Theory And Practice Of HIV Counselling

A Systemic Approach

Robert Bor, Riva Miller, Eleanor Goldman

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135063726
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

First published in 1993. This new handbook clearly describes the theory and practice of systemic HIV counselling; identifying, assessing and managing problems. It combines theory, practice, dialogue and case examples. The approach is sympathetic to time pressures in clinics or community agencies; this 'survival kit' will help health care workers worldwide develop counselling skills. This book is for those involved in the professional care of persons with HIV, some of whom may be specialist counsellors, although the majority may be doctors, nurses, social workers, psychologists and those from allied professions who counsel patients as part of their daily work.

PART ONE

THEORY OF SYSTEMIC HIV COUNSELLING

ONE

Introduction and Overview

‘What is the use of a book’, thought Alice, ‘without pictures or conversations?’

Lewis Carroll

Confidentiality prevents us from publishing pictures, but we have recorded many conversations. Names have been altered to preserve the anonymity of the individuals concerned. We hope that these may serve to illustrate some of the dilemmas faced by those infected with HIV and by others in the systems which they inhabit – family, lovers, medical workers and counsellors, to name but a few. They also demonstrate how solutions can sometimes be found through open communication.

Since AIDS was first recognized as a new health problem in the USA in 1981, counsellors and other professionals have been at the forefront of care-giving to people infected with or affected by HIV. Alongside the rapid advances over the decade in the fields of epidemiology, virology, immunology, clinical management, nursing care, clinical therapy and prophylaxis, there has been a supreme effort to understand more about the psychosocial sequelae of HIV disease and to translate that comprehension into counselling. A wide range of professionals recognize that counselling is not new to their work. However, recent emphasis on HIV counselling and the apparent special features this may encompass may affect how some people view the counselling task. Some have trained to become specialist HIV counsellors whilst for others it has meant taking another look at their counselling skills and enhancing them. For the majority of professionals, a basic competence in HIV counselling may be sufficient to help them identify and manage patient problems in the course of their work. This experience can, in turn, enable them to feel more confident in talking to patients about sensitive issues such as sex, sexuality, disfigurement, death, dying, bereavement and social stigma. We have written not only for experienced counsellors who have an interest in developing their skills in HIV counselling, but also for the range of other health care providers who manage HIV-related problems in the course of their work.

There is some difference between being a counsellor and having counselling skills. Many health care professionals have a primary training in medicine, nursing, physiotherapy or other allied professions. Almost all of them counsel in the course of their work. They constantly interact with patients, giving information, clarifying treatment options and helping people to adjust to new, and sometimes unwelcome, circumstances. Specialist counsellors, on the other hand, are usually people who have advanced training in counselling, psychotherapy or family therapy, some of whom may be professionally trained in other disciplines, such as medicine, clinical psychology, nursing or social work. Although specialist training is not a requirement to practise as a counsellor, there are likely to be occasions when any counsellor sees the need to refer a patient to a specialist counsellor in the same way as a doctor may refer medical problems to a specialist colleague. The ideas presented in this book may be of use both to specialist counsellors and others who counsel. When we use the term ‘counsellor’ in the text, it may apply to any of the professions mentioned.

The special problems that arise in the context of HIV disease management, coupled with time constraints in some clinical settings and the complex dilemmas and powerful feelings invoked by this problem, may challenge people's existing counselling maps. This book attempts to convey one particular map that has been applied and developed in several clinical settings and in relation to a range of social and clinical problems. There are other maps and theories that may be equally relevant.

This volume is a companion text to our previous publication, AIDS: A Guide to Clinical Counselling (London: Science Press, 1988). The basic tenets of HIV counselling were set out in that book and an approach to counselling sessions was described. Readers are encouraged to refer to that text for additional information on HIV counselling practice. The ideas set out there have been extended and largely reflect the developments in our counselling and therapeutic approach and style as a result of our continuing experience in this field, the changes in the socio-medical context of HIV disease and the challenging questions about our practice put to us by our colleagues and students. The emphasis on psychological theory, in this case a systems approach, is conveyed in this book.

All models of diagnosis and treatment exist in a theoretical framework. Both assessment and treatment are linked to the counsellor's theoretical ideas. In the traditional medical model of diagnosis, there is an individual orientation which leads one to look for indications of problems inside the person and to direct treatment exclusively at the person as the intervention target.

The systemic view considers the reciprocity of relationships. For instance, if something happens to one member of a family, it will affect the rest of the family, whose response, in turn, will affect the behaviour of that individual. This means that behaviour cannot be studied in isolation without taking into account the situation in which it occurs. All behaviour is part of an interactive process whether at home, at work, or in a counselling session. The counsellor may influence the patient whose reactions, in turn, have an effect on the counsellor. Counselling is not a process of ‘doing something to someone’. It is best defined as an interaction between the counsellor and the patient, and also includes others such as the patient's family, lovers and friends, and the counsellor's colleagues, as well as members of the health care team. Systemic counsellors address the belief systems which influence the patient's behaviour in the context of his social setting.

The system may be the person with HIV and his family, or it may be the patient and his health carers. The authors, comprising a multidisciplinary team of a clinical psychologist, a social worker and a medical doctor, represent a system. They have different backgrounds but are linked by being family therapists and working in the same hospital setting. A counsellor and an individual client can also represent a system.

Systemic work can be accomplished with an individual by linking him with others in his system, even if they are not present at the interview, by asking hypothetical questions about their views, for example, ‘If your girlfriend were here today, what would she say was her greatest concern?’

Systemic thinking crosses cultural boundaries and takes into account religious and ethnic beliefs. Every event has a past and a future and these need to be explored.

Most importantly, systemic counsellors should help the individual and his family to consider the resources they already have and those they might seek out to help them cope. Asking how they have coped with difficulties in the past and hypothetical questions about future coping will link them with others and enable them to acquire different views of their situation.

We have thought a good deal about the tasks of counsellors and some of our beliefs; the contents of the first six chapters describe these more fully. The main beliefs we adhere to and which influence our approach to counselling can be summarized as follows:

• We do not believe that HIV disease inevitably or invariably leads to psychological or social problems for everyone, although problems can arise at different points in the course of illness.

• Medical or physical problems have implications for relationships, whether these are between family members, lovers or health care providers. They can also affect people's view of themselves.

• The ‘family’ may be the patient's most important social system: it may be a biological or social entity. We do not have predetermined views about relationship constellations; for example, two men in an enduring relationship may be a family. Problems about HIV disease may arise in the context of family relationships and can be resolved within them.

• We have clear goals and objectives for the counselling session, based on systemic theory, which are to define the problem, consider for whom it is a problem and work towards its resolution. However, we do not have fixed ideas about what would be the best solution in a particular case.

• We do not believe that there is only one approach to counselling. Different ideas are healthy and may themselves even be therapeutic. Whichever route one takes, a map is necessary to help to conceptualize problems and their possible resolution. Theory is also important for teaching others about counselling. In some circumstances, counsellors may even have to explain their actions to others in a court of law, and theory may be an important aspect of this. Underdeveloped training in psychological theories or vague theoretical ideas are a recipe for confusion in counselling or therapy sessions and for both confusing and abusing the patient.

• The objective reality of HIV as an illness affects people in different ways. Our task as counsellors is to help patients identify what meaning this illness has for them. We are dealing with ideas and beliefs. As Hoffman (1981, p. 344) states, ‘the reality “out there” is unknowable because it changes as we watch, and because our watching changes it.’ As counsellors, we continually ask questions of ourselves that help us to understand what assumptions we may be making about people, their relationships and their adjustment to illness. Our concern is to avoid situations in which patients may feel pushed to see things in the way we see them, or where we inadvertently disqualify their ideas or feelings.

We describe a counselling approach as it relates to psychotherapeutic counselling rather than information-giving counselling. The emphasis is on dealing primarily with psychosocial problems as they relate to HIV disease rather than on health education. Our focus is limited to the management of psychological and social problems with a description of a particular theoretical approach. A problem-focused systemic counselling approach is useful for several reasons.

1 HIV disease is foremost a medical problem, with psychological, social, political, economic and legal sequelae. It is not inevitably a psychological problem. This counselling approach addresses the multiplicity of problems associated with HIV disease. While a diagnosis of HIV infection can lead to major psychological problems, such as depression, adjustment reaction or an exacerbation of existing problems, these are rarely the main, underlying or enduring problems for people with HIV disease.

2 An overemphasis on psychological care may inadvertently cause some patients to believe they have a psychological problem. The counselling approach described in this book starts out with the premise that problems first need to be identified and defined by patients or health care providers. Most psychological problems can be assessed and managed, and in some cases prevented, in the course of comprehensive medical care.

3 Increasing workloads and constraints arising from pressure on time mean that health care providers may need to ‘achieve the most’ with their patient in the shortest possible time. The conventional fifty-minute psychotherapy session may be mostly inappropriate to HIV management. Brief, problem-focused counselling emphasizes problem identification and resolution. A clearly mapped-out plan of action may itself be a major psychotherapeutic intervention for a patient who is uncertain, anxious or bewildered about his recent diagnosis of HIV infection. Although the number of sessions may be fewer than with conventional psychotherapy, problem-focused counselling can sometimes extend over a longer period, with sessions being held at greater intervals.

4 Patients increasingly expect health care providers not only to be experts in their chosen field such as medicine, nursing, laboratory science or social work, but also to have the sensitivity and skills to discuss complex treatment and care issues. The systemic approach attaches importance to conversational and problem-solving skills.

5 The counselling skills described can be applied to general problem-solving. Counsellors can never be taught ‘what-to-say-when’ in any psychotherapeutic approach. Systemic counselling introduces the concept of a ‘map’ for problem-solving. There are clearly set out procedures in the counselling map and these can be easily adapted to fit with most psychotherapeutic approaches, including client-centred, cognitive and psychodynamic ones, and in response to a wide range of problems which patients may describe.

Skills for counselling people with HIV disease may be of use to the majority...