MODULE NAME: COUNSELLING CMT: 05206 NTA LEVEL 5, SEMESTER 2 QUALIFICATION: TECHNICIAN CERTIFICATE IN CLINICAL MEDICINE FACILITATOR’S NAME: G. MINJA DATE: 2ND MAY 2019 PRINCIPAL OUTCOME: 1. Apply basic principles of clinical examination and diagnostic procedures to reach proper diagnosis Enabling Outcome: 2.3 Apply effective counselling skills in managing clients Sub enabling out comes: 2.3.1. Use effective counselling skills 2.3.2. Describe various types of HIV counselling to general and Key Population Cont.... 2.3.3. Demonstrate counselling skills in providing health care services to HIV clients 2.3.4.Demonstrate HIV counselling and testing skills 2.3.5. Provide counselling to patients with other chronic illnesses 2.3.6. Provide counselling to PWUDs and PWIDs MODULE SESSIONS Session 1: Counselling skills in managing clients Session 2: Overview of HIV Testing and Counselling Approaches in Tanzania Session 3:Pre-Test Counselling in Voluntary Counselling & Testing (VCT) Session 4: Post-Test Counselling in Voluntary Counselling &Testing (VCT) Session 5:Provider Initiated Testing and Counselling (PITC) Cont.... Session 6: Family Counselling Session 7: Couples Counselling Session 8: Crisis Counselling Session 9: Counselling in providing health care services to HIV clients Session 10: Chronic illness counselling Session 11: PWUD (People who use drugs) and PWIDs (People who inject drugs) counselling SESSION 1: EFFECTIVE COUNSELLING SKILLS IN MANAGING CLIENTS Related Tasks By the end of this session, students are expected to be able to: 1. Define terms used in counselling 2. Identify types of HIV counselling 3. Identify guiding principles used in counselling 4. Explain characteristics of a good counselor 5. State general approach to counselling DEFINITION OF TERMS Counselling; is an activity that help client/ patients to gain the information, motivation and skills to deal with their problems. OR Counselling; is an interpersonal relationship between someone actively seeking help from someone trained and willing to give help Cont.... Pre – testing counselling: is a dialogue between a client and a counsellor before the HIV test is performed Post-Test Counselling • Is a dialogue between a client and counsellor when the HIV test results are ready and are about to be given to the client Cont..... PITC (Provider-Initiated Testing and Counselling) • Refers to HIV Testing and Counselling which is recommended by health care providers (HCPs) to persons attending healthcare facilities. (CITC) Client Initiated HIV Testing and Counselling In this approach, also known as Voluntary Counselling and Testing (VCT), client(s) voluntarily make the decision to learn their HIV status GOALS OF COUNSELLING The goal of counselling is to help patients discover their own thoughts and feelings In addition, counselling can help clients/patients manage their situations by: • Providing emotional support and safety in times of crisis • Helping people to explore their emotions • Helping people make informed choices and change their behaviours based on accurate information THE OUTCOMES OF COUNSELLING The results or decision of a counselling process aim to enable the patient to: Make some of the changes that he/she wants in life Develop positive relationships and explore his or her potential Cope with painful situations, like death, terminal illness and disability TYPES OF COUNSELLING There are three (3) types of Counselling Individual counselling Group counselling Couple counselling 1. INDIVIDUAL COUNSELLING: • Individual counselling is a one-to-one helping relationship in which the counsellor helps the client to accept, solve or cope with the problem. Cont.... Features of individual counselling includes client comes on his/her own or he/she is referred from another counsellor/source. Client coming for counselling may be an adult, youth or child who is: Able to talk rationally Mentally distraught – unable to think/talk rationally With varied life experience Duration of individual counselling A helping relationship may be one, a few or many sessions. The setting in which the relationship occurs whether it is a counselling centre, VCT centre/hospital. The nature and duration of individual counselling cannot be determined until the nature of the problem is clarified. Cont.... • In most cases the initial session begins in a similar way of staying with a client for 45 minutes to 60 minutes per session. • Counselling relationship may terminate when a counsellor and client conclude a successful counselling relationship or client referral is made 2. GROUP COUNSELLING: • Group counselling is a one-to-group helping relationship in which the counsellor works with the group in seeking a solution to their common problem. Example couples is considered as group • Group Counselling is designed to help clients in a group to achieve increased understanding integration, and acceptance of reality, socialization, realistic goals, adaptability and responsibility for self. Cont.... • The general aim is to help members appraise themselves so that they may gain understanding, and broad perceptive of themselves in relation to others Features of Group Counselling: A group of clients must have the following features; • Clients in the group must have a common problem. • There must be active integration among members. COUPLE COUNSELLING Couple refers to two people, usually of opposite sex, who may be: Married Cohabiting (not married but a man and woman are staying together) Friends Couple counselling occurs when two individuals who have had or who intend to have sexual relations wish to discuss issues concerning HIV together and look for ways to cope with the situation. Cont.... Usually two people come in for couple counselling if: They intend to get married One or both member/s is/are sick They intend to have children They are having conflicts in the home around being honest about sexual practices and safer sex Cont.... The couple has a sick child; or the child dies of AIDS related complex They have been referred to the clinic by a doctor • Homosexual male and homosexual female couples are also at risk of transmitting HIV to one another. • Couple counselling can also be offered to them just as to heterosexual couples. GUIDING PRINCIPLES OF COUNSELLING • A counselor must observe the 3 C’s which are the guiding principles for HIV counselling testing: – Confidentiality – Counselling – Informed Consent GUIDING PRINCIPLES IN PITC 1. CONSENT • Informed consent, one of the three guiding principles of testing and counselling, it is the process during which clients receive clear and accurate information about HIV testing in order to make an informed decision about whether to accept or decline testing. Informed consent can be written or verbal in certain situations by the caretaker. • It is the responsibility of the healthcare provider obtaining informed consent to make certain that the following elements of informed consent are addressed: Cont…. – Clarify the purpose and benefits of testing, counselling – Ensure an understanding of the testing and counselling process – Respect the client’s testing decision • Remember, the client can decline the HIV test, but that should not affect their medical attention. 2. COUNSELLING: Patient will receive pre-test and posttest counselling • The result of HIV testing should always be offered in person as part of an individual (or couple) post-test counselling session. Along with the result, appropriate post-test information, counselling, and referral should also be offered Cont…. HIV test results and post-test counselling must be given to all people who are tested. HIV-negative persons need test results and counselling which includes prevention messages, and information about safer sex practices. Always Provide HIV test results in person Offer counselling or referral Healthcare providers should ensure privacy when providing HIV test results Whenever possible, test results should be provided in a private area or room Cont….. – Healthcare providers should reassure the client that the post-test conversation and the test results will be kept confidential. – During the post-test counselling session, healthcare providers should inform the client that follow-up treatment, care, and support are available, including support for disclosure when needed. 3. CONFIDENTIALITY • Maintaining confidentiality is an important responsibility of all healthcare providers and is essential to establishing and maintaining client trust. Test result will not be shared with others except healthcare providers providing services to the patient Cont…. • It means: – All client information is kept private – Information is shared only on a ‘need to know’ basis – All medical records and registers are kept in secure place • Clients should be informed that personal and medical information, including HIV test results, may only be disclosed to other healthcare providers in order to ensure that the client receives the appropriate medical care. Cont…. – Healthcare providers should emphasize; however, only those health care providers who are directly involved in the client's care will have access to the medical records—and only on a ‘need-to-know’ basis. – Anyone not directly involved in a client’s care, for example, a receptionist, should not have access to client medical records because they do not need to know a client’s HIV status in order to perform their job. • All medical records and registers, whether or not they include HIV-related information, should be kept confidential and stored in a safe, secure place. CHARACTERISTICS OF A GOOD COUNSELOR Consider what kinds of most important qualities or character, one needs to be an effective counsellor, what it looks like to be an effective counselor and what skills are needed to be an effective counselor Characteristics of an effective counsellor are: Competence Maintains confidentiality Trustworthiness Demonstrate self awareness and understanding Cont…. Good psychological health Can build good rapport Show warmth and sensitivity Show empathy Remain objective and open minded Active listener Be able to reflect and clarify their needs Patience Be non-judgmental BARRIERS IN COUNSELLING • It is important to note that the counselling process is not always smooth. • Sometimes the process is blocked or hindered by various factors. • Counsellors should recognize those factors and handle them effectively • In counselling you may find also resistance RESISTANCE Resistance is the conscious or unconscious defence that prevents material in the unconscious from coming into awareness. Resistance is a defence mechanism where information is suppressed knowingly or unknowingly. - For example, a girl who has difficulty remembering the details of being raped. Resistance can occur at any time in the helping relationship. Cont…. Resistance is often a response by the client who is feeling threatened by the counselling relationship. It protects against fear, anxiety, anger, depression and embarrassment. Resistance can also result from inappropriate counsellor behaviour. Counsellors may also bring resistance and unfairness to their work. Visible fatigue or burnout on counsellor’s side can also encourage client to be resistant. TWO LEVELS OF RESISTANCE A).Client’s resistance in allowing thoughts and memories to be known to the counsellor. B).Client’s refusal in disclosing painful, frightening and embarrassing issues, feelings, behaviour and materials to a counsellor. SIGNS OF RESISTANCE • Resistance becomes visible when the client: – Begins to come late to appointments or forgets them altogether. – Questions counsellor’s ability/competence – Is not assured of confidentiality Cont…. Does not know how to begin • For example, teenagers failing to start telling their stories Talks non-stop on the same issue while avoiding others Is unable to speak DEALING WITH RESISTANCE • Resistance should be dealt with from a client’s point of view. • Resistance is usually a defence mechanism, and when the client recognizes that the resistance is not needed, it will be dropped. Cont…. • Defence mechanisms are usually unconscious and people do not even know that they are using them. • A well-timed interpretation of the client’s feelings, situation, etc. that helps the client see what is happening. • The client should never be blamed of being purposely closed. • It takes time to work on resistance. • Resistance is unconsciously dropped when the client feels more comfortable with the counsellor. Note: • Sometimes, once a good environment has been created by the counsellor, if the client still seems resistant, it might be because the client does not even recognize that they are being so. • If the counsellor at this time gently helps the client recognize that they are being resistant by pointing out behaviours that suggest so and explains that these behaviours will be a barrier in the counselling process, the client might be able to overcome resistance and start being more open and free with the counsellor. TRANSFERENCE • Transference is the process by which emotions associated with one person, such as a parent, unconsciously shift to another, especially to the counsellor. • Effective counselling is a very close process in which a client is exposed to the counsellor’s behaviour, communication style, gestures, sense of joking, expression of interests, caring, support and argumentative style. Cont…. • Transference occurs when a client identifies the counsellor as being similar to an important person in their past such as a parent, lover or any significant other. • Positive transference includes feelings of love, respect, friendliness and dependence toward the counsellor. • Negative transference expresses unfriendly, mistrusting and fearful feelings towards the counsellor. Cont…. • When transference is diagnosed it must be dealt with adequately in order to facilitate healthy growth during counselling. • Positive transference is often helpful in lowering client’s resistance. OVERCOMING BARRIERS TO COUNSELLING • It is important for a counsellor to step back and be attentive to the process of counselling while encouraging progress in sessions. • Counsellors should seek help from supervisors when required. • For supportive supervision, the counsellor should seek assistance from the immediate counsellor supervisor at the site, and there should also be regular supervision from the Council Health Management Team (CHMT) and the Regional Health Management Team (RHMT) to adequately support counsellors. Cont.….. • Regular meetings with supervisors are important to share experiences and avoid burnout. • Simple techniques such as good listening skills and body language demonstrating the counsellor’s attention can be helpful while overcoming barriers in counselling. ACTIVE LISTENING AND SILENCE Tips for Active Listening Give space and time for people to say how they feel. Do not be afraid of silences; give time to think and reflect. Do not show your judgement. Listeners are human! Of course they have opinions; the important point is their opinions do not prevent them from listening. Cont.... Acknowledge that other people’s thoughts, opinions and feelings are valid and don’t try to argue other people out of their feelings. Listen actively -- watch out for messages sent and RESPOND to them. Ask for clarification or explanation when you do not understand something. - For example: ‘I don't quite understand what you mean; could you help me by saying some more about this?’ -Do not state emotions, thoughts and feelings, but offer space to explore them. EXAMPLES OF NON-VERBAL GESTURES Feature Body position Eyes Eye contact Body posture Examples Tense, relaxed, leaning toward or away from Teary, open, closed, excessive blinking, twitching Steady, avoiding, shifty Stooped shoulders, drooping body, legs crossed, rigid, relaxed Cont.... Body movement Mouth Knee jerks, taps, hand and leg gestures, head nodding pointing fingers, dependence on arms and hands for expressing message, touching Smiling, lip biting, licking lips, tight lips, loose lips, shaking lips, grinding jaws Cont.... Facial expression Skin General appearance Voice Animated, bland, frowning, puckers, grimaces Perspiration, paleness and colour change Clean, neat, sloppy, well groomed. Fast, slow, jerky, high pitched, whispers KEY POINTS There are three types of Counselling Individual counselling Group counselling Couple counselling • A counselor must observe the 3 C’s which are the guiding principles for HIV counselling testing: – Confidentiality – Counselling – Informed Consent Evaluation • What bare types of counselling? • What are the guiding principles of counselling? • Mention characteristics of a good counsellor References • NACP (2008). HIV and AIDS Voluntary Counselling and Testing: Participant’s Manual. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control Programme. • NACP (2008). HIV and AIDS Voluntary Counselling and Testing: Trainer’s Guide. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control Programme. • NACP (2009). National Training on Provider Initiated HIV Testing and Counselling. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control Programme. END OF SESSION THANK YOU FOR LISTERNING AND PARTICIPATION