood-changing ingredient in beer, wine or hard liquors such as vodka and gin. Mood-altering – This means that the substance changes the way a person feels, both emotionally and physically. Some drugs depress people, while others make users feel more energetic and better able to think, at least for a short time. Substances – This is a name for any mood-altering ingredient. We will use the phrase “alcohol and other substances”. Some people say “alcohol, tobacco and other substances”. Substance abuse – This is a formal diagnosis. According to the American Psychiatric Association, it refers to repeated substance use that leads to one or more of the following situations: ᭜ failure to perform as expected at home, work or school physical hazards such as drunk driving legal problems continued use, despite social or interpersonal problems caused or made worse by the substance use.

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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 didn’t 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 finds 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 sacrificed 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 one’s stomach and throwing up, and seizures.

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What causes substance use?
There are different ideas about what causes substance use. A few suggestions include: ᭜ People use illegal and legal substances as medicines to alleviate negative feelings. This is called self-medication. Substance dependence or addiction is a physical disease. It seems as though some people may be more likely to suffer from it if their parents or grandparents had the disease. Substance abuse has physical, emotional, social and spiritual causes and results. For example, people who are alcoholics and spend their time at shebeens have a physical problem. They are unlikely to have healthy relationships, and are likely to be alienated from spiritual feelings.

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Results of substance use
Substance use encourages the spread of HIV in several ways: ᭜ Alcohol and other substances make people have fewer inhibitions, leading to sex or violence or both. People who have used substances will often use poor judgment. If safer sex practices are known, they may be overlooked, forgotten, or ignored. Even if the person wants to, in an intoxicated state he or she may be unable to use a condom or to negotiate safer sex. Some people may exchange sex for alcohol and other drugs.
Inhibitions are feelings or judgments that stop or slow behaviours, thoughts or other feelings.

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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 can’t 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 benefit from counselling. Instead, he should be in a programme that treats the addiction. Other people argue that addressing a person’s issues has to start somewhere and that a compassionate counsellor can have some effect.

No substance abuse counselling in your community?
You may be saying, “These arguments are meaningless here, and so is this chapter. There is no special interest in caring for drinkers and dagga smokers in my community, and there are no treatment programmes.” This may be true. So should we ignore these problems, or should we try to do something about them? You could ignore a client’s substance use or you could begin to confront it, using this chapter as a guide. With some clients, treatment for HIV and AIDS may be a start to offering treatment for substance abuse and mental health problems.

Tools for substance use counselling
Community-based HIV counselling needs to take the special needs of people using alcohol and other substances into account. How do you start?

The counsellor’s attitude
Many counsellors are condemning of people who abuse or are addicted to substances. Often counsellors have had experiences with substance users in their own lives and hold anger that has not been resolved. Their attitudes may represent religious or community attitudes that view substance use as a moral weakness. The first step to successful substance use counselling is for the counsellor to understand her own feelings and resolve those feelings, or at least shield the client from those emotions.

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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 doesn’t 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 first and substance use raised again at a later stage. Assessment questions you could ask include: ᭜ ᭜ What substances are used? (Don’t forget tobacco.) How much is used daily or weekly? If someone says three drinks, find 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 client’s attitude? Does he think substance use is a problem? Does he want to do anything about it?

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Understanding and dealing with the client’s needs
Some clients who use substances don’t believe or admit that heavy drinking or smoking can cause problems. They don’t believe they have a problem with substance use. Others suspect they should stop using, but they need help admitting it to themselves. Should a counsellor deal with both types of people in the same way? Two psychologists have created a way to understand substance users and to help counsellors address their situations. Their thinking is described in a book called Motivational Interviewing: Preparing people for change, edited by Miller and Rollnick and published in 2002. Motivational Interviewing has had an enormous effect on how many counsellors help people to change. Before this book was published, counsellors would confront clients, and, believing that clients didn’t know enough about the effects of substance use, tell them what to do. Miller and Rollnick, however, took a different approach: ᭜ They suggested that the counsellor/client partnership should encourage change rather than force it. They worked on the basis that a client had the resources (inner strengths) and motivation for change. They suggested that the counsellor should tell the client that he has the right and ability to decide what to do with his own life and to make informed choices.

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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 five 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 find 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 client’s 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 confidence. For a person in the contemplation stage, the counsellor’s goal is to help the client continue to explore the problem, including discussion of risks and benefits.

Motivate the client
The client is motivated to change within the safety of a relationship with a caring and skilful counsellor. The counsellor builds up the client rather than tearing him down. The counsellor acknowledges that the client will decide for himself whether or not to change, and helps him with that decision and the behaviours that follow. Giving orders, arguing, giving advice, or telling the client what to do just won’t work.

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The Transtheoretical Model
Stage Client’s situation Client says Counsellor’s action

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 don’t have a problem.” Explore situation, listen, feedback. “Don’t tell me what to do.” Defuse resistance, offer options.

“There’s nothing I can do.” Instil hope, build confidence. “There’s little risk.” “I’m thinking about it.” Empathy, reflective listening. Help client think through risks of behaviour and benefits of change, instil hope that change is possible. Assess strength of commitment, help client develop most effective plan. Affirm client, help with plan and revisions. Reassure, motivate.

Preparation

“I’m ready.”

Action Maintenance

Implements the plan.

“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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Affirm the client
The client may not believe he can change. The counsellor’s role is to have the client accept that he has the strength and resources to end a self-destructive behaviour.

Use other strategies
Several concepts or strategies may help: Identify triggers. Triggers could be internal feelings or something in the client’s environment that make him want to use drugs. A trigger might be a feeling of despair, or walking past a shebeen. Clients can be taught to reinterpret the feelings or to avoid people or places that make them crave the substance they use. Identify harm reduction strategies. If a client does not want to end his substance use, he can be urged to modify his behaviour so that harm can be reduced. Improve nutrition and increase physical activity. Good nutrition is important for people with HIV and doubly important for people who have HIV and a substance use problem. For these clients, the counsellor must stress improvement in nutrition. If the client tends not to walk or engage in other physical activities, such as gathering or chopping wood, such physical activites should be encouraged. Changes in nutrition and exercise should be watched. Get the support of family and friends. The support of family and friends can be helpful to a person who is trying to end substance use. With the permission of the client, the counsellor can get them to help and identify useful tasks, such as visits with supportive goals and activities, providing and preparing nutritious food, avoiding drinking or other substance use in the presence of your client, and promoting alternative safe activities, such as playing with family children rather than going to a shebeen. Accept the client whatever the outcome. The client will change when he wants to. He may not change at all. The counsellor should not reject the client who does not change. If the counsellor is angry, then she needs to work out why – perhaps her counsellor or supervisor can help.
Triggers are feelings, people or places that remind people of an experience.

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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 Office near you”, you will get a list of country centres. You can then click on a country. Or contact the South Africa centre at [email protected]. To read The Big Book, the basic book about Alcoholics Anonymous, go to: www.aa.org/bigbookonline

Making community connections
If there is already a specialised substance use treatment programme running nearby, a skilful counsellor will meet the director and staff before she has a client who needs those services. With the personal and professional relationship already in place, the counsellor can refer a client to the programme. Substance use treatment programmes should ideally address mental health and HIV issues. Unfortunately, this is often not the case.

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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 continent’s 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 client’s 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 person’s own history of loss has a great effect on the way that person deals with more loss. For example, if a woman hasn’t finished mourning the loss of her own son, it would be difficult 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 findings still apply.

The sense of loss begins with an HIV diagnosis
A sense of loss, and the grief that comes with HIV infection, doesn’t begin with death. Noel Elia wrote that as soon as the client finds out that he is infected with HIV, he immediately begins to grieve the fact that his negative status is gone. Because the person is now living with HIV, the future changes immediately and changes forever. The news of HIV infection also can mean the belief that other losses will come, such as: ᭜ loss of love ( “Who would love an HIV-infected man or woman?” ) the loss of sex without a condom the loss of the possibility of parenthood, if the man and woman are concerned about risks of infection.

᭜ ᭜

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 Kübler-Ross created a useful way to understand a person’s reactions to the news that he is dying. She identified five stages of reaction: ᭜ Denial. A person saying, “No, not me, it cannot be true” expresses this. The author suggests that this first phase gives a person time to think about the news and then find 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 I’m 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 won’t see his son become an adult or a woman knowing she’ll never meet a grandchild). ᭜ Acceptance. During this final 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 isn’t a happy time – it’s 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 everyone’s reactions. Some people face death head-on and don’t 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. Worden’s 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 find 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 doesn’t hinder him or her from living effectively.

᭜

Working through grief
In his book, Grief counseling and grief therapy, Worden describes counselling principles and procedures to help clients work through grief and mourning: ᭜ Help the survivor to realise and admit that the loved one has died by encouraging the person to talk about the loss. Help the survivor to identify and express his or her feelings that include anger, guilt, anxiety, helplessness and sadness. Help the survivor to live without the deceased person by helping the survivor to make decisions on his or her own. Provide continuing support, especially about three months after the loss and at the first anniversary of the death. Educate clients that it is normal to grieve and reassure them they are not going crazy. Allow for individual differences, understanding that there are many ways to grieve.

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᭜

Examine the client’s defences and coping styles. If they are causing problems, help the client find different ways to express grief. For example, if a widow won’t 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 child’s 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 don’t 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 counsellor’s role “… is to offer comfort, help find clear answers (that are acceptable to the family) for the child’s asked and unasked questions, invite and witness the experience and the expression of feelings, and nurture hope.” Dottie Ward-Wimmer

Other counselling issues
Encourage religious and spiritual expression
People who have suffered loss may, with time, begin to neglect the religious beliefs and spirituality that comforted them in the past. Even if they don’t want to say it or even believe it, the neglect may come because they blame God for the death of their loved one. Or they may be so distraught by the death that they neglect many normal activities. The client may think (rightly or not) that members of the church community have expressed judgments about the loved one who died of AIDS. The counsellor should monitor this and ask her client why he isn’t taking comfort from the church community. Barriers can then be explored.

Avoid statements like “It was God’s will”
All experts in dying and death warn counsellors against saying things that are meant to be empathetic, but are ill-advised. Some people believe that a person has died because God “called” the dead person. If so, this may be of comfort. However, it is a little tricky for a counsellor to say, “It was God’s will” in an attempt to comfort the survivors. Firstly, this presumes that we know the will of God. Secondly, are deaths due to warfare, urban or domestic violence, or through starvation also God’s will? While saying the death was God’s will may seem to help in the short-term, it raises religious questions about God’s role in our everyday lives. Sister Pascal Conforti has suggested that God doesn’t like HIV and AIDS any more than we do. Other phrases to avoid include, “I know how you feel,” when you haven’t suffered a similar loss, and “Life will go on.”

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Rather, say something like, “I’m 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.

Be there after the others drift away
Many people who have suffered loss note that weeks or months after the death is the hardest time. Friends and family who gathered for the funeral and feasts have left, leaving the survivor to cope. The counsellor must continue to provide support during these times. Support is also necessary at anniversaries, which used to be special occasions but now are times for remembrance and pain. The birthday of the deceased and wedding anniversaries can be times when memories flood back and support is appreciated.

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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 find 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 client’s 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.

Many caregivers neglect themselves
Unlike the woodcarver, many HIV and AIDS counsellors do not take good care of their precious tools – themselves. They take on too many clients and work too many hours.

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There is always someone needing help knocking on the door and they don’t turn people away. They don’t 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 selfless to heart. Organisations and clients love these types of counsellors because they are dedicated to their clients’ welfare and they work extremely hard.

HIV and AIDS impose extra burdens
No areas of health care and counselling are emotionally easy. But HIV and AIDS, at the intersection of so many problems, are especially difficult. The clients’ situations are complicated and often can’t be fixed, but only changed a little. Counsellors witness the suffering, orphaning and deaths of children. They accompany adults on a long and difficult biomedical, emotional, social and spiritual journey. The counsellor’s compassion and competence face repeated challenges.

HIV and AIDS in your own life
Living in Africa, it is difficult not to be touched by HIV and AIDS in many ways. A family member may be HIVinfected or one may have died of AIDS. Or, in addition to your counselling work, you may be caring for the children of a sister who has died. It’s easy to see how a person can become overwhelmed.

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Effects of listening to stories of trauma
Some researchers now believe that people who listen to victims’ stories about traumatic events are deeply emotionally affected by them. They believe that the counsellor becomes emotionally traumatised.

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 find they cannot talk about their work with friends or new acquaintances. They find that people change the subject abruptly or walk away because they feel uneasy about HIV and AIDS. The counsellor feels increasingly isolated.

Burnout, depression, despair and nihilism
“Burnout” is a term that was first used by a psychologist named Herbert Freudenberger. It is now such a popular concept that many books have been written on the topic, including a book on HIV and AIDS care and burnout.
Nihilistic means that a person believes absolutely nothing can be done to improve a situation.

Burnt-out counsellors are always exhausted, irritable, emotionally numb and joyless. They don’t laugh, rarely have sex with their partners, and are cynical and despairing. A burnt-out counsellor is nihilistic. That’s 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.

What is wrong with this picture?
Some people may disagree, but there is something wrong with selflessness and overwork. The selfless and overworked counsellor is this century’s martyr. Early Christians earned the title of martyr by giving their lives for their faith. Some

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were burned alive. In the HIV and AIDS care context, we have counsellors burnt out alive. The selfless, 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 selflessness 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 finances may be, must be more sensitive to the needs of their employees and volunteers.

The “We can’t do that!” response
Several pages follow, containing suggestions that you could try. But before you say, “I can’t do that!” or, “We can’t do that!” remember that this response is just the same as your client not being able to see the possibility of change. We say to our clients, “If you do this, you’ll feel better.” Then we wonder why our client can’t change so he can feel better. Now you have the opportunity to acknowledge that when you say, “We can’t do that!” you are being just like your clients. What’s my response? “You can do that. You just have to give it a try.”

Strategies to keep yourself emotionally healthy
You can do these. Just try.

Value your presence
Often there isn’t much that a counsellor can do to make a visible and significant difference. The counsellor then feels incompetent and frustrated. Focusing only on the visible

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changes means that you don’t 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 client’s 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.

Make your needs known to yourself and then to others
People who spend so much time meeting the needs of others may either lose touch with their own feelings of need or, if they know their needs, they still neglect themselves. When people are not in touch with their own feelings, there is a danger that these feelings may emerge in different forms. Sometimes the connection between the emotions and the behaviour may be overlooked. For example, a counsellor working for a community organisation may start missing appointments with her clients. She offers what sound like good excuses for her absences and she believes that these explanations are true. Initially the counsellor does not understand that her absences are actually expressing her feeling of being overwhelmed. The absences serve the purpose of giving her relief. If a person knows what she needs emotionally, what could be the reason for not asking other people to help meet those needs? It may not be culturally acceptable to ask for help. A person may say that “neediness” is weakness, so instead the person starves emotionally. One way to understand these issues and do something about them is through counselling. Do you have a reason for not getting counselling, such as it costs too much or you don’t have the time? Please see page 35 and read the section on rationalisation. Why would you offer someone a service that you don’t feel comfortable with yourself? Perhaps your discomfort with counselling is somehow communicated to your clients.

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Beware of rescue fantasies
The counsellor who thinks she will transform a client’s life is fooling herself and creating a situation that is an emotional disaster for the client. The counsellor, to meet her own need to feel powerful, may push a client to make changes that show the counsellor’s power. This communicates to the client that he isn’t good enough. When the client cannot satisfy the counsellor, the client feels like a failure. The counsellor, in reaction to the inevitable failure, will be angry with the client. Counsellors should always remember that counselling is a process to empower the client to take control of his or her own decisions and actions. Counsellors should be aware of their needs to make clients into something they are not, to rescue them or to change them. Counselling is for the welfare of the client. If a counsellor acts on her rescue fantasies, she will hurt her client.

Accept tiny changes as success
Too many counsellors want to see large changes in their clients. Improvements make some counsellors feel competent and good about themselves. A more skilful approach is to help the client with small changes. When one occurs, this is a success! The counsellor should celebrate that, rather than look at it as insignificant.

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 don’t 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 don’t do it, these people won’t 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 can’t 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 isn’t 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 doesn’t have to fall on her. She can decide to say no to additional responsibilities.

Get supervision that allows you to express yourself emotionally
A counsellor working with clients with HIV and AIDS cannot be expected to do a skilful job without supervision. Too many emotional issues arise that can push the counsellor into making mistakes. Supervision should be an opportunity to discuss emotional reactions to clients, as well as plans and techniques. It is the time when you should be able to say, “This situation breaks my heart” or, “I can’t stand this guy.” Often the supervisors are the same people who promote or fire employees. Counsellors may pretend all is well, in order not to jeopardise their jobs. Counsellors should request supervision from a neutral party.

Surround yourself with beauty
Offices in medical clinics and NGOs don’t have to be ugly. Even if the building is unattractive, your office can be alive and beautiful. Bring some flowers or pretty grasses to work and share them with clients. Ask your child to draw some pictures and display them. Take down the “How to use a condom” poster (everyone’s seen it already), ask an artistic client to draw something on the blank side and then display it. Too many people just accept office walls that are blank and ugly.

Get in touch with your spirituality
Many people in health care have said that HIV and AIDS have helped them renew or find appreciation of spirituality and religion. The epidemic reminds them that life is brief and that our bodies are fragile. It raises questions about the meaning and value of our lives and our souls. Counsellors often begin to re-examine these issues.

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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?

Tell a joke a day
When burnout or depression begin, humour is one of the first casualties. One way to keep burnout away is to express a sense of humour. Tell family and colleagues one joke a day, at least. If you can’t think of any, ask a child.

Travel
When you travel, you find that there are other places in the world where HIV and AIDS are not a constant theme. You find new beauty and you may meet new people. Travellers return with stories that aren’t related to HIV and AIDS. Travel is renewing and replenishes the soul. You don’t have to take a trip around the world – take the bus to another town. Visit relatives you haven’t seen in a while, even if they’re 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.

Care for yourself when you lose a loved one
You may already have lost family members and friends to AIDS. More losses may occur. When you are grieving, consider the advice you’d give others, including: ᭜ ᭜ cry as you need to for as long as you need to accept the comfort of others.

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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Organisational strategies to keep staff emotionally healthy
Organisations can be emotionally unhealthy. Think of an organisation as a living thing. Organisations are born and die, and they have many troubles in between. The emotional health of an organisation can affect the health of the staff members. Administrators and staff members can do things to keep their organisations healthy or to make them poisonous.

Pay attention to organisation “side shows”
Organisations that deal with life and death issues such as HIV and AIDS often have a significant amount of staff members fighting with each other, complaining and confronting supervisors. On the surface, these battles seem based in reality. But, if these situations are longer or more heated than they should be, something else may be going on. It could be that the arguments are created unconsciously to avoid the stressful work and feelings that come with the HIV-related daily work. A wise administrator will recognise this and suggest staff consider its possibility. It may be that the people causing all the tension need to find work in other areas. Life is too short to be unhappy. For the sake of their happiness, perhaps they should leave the job.

Give rewards
Because working with people affected by HIV is so stressful, a flexible 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, flexible work schedules and in-service training that both educates and provides a break from client care. They could also: ᭜ ᭜ Reduce a counsellor’s responsibilities during a time of crisis or mourning. Reduce the number of hours that staff members have to be available “on call” after regular office hours. Budget sufficient 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 agency’s 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 office 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.

᭜ ᭜ ᭜

᭜

᭜ ᭜ ᭜

᭜

Ultimately, it may be wise to leave HIV and AIDS work
Ultimately, it may be wise to leave HIV and AIDS work. A colleague once wrote that a significant sign of AIDS burnout is the belief that leaving this work is not acceptable. In sports, some people can sprint 100 m and others can run 20 km. Both are important. It may be that a year or two of quality counselling work is your contribution. You should be able to acknowledge and celebrate your contributions during that time. If you can counsel for a longer period, that is great. If AIDS has taught us anything, it has taught us that life is short. We must focus on the quality, not the quantity, of life. Take stock of your accomplishments and acknowledge the divine spark that made them possible. Move on, with full knowledge that you’ve changed the world.

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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

More basic information
Catholic AIDS Action publications
The publications at the top of the next column are available from CAA. Please write or telephone for price information: Catholic AIDS Action PO Box 11525 Windhoek NAMIBIA Telephone: +264-61-27-6350 Fax: +264-61-27-6364 E-mail: [email protected]

Lifeline/Childline contact details
LifeLine/Childline in Namibia and other countries offers counselling at various venues. Consult your local telephone directory for contact details.

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Information for advanced readers
If you feel you have mastered the concepts of this book, or simply want to increase your competence, many sources of information are available for advanced readers. In addition to the list below, check the books in the References list at the end of this chapter.

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 organisation’s website is www.safaids.org.zw.

Books
Barnett, T. & Whiteside, A. (2002). AIDS in the twenty-first 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.

Accessing information on the Internet
If you have access to a computer that is connected to the Internet, you have a wealth of information available to you. If your organisation or supervisor has Internet access, ask if they would occasionally print out material and distribute it to the staff.

Search engines
The web is vast, but you can search for specific information by using “search engines”. After you’ve 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 specific 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 scientific findings. 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

E-mail lists and reports
Much useful information is distributed through e-mails. To receive e-mails, you have to have access to a computer with Internet capabilities. To sign up for a free e-mail account, go to www.uk.yahoo.com, www.msn.com (for Hotmail), or local websites. Then, to receive your e-mails, you go to the appropriate website and follow directions to access the mail. An organisation with Internet access can sign up for various informative e-mail lists, print out and display the correspondence on a notice board.

Some lists to join
For African HIV and AIDS news, subscribe to the United Nations Office for the Coordination of Humanitarian Affairs Integrated Regional Information Networks at http://www.irinnews.org/subscriptions. Free subscriptions to Africa-specific HIV information and discussion groups are available through http:// www.healthnet.org. Click on “information resources” to see a list and subscribe.

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Reference information for books and articles mentioned in this text
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders. (4th ed. Text Revision). Washington, DC. Conforti, P. (1997). Spirituality. In M. G. Winiarski (Ed.). HIV mental health for the 21st century. New York: New York University Press. DiClemente, C.C. & Prochaska, J.O. (1985). Processes and stages of change: Coping and competence in smoking behavior change. In S. Shiffman & T. A. Wills (Eds). Coping and substance abuse (pp. 319-342). New York: Academic Press. DiClemente, C.C. & Prochaska, J.O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In W.R. Miller & N. Heather (Eds). Treating addictive behaviors (2nd ed.). New York: Plenum Press. DiClemente, C.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. Elia, N. (1997). Grief and loss in HIV work. In M.G. Winiarski (Ed.). HIV mental health for the 21st century. New York: New York University Press. Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.

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: [email protected] 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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