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COUNSELING
BY
MR. ACTO
PREFACE
HIV/AIDS COUNSELING:
• an important element
• the best help
• The best deal with the psychosocial issues of
the person.
• a key entry point to prevention of HIV
infection
• can access scientific information
• to reduce risks and remain HIV negative
• provided psycho-social support
• to bring in behavioural change
PREFACE
Counseling in HIV/AIDS is an important element of HIV care.
It deals with the psychological needs of the individuals with
HIV. Counseling is the best help that a provider can provide
to the individual to cope up with the disease and its
consequences. HIV virus not only attacks immune
mechanism of a human being, but also affects person’s
mental health. People living with HIV/ AIDS (PLHAs) have to
face a lot of uncertainties pertaining to their social status,
health and well being, issues pertaining to families, jobs etc.
The uncertainties arise mainly due to the perceived stigma
and anxiety that an individual with HIV faces. Thus it is a
mandate to provide HIV counseling at the time of its
diagnosis in order to best deal with the psychosocial issues of
the person.
HIV counseling and testing services are a key entry
point to prevention of HIV infection and to the
treatment and care of people who are infected with
HIV. At the time of availing counseling and testing
services, people can access scientific information
about HIV prevention and care and undergo HIV test
in a supportive and confidential environment. People
who are found HIV negative are supported with
information and counseling to reduce risks and
remain HIV negative. People who are diagnosed with
HIV infection are provided psycho-social support and
are linked to the treatment and care
Counseling also can be the first step towards
desirable changes in client’s behavior. Counseling
interventions are also used widely to bring in
behavioural change. Desired behavioral change in
HIV disease could be safer sexual behaviour for HIV
prevention, better control over emotions, improved
adherence, steps towards prevention of secondary
transmission, better care seeking, interactive social
life, improved interpersonal relationships, returning
to employment, etc. These optimistic ways of life
helps client in leading his life more smoothly with
better quality of life
definition
• The process that occurs when a client and counselor
set aside time in order to explore difficulties which may
include the stressful or emotional feelings of the
client”.
• an act of helping the client to see things more clearly,
possibly from a different view-point
• an interaction between client and a counselor that
leads to enhancing the ability of the client to take a
better decision.
• Essentially a confidential dialogue between an
individual/couple and a counselor, aimed at enabling
the individual to make personal decisions in the
DEFINITION
Counseling Psychologists and Psychotherapists define
counseling as, “The process that occurs when a client and
counselor set aside time in order to explore difficulties which
may include the stressful or emotional feelings of the client”.
The other definition of counseling says that it is an act of
helping the client to see things more clearly, possibly from a
different view-point. This can enable the client to focus on
feelings, experiences or behaviour, with a goal to facilitating
positive change. Counseling is an interaction between client
and a counselor that leads to enhancing the ability of the
client to take a better decision. NACO defines counseling as
“Essentially a confidential dialogue between an
individual/couple and a counselor, aimed at enabling the
individual to make personal decisions in the context of
HIV/AIDS” (NACO, 2004)
Effective Counseling
Speak openly
Identify the reasons
Predicts barriers
Discovers strengths and weaknesses
Learns skills
Designs strategies
Practices the strategies
Does not get upset with the same problem in
future
With effective counseling the clients becomes
empowered and able to …
Speak openly about the things that are bothering
him/her
Identify the reasons for his/her concerns
Predicts barriers for overcoming his/her problems
Discovers his/her strengths and weaknesses
Learns skills to overcome the weaknesses
Designs strategies to overcome his/her worries/
problems
Practices the strategies
Does not get upset with the same problem in
future
Type
• Client Initiated Counseling; as a voluntary counseling session
• Provider Initiated Counseling: recommended by client’s health
care provider (HCP) as a part of the treatment given to him/her
• Pre-test Counseling : This counseling aims at preparing the client
to undergo HIV test
• Post-test Counseling : review of the HIV information provided at
pretest counseling sessions is done. One should also assess the
anxiety and stress level of the client. HIV test result is informed,
explained and his/her understanding of it is judged
• Crisis Counseling : an individual’s reaction or response to the
situation
• Grief Counseling : Grief or bereavement is a human response to a
permanent loss of someone near and dear. Most of the times this
loss is in the form of death.
• Adherence Counseling : become manageable illness with the
advent of Anti Retroviral Therapy (ART) and mainly associated
with antiretroviral treatment, it should also be included in the
context of any other long term treatment like AKT (treatment
for tuberculosis). Adherence counseling includes assessment
of commitment of the client to take the treatment life long,
education about the treatment and its side effects,
anticipation of barriers, identifying the ways to overcome
them, communication with healthcare provider, concept of
resistance etc.
• Couples Counseling : In the field of HIV, couple counseling plays very
important role in sustaining couple relationship, family and social life of an
individual. This counseling aims to maintain the relationship trustworthy,
sensitive and based on the mutual understanding. The objective of the
counseling should not be to find out who was the source of the infection
within the couple or how the infected person got it. Rather, the couples
counseling helps to build harmonious, careful, supportive and healthy
couple relationship
Types of Counseling in HIV/AIDS HIV counseling can broadly be
divided into 2 sub-groups as ‘Client initiated testing and
counseling’ and ‘Provider initiated testing and counseling’.
1. Client Initiated Counseling : As the name suggests, client initiated
counseling is a counseling service opted by the client himself. We
can also call it as a voluntary counseling session. This counseling
depends upon client’s perception of risk of getting HIV and need for
test. Clients visiting VCT centers is an example of client initiated
counseling.
2. Provider Initiated Counseling : On the other hand provider
initiated counseling is recommended by client’s health care
provider (HCP) as a part of the treatment given to him/her. Provider
initiated counseling and testing helps the doctor or HCP in treating
the client in better manner. Recommending HIV test under
antenatal care or under RNTCP are few examples of provider
initiated counseling
3. Pre-test Counseling : This counseling aims at preparing the client to undergo HIV test. In this
counseling client is provided with the complete information regarding HIV/AIDS covering routes of HIV
transmission, difference between having an infection and suffering from AIDS. Describing relationship
between STI and HIV, parent to foetus transmission and its prevention, HIV prevention in general and
treatment. Client’s HIV risk assessment is also done in pre test counseling. Assessment is made about
whether the client understands his vulnerability towards HIV infection. This is called as ‘Risk Appraisal’.
Risk reduction plan is developed and risk reduction goals are set up in this counseling. Psychological
and mental preparation to accept the HIV report is done during pretest counseling, also client is
counseled for management of anxiety and stress he/she faces till the report comes. Client undergoes
blood collection for HIV test after written informed consent based on his/her own choice to undergo a
test.
4. Post-test Counseling : In this session, review of the HIV information provided at pretest counseling
sessions is done. One should also assess the anxiety and stress level of the client. HIV test result is
informed, explained and his/her understanding of it is judged. If report is negative, concept of window
period is explained and the need for retesting is explored. Risk reduction plan is reviewed and
adherence to it is assessed. Adherence to safer sex practices is emphasized. Partner testing is also
recommended. If the report is positive, his/her emotional reaction to the test result is observed and
the client is allowed some time for his/her emotional outburst. NACO VCT guideline (NACO, 2004)
provides details about psychosocial issues of PLHAs. Depending on the emotional reaction and client’s
capacity and ability to comprehend, information about healthy life style is provided. Repeated
counseling sessions are scheduled as per requirement. Partner testing and safer sexual practices are
emphasized. Pre ART assessments are explained and done. Information about ART and prevention of
opportunistic infections is also provided to the client. Social support mechanism is discussed with the
client and disclosure of one’s HIV status to a significant other is encouraged weighing the risks and
benefits of it. Client’s willingness, ability and confidence to disclose HIV report is assessed and the
disclosure is planned accordingly
5. Crisis Counseling : Crisis is not a traumatic event or experience in itself but it is an
individual’s reaction or response to the situation. Crisis counseling is restricted only
to that particular event which has triggered the crisis. It minimizes the severity of the
traumatic situation. This type of counseling is required till the reaction to the trigger
lasts. Assessment of the situation, educating and helping the client to understand
the situation, offering them support, encouragement to get support from near and
dear ones to overcome the crisis, helping to establish dialogue between different
people affected by the crisis and finally developing coping strategies for the situation
are major aspects of crisis counseling (Coats, 1990). The success of crisis counseling
lies in identifying the trigger and developing strategies to remove it.
6.Grief Counseling : Grief or bereavement is a human response to a permanent loss
of someone near and dear. Most of the times this loss is in the form of death. In the
field of HIV, counselors come across many situations where they have to counsel the
children or spouses of the HIV infected individual after his/her death. Main aim of
this type of counseling is assisting a person accepting the death and minimizing the
feeling of insecurity and loneliness. Grief counseling includes few steps like assessing
the perception of death, providing emotional support and bringing the client back to
normal life. We may see different types of manifestations of grief experienced
depending upon the age, sex, amount of closeness of relationship with the person
and economic dependence on the person who died
7. Adherence Counseling : HIV is no longer a fatal/incurable disease. It
has become manageable illness with the advent of Anti Retroviral
Therapy (ART). adherence counseling is mainly associated with
antiretroviral treatment, it should also be included in the context of
any other long term treatment like AKT (treatment for tuberculosis).
Adherence counseling includes assessment of commitment of the
client to take the treatment life long, education about the treatment
and its side effects, anticipation of barriers, identifying the ways to
overcome them, communication with healthcare provider, concept of
resistance etc. Adherence counseling should become an integral part
of all drug pick up appointments of the patients. In this, counselors
should be able to identify the barriers to adherence, which may
include forgetfulness, attitudinal barriers, fear of side effects, cultural,
religious and socio-economic factors. Adherence counseling is not only
a counselor’s responsibility but it’s a team work to be performed by
doctors, nurses, pharmacist and patients
8. Couples Counseling : In the field of HIV, couple counseling plays very important role
in sustaining couple relationship, family and social life of an individual. This
counseling aims to maintain the relationship trustworthy, sensitive and based on the
mutual understanding. The objective of the counseling should not be to find out who
was the source of the infection within the couple or how the infected person got it.
Rather, the couples counseling helps to build harmonious, careful, supportive and
healthy couple relationship. If the couple is HIV discordant, the issue becomes more
sensitive. It becomes very crucial that counselor pays equal respect to both the
members of a couple, listens to both and remains neutral during discussion. Effective
couples counseling session helps in normalizing the feelings, reactions and
experiences of the couple. The couples counseling may differ according to the HIV
status of the couple. HIV discordance might affect couple relationship because of the
immediate psychosocial aspects like feeling of betrayal, anger and uncertainties in the
HIV negative partner. Counselor creates a favorable environment to establish a
dialogue between them, prevents blaming, and advises on different ways to support
each other, effectively tackling family issues, caring each other and preventing HIV
infection to the partner. The counselor helps to establish respect for HIV infected
partner and importance of uninfected partner. Counselor also helps to empower
them to deal with the emotional crisis situations
Skill
Empathy : tries to bring the equality between a counselor and a
client. Empathy in other words can be explained as “Putting
one’s feet into client’s shoes”. When the counselor will try to
empathize with the clients, meaning he/she will share his /her
emotions, and socio economic and environmental back ground,
leading to more realistic design of the behavioural change plans.
Active Listening : Active listening is ‘listening for meaning’. It is a
process in which, the counselor listens more and talks less.
Acceptance : accepting the client without any prejudices, beliefs
and attitudes from the counselor’s side but the client is accepted
with all his/her attitudes, beliefs
Patience : has to provide the same information again and again.
and have a lot of patience in dealing with such situations.
Proper Questioning with Necessary Probes : Accurate risk
assessment would require skillful probing. Questions need
to be open ended, and framed in simple language, take care
of his/ her body language, facial expressions and voice tone
should be soft and neutral.
Proper Use of Silence : It is not necessary that during the
counseling sessions there should be continuous discussion
between clients and the counselor. There should be some
silent slots in between. This silence gives time to the client
to think about what to express and how to express it. Also it
provides space to experience and internalize the feelings. It
also gives freedom to the client to decide whether or not to
continue.
Counseling Skills
As mentioned above, counseling is an interaction between two people aimed towards
enhancing client’s ability to take fair decision and adapt favorable changes. Counseling is a
science as well as an art. So to be a good counselor one has to understand a set of techniques
and to adapt some skills that would make the counseling service more effective. These skills also
can bring in the trust worthy relationship between a counselor and a client. The counseling skills
can be practiced by verbal communication and can be demonstrated to the client by non verbal
communication.
We can list out these skills as follows:
• Empathy : The term empathy should not be confused with the term Sympathy. Sympathy has
a shade of compassion towards the person in problem. Sympathy indicates power relationship.
But the term Empathy tries to bring the equality between a counselor and a client. Empathy in
other words can be explained as “Putting one’s feet into client’s shoes”. When the counselor will
try to empathize with the clients, meaning he/she will share his /her emotions, and socio
economic and environmental back ground, leading to more realistic design of the behavioural
change plans.
• Active Listening : Active listening is ‘listening for meaning’. It is a process in which, the
counselor listens more and talks less. But through this process counselor conveys empathy,
courage and emotional support to the client. By paraphrasing or summarizing the things the
client has reported, the counselor can know that whatever he/she has understood is correct. By
using some minor probes like, ‘is it so?’, ‘hmm’, ‘ok’, the counselor can convey the message to
the client that he/she is listening to the client and is genuinely interested in his problem. Proper
environment and ambience at the counseling place, body language, and proper eye contacts are
also important contributors to active listening
• Acceptance : Acceptance is one more important quality of a good
counselor. Acceptance means accepting the client without any
prejudices, beliefs and attitudes from the counselor’s side but the client
is accepted with all his/her attitudes, beliefs. Accepting the client
without criticism helps in designing the realistic behavioral change plan.
Additionally the criticism or preaching on moral behavior may bring
inhibitions in the client-counselor relationship.
• Patience : Clients may ask same questions repeatedly. This happens
due to limited or sometimes wrong information about HIV/AIDS and
sexuality. Counselor has to provide the same information again and
again. Sometimes it becomes difficult for the client to change his sexual
habits immediately and it may be required to schedule multiple
counseling sessions. The counselors need a lot of perseverance and
continued evaluation of their effort and need to repeatedly modify their
strategies. Counselors should have a lot of patience in dealing with such
situations.
Proper Questioning with Necessary Probes : While taking case
history, a counselor needs to ask questions to the client. Accurate
risk assessment would require skillful probing. Questions need to
be open ended, and framed in simple language. The counselor has
to take care of his/ her body language, facial expressions and voice
tone while asking the questions. The tone should be soft and
neutral. Client should not feel that counselor is unnecessarily
trying to enter into his personal matters.
• Proper Use of Silence : It is not necessary that during the
counseling sessions there should be continuous discussion
between clients and the counselor. There should be some silent
slots in between. This silence gives time to the client to think
about what to express and how to express it. Also it provides
space to experience and internalize the feelings. It also gives
freedom to the client to decide whether or not to continue.
Tools
• Ambience of the Counseling Room : Counseling room should have a
calm and quiet environment where the client can feel secured and
protected.
• Diary : Counselor should maintain daily diary. He/she can put follow
up dates, reminders, and important issues with regards to the client
to be followed up with other colleagues
• Counseling Notes : Detailed counseling notes help in identifying
exact problem, providing best possible intervention and counseling
leading to desired counseling goals.
• Education Material : Education material could be used to give correct
scientific information
• List of Referral Services : Counselor’s role does not end with the end of
counseling session but counselor should have a holistic approach
encompassing health, family life, social life, and empowerment of the
client
Tools Used in Counseling
a. Ambience of the Counseling Room : Counseling room should have a calm
and quiet environment where the client can feel secured and protected.
At the same time he/she should 198 HIV / AIDS in India feel confident
about the confidentiality. Privacy should be demonstrated to the client.
The room should be free from any kind of disturbance like outside noise,
ringing telephones, people disturbing in between. Total privacy should be
observed at the time of counseling.
b. Diary : Counselor should maintain daily diary. He/she can put follow up
dates, reminders, and important issues with regards to the client to be
followed up with other colleagues e.g. change in medicine, referral made,
follow up and feedbacks on referrals. In order to give complete care, client
should be followed up even if he exits the health care facility and goes
into other care. This kind of follow up help in gaining trust of the clients,
making best possible referrals in case of other clients, and getting
enriched by own experience.
c. Counseling Notes : Detailed counseling notes help in identifying exact
problem, providing best possible intervention and counseling leading to
desired counseling goals.
d. Education Material : Education material could be used to give correct scientific
information. The material may include general information flip chart, drug
information, and other facts. Using education material helps in restricting
misconceptions and rumors. Some video clips which explain HIV life cycle or drug
action on HIV can be used for creating audiovisual impact.
e. List of Referral Services : Counselor’s role does not end with the end of counseling
session but counselor should have a holistic approach encompassing health, family life,
social life, and empowerment of the client. Counselor should be able to provide
possible solutions to client’s worries and concerns. Clients concerns may not always be
related to health, HIV or treatment. Concerns and worries related to children and
family and their future is one of the foremost important concerns bothering them. The
concerns can also be related to financial condition, social life and children’s education.
Counselor should be able to link them up with appropriate service provider,
government schemes and try to resolve their problem and empower them. This is the
way to demonstrate empathy instead of just being sympathetic towards their problem.
To be able to do so a counselor should be knowledgeable about government
programs, NGO schemes, and new policies. He/she should be able to establish linkages
with such service providers. A list of these referral services can help counselor in
providing best possible services to the clients.
Understand Your Limits
• over confident.
• keep in mind that they cannot play a role of a
doctor for the client.
• empower the client and not to make them
dependent on counselors.
• Hence counselors should be very open to
understand their limits
• should be able to tell the clients the areas
where they cannot help them.
Understand Your Limits
While providing services, at times, counselors
become over confident. Counselors should be
cautious about their own ability and extent to
which they can solve client’s problems. They
should always keep in mind that they cannot
play a role of a doctor for the client. Their role is
to empower the client and not to make them
dependent on counselors. Hence counselors
should be very open to understand their limits
and should be able to tell the clients the areas
where they cannot help them.
Documentation
1. Deciding Counseling Strategy : Documentation of counseling
process helps the counselor himself to establish a link
between the previous session and the current session and
follow up in right direction. Counselor can even write about
family history and make use of this information at right time.
This helps in building rapport and gaining trust
2. Accountability : Documentation helps in demonstrating that
the counseling was done in non coercive and conducive,
supportive environment and appropriate decisions were
made based on discussions with the client.
Counseling Documentation
Counseling is a science because of the standardized processes and behavioral
interventions to bring in behavioural change. Behavioural change is a long process and
hence documentation is very important to document how behavioral change occurred
and what were the triggers for risk behaviors and what Counseling for HIV 199
facilitated desired behavioural change. Appropriate documentation may provide help
in better health care or intervention.
Documentation is required for a two reasons.
1. Deciding Counseling Strategy
Counselors handle many clients at a time. Every case is unique in itself and counseling
is always done with a client centered approach. Counselor cannot remember all cases,
their problems, and strategies implemented for them. Documentation of counseling
process helps the counselor himself to establish a link between the previous session
and the current session and follow up in right direction. Counselor can even write
about family history and make use of this information at right time. This helps in
building rapport and gaining trust. E.g. “Your daughter’s marriage was nearing when
you came last time. How was the marriage?” Documentation may helps in guiding
health care also. E.g. in case of adherence counseling, counselor can document missed
pills and reasons for missing pills. Clients may inform symptoms to counselors and not
to doctors because of power relationship with doctors. In this case counseling notes
can provide clues for medication changes or other health care requirements
2.Accountability
Documentation helps in demonstrating that the counseling was done in
non coercive and conducive, supportive environment and appropriate
decisions were made based on discussions with the client.
Documentation especially becomes important in case of informed
consent process, initiation of ART, discussion regarding extreme
emotional stresses like suicidal ideation, depression, major decisions like
breaking relationships. Sometimes these records gain importance in
case of medico legal cases. People with HIV disease may be involved
with the health care facility for longer time period; many become
defaulter and again enter into care after some time period. They often
shift to other facilities. The appropriate documentation helps in sharing
behavioural histories if required for health care. The records also help
counselors when the client or his relatives raise grievances during the
counseling care or after long time gap
Content documentation
1. Detailed case history:
a. This includes education, family background, family members,
and their relation with the client, biological as well as at
emotional level.
b. It may include occupational details like type of work,
professional relations with colleagues and superiors also.
c. If available, the history of past medical records and health
problems.
d. History of any past traumatic condition and the way the client
resolved it.
2. Documentation of counseling:
a. Includes problem description in short.
b. Points discussed with the participant.
c. Solutions reached at.
d. Follow up items till next visit.
Contents of well documented notes could be illustrated below:
1. Detailed case history:
a. This includes education, family background, family members,
and their relation with the client, biological as well as at emotional
level.
b. It may include occupational details like type of work,
professional relations with colleagues and superiors also.
c. If available, the history of past medical records and health
problems.
d. History of any past traumatic condition and the way the client
resolved it.
2. Documentation of counseling:
a. Includes problem description in short.
b. Points discussed with the participant.
c. Solutions reached at.
d. Follow up items till next visit.
Form Documentation
1. Narrative notes
2. SOAP : Subjective, Objective,
Assessment and Plan.
3. DAP : Data, Assessment and Plan.
4. IEP : Individual Education Program.
5. FOR : Functional Outcome Reporting
The documentation of counseling procedures can be done by using
some formats: 200 HIV / AIDS in India
1. Narrative notes
2. SOAP : Subjective, Objective, Assessment and Plan.
3. DAP : Data, Assessment and Plan.
4. IEP : Individual Education Program.
5. FOR : Functional Outcome Reporting