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Manual on Advance Counselling for ICTC Counsellors Facilitator’s Guide Manual on Advance Counselling for ICTC Counsellors Page 1 HIV/AIDS Updates and Knowledge Session Overview: Global, regional and national epidemic. Epidemiology of HIV/AIDS Understanding prevalence and incidence NACP IV Session Objectives: By the end of this session, participants will be able to: Understand the global and national HIV/AIDS epidemic Define prevalence and incidence and differentiate between the two List prevalence categorization of the state & district Describe goals, objectives and focus areas of NACP IV Time allowed: : 3 hours Materials required: Time allowed: : Laptop LCD Method: Time allowed: You as the training co-coordinator will have to invite a resource person from the SACS or any other individual who is well versed with the National AIDS Control Programme. This person should : facilitate the session covering the following points: Manual on Advance Counselling for ICTC Counsellors Page 2 Unpacking the epidemic –understanding global, regional and national HIV/AIDS epidemic. Epidemiology of HIV. Understanding how prevalence and incidence is calculated Meaning of a concentrated v/s a generalized epidemic Male/female HIV prevalence, incidence and ratio Rate of incidence and prevalence amongst MARP’s Categorization of states and districts based on the HIV prevalence NACP-IV- goals, objectives and focus areas Functions of the department of AIDS Control Principles of ‘getting to zero’. Manual on Advance Counselling for ICTC Counsellors Page 3 Use of ‘Self’ in the Counselling Process Session Overview: Awareness of our values/beliefs- 30 minutes Understanding our values/ beliefs, attitudes, strengths and weaknesses -30 minutes Factors that help us to grow and those that hinder growth- 30 minutes Are you in control? - 30 minutes Session Objectives: By the end of the session, participants will be able to: Understand the concept and importance of self awareness. Explore one’s own beliefs, attitudes, strengths and weaknesses. Enumerate the use of self in the counselling process. List the factors that facilitate or hinder professional and personal growth allowed: Time : 3 hours. Materials required: Time allowed: White board markers : Permanent markers Chart papers Paper Scissors Method: Time Preparation allowed: before the session: : Manual on Advance Counselling for ICTC Counsellors Page 4 You as the facilitator: Will print out the case studies for Activity 1. Print out the figure given in annexure 2 and photocopy the same as per the number of participants. Activity 1: Awareness of our values/beliefs (30 minutes) Divide the participants in to four groups Hand over one of the case study (Annexure 1) to each group. Ask the participants to go through the case study. Each case study has a statement written on to the paper. The participants have to discuss the case study in the light of the statement and present the gist of the discussion. To be aware of one’s own strengths and weakness helps us to be an effective counsellor. The counsellor needs to be aware of one’s own values, morals, attitudes and prejudices when working in the field of HIV counseling. Counselling in the field of HIV/AIDS means dealing with highly sensitive and personal issues of sexuality. Therefore a counsellor must be aware of his/her own attitudes and beliefs about sexuality, to help him/her work with client’s issues of sexuality. The counsellor should develop greater cognitive flexibility and understand how their own identities may influence the counselling process. For example in the counselling process, a counsellor from a religious background whose religion prohibits consumption of liquor may find it difficult to accept alcoholism. The counsellor may face a problem/dilemma while counselling a client with an alcohol addiction. The counsellor needs to be aware of his/her own biases so as to control his/her emotions while counselling. Activity 2: Understanding our values/ beliefs, attitudes, strengths and weaknesses (30 minutes) The facilitator will inform the participants that they will now introspect about themselves with the help of their partner. Divide the group into pairs. Handover annexure 2 to each participant. Ask the pairs to discuss their values/belief, attitude, strengths and weaknesses with their partner. In a pair when one partner is introspecting and talking about his/her own values/ beliefs, attitudes, strengths and weaknesses the other partner listens. Ask the participants to list down the values/ beliefs, attitudes, strengths and weaknesses on the four sides of the figure which was provided to them for this purpose. After completing the task ask the participants to discuss the same. Manual on Advance Counselling for ICTC Counsellors Page 5 This activity is then reversed and the partners switch roles. Each person is given 20 minutes to think and talk. The partner that is listening will help the person who is sharing to introspect on the four domains values/beliefs, attitudes, strengths and weaknesses. Some of the questions that can help us introspect are: What are some values that describe you? What are some beliefs that are very important for you? What are some views that you stand for? What are some important attitudes your family and upbringing has taught you? What do you like in yourself? What are the qualities others praise you for? What do others say that you are good in? What are some of the things that people who like you, say that you should change? What are the things that you would like to change in yourself? Activity 3: Factors that help us to grow and those that hinder growth (30 minutes) Let the same pair of activity 2 continue to sit together. The pair takes out a sheet of paper for each participant. Ask the participants to draw a tree on the sheet of paper. Ask them to imagine that they are a tree. They have to introspect and think of themselves as a tree and discuss with the partner what are the factors in themselves and their environment that helps them to grow and factors that hinder their growth. In the pair, one person will introspect and while the partner draws a tree on a sheet of paper. After drawing the tree, the partner lists (on top of the tree) the factors that help the person to grow as well as factors that hinder the partner in personal growth(below the tree). The pair will then switch roles and other partner will talk and the other will draw the tree and list down the factors that help in the partners growth and the factors that hinder the growth in the partner. Some questions that will help us introspect are: What are the factors in your personality that help you to perform better in your work? What are the factors in your environment that help you to perform better in your work? Who are the people in your family/ friends/ workplace who help and encourage you to move ahead in life and work? What are the factors in your personality that hinder your performance in your work? What are the factors in your environment that hinder your performance in your work? Manual on Advance Counselling for ICTC Counsellors Page 6 Activity 4: Are you in control? (30 minutes) The pair continues to sit together. The participants can put both the sheets of paper from activity and activity in front of themselves( the self figure and the tree). Now ask the participants to further analyze which of the points listed on both the sheets are either “in my control” and” not in my control”. Against each of the points listed, the participants write “in my control”for the points they feel are in her/his control. Those not in her/his control, ask them to write “not in my control”. Let the participants discuss and share this list in open with their partner. Further discussions can be initiated, where the partners may give suggestions or share experiences on how they deal with these situations.. For example, if a participants shares that managing his/her boss is a limitation and feels it is “not in his/her control”, the partner could propose ways of handling the difficult situation. Let’s work to increase factors that are “in my control” and learn to deal with the factors that are” not in my control”. In our life we have success and failures. These success and failures we can attribute to factors that are in our control and some factors in the environment, which are outside our control. This is called the locus of control. Those factors that are in our control are deemed as “internal locus of control”. For example, a counsellor is not very confident in counselling because he/she feels she/he lacks knowledge. This factor is in the control of the counsellor as she/he can make efforts and increase their knowledge and thereby become more confident. Those factors that we cannot control are called “external locus of control”. For example a counsellor has ailing parents who need medical attention. In this case, the situation is not in the control of the counsellor. Persons who develop an internal locus of control believe that they are responsible for their own success. Those with an external locus of control believe that external forces, like luck, destiny play an important role in their life. Manual on Advance Counselling for ICTC Counsellors Page 7 Annexure 1 Awareness of our values / beliefs: CASE 1 Jaspreet is a HIV/AIDS counsellor. She belongs to a conservative family. She believes that premarital sex is a sin. Jaspreet finds it difficult to counsel her client who is a college student about safe sex practices. Discussion Point: Our socialization teaches us values certain beliefs. We need to be conscious of them. Awareness of our attitudes CASE 2 Amir is an ICTC counsellor. His parents separated after a violent relationship. He now questions the institution of marriage. Amir has a HIV positive client with a marriage problem. It is a challenge for him to counsel the client. Each time the client presents his problems, Amir’s attitude towards marriage makes him biased. Discussion Point: Do we have control over our attitudes? Do they make us biased? Awareness of our strengths/gifts CASE 3 Rama is a very effective counsellor. She works hard with her clients. Rama’s center-in-charge appreciates Rama’s counselling. Rama thanked her with humility. Rama is aware of her strengths and acknowledges it with humility. She does not minimize her strength or play it down. She celebrates her strength by sharing it with others. Discussion Point: Like Rama we too are complimented on our strengths and gifts. Are we aware of these strengths or gifts that we posses? Awareness of our limitations CASE 4 Susheel works as an accountant. He is overburdened with work and his supervisor is not willing to appoint another accountant to share his load. He has to work extra hours to complete his work. Due to recession, he is unable to get any new job despite searching for sometime. Susheel is very Manual on Advance Counselling for ICTC Counsellors Page 8 meticulous about his work and feels that the workload is not permitting him to work to his best potential.. Discussion Point: Like Susheel we too face many limitations in our environment and in our self. Are we aware of these limitations? Annexure 2 VALUES/BELIEFS STRENGTHS ATTITUDES WEAKNESSES Manual on Advance Counselling for ICTC Counsellors Page 9 Understanding counseling as a skill and core competencies Session Overview: Preparation time - 30 minutes Demonstration - 50 minutes Discussion - 25 minutes Summarization - 15 minutes Session Objectives: By the end of the session, participants will be able to List skills required for counsellors Practice the skills required for counsellors Time allowed: : 2 hours Materials required: Time allowed: : Chart paper Papers Markers Manual on Advance Counselling for ICTC Counsellors Page 10 Method: Time Preparation before the session: allowed: You as the facilitator will photocopy the handout on counsellor competences for all the participants. : Divide the participants into 5 groups; distribute the handout on counsellor competences to all the participants. Each group were be given one set of skills viz. Group 1 – Inter personal relationships Group 2 – Gathering information Group 3 – Giving information Group 4 – Handling special circumstances Group 5 – Counselling micro skills Inform the participants that each group has to go through their set of skills in the handouts & prepare a role play demonstrating that particular set of skills. The verbatim statements given in the handout can be used in the role play. The facilitator will have to play an active role in this activity & may need to step in to clarify correct or demonstrate a particular skill if required. Each group will be given 30 minutes to prepare for skill demonstration & another 10 minutes to demonstrate the skill. A five minute discussion can follow each demonstration. Key points to emphasize: These are the basic skills required for counsellors to undertake HIV counselling. These are the tools of the counselling process. Manual on Advance Counselling for ICTC Counsellors Page 11 Tips to the facilitator: Please manage time for this session effectively The skills might overlap with each other. Kindly communicate the same to the participants as well, The handout is given as an aid for the participants to develop their role plays. Please feel free to substantiate the description of the skill or the verbatim mentioned in the handout during the course of the session. Manual on Advance Counselling for ICTC Counsellors Page 12 Linkages for Effective Counselling ges Session Overview: Session objectives: - Lecture – 5 minutes Case discussion in small groups – 45 minutes Services available under NACP and its linkages: PPT and large group discussions – 30 mins Panel discussion – 90 minutes Summarization and Question & Answers -10 minutes Session Objectives: At the end of this session, participants will be able to: List various types of referrals required for clients so that their needs can be addressed List health and other services with which counsellors should make programmatic linkages List and discuss reasons why clients do not access services Discuss the advantages of creating an effective system of referral and linkages. Discuss the benefits of this system for clients as well as for the effective implementation of the national programme List various challenges while developing programmatic linkages and making referrals Time allowed: : 3 hours Manual on Advance Counselling for ICTC Counsellors Page 13 Materials required: Time allowed: White board markers : Permanent markers Chart papers Paper Scissors Method: Time allowed: Preparation before the training: : You as the facilitator will have to photocopy the cases listed in Annexure 1. Invite three panellists (listed in activity 4) for the panel discussion. Activity 1: Session Objectives (5 minutes) Activity 2: Case Discussion in small groups (45 minutes) Divide the participants in 3 or 4 groups (depending on batch size. There will be 5 -6 members in each group). Each group will be given a case study. (The case study will be of a client who requires support other than HIV testing and counselling.) Instruct the participants to read the case study carefully and think about what type of support (which includes counselling, linkages to various services and any other support) the client needs. The points can be listed on a paper. (To make it experiential, the facilitator can ask participants to imagine themselves as the client and then list the type of support he/she may require). After small group discussion, each group will discuss their points in large group. Facilitator will summarize the discussion. Manual on Advance Counselling for ICTC Counsellors Page 14 Following points to be highlighted – The client should be viewed as a person/human being as opposed to only being seen as a client at HIV testing centre. The client should be viewed in a broader context, so as to understand his/her vulnerability and consequently to address the client’s needs other than HIV testing. Clients need various types of services and support apart from HIV counselling and testing. Any specific centre cannot fulfil all the needs of a client. Hence the counsellor should develop linkages with various centres and services (in both the health as well as the non health field) in order to make appropriate referrals. Activity 3: What types of services are available under NACP and what type of linkages are emphasized in NACP? Why? – Large group discussion while using power point presentation (30 minutes) Activity 4: Panel discussion (90 minutes) Three persons will be invited for the panel discussion: Senior counsellor or district supervisor. If they are not available, official from SACS- BSD/ART department also can be invited. These persons are service providers and hence they need to be invited to understand service provider perspectives. A person from positive network and from MSM/TG/FSW NGO who seeks services. Government official. For example municipal corporation officer who is familiar with various government schemes.(If this person is not available, then panel discussion can be conducted with remaining persons) Manual on Advance Counselling for ICTC Counsellors Page 15 The facilitator will interview them and participants also can be encouraged to ask a few questions at the end. Questions for counsellor – What types of services are provided by your centre? What linkages do you have with other programmes under the NACP? What types of challenges do you face while referring clients to other programmes? How do you ensure whether the client has reached the centre to which you have referred them? What are some of the reasons why clients do not avail services and especially when the services are free? How do you help clients avail these services? Can you share a few challenging and successful cases in terms of creating effective linkages? Questions for a person from NGO and positive network – What types of services are available for you under NACP programme? Are there any challenges in accessing these services? What are the challenges? Have you ever discussed these challenges with any concerned officials? What are your other needs apart from NACP services? Are these needs being addressed by the HIV counselling centres? If yes, how? Can you please share one example where you or your team members have benefited by the services? Alternatively can you share an example where appropriate services were not received? Though services are available, many a times these services are not availed by persons who are in need of them. According to you what are the reasons for the same? Manual on Advance Counselling for ICTC Counsellors Page 16 Questions for government officialWhat are the schemes available in your dept or other government departments? What are the requirements to avail the benefits of the same? In your experience, do persons avail the benefits of the schemes? What are the challenges you face in providing these benefits? How can these challenges be addressed to ensure that, a large number of persons from marginalized groups and HIV positive persons benefit from these schemes? (In case panel discussion is not possible – following alternative activity can be done) Divide participants in 3 groups. Group A – ICTC centre in a remote area, where access is difficult. One public transport bus comes there in the morning and goes back in the afternoon. Private transport is available, however it is very expensive. Group B – ART centre at a district hospital where counsellor counsels 70 – 80 clients each day. Group C – STI counselling centre at district hospital where a counsellor get various clients that are referred by the STI officer, in addition to direct walk in clients. These groups will be given challenging cases and they need to work on counselling and referral strategies for the cases. (Refer Annex II for cases) They also need to establish systems at place for referrals and linkages. Each group will share their experiences in large group. Manual on Advance Counselling for ICTC Counsellors Page 17 Points for Debriefing – a) What challenges did you face while linking clients to additional services? b) What strategies did you undertake to address these challenges? c) In your experience do you think that the strategies discussed are practical and can be replicated in the field of HIV/AIDS counselling? Activity 5: Summarization (10 minutes) Manual on Advance Counselling for ICTC Counsellors Page 18 Annexure I Cases for discussion – Case 1: A, 6 year old girl is suffering from Puemonia. She falls ill very frequently. The doctor advised for HIV test and the test is positive. The girl is an adopted child of her parents . The child’s biological father was an auto driver and died due to fever which was untreated. Later, her mother also died of TB. The girl is adopted by her father’s distant cousins. The couple who adopted the girl now want to disown her, as she has tested positive. The man informs the counsellor that he is a poor fisherman and cannot bear the burden of the girl’s illness. He request the counsellor to give them contact details of orphanages where they can send the girl. Case 2: A 28-year-old woman has come for her second ART preparatory counselling session. She works as a sex worker on the beachfront. Her CD4 is 34 and she had developed herpes zoster in the previous year. She is been losing weight steadily, feels weak and finds it difficult to concentrate. Also she is not been able to go to work for the past few weeks, as she has been feeling unwell She is a widow, living in a slum with two friends who also work as sex workers. As she is ill, her friends have been supporting her. She is keen on starting ART. However, she is planning to visit her family in a distant city next month. Demonstrate how you would help this client. Case 3: The client is a 62 year old woman who is the sole caregiver of her infant grandchild, aged 2 years. The child’s parents died after a long battle with HIV. The grandmother’s sole possession is the hutment where she lived with her husband. However recently her Manual on Advance Counselling for ICTC Counsellors Page 19 husband abandoned her to live with a younger woman. The grandmother is now suicidal, and feels her only escape from the situation is to kill herself as well as her grandson. Case 4: A 54 years widow is admitted in a private hospital for the treatment of a tumour in her stomach. She is HIV positive as per the hospital report. The hospital is now asking the woman to pay more money for her treatment than earlier quoted as she is HIV positive. Her son who is a college student has found an ICTC center in a nearby government hospital and has come to meet the counsellor there. The son tells the counsellor that he cannot afford the charges, which the private hospital is now asking for. He also shares that he always suspected that his father who had died a few years earlier was HIV positive. Manual on Advance Counselling for ICTC Counsellors Page 20 Annexure II Cases for discussion for ICTC Case 1: A 15 year old girl has come with complaints of white discharge and stomach ache. The counsellor asks her to bring her mother to the clinic as the girl is a minor and cannot give consent for an HIV test. The girl is refusing to call her mother. The counsellor phone calls the girl to follow up with her, however she does not take the counsellor’s call. Also she does not respond to the phone calls that the counsellor makes, to follow. The counsellors then sends the outreach worker (ORW) to contact the girl. However the girl tells the ORW that she has never been to the center. Case 2: A 45 year old man is tested for HIV and is found positive. He is a landless farmer and works as a daily wage labourer in another’s fields. Owing to the drought in the area, he is unable to get any work and therefore does not have money to travel to the district to access the ART center and its services. Case 3: A 20 year woman is pregnant and has tested positive for HIV. She is referred to the District ART centre by the counsellor. However when the counsellor is cross checking his data with the District ART centre, he finds that the woman had not reached the centre. He remembers that during post test counselling the woman shared that she was in conflict with some of her family members. The counsellor tries to call her, but is unable to contact her. Case 4: A long distance truck driver is tested for HIV at a centre. However, the truck driver leaves for his next destination, without collecting his report (which is HIV positive) as the report was delayed owing to the Medical officer unavailability. The counsellor is worried that he will not be able to disclose the truck driver’s report to him. The counsellor calls the truck Manual on Advance Counselling for ICTC Counsellors Page 21 driver, who informs him that the truck’s route has changed and he will not be visiting the area(where the counsellors is located) anytime soon in the future. Cases for discussion for ART Case 1: A hotel waiter who is HIV positive is registered for ART and begins his medication. After 2 months, the ART counsellor is unable to trace him. The Outreach Worker (ORW) goes in search of the client and is informed by the other waiters that the client has returned to his village in Bihar. The ORW tries to get the address and contact details of the client but the other waiters provide her with incomplete information. Case 2: A sex worker comes to ART centre. After her CD4 test, the doctor starts her on ART. During counselling session, she informs the counsellor that she does not have a permanent address. She travels from one place to another during various festivals and seeks clients at various fairs at distant religious places. She expresses her inability to seek treatment from one particular centre. Case 3: A daily wages worker is HIV positive and has begun ART. He does not come to seek medicines for two months. When the ORW tries to contact him, he informs her that the timings of the ART centre are inconvenient to him, as he is daily wage labourer and cannot afford to visit the centre in the day as he loses his income for the day. Manual on Advance Counselling for ICTC Counsellors Page 22 Cases for discussion for STI Case 1: The client is an 18 year old boy who has come to the STI clinic after attending a group education session on STI and HIV in the community. He informs the counsellor that his friend is suffering from a genital ulcer. As the session progresses, he shares that that he himself has the ulcer, which he noticed a few days ago. He explains that his friends had forced him to have sex with a sex worker. He is now scared that his parents will know about his act when if goes to the doctor in his own neighbourhood. Additionally he shares that he cannot take medicines at home since his parents may notice this and will force him to explain reasons for the same. He further added that he cannot come to clinic repeatedly as he is afraid that he may be seen by his neighbours Case 2: A 32 year man is on treatment for painful genital sores. However, his health is declining and he is constantly admitted to the hospital. Consequently he loses his job. Recently he has been employed as a daily wage worker at a construction site. Owing to the nature of his work, he is unable to come to the center for follow up treatment. When the counsellor phone calls him, he refuses to come to the center as he says that he will lose half a day’s wages or risk losing his current source of income. Case 3: A truck driver who HIV positive and is currently on ART informs the counsellor that he is unable to adhere to ART owing to his uncertain duty hours, and erratic sleep as well as food patterns. He also dismisses the possibility of follow up at any one particular place as his work takes him to varied and distant locations. References:1) HIV Counselling Training Module (Handouts), National AIDS Control Organisation, Year 2006 2) Refresher Training Programme for ICTC counsellors ( Second edition)Trainee’s Handouts, April 2011 Manual on Advance Counselling for ICTC Counsellors Page 23 Understanding Marginalization and Vulnerability in the context of HIV/AIDS ges Session Overview: Introduction to the session - 10 minutes Our story ( Understanding marginalisation) – 25 minutes Piece of the sky ( Experiencing marginalisation) – 40 minutes Plotting marginalisation – ( Understanding stigma and discrimination) 25 minutes Cause and effect ( Understanding vulnerability in the context of the social drivers and structural factors of the HIV/AIDS epidemic ) – 40 minutes Making the connection ( Developing strategies to reduce marginalisation and vulnerability at the structural level ) – 40 minutes Session Objectives: At the end of this session, participants will be able to: Understand the concept of marginalisation and vulnerability in the context of HIV / AIDS. List the structural factors and social drivers that make individuals vulnerable to HIV infection. Appreciate the linkages between addressing the social drivers and thus achieving the goals of the national programme. Enumerate ways to include the perspectives gained from this session into counsellor training programmes. Time allowed: : 3 hours Manual on Advance Counselling for ICTC Counsellors Page 24 Materials required: Time allowed: : White board markers Permanent markers Chart papers Paper Scissors Double sided tape Method: Time allowed: : Preparation before the session: You as the facilitator: Photocopy handouts and leaflets for all the participants. Print the identities outlined in Annexure 1 and prepare chits of the same for activity 3 Ascertain a space for the ‘Piece of the sky’ activity. This activity will need a large area that can accommodate approximately 20 or more participants. (The space could be either indoors or outdoors). This area should include a wall or any other solid structure, as participants will asked to stand in a horizontal against this structure/wall. Photocopy Annexure 2 for all the participants. Introduction to the session and going through the objectives (10 minutes) Introduce the session and outline the objectives of the session Activity 1: My story - Understanding marginalization (25 minutes) Start this activity by asking the participants to think of at least one way in which they have felt ‘marginalised’, i.e., any one way in which they have felt that they have a disadvantage over most people or the dominant group.” Manual on Advance Counselling for ICTC Counsellors Page 25 In case there is a need to elaborate, the facilitator can say: “This may be within your family, your friends, colleagues, city and state. Anywhere where you felt you were treated as less visible or less important than some or all other people. For any one or more reasons have you ever felt at the margin and not in the mainstream. The facilitator can then ask the participants to voluntarily share their experiences. To begin the discussion, the facilitator can share his /her own experiences Key points to emphasize: We all have felt marginalized at different times for different reasons. It could be because of the profession we chose, our marital status, weight etc. Marginalization refers to the reduced power and importance of certain people in our society. The social process of becoming/being made marginal (especially as a group within the larger society) is a means to keep someone away from power, because of the choices they make in their identities, practices or appearance. The facilitator can then ask the participants to go read the handout on marginalization in order to further understand marginalization. Alternatively the facilitator can also present the same as a power point presentation; however the handout has to be given to the participants for their quick reference. Activity 2: A piece of the sky – experiencing marginalization * Print out the identities (Annexure 1) on a piece of paper and then cut them and convert each identity as a separate chit. Hand over one chit to each participant. In case there are more participants than the identities, ask some of the participants to play the role of an observer. Give participants some time to understand the identity and relate to the same. Move the participants to the space designated for this activity. Ask the participants to stand in a horizontal line and hold hands. The participants should be facing the wall/solid structure and there should be some distance between them and the wall. Inform the participants that you will be reading a list of questions listed in (Annexure1). The participants have to answer the questions from the point of the view of the identity Manual on Advance Counselling for ICTC Counsellors Page 26 they have assumed. If they feel that the answer is ‘yes’, they need to take one step forward and if the answer is ‘no’ they need to move one step backwards. Urge the participants to get into the role of the identity and begin thinking of themselves as the ‘identity’ they have assumed and not as themselves. Explain to them that the answer to some of the questions can be yes for themselves but no for the identity they are playing out. Inform the participants that they have to hold hands for as long as possible. After reading all the questions, ask the participants to look around at the others in the line and observe the following : Who is still holding hands? Who is ahead of the others in the line? Ask the participants to then mention the identity they were acting out. Note where people stand : what does this tell us about opportunity vis a vis the role we were playing Now ask the participants to run and grab a space for themselves against the wall. Following this ask the participants to assemble back into the training hall. Ask the participants to share their experiences of doing this activity : How did they feel when they had to take a step backwards? How did it feel to leave hands? At the end of all the questions, who was nearest to the wall and who was the farthest? What does this say about the opportunities that are available to some and not to others? Who could grab the wall? Who could not? Did anyone try to accommodate others so that they could also touch the wall? Do we take our privileges for granted? Where there any participants, who did not try to run toward the wall at all? If yes, why? At the end of the discussion ask the participants to ‘de -role’. They could say the following – “ I am ( name of the participant ) , I am not a policeman” ( the role the participant was playing) What connections can you draw between this exercise and the previous discussion on marginalisation? How did you feel to be in a marginalised position without doing anything to be in this position? Ask the participants if they could identify some factors that further marginalise individuals? Some of them could be education, socio-economic status, religion. Introduce the topic of marginalisation in the context of HIV/AIDS and ask the participants to name the marginalised groups in the context of HIV/AIDS (* This activity is adopted from the ‘Car Park’ activity developed by CARAT, TISS and ‘Power Walk’ activity developed by TARSHI) Manual on Advance Counselling for ICTC Counsellors Page 27 Key points to emphasize: Those with greater opportunity owing to either the social groups ,family or caste they belong to, enjoy more benefits and power to make choices in their lives. Those people who lack access to opportunities may be ‘left behind’. One particular person may also have multiple advantages – for example in India, a person who is an educated upper-middle class Hindu, male living in a metropolitan city has multiple advantages over a lower-middle class Muslim woman who has very little education and lives in a village or small town. Often the more ‘different’ a person appears from the ‘norm’ in society, the greater discrimination and marginalization faced. Marginalization has many interpretations and is experienced differently by each person. These experiences can further vary due to the influence of structural factors like age, class, caste, gender, educational status, disability ,and access to services. Tips to the facilitator: Manual on Advance Counselling for ICTC Counsellors Manage your time effectively from the beginning. Make sure participants do not see this activity as a judgment of them being fortunate or unfortunate, but rather a chance to examine opportunities and privileges individuals have in society Encourage participants to get into the role. There is a possibility that the participants will not imbibe the identity to the fullest and will answer based on what they feel. If such a situation arises, the facilitator will have to discuss the same and address issues of the perceptions of the participants regarding a particular community/ identity. De rolling is extremely important for this activity The facilitator is free to add or subtract more identities and frame more questions for this activity. Page 28 Activity 3: Plotting marginalization discrimination) 25 minutes (Understanding marginalization, stigma and Distribute Annexure 2 to each participant. Instruct the participants to list out the various identities mentioned in the annexure 2 within the concentric circles, based on the level of stigma and discrimination they experience in their societies/communities.For example, identities that experience the least amount of discrimination will fall into the inner most circle, whereas the outer most circles will have the most marginalized identities. Give participants 10 minutes to complete the activity. Invite participants to share how they have listed the identities in the concentric circles and explain the basis upon which they categorized identities. Suggested Questions: Were there similarities among the least marginalized people? Similarly were there any similarities among the most marginalized? How does society stigmatise some of these identities? What do the similarities indicate about certain identities? Are there some groups such as married men that experience the least stigma and most opportunities in society? Are there stereotypes associated with any of these identities? How would these stereotypes cause discrimination or marginalisation of those concerned? Who creates these stereotypes and decides what is ‘normal’? Why/How are these stereotypes and this marginalisation maintained? For example, do media images of certain identities help perpetuate these attitudes or do laws or customs in a community maintain this marginalisation? [Source: TARSHI (2006).Basics and Beyond: A Manual for Trainers, India] Manual on Advance Counselling for ICTC Counsellors Page 29 Stereotypes maintained in society and communities contribute to stigma and discrimination against certain individuals like MSM or IDUs. These individuals are called ‘marginalised populations’ viz MSM, IDU, FSW and migrant populations. Stigma and discrimination can result in violence, abuse or denial of services and information for individuals.(Participants can go through the handout provided on stigma and discrimination for further clarity) Though they are strong linkages between stigma and discrimination, they are also different from each other. A person can experience stigma without any experiences of marginalization. For example, a person may be stigmatized for being a lesbian but because of other factors in her life (income, class, caste, race) she may not be marginalised. Tips to the facilitator: Participants may not be familiar with some of the identities listed. If necessary, go through the identities beforehand and discuss any questions they might have about the identities. Participants may express discomfort around some identities, especially those that are new to them or those considered ‘wrong’ according to certain cultures/religions. Be sensitive to the above and encourage participants to participate in the exercise in the spirit of learning, even if they do not fully understand them. In case of shortage of time, this activity can be clubbed with the tea break and the participants can complete the exercise with ‘working tea’. However the discussions outlined in ‘key points’ are crucial and should be undertaken. Activity 4: Cause and effect (Understanding vulnerability in the context of the social drivers and structural factors) – 40 minutes Divide the participants into 4 groups. The task of each group is to discuss how structural factors like health, poverty and laws make marginalized communities viz female sex workers, men who have sex with men, intravenous drug users and migrant populations vulnerable to HIV infection. In case the participants need more clarity, you could tell them how individuals are forced to migrate due to poverty and how isolation and alienation in a new city can put them at a risk to HIV/AIDS. Manual on Advance Counselling for ICTC Counsellors Page 30 Inform the participants that they have 10 minutes to complete the discussion and 5 minutes for presenting the discussion points. Key points to emphasize: The term driver relates to the structural and social factors, such as poverty, gender inequality and human rights violations that increase people’s vulnerability to HIV infection. These factors operate at different societal levels and different distances to influence individual risk and shape social vulnerability to infection. Structural factors can be understood as the factors external to individual. These factors arise out of political, employment or economic conditions such as poverty and migration. Recently the term driver is also used to describe those risk factors which are so widespread as to account for the increase and maintenance of an HIV epidemic at the population level. It is important to understand that it is not just individual behavior or choices that put people at risk to HIV infection. Choice is never absolute. There is ample epidemiological and demographic evidence from the trajectory of the HIV pandemic to show that certain populations are more vulnerable to infection because of the particular social, cultural, economic and legal circumstances to which they are subject. Women have inequitable access or control over a range of different resources like economic resources, political resources, social resources, information/ education and internal resources. This has resulted in women having limited control over their own health, the timing, context and safety of intercourse, and vulnerability to genderbased violence and HIV/AIDS (Participants can go through the handout on Gender & HIV and Sex, Sexuality and HIV for further clarity.) In India, it has been seen that marginalised populations that live in an environment of inequity, criminalisation, oppression and violence have an increased vulnerability to HIV and AIDS, and have been disproportionately affected by it. Tips for the facilitator: Request the participants to go through the leaflet on structural factors and vulnerability. Inform them the leaflets are provided to them as a quick reference when they have to conduct the session. The participants also need to go through the handout on ‘ Marginalized population outside the pale of human rights’ for further clarity. Alternately the entire set of handouts and leaflets can be mailed to participants a week prior to the training, to enable them to come prepared for the session. Manual on Advance Counselling for ICTC Counsellors Page 31 Activity 5: Making the connections (Developing strategies to reduce marginalisation and vulnerability at the structural level) – 40 minutes Continuing in the same groups ask the groups to discuss what can be done at the structural level ( health , legal, economic ) to reduce marginalization and vulnerability to HIV /AIDS . At the same time ask the groups to also discuss strategies that can make the counseling centres (ICTC, ART and STI ) sensitive to the needs of marginalized population and reach out to marginalized groups. Key points to emphasize: HIV prevention and care efforts cannot succeed in the long term without addressing the underlying drivers of HIV risk and vulnerability in different settings. Linking clients with government schemes or livelihood programmes can be some of the options to mitigate the vulnerabilities arising out of poverty or loss of livelihoods. Sensitizing the judicial system, the police force and the public health system about needs of persons belonging to alternate sexuality can be another option of reducing marginalization and vulnerability of MARPs. (Participants can read the handout on ‘Law and the marginalized population’ for further clarity) Stigma, marginalization and a sense of being different from the normative model can lead to clients experiencing unique stressors and challenges in their lives. Counsellors should know about these challenges and adapt their counseling and counseling centres (ICTC, STI and ART) to provide affirmative services to their clients (For more information on affirmative approach to counselling, please go through the manual developed by Saksham included in your CD) Counsellors at the ART centers need to develop different adherence strategies for sex workers keeping in mind their working hours. For migrant workers, counsellors can suggest and include the ‘transfer out’ option to enable migrants to seek services at their desired location. The ICTC centers can be kept open till late evening to provide services to populations that are unable to access services in regular time.(for example persons who are engaged in daily wage work, MSM or FSW clients) STI counselors need to be sensitive to and include partners of MSM and regular partner of FSW in partner treatment. In case of shortage of time, activity 4 and 5 can be combined and group 1 and 2 can undertake the tasks listed in activity 4 and group 3 and 4 can undertake the tasks listed in activity 5. Manual on Advance Counselling for ICTC Counsellors Page 32 Annexure I Activity 1: Identities for piece of the sky (Please cut along the dotted lines and fold the same into small chits) Heterosexual married woman who is a house wife. Her husband works as a taxi driver ------------------------------------ ------------------------------------------------------ Heterosexual Hindu male, who is married, is an engineer and works in a government undertaking ------------------------------------ ------------------------------------------------------- Female sex worker who operates from a brothel ------------------------------------ ------------------------------------------------------- Hindu policeman who is single ------------------------------------ ------------------------------------------------------- MSM who works in a massage parlor ------------------------------------ ------------------------------------------------------- Gay man who works in a multinational company ------------------------------------ ------------------------------------------------------- Female IDU who is Catholic ------------------------------------ ------------------------------------------------------- Unmarried Muslim male who works as an embroider ------------------------------------ ------------------------------------------------------- Unmarried Hindu girl who is a teacher in a public school ------------------------------------ ------------------------------------------------------- Transgendered person who begs for a living ------------------------------------ ------------------------------------------------------- Manual on Advance Counselling for ICTC Counsellors Page 33 Transgendered person who works as a dancer in a dance bar ------------------------------------ ------------------------------------------------------- Home based female sex worker who is married ------------------------------------ ------------------------------------------------------- Muslim male who has migrated from his hometown, lives in Delhi and works at a construction site ------------------------------------ ------------------------------------------------------- Lesbian woman who works as a receptionist in a five star hotel ------------------------------------ ------------------------------------------------------- Male who is undergoing the sex reassignment surgery procedure and works in an NGO ------------------------------------ ------------------------------------------------------- Bisexual man who works as a watchman ------------------------------------ ------------------------------------------------------- Hindu male who works as a rag picker ------------------------------------ ------------------------------------------------------- Muslim girl who holds a doctoral degree and works as a professor in a university ------------------------------------ ------------------------------------------------------- Catholic female who works in a bakery ------------------------------------ ------------------------------------------------------- Parsi female who runs a boutique ------------------------------------ ------------------------------------------------------- Manual on Advance Counselling for ICTC Counsellors Page 34 List of questions for the facilitator: (Not to be photocopied) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Will you get a loan? Can you make your passport? Can you hold your lover’s hand in public? Can you go abroad for further studies? Can you marry your lover / lovers? Will you get respect in a public health setting? Can you adopt a child? Can you get a job in the government sector? Does your family know about your profession? If yes, is your family proud of your profession? Do you get promotions at your work place? Will you get medical insurance? Does the majority of the country celebrate your festivals? Can you afford an IVF? Can you contest in an election? Manual on Advance Counselling for ICTC Counsellors Page 35 Annexure 2 Plotting marginalization Heterosexual: An individual who is sexually attracted to people of a gender other than their own and/or who identifies as being heterosexual. Bisexual: An individual who is sexually attracted to people of the same gender and to people of a gender other than their own, and/or an individual who identifies as being bisexual. Homosexual: An individual who is sexually attracted to people of the same gender as their own, and/or who identifies as being homosexual. Asexual: An individual who is not sexually attracted to other individuals. Transgendered person: An individual who does not identify with her/his assigned gender. Transgendered people may or may not identify as homosexual, bisexual or heterosexual. For example transgendered people can be men who dress, act or behave as women do, but do not necessarily identify as homosexuals. Transsexual: An individual who wants to change from the gender they are born as to another gender. Surgery, hormonal treatments, or other procedures can be used to make these changes. People in this group may or may not identify as homosexual, bisexual or heterosexual. Intersexed person: An individual born with some or all physical characteristics of both males and females. They may or may not identify as men or women. Lesbian: A woman who is sexually attracted to other women and/or identifies as a lesbian. Gay: A man who is sexually attracted to other men and/or identifies as gay. This term can also be used to describe any person (man or woman) who experiences sexual attraction to people of the same gender. Queer: Those who question the heterosexual framework of identity and relationships. This can include homosexuals, lesbians, gays, intersexed and transgendered people as well as heterosexuals. To some this term is offensive, while other groups and communities have adopted it as a statement of empowerment to assert that they are against a dominant heterosexual framework, and dissatisfied with the labels used to categorise people on the basis of sexuality. Manual on Advance Counselling for ICTC Counsellors Page 36 Transvestite: An individual who dresses in the clothing typically worn by people of another gender for sexual arousal and gratification. Often transvestites are men who dress in the clothing typically worn by women. Female to male transsexual: A person born as a woman who wants to change her gender to become a man. Surgery, hormonal treatments, or other procedures may be used to make these changes. This individual may or may not identify as homosexual, bisexual or heterosexual. Male to female transsexual: A person born as a man who wants to change his gender to become a woman. Surgery, hormonal treatments, or other procedures may be used to make these changes. This individual may or may not identify as homosexual, bisexual or heterosexual. Married woman: A woman who is in a committed relationship with another person that is legally recognized by the state/country she lives in. Married man: A man who is in a committed relationship with another person that is legally recognized by the state/country he lives in. Unmarried woman: A woman who is not in a committed relationship with another person, which is legally recognized by the state/country, she lives in. Single person: A person not married or in any committed relationship with another person. Sexually active man: A man who engages in sexual activities. Sexually active woman: A woman who engages in sexual activities. Sex worker: A person who negotiates and performs sexual services for remuneration. Some use this term to mean only prostitution, while others use the term to refer to those in the sex industry such as porn actors, bar girls, striptease dancers, performers in peep shows, live sex shows etc. this is not the social or psychological characteristic of a class of women, but an income-generating activity or form of employment for women, men and transgendered people. Manual on Advance Counselling for ICTC Counsellors Page 37 [Source: TARSHI (2006).Basics and Beyond: A Manual for Trainers, India] Manual on Advance Counselling for ICTC Counsellors Page 38 Counselling People from Marginalised Groups ges Session Overview: Watching films and debriefing (30 minutes) Walk a mile in my shoes (Role play and counselling skills demonstration) (2 hours) Session Objectives: By the end of the session participants will be able to: Appreciate that people from marginalised groups are more similar to, than different from those in mainstream groups. Examine that how it feels to be part of the marginalised groups. Identify that the same set of skills is needed for counselling people from marginalised as well as mainstream groups. Demonstrate skills to counsel people from different marginalised groups. Time allowed: : 3 hours. Materials required: Time allowed: Fims from Visual Voices: : ‘Migration’ ‘68 Pages’ ‘Santi, Lucy and Thoibe’ OR ‘Shingnaba Challenge’ Handouts (2 each) for cases Manual on Advance Counselling for ICTC Counsellors Page 39 Method: Time prior to the Session: Preparation allowed: 1. A. (i). Watching films: : Participants watch all the films listed above on any of the evenings before the day this session is to be held. As an alternative, the films can be sent to the participants in advance and watched by them in their own time before coming for the training. Participants can be exempted from watching a film they have already seen (most have seen 68 pages). 2. B. (i). Debriefing of the films: minutes: The facilitator asks the participants the following questions: In the films that you saw, do you think some characters were marginalised and some advantaged? Do you think marginalisation places people at a higher risk for HIV? Why or Why not? Were any of your misconceptions clarified after watching these films? If yes, which ones? In any of the films, did you feel that any one character was at fault for the events that took place? Were the people or situations depicted in the films similar to the people you see in your work? What conflicts and struggles might a counsellor go through in working with people living with HIV/AIDS? How would you use the insights gained from these films to counsel your clients with regard to safer sex? The facilitator can ask the participants for a quick naming of the marginalised groups in the context of our work with HIV. The facilitator can inform the participants that the current session will be focussed on four marginalised groups: Men who have Sex with Men (MSM), Transgender persons (TG), Female Sex Workers (FSW), and Intravenous Drug Users (IDU). (ii). Walk a mile in my shoes: 2 hours: Having understood the different aspects of marginalisation in the previous session, in this session the participants practice counselling people from marginalised groups Notes to the facilitator: A. Each participant needs to practice counselling in this session. Please ask the participants to Page 40 take a moment and refresh the skills practiced in skill lab 1. Encourage them to very consciously apply the same skills in this session as well. B. The focus needs to be on practicing counselling skills and NOT on the acting of the ‘client’. C. Four groups need to be formed, Manual on Advance Counselling for ICTC Counsellors As mentioned in the note D above, the facilitator can ask the participants about which marginalised groups they feel most confident to deal with (from MSM, TG, FSW and IDU). The facilitator can ask which group each of them feels least comfortable / confident in dealing with. The facilitator can make 4 groups comprising of participants who feel least confident in dealing with that population. There can also be one group leader in each group who feels confident in dealing with that population. There may be some hesitation or anxiety among the participants in this way of forming groups. The facilitator can reassure them by saying that this is the opportunity to learn and that this is a safe space as we cannot do any harm to any real client by practicing here. The person who feels most comfortable in dealing with that particular marginalised group is the only one given one of the following cases, and is asked to get into the role, and come to the ICTC as a client. The other members of the group take turns to act as the counsellor. Each participant needs to act as a counsellor. While one person is acting as the counsellor, the others are to be very attentive and make a note of each skill that is being used by the counsellor. As soon as one participant (counsellor) begins to feel stuck, the facilitator signals to another participant from the same group to take over as a counsellor. The facilitator can be present right next to the counsellor to support them, but keep their intervention to the minimum. Manual on Advance Counselling for ICTC Counsellors Page 41 a. Sushma (aka Sushil) was taken to their community by the hijras who came for ‘toli badhai’ at the time of her birth. While her parents had told everyone she was born a girl, the hijras found out that she was born intersex. She is now in her mid-30s, lives with other hijras and goes for ‘toli badhai’. She says that toil badhai is not enough to survive on now and she has to resort to begging and sex work to make a living. When spoken to, she speaks in a ‘normal’ style, though she says she claps and threatens people at the traffic signals and local shops because that gets her more money. She has not undergone an HIV test, but is thinking about it. She misses her family sometimes, and cries a lot. She cannot go to meet them because she does not get permission from her Guru in the community. ------------------------------------------------------- --------------------------------------------------- b. Salman, 24, is the only child of educated parents working in a city. His parents brought him up with a lot of love and affection. They hoped that he will keep up the family pride through education, marriage and by bringing a descendant to carry forward the family name. The parents found him to be a very ‘good’ child who always respected and obeyed them, was focused in his studies and never ‘wasted’ time on girls. Salman completed his education and got a ‘respectable’ job in a company after his MBA. Salman knew from the time he was about 12, that he was different. He was never interested in girls, and found himself getting attracted to boys no matter how much he tried to stop himself or got punished or made fun of. He searched the net and found terms like homosexuality and gay, that helped him understand himself better. Once he came out to himself, he gradually came out to some of his childhood friends, who were initially surprised, but eventually accepted him. But when he came out to his parents, they were shattered. They cried everyday and urged him to not be so selfish so as to forget all they have done for him. They pleaded to him to get married and even arranged a few meetings with a few ‘good’ girls. He met them on parents’ insistence, but put his foot down that he will not marry a woman. He would be very upset to see his parents so distraught, but was sure it is impossible for him to ‘change’, and thus he did not want to cheat on a woman by marrying her. He has a few casual partners with whom he mostly practices safer sex, and sometimes under the influence of alcohol. He has never undergone HIV test, and believes he is negative. Upon his parents’ insistence he agreed to go with them to a psychiatrist, who told them that he cannot be changed as his sexual orientation (homosexuality) is ego-syntonic. His parents are upset that even a psychiatrist is unable to help them change their son. Salman is happy with his life and thanks God for blessing him with loving parents, a few good friends – gay as well as straight, and for all appreciation he gets at work. He hopes to find a partner and settle down with him and adopt a child. The only reason he feels sad is that his parents do not accept him as he is. He is part of the gay support groups and is trying to get his parents to attend some of the meetings where accepting parents of a few other gay people also come. He also hopes Manual on Advance Counselling for ICTC Counsellors Page 42 not only he but also his future partner are accepted by his parents and that he can take care of them in their old age. ----------------------------------------------------- -------------------------------------------------- c. Neetu is 26 years old and is 3 months pregnant. She has come to the ANC clinic for routine examination and is found to be HIV+. Both she and her husband were taking IV drugs. Her husband also had multiple sexual partners. Her husband was very controlling such that he did not allow her to go to the ICTC or for additional support from NGO. He did not also allow her to enrol for pre-ART registration. Her husband strictly objects visit by any facility center staff also. She is financially dependent on him as she was also not allowed to run a small shop which she was running earlier. -------------------------------------------------------- ----------------------------------------------- d. Priya is a 36-year-old married woman with 2 kids. She worked as a teacher before and soon after marriage, but left work because she wanted to give time to her children. They were then managing with the salary her husband got from his job at a private company. Priya was a very dedicated mother and loved to see her children growing well. Her husband had been rather supportive of her even when she had a few difficulties with her mother-in-law. Whenever she and her husband had fights, they would make up before the end of the day. About 7 years back her husband fell ill and gradually became bedridden. He lost his job. The doctors told them that his kidneys had failed due to which he needed dialysis. The medical procedure was an expensive one. It was very difficult for them to manage it with no income. Not knowing what else to do, she started giving sexual favours to her neighbourhood men for exchange of money. This was the only way she could spend enough time with her children and ailing husband as well as get some money for all the expenses including the husband’s treatment and children’s education. Her sexual partners also knew the reason she was doing sex work. One of them then suggested a brothel from where she could work as she would get more clients and more money there. She felt very sad thinking about it. But she decided to go ahead because the husband’s dialysis was now needed every week, costing about Rs 6000 each time. She had taken this decision with husband’s consent, but managed to still hide this from children. She would get her HIV test done periodically. Her present test result also shows she has no HIV infection. ---------------------------------------------------- Manual on Advance Counselling for ICTC Counsellors --------------------------------------------------- Page 43 Note: Each case is given to one and only one person in the group. The other members of the group do not know the case details before they see the role play. The details are given in each case description for the participant playing the client to get into the case. Each case starts only with a role play of a counselling session at the ICTC. It is up to the counsellor to elicit the client’s thoughts, feelings, and experiences. The facilitator needs to be supportive and proactive during the role plays and ensure that each participant practices being a counsellor. At the end of each role play and before starting the next one, the facilitator needs to give clear, specific and objective feedback. The feedback needs to start with what each ‘counsellor’ did well, what specific skills were used well, what more could have been done, and what could have been done differently. The feedback needs to star by asking the ‘client’ how they felt, followed by asking each ‘counsellor’ for feedback to themselves and other ‘counsellors’. Each role play should get over within 30-35 minutes, leaving about 10 minutes for debriefing. The final message that needs to be conveyed is that counselling with marginalized populations does not require a separate set of skills; the skills that were learnt and practiced in skill lab 1 are the same skills that can be used for counseling marginalized populations. The counselors just require an awareness and sensitivity to the dynamics of marginalization in general and to each marginalized group in particular. If a counsellor sees a client as a human being, just like any other human being, rather than focusing on their membership in the marginalized group, the task can seem much easier. Mental Health Aspects of HIV/AIDS Manual on Advance Counselling for ICTC Counsellors Page 44 Session Overview: Introduction to the session - 2 minutes To discuss the relevance of mental disorders in the context of HIV – 10 minutes Introduction to the meaning of mental health and mental illness – 15 minutes To discuss planning a referral to a mental health professional – 10 minutes Role plays – 90 minutes (or more) Orientation to the broad categories of mental disorders – As per the availability of time Session Objectives: At the end of this session, participants will be able to: Understand the meaning of mental health and mental illness Know the broad categories of mental disorders Understand the relevance of mental disorders in the context of HIV Plan a referral to a mental health professional Enhance competence in counselling for some common mental health problems in the context of HIV Time allowed: : 3 hours Material required: Time allowed: PPT slides and projector : White board markers Permanent markers Chart papers Handouts Method: Manual on Advance Counselling for ICTC Counsellors Time allowed: : Page 45 Preparation before the session: You as the facilitator: Send the PPTs, reading material, and the handouts to all the participants in advance, with instruction that ideally they need to go through it thoroughly Go through the same in advance Inform the participants that an essential reading is “When and how to make a referral to a mental health professional” Divide the participants into 4 groups. Each group needs to read and come one of the four handouts – Dealing with anger, dealing with anxiety, dealing with suicidality, dealing with sleep difficulties. These need to be covered by the participants. Make 2 copies of each case for role plays – one for the ‘client’ and one for the facilitator I. II. III. IV. Introduction to the session and going through the objectives (2 minutes) Introduce the session and read out the session objectives Introduce to the meaning of mental health and mental illness (15 minutes) Discussing the relevance of mental disorders in the context of HIV (15 minutes) Ask the participants “Can you think of how HIV and mental health may be linked?” and “Can you think of any cases where you saw this link?” (3-5 minutes) The PPT slides have a summary of the material sent to the participants. The participants are invited to share their thoughts on each factor as the facilitator goes over the slides. (10 minutes) Go over the slides To orient the participants to the broad categories of mental disorders (40minutes) THE FACILITATOR NEEDS TO KEEP A TAB ON THE TIME AND BE QUICK WITH THIS SESSION The facilitator can say that this session will be conducted by the participants by reading out the slides, as they have already read the material. Thus the participants need to be ready to come up quickly. The participants need to be informed that each of them will go over about 3-6 slides quickly. The facilitator can keep picking up chits of names of participants, and call them when the PPT slide indicates that another participant needs to be invited. V. To discuss planning a referral to a mental health professional – 10 minutes This section will be covered through participants answering questions. The first slide of the PPT has the questions, which the facilitator can ask the participants. The remaining slides have to be shown to the participants very quickly and only if needed, as they contain the answers to the questions asked in the first slide. Manual on Advance Counselling for ICTC Counsellors Page 46 VI. Role Plays Role plays need to be given adequate time, because they are likely to help enhance skills while most of the other things covered in the session can be learnt through reading. Call upon group 1. Give case study 1(to deal with the issue that group 1 has prepared) to a different group, and ask the ‘client’ to enact, while Group 1 counsels that client. This is so that the person / group acting as the counsellor remains oblivious to what the client will present, as it happens in the actual setting. Please note that the ‘client’ (and not the counsellor) can be handed over one of the cases. The client can summarise to the counsellor and the audience at the same time the brief information given there, so that time is not wasted collecting basic information. The client can be asked to add or make up more information as needed. The person acting as a counsellor can also be asked to write a referral note to a mental health professional if needed, but before that also demonstrate counselling skills. In the role play, the facilitator needs to be supportive to the person acting as counsellor and help if they get stuck. The other participants can also be invited to help if need be and if time permits. Tips to the facilitator: The facilitator needs to send the essential reading and the handouts to the participants in advance. This is especially important as the session duration is limited and the time can be utilized best only if there is some amount of familiarity with the various terms being used. There is a lot of stigma around mental illness. The facilitator needs to make sure to not make fun of mental illness or the mentally ill, and to gently dissuade the participants also from doing so. All the handouts except essential reading are likely to be helpful if the counsellor keeps them handy at their counseling desk. Case 1 for role play: To be handed over to the person acting as a client and NOT to the person acting as a counsellor The ‘client’ to summarise to the counsellor and the audience at the same time: “I am a married woman. I have recently come to the city from a village, where I studied up to 12th class. My husband works as an assistant to an electrician. I got to know that he has TB and HIV, and today I got to know that I also have HIV.” “I feel as if everything is over, as if there is no point living. I will die, my husband will die. No one in the village will accept me. I want to end my life (begins to cry).” Manual on Advance Counselling for ICTC Counsellors Page 47 Case 2 for role play: To be handed over to the person acting as a client and NOT to the person acting as a counsellor. The ‘client’ to summarise to the counsellor and the audience at the same time: “I am a 23-year old male. I had accompanied a friend for TB test, and got my HIV test also done when he was getting it. I was surprised to know that I was positive.” “After that, I have been finding it very difficult to sleep. I take a long time to fall asleep. This affects my work performance as a salesman at a shop, and makes me irritated.” Case 3 for role play: To be handed over to the person acting as a client and NOT to the person acting as a counsellor. The ‘client’ to summarise to the counsellor and the audience at the same time: “I am 36 years old. I have 2 children, and my husband works in an office. I got to know of my HIV 4 years back, and I have been on ART. “I sometimes feel so angry that I just cannot control myself. Because of this I sometimes hit my children and then I feel very bad and cry because I love my children a lot.” Case 4 for role play: To be handed over to the person acting as a client and NOT to the person acting as a counsellor. The ‘client’ looks very anxious, and summarises to the counsellor and the audience at the same time: “I am 34 years old. I have 2 young children, and I run a small business. I got to know of my HIV 2 years back, and I have been on ART. “I am very worried about what will happen if I die. I know that I will not die, but I get startled very easily, I keep thinking constantly about all the negative things, even though I try very hard not to. I just cannot be positive no matter how hard I try. I know I need to eat, but I do not feel like. I cannot concentrate on anything, and that is why my work is also affected. I love my family and I do not want to trouble them with my worries.” Implementing Behaviour Change Techniques Manual on Advance Counselling for ICTC Counsellors Page 48 Session Overview: Power Point lecture on transtheoretical model (15minutes) Nukad Naatak/ Skit & brainstorming (20 minutes) Hands on practice to measure readiness & confidence (20 minutes) Ambivalence to change-Exercise on cost benefit (20 minutes) Discussion on Preparation, Action, Maintenance and Relapse (25 minutes) Power Point lecture on the concept of Motivational Interviewing(20 minutes) Session Overview Exercise to practice art of motivational interviewing (40 minutes) Total Time: Three hours (180 minutes) Quiz for revision (15minutes) Developing reflective diary for take home message (05 minutes) Alternate methodology (instead of Nukad Naatak a small video clipping can be screened) Session Objectives: At the end of the session, the participants will be able to To measure the readiness & confidence of the client to change behaviour To examine the level of ambivalence to change To demonstrate the use of decisional matrix for cost- benefit analysis of targeted behaviour To practice the technique of stimulus control To practice the skills in Motivational Interviewing Time allowed: : 3 hours. Materials required: Time allowed: Power point presentation : Manual on Advance Counselling for ICTC Counsellors Page 49 Case studies for role Play/ Videos clips Cost Benefits sheet (As per participants) Readiness Ruler sheet (As per the number of participants) Confidence Scale sheet (As per the number of participants) Motivational Interview Guide (03sets= 01for facilitator, 01Demonstrating Participant, 01Training Institute) White board markers, Sheets, Flip chart Two chocolate for prize Method: Time allowed: : Opening session with question serves the following purpose: 1) It helps participants to understand that it is sometimes important to change the behaviour. 2) It helps facilitator to measure the involvement as well as viewpoints of participants about the topic. 3) It will help participant to see the relevance of the session. Lecture using PPT (15 minutes) Open the session with question on “why do we need to change our behaviour” (don’t take more than 2 minutes for this) Key points to emphasize Discuss different stages of transtheoretical model with exclusive emphasis on techniques in each stage. Through asking question make sure that participants have clear idea of each stage and the respective techniques. Ask participants to share their real life experience to reflect upon the stages & techniques of transtheoretical model in each stage Manual on Advance Counselling for ICTC Counsellors Page 50 Explain transtheoretical model of behaviour change with the help of slides given in ICTC Refresher module of NACO, 2011. Nukad Naatak/ Skit& brainstorming (20 minutes) 1. Ask three to four participants to volunteer to do the nukad naatak where they will perform a situation in which a person is in pre-contemplation stage. *Naatak can be derived from the Behaviour Change Story given in the ICTC refresher module of NACO, 2011 2. Naatak would be freezed at a significant point where the client is not even thinking Key points to emphasize Discuss how difficult it is to raise the consciousness level when person is in pre-contemplation stage. Talk about the point in naatak where the technique of dramatic relief, self-re-evaluation, and environmental reevaluation was used. Elaborate that reasons for pre-contemplation can fit into the "four R's": reluctance, rebellion, resignation, and rationalization. (DiClemente (1991) Reluctance – Not wanting to consider making changes due to lack of not being fully conscious of their behavior and its effects; being comfortable with where they are. Rebellion – Being argumentative and hostile towards the clinician; imagining that the therapist is a part of a coercive social control that is unwanted. Resignation – Given up on making changes that are desired but seem beyond the persons grasp. Rationalization – Not willing to change because they have somehow figured out that the problem is not theirs; having rationales for not changing; denial and minimization of problems are often common. As client may be strongly attached to these feelings thus it is very important for a counsellor to move tactfully from pre-contemplation to the stage of contemplation. about bringing about any change in his life. Facilitator would request any one participant to come over and play the role of a counsellor but he/she can use any one technique of behaviour change as mentioned in transtheoretical model. Thus the first person may demonstrate the technique of consciousness raising likewise other participant would come and demonstrate the techniques of dramatic relief, self-re-evaluation and environmental reevaluation. Facilitator would collect the feedback from larger audience and also ask them if the demonstrated techniques could better be used. 3. Finally the facilitator will cover up if any important point was left out. He would consolidate the learning about pre-contemplation and different techniques used to move a person from pre-contemplation to contemplation. Manual on Advance Counselling for ICTC Counsellors Page 51 4. Facilitator would explain that the most important and difficult stage for a counsellor is precontemplation. As in this stage client is either unaware or not at all thinking about any change. Thus for a counsellor it is imperative to gauge the level of readiness of the client. If counsellor gets clear idea of client’s readiness to change he/she may plan his/her session accordingly. He may also be able to decide upon when to move the client from one stage to another. 5. Say, for a counsellor it is also very useful to understand the level of confidence to change of the client. The low level means the client is though ready but not confident and on the other side extremely high level depicts over confidence which may be the result of over enthusiasm to change that may be temporary and cause slip back situation. In both the situations counsellor has to help the client to reach the desired level of readiness and confidence before moving ahead. Hands on practice to measure readiness & confidence (20 minutes) 6. Say that so for we have understood that it is very important for a counsellor to gauge the readiness & confidence of the client as this will help counsellor to match his/her pace with the client and help him/her (client) to understand the importance of change. Explain that counsellor can understand the level of readiness and confidence of the client to bring change with the help of readiness and confidence ruler. *See readiness & confidence ruler as Annexure1at the end of this chapter 7. Request three participants to volunteer. 1 counsellor, 1 client and 1 will write down the responses at white board/flip chart. 8. Facilitator would act as a counsellor and demonstrate the use of readiness scale & confidence ruler. One of the participants would play the role of client. The client would be given a precontemplation situation to perform. The larger group would be given a copy readiness scale and confidence ruler. As per the response of the client each participant would mark the levels in scale and ruler. *See readiness & confidence scale as sample questions as Annexure Key points to emphasize 1 at the end of this chapter Explain the interpretation of levels in the scale and ruler. The session for someone in the precontemplation stage should focus more on feedback in order to motivate the client to take action. Providing some information about the hazards of continuing the targeted behaviour may be beneficial Manual on Advance Counselling for ICTC Counsellors Page 52 9. Say that with this exercise we can understand the importance of measuring readiness and confidence to change. As we have seen that though the client was ready to change but at the same time having some doubts and fears which could only come on the surface when the counsellor tried to know the level of readiness. Once counsellor gets clear idea of client’s doubt, fears and confusions then only he can help the client to move from pre-contemplation to contemplation. As the readiness is the foundation stone for confidence to change target behaviour thus giving client appropriate time while measuring readiness is vital. When client comes to counsellor and shows his/her readiness to change with some level of confidence he presents a situation of ambelivence where he/she is confused between pros and cons of behaviour change. In this stage though the client has started to contemplate but still not able to take decision with confidence. At this point when client has started to contemplate but not able to take decision counsellor may help his/her client to reduce or erase the doubts and fears. 10. Say that counsellor can help his/her client through making decisional matrix with his/her clients. With the help of matrix client can understand the short and long term cost and benefits of any behaviour. This exercise can help client realize the cost of any behaviour over benefits. Ambivalence to change-Exercise on decision matrix for cost benefit (20 minutes) Key points to emphasize Explain that this exercise would help counsellor as well as client to understand the ambivalence to change and also reasons to stay in a pre-contemplation stage or to move to the stage of contemplation. It will also help in making decisional balance. Before moving ahead briefly explain the concept of ambivalence. (See Annexure2 for Ambivalence) Manual on Advance Counselling for ICTC Counsellors Page 53 11. Ask participants to make pairs. Give each pair a copy of decision matrix for cost benefit sheet. Explain that one person in each pair would administer this sheet on his/her partner. The person administering the sheet would ask his/her partner to share/imagine behaviour which people perceive as risky/harmful for him/her but he/she does not. 12. Person administering the sheet would fill it as per the response of her/his partner. *See Decision matrix sheet for Cost Benefit as Annexure 3 at the end of this chapter 13. Randomly ask 4-6 participants to share their sheets. Ask both the administering person as well as her/his partner to share briefly whether this exercise helped them to understand the problem behaviour and also the ways to contemplate. 14. Write down their responses on white board/ flip chart. Take the common points and make a consolidated list to make a point that how one may be moved from pre-contemplation to contemplation stage if proper analysis of cost and benefits of certain behaviour is made. Discussion on Preparation, Action, Maintenance and Relapse (25 minutes) 15. Before moving ahead briefly revise the topics covered. Ask participants about readiness to change importance of confidence scale and cost benefit matrix. Clear, if any doubt arises. Preparation Stage Explain that so far we have understood that how we can move a client from precontemplation to contemplation stage. Now we will try to understand what we can do with client in preparation stage. Key points to emphasize Remind participants that counsellors can use the process of self-liberation to help people to move from the early stages of behaviour change to actual action. Self-liberation is both a belief that one can change as well as a strong commitment to the change process. Some ways of using this particular process of change include Manual on Advance foraICTC Counsellors linking change with clearCounselling dates, ensuring personal sense of efficacy with regard to the change process andPage 54 offering the client more choices. With regard to the last suggestion, research shows that people are more likely to be positive when presented 16. Remind them about the technique of self- liberation. Ask participant to quickly explain the technique of self-liberation. Say that to harden the decision of client taken in the previous stage (contemplation) it is useful to make client realized that he has been successful in overcoming his thought of not able to change the targeted behaviour. Now he is quite determined to go for preparation to take some action. This feeling of travelling from unawareness to awareness and from contemplation to preparation helps the client liberate himself from state of ambivalence to clear mind set about the action. Here the feeling of selfliberation takes place. Client has now released himself from doubts and eager to get prepared to take some action. At this stage it becomes essential to help client self-reflect upon his own self. This self-reflection may help him to take confident steps in later stages of action and maintenance. Counsellor can help his/her client to take firm decision to take action. Counsellor needs to help client in realizing that he has made some steps that he has never thought of before. He may also talk to the client about his/her action plan for future. For this Self Reflection format can encourage the client to do desired preparation and thereby action. *See self reflection format as Annexure 4 at the end of this chapter 17. Brainstorm with participants (counsellors) on how they can help their clients in the preparation stage. Give them an example of a MSM client of 23 years of age who is having multiple partners and did not use condom (pre-contemplation) in any sexual encounter and now after several counselling sessions he has started thinking about using condom. Manual on Advance Counselling for ICTC Counsellors Page 55 Key points to emphasize Sa It is significant to reinforce the decision of the client to make change. Counsellor can help the client in taking small initial steps. Counsellor can provide free condom in case client feels hesitant in buying condom from the shop. Counsellor can also talk about any myths & misconceptions client may be having about using condom. Client may be informed about social marketing of condom under which one can get condom with out any embarrassment from the vending machines. Counsellor can give information about the locations of such vending machines. (Sulab Shauchalaye (Public Toilets), Paanwaala, Petrol Pumps, TI NGOs etc) Action Stage 18. Facilitator may start talking about action stage with small brainstorming on why is action so difficult-make a list and why is action so easy-make a list. This will help participants to understand that sometimes talking about action help in generating good action plan. 19. Explain that in the action stage it is very significant to do proper monitoring of the daily activities of the client this may reduce the chances of slipping back to previous stage. To further harden understanding give them the following situation: Situation: Suppose you are a counsellor and you have a positive client who is on ART for last few months. Because of your counselling he is adhering to the dosages but he is careless about his eating habits which sometimes cause a lot of health problem like lose motion, fever etc. Counsellor has so far been successful in making him understand the importance of nutritional diet but it has been observed that client is not having any concrete action plan to bring desired change. 20. Say here your goal as a counsellor is to help client make action plan on the above given situation. 21. List down all the important points and fill gaps through explaining points not clear to participants. You may say that, counsellor after collecting all the necessary information about client’s daily eating habits may help the client to prepare a time table to correct client’s eating time. Counsellor Manual on Advance Counselling for ICTCmay Counsellors also help his client in developing nutritional diet chartPage which56 may be categorized into Breakfast, Lunch and Dinner Alternate Methodology: Draw a blank diet chart or time table on flip chart and fill it as per the responses of participants. Help participants to be relevant and specific to prepare an effective chart or time table. Maintenance 22. Remind participants about the stage of maintenance. Randomly ask participants to summarize the concept of maintenance in transtheoretical model. Key points to emphasize Say that people in the maintenance stage have been successful in sustaining their changed behaviours for a period of 6 months. They become less susceptible to thoughts of relapsing – of returning to the earlier behaviour. Talk about different techniques for this stage: Stimulus control, counter conditioning and contingency management. Suggestion: Resource person can read more from NACO Refresher module, 2011. Also discuss why people slip back? And role of ongoing support & follow up in maintenance? (Please see point No.27 for people slip back.) 23. Say that we can help as a counsellor our client to identify and control cues that remind him/her of risky behaviour. Such control of environmental cues is called stimulus control. 24. Say, if I am an IDU can you help me identifying the potential the stimulus that I need to control to remain in maintenance stage. 25. Jot down the responses on flip chart. Make two columns. Write Stimulus in part and strategies to control in the other. Manual on Advance Counselling for ICTC Counsellors Page 57 Example: Why people slip back (Stimulus Control) Stimulus Control Strategies In the case of IDU who is getting back to drug use Make new friends Old peers Drug peddler Avoid/ change the way where they may possibly catch him Occasions/ parties where it may Evade/ get engaged in some important work the same day. Withdrawal Use counter conditioning techniques like: go for OST as substitution of the drug, or less harmful drug like cigarette etc. In the case of MSM who is slipping back from safe sexual practices Partner does not like condom use It is not easy to use condom as we need extra lubricant to use it Lubricant is not cheaply available & we don’t have money In the case of FSW who is slipping back from the use of condom I am losing my clients It is difficult to make clients use condom I am growing old so I am losing my negotiating power to use condom 26. After filling the table for IDU ask participants to fill the table for MSM & FSW. Help participants to be focused on slip back only which means client was practicing the desired behaviour but now slipping back to risky behaviour. 27. Say that it would be very useful if counsellor can make such table with his/her client. This will help both client as well as counsellor in identifying the potential reasons to relapse and also the strategies to control the relapse. Here also talk about contingency management as a process of reward and punishment to ensure successful maintenance of behaviour change. 28. Finally talk about the possibility of relapse. Manual on Advance Counselling for ICTC Counsellors Page 58 Key points to emphasize Explain that to reduce the possibility of relapse, counsellors must work with clients to identify and avoid potential pitfalls. This is termed relapse maintenance. It involves the skill of anticipatory guidance where the counsellor informs the client about potential dangers ahead (e.g., based on experience with other clients.) Suggestion: Resource person can read more from NACO Refresher module, 2011 29- Say that so far we have understood all the stages of transtheoretical model of behaviour change. We have also understood how we can move from one stage to another stage of change. We have learned that there are some techniques specific to each stage. Now it is significant to understand that how the counsellor can keep his/her client motivated through all the stages of change. No matter the client is in which stage the role of counsellor is to interact with his/her client in a manner that client should not slip back. Thus to ensure the constant motivation it is very useful for a counsellor to practice the skill of motivational interviewing. Power Point lecture on the concept of Motivational Interviewing (20 minutes) Key points to emphasize Explain that motivational interviewing is defined as ‘A directive, client -centered counseling style for eliciting behaviour change by helping clients to explore and resolve ambivalence.’ (Rollnick and Miller, 1995) “Motivational interviewing has been practical in focus. The strategies of motivational interviewing are more persuasive than coercive, more supportive than argumentative. The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments” (Miller and Rollnick, 1991, pp. 51-52). The four principle strategies of MI are: 1. Get a conversation going - express empathy through reflective listening. 2. Develop discrepancy between clients' goals or values and their current behaviour. 3. Avoid argument and direct confrontation and adjust to resistance rather than opposing it directly. 4. Support self-efficacy and optimism. (Please see Annexure 5 for more details on Motivational Interviewing) clarity you can also talk about FRAMES. (Please see Annexure 6 to learn about 30- ExplainFor thatmore to bring about desired change in the behaviour of the person it is very important FRAMES. to keep the client motivated. To keep the client motivated empathetic, client centred and nonconfrontational approach is required. This approach is called a Motivational Interviewing Manual on Advance Counselling for ICTC Counsellors Page 59 (MI). With the help of PPTs and reference material on MI explain in brief the concept and relevance of MI in Transtheoretical model of behaviour change. Exercise to practice skill of motivational interviewing (40 minutes) 31- Having explained the concept of motivational interviewing request two of the participants to volunteer to demonstrate the skill of motivational interviewing. 32- One of the two participants would play the role of a client and other of counsellor. 33- Counsellor would be given strategies & principles for MI. Facilitator would explain it to counsellor. *See strategies& principles for MI with sample questions as Annexure 4 at the end of this chapter 34- Client would be given a case study to role play. Make sure that counsellor should not know the case given to the client. Facilitator would explain the following case to the client: Case: Raveena is a 20 years old FSW. She lives in a brothel where she entertains on an average 07 client a day. She is also having one babu (regular partner). For last few months she is having lower abdominal pain and heavy discharge. She believes that she will lose her clients if she asks them to use condom. 35- Ask counsellor to use the skills of motivational interviewing. Say you have to go step by step covering all the stages of transtheoretical model using techniques relevant to the given case. 36- Facilitator would take feedback from larger group first and then consolidate the session by filling gaps. Alternate Methodology: Facilitator may choose three counsellors from participants whereas the client would be the same. First counsellor would demonstrate the use of MI skills in pre-contemplation and contemplation stage Second would move client from preparation to action stage and the Third counsellor would help the client in the maintenance and relapse stage. (Use the same case as given above) 37- Facilitator would observe the session and make sure that the MI principles are being followed. Once the session gets over facilitator would ask participants to respond to the role played. The relevant responses would be jotted down on flip chart/white board to consolidate the important points about MI. Quiz to sum up (15minutes) Manual on Advance Counselling for ICTC Counsellors Page 60 38- To consolidate the important points conduct a quiz. To create a competitive environment divide participants into three team. Say each correct answer carries 10 points and wrong answer would take away your 5 points, so be careful. The team which after seeing the question say “Bingo” first will get the opportunity to answer. If the first team fails to answer then it will pass the question to any of the two teams. Winner team will get the prize. *Please See sample question with answers as annexure 7 Developing reflective diary (05 minutes) 39- To ensure the take away messages give participants a sheet called reflective diary. Explain it to participants and help them to fill it. This will help them to develop a list of points to be remembered while practicing transtheoretical model Please see annexure-8 for reflective diary Annexure-1 Manual on Advance Counselling for ICTC Counsellors Page 61 The Readiness Ruler A simple way to find out how important the client thinks it is to change his/her behaviour is to use the ‘readiness ruler’. This is just a scale with gradations from 1 to 10, where 1 is “not at all important” and 10 is “extremely important”. Client may be asked to rate how important it is for him/her to change behaviour. Counsellor the client: Questions to measure Readiness: (These questions are just an example, counsellor needs to ask question as per the situation) Counsellor: So would you like to share with me your reason to come here? Client: Yes, I am into injecting drug use & I have heard that you can help me get rid of this addiction!! Counsellor: It is very good that you want to get rid of your habit of injecting drugs. But here I would like you to answer few of my questions, may I ask you some questions: Client: Sure!! Counsellor: How important is your drug use for you? On a scale of 01 to 10 (1=not important and 10= extremely important) Client: I would say 05 Counsellor: Why 05 any specific reason. Client: Yes, I am ready to get rid of this habit but I feel relaxed when I take it and free from worldly tensions, thus I feel it is important for me. Counsellor: I can understand that it takes you away from the worldly tensions. Client: Yes.. Counsellor: But you are still ready to change this behaviour, right? Client: yes.. Counsellor: I must say you have thought of taking step which very few people dare to take.. if I ask about the level of your readiness to change on 1-10 scale where do you see yourself.. Client: 06 Counsellor: I must say you have strong will power as you have given yourself 06 out of 10 but may I know if there is any reason that you set your level of readiness at 06. Client: Yea!! Actually I love my family and with this habit my family has to look down in the society.. Counsellor: I really appreciate your respect and care for your family. I am sure very soon you will be able to get rid of your drug addiction.. Please see the Readiness ruler below :( The readiness ruler is not necessarily be developed by the counsellor while doing counselling rather it is a way a counsellor can measure the readiness of the client. 1 2 3 4 5 not ready to change unsure Pre-contemplation Contemplation Stage Stage 6 7 ready to change Preparation Stage 8 9 10 trying to change Action Stage According to Miller’s ‘Readiness Ruler’ the client’s scale of response from 1 to 10 reflects their readiness to change as follows: 1 - 3.5 = not ready to change 3.5 - 5.5 = unsure 5.5 - 8.5 = ready to change Manual on Advance Counselling for ICTC Counsellors Page 62 8.5 - 10 = trying to change The readiness ruler can be used at the beginning of a counselling session to help gauge the client’s stage of change or it can be used during the intervention as a way of encouraging the client to talk about reasons for change. The confidence ruler The confidence ruler can be used with clients who have indicated that it is important for them to make a change, or it can be used as a hypothetical question to encourage clients to talk about how they would go about making a change. Counsellor may ask the following questions: Questions to measure confidence: (sample questions) Question: How confident are you about changing? Or how confident are you that you can cut down or stop your substance use on a scale of 1-10 - (1 = not confident, 10 = very confident) Question: Why did you score yourself so high/low? Question: What would help to move you higher on the scale? Question: How high on the scale would you need to be to change? 1 2 3 Not at all confident 4 5 6 7 8 9 10 Extremely confident It is not necessary to use this visual tool, but it may be helpful, especially for clients with low literacy or innumeracy. For some clients, it may be enough to describe the scale using words. Having asked the scaling question, if they answer 7 or below, ask about the things that may prevent them from taking their next step. Ask what would have to be different for them to take action. Annexure-2 Manual on Advance Counselling for ICTC Counsellors Page 63 Ambivalence Regardless of their theoretical model, effective counsellors must find ways to manage the ambivalence they will encounter with clients. (Auld, Hyman, & Rudzinski, 2005). Ambivalence is the painful experience of feeling stuck between polarized feelings about an idea, a thing, or a person. At the core of resistance is ambivalence (Stark, 2002), the experience of having simultaneously occurring feelings about an idea, a thing, or a person. This term was coined in 1911 by Eugen Bleuler to capture this internal juxtaposition of polarized feelings. Graubert and Miller (1957) discuss Bleuler’s thoughts as follows: Ambivalence [according to Bleuler] is a phenomenon whereby pleasant and unpleasant feelings simultaneously accompany the same experience. A mother, who laughs while speaking about the child she has murdered, presents the phenomenon of ambivalence. There are two different feelings about her act, which she cannot bring to a logical conclusion. A patient who protests that he wants to leave the ‘asylum’ and does not do it, even if invited to do so, is also ambivalent, says Bleuler. There is a ‘rift between the two thoughts or the two feelings.’ The ‘idea of leaving remains governed by two ideas, contradictory and unconnected. Ambivalence can simply be defined as experiencing multiple feelings about one’s situation. Such ambivalence can be the very phenomenon that keeps individuals trapped in addictive behaviors (e.g., substance abuse, eating disorders) and sometimes destructive and painful situations (e.g., IPV). Removing ambivalence is likely to greatly enhance a woman’s ability to break free of an abusive situation with an intimate partner. Motivational interviewing (MI) has been found to be effective in removing ambivalence and increasing an individual’s confidence in his or her ability to make positive changes in his or her life (Miller & Rollnick, 2002; Wahab, 2005). Annexure-3 Manual on Advance Counselling for ICTC Counsellors Page 64 Decision matrix sheet for Cost Benefit: Short Term Benefits Long Term Benefits Scores Benefits Cost The decision matrix helps you to weigh the benefits and costs of a given behaviour by scoring them and comparing scores. You can change the parameters to suit your client's situation. Ask your client to fill in the boxes with various benefits and costs, in the short and long-term, and then ask your client to score each on a scale of 1-10, based on their relative importance (higher scores mean greater importance). If the score for the benefits of change is higher than that of the costs of change, your client will hopefully recognize that changing his/ her behaviour may be ideal. However, if the score for costs is higher, then that may mean that your client is not willing to make a change at this time. Below is an example of a filled decision matrix that weighs the costs and benefits of Using injecting drugs: Benefits Cost Short Term Benefits Helps me relax (6) Enjoy drinking with friends(7) Could lose my family (8) Bad example for my children (8) Damaging my health (3) Spending too much money(3) Long Term Benefits Forget my problems (4) Score 17 Impairing my mental ability (3) Might lose my job (5) Wasting my time/life (2) 32 Annexure 4 Manual on Advance Counselling for ICTC Counsellors Page 65 Self- Reflection Format Target Behaviour: Condom Use Why I was not thinking to change the target behaviour Why I decided to change It will reduce pleasure my I came to know that it will be the same pleasure if I use it properly I have sex with known I have realized that people even the known people may have sex with others. She may get pregnant if I don’t use. I feel burning if I use Condom never causes it burning. Changing brand can help me I don’t think it will It can save me from make any difference infections Buying condom is not It available at all shops comfortable and one can buy it without any problem. Besides, Govt. provides it at concessional rate through vending machines. It is also freely available at different outlets like public toilet, paanwaal, NGO centres etc. What I did to get ready for change What will I do in future I made up my mind to I will use it in all my sexual give it a try encounter I bought condom even I would make sure that I will for known people. use condom even with regular and known partners. I bought condom of I felt that changing condom different brand brand has really helped me. Now I don’t feel any burning I enjoyed more while I will make sure that I use it in using it as I knew that I every encounter will not get exposed to any kind of infection now. Knowing condom I As it’s easily available so I took it from vending would continue using it in machine at petrol future. pump. It was embarrassment free and I had no problem in getting it from there. Annexure-5 Manual on Advance Counselling for ICTC Counsellors Page 66 Motivational interviewing Motivational interviewing (MI), originally described by Miller in 1983 and more fully discussed in a seminal text by Miller and Rollnick in 1991, has been used extensively in the addiction field (Dunn, Deroo, & Rivara, 2001; Noonan & Moyers, 1997; cit. in. Resnicow.K, Dilorio.C, E.Soet.J, Borrelli.B, Hecht.J, Eenst.D, 2002). There has been considerable recent interest on the part of public health, health psychology, and medical professionals in adapting MI to address other health behaviors and conditions, such as smoking, diet, physical activity, screening, sexual behavior, diabetes control, and medical adherence (Emmons & Rollnick, 2001; Resnicow, DiIorio, et al., 2002; cit. in. Resnicow.K, Dilorio.C, E.Soet.J, Borrelli.B, Hecht.J, Eenst.D, 2002) Motivational interviewing (MI) is a client- centered strategy designed to elicit behavior change by assisting clients to explore and resolve ambivalence to change (Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: Guilford Press; 2002. 73. & Miller WR, Rollnick S. Motivational interviewing: Resources for clinicians, researchers, and trainers. Motivational Interviewing Web site. http://www.motivationalinterview.org/index.shtml. Updated August 1, 2006. Accessed August 27, 2008, cit. in. JOANNE M. SPAHN, MS, RD, FADA; REBECCA S. REEVES, DrPH, RD, FADA; KATHRYN S. KEIM, PhD, RD, LDN; June 2010) MI is neither a discrete nor entirely new intervention paradigm but an amalgam of principles and techniques drawn from existing models of psychotherapy and behavior change theory. MI can be thought of as an egalitarian interpersonal orientation, a client centered counseling style that manifests through specific techniques and strategies. A key goal of MI is to assist individuals to work through their ambivalence about behavior change, and it appears to be particularly effective for individuals who are initially low in terms of readiness to change (Butler et al., 1999; Heather, Rollnick, Bell, & Richmond, 1996; Miller & Rollnick, 1991; Resnicow, Jackson, Wang, Dudley, & Baranowski, 2001; Rollnick & Miller, 1995 cit. (Resnicow.K, Dilorio.C, E.Soet.J, Borrelli.B, Hecht.J, Eenst.D, 2002) The fundamental premise for motivational interviewing is that patients are often ambivalent to change, and ambivalence affects a patient’s motivation and readiness to alter behavior. The “motivational” part of the term underscores the fact that motivation is fundamental to change. An individual must be ready, willing, and able to change. The word “interviewing” differentiates this method from treatment or counselling and enables patients and providers to examine events together. The concept can be likened to two people sitting side by side, paging through an album of Manual on Advance Counselling for ICTC Counsellors Page 67 family pictures. The storyteller turns the page; the listener wants to learn and understand and, as such, may ask questions. Motivational interviewing focuses on an individual’s current interests and concerns, respects and honours a person’s autonomy to choose his or her own care, and is a collaborative, not prescriptive, approach in which the counsellor evokes the person’s internal motivation and resources for change. The key principles of motivational interviewing can be described by the acronym READS: roll with resistance, express empathy, avoid argumentation, develop discrepancy, and support self-efficacy. In motivational interviewing, the provider does not directly oppose resistance or argue the point with a patient, but rather rolls or moves with it. Motivational interviewing is like dancing: rather than struggling against each other, the partners move together smoothly. (CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN, 2005) Research indicates that MI is particularly useful with clients who are less motivated or ready for change, and who are more angry or oppositional. For these populations, action-oriented counselling with a goal of behaviour change is likely to evoke resistance and reactance. From a Transtheoretical perspective, this happens because of a mismatch in stages of change: The counsellor is working at the action stage, whereas the client is in the earlier pre-contemplation or contemplation stage (Prochaska & DiClemente 1984; cit. (Hettema.J, Steele. J, and Miller.W.R, 2005). Other studies find that use of MI in HIV/AIDS intervention on one-one and with group resulted in promoting ART adherence and safer sex practices in HIV positive men & women. Holstad MM (2011) & (Holstad MM, 2012) Study conducted by Golin CE,( 2012 ) reveals the individualized nature of MI allows the counsellors to target each client’s unique needs and behaviours. Another study by Yeagley EK, (2012) concludes that MI is collaborative and patient-cantered, and it incorporates both assessment and intervention within each session. Furthermore, developing proficiency in MI does not require advanced training in psychology or counselling. Traditional patient counselling has not been consistently effective and new interventions to improve adherence to medications are needed. Motivational interviewing is a patient-cantered method that can be used to improve medication adherence. (CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN, 2005) I-Strategies of motivational interviewing Manual on Advance Counselling for ICTC Counsellors Page 68 O.A.R.S: Open-Ended Questions • Open questions gather broad descriptive information • Facilitate dialogue • Require more of a response than a simple yes or no • Often start with words like “how” or “what” or “tell me about” or describe” • Usually go from general to specific Affirm • Must be done sincerely • Supports and promotes self-efficacy • Acknowledges the difficulties the client has experienced • Validates the client’s experience and feelings • Emphasizes past experiences that demonstrate strength and success to prevent discouragement Reflective Listening • Reflective listening begins with a way of thinking • It includes an interest in what the person has to say and a desire to truly understand how the person sees things • It is essentially hypothesis testing • What do you think a person means may not be what they mean Repeating – simplest Rephrasing – substitutes synonyms Paraphrasing – major restatement Reflection of feeling – deepest Summarize • Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on to another stage. • Summaries can link together client’s feelings of ambivalence and promote perception of discrepancy II-Motivational Interviewing 4 Principles Express Empathy • Acceptance facilitates change • Skilful reflective listening is fundamental to expressing empathy • Ambivalence is normal Develop Discrepancy: This is accomplished by thorough goal and value exploration • Help the client identify own goals/values • Identify small steps toward goals • Focus on those that are feasible and healthy • When substance use comes up explore impact of substance use on reaching goals/consistency with values • List pros and cons of using/quitting (decisional balance/payoff matrix) Manual on Advance Counselling for ICTC Counsellors Page 69 • Allow client to make own argument for change Roll with Resistance • Avoid argumentation Human beings have a built in desire to set things right (righting reflex) When the righting reflex collides with ambivalence, the client begins defending the status quo If a person argues on behalf of one position, he/she becomes more committed to it • Resistance is a signal to change strategies Support Self-Efficacy • Express optimism that change is possible • Review examples of past successes • Use reflective listening, summaries, affirmations • Validate frustrations while remaining optimistic about the prospect of change Source: Miller and Rollinick, Motivational Interviewing: Preparing People for Change, Guilford Press 2002. Examples of motivational interviewing techniques I: When the client is in a pre-contemplation stage (e.g., when the client is not considering change–“Weight is not a concern for me”) Goals: 1. Help client develop a reason for changing 2. Validate the client’s experience 3. Encourage further self-exploration 4. Leave the door open for future conversations 1. Validate the client’s experience: “I can understand why you feel that way” 2. Acknowledge the client’s control of the decision: “It’s up to you to decide if and when you are ready to make lifestyle changes.” 3. Repeat a simple, direct statement about your stand on the medical benefits of making change “I believe that your behaviour of injecting drug use is putting you at risk for HIV & Hepatitis. Making some lifestyle and behavioural changes could help you get rid of this risk , and improve your health substantially.” 4. Explore potential concerns: “Has your addiction created difficulties in your life?” “Can you imagine how your addiction might cause problems in the future?” 5. Acknowledge possible feelings of being pressured: “It can be hard to initiate changes in your life when you feel pressured by others. I want to thank you for talking with me about this today.” 6. Validate that they are not ready: “I hear you saying that you are not ready to bring change right now.” 7. Restate your position that it is up to them: Manual on Advance Counselling for ICTC Counsellors Page 70 “It’s totally up to you to decide if this is right for you right now.” 8. Encourage reframing of current state of change–the potential beginning of a change rather than a decision never to change: “Everyone who’s ever got rid of injecting drug use starts right where you are now; they start by seeing the reasons where they might want to leave the habit. And that’s what I’ve been talking to you about.” II: When the client is in a contemplation stage (e.g., when the client is ambivalent about change - "Yes my addiction is a concern for me, but I’m not willing or able to begin changing this behaviour within the next month.") Goals: 1. Validate the client’s experience 2. Clarify the client’s perceptions of the pros and cons of attempted change in behaviour 3. Encourage further self-exploration 4. Leave the door open for moving to preparation 1. Validate the client’s experience: “I’m hearing that you are thinking about bringing change in your behaviour but you’re definitely not ready to take action right now.” 2. Acknowledge client’s control of the decision: “It’s up to you to decide if and when you are ready to make lifestyle changes.” 3. Clarify client’s perceptions of the pros and cons of attempted behaviour change: “Using this decisional matrix, what is one benefit of bringing? What is one disadvantage/cost of changing behaviour?” 4. Encourage further self-exploration: “These questions are very important for beginning a successful behaviour change. Would you be willing to finish this at home and talk to me about it at our next visit?” or you would like to talk to me right now. 5. Restate your position that it is up to them: “It’s totally up to you to decide if this is right for you right now. Whatever you choose, I’m here to support you.” 6. Leave the door open for moving to preparation: “After talking about this, and doing the exercise, if you feel you would like to make some changes, the next step won’t be jumping into action – we can begin with some preparation work.” III: When the client is in a preparation stage (e.g., when the client is preparing to change and begins making small changes to prepare for a larger life change – “My addiction to injecting drug use is a concern for me; I’m clear that the Manual on Advance Counselling for ICTC Counsellors Page 71 benefits of attempting to change outweigh the disadvantages/cost, and I’m planning to start within the next month.”) Goals: 1. Reinforce the decision to change behaviour 2. Prioritize behaviour change opportunities 3. Identify and assist in problem solving 4. Encourage small initial steps 5. Encourage identification of social supports 1. Reinforce the decision to change behaviour: “It’s great that you feel good about your decision to make some lifestyle and behaviour changes; you are taking important steps to improve your health.” 2. Prioritize behaviour change opportunities: “Looking at drug addiction, I think the biggest benefits would come from switching from injecting drug use to non-injecting (use risk reduction techniques). What do you think?” 3. Identify and assist in problem solving: “Have you ever attempted to get rid of this addiction? What was helpful? What kinds of problems would you expect in making those changes now? How do you think you could deal with them?” 4. Encourage small, initial steps: “So, the initial goal is to try some substitutions” 5. Assist client in identifying social support: “Which family members or friends could support you as you make this change? How could they support you? Is there anything else I can do to help?” Source: These scripts were developed by the UCLA Center for Human Nutrition, and are available at http://www.cellinteractive.com/ucla/physcian_ed/scripts_for_change.html IV: When the client is in an Action stage Client in the action stage are ready to make an initial attempt to change their behaviors, but may not be confident yet about their abilities to succeed. Your goal is to decrease the barriers to change. ENCOURAGE progress “I’m impressed with what you’ve been able to achieve.” “On a scale of 1-10, where were you before? And now?” “A 7 is great. You’ve come a long way compared to the 2 where you were when you started.” “Is a 7 where you want to be right now? If not, what would it take to get you to 10 (or 9 if that is the patient’s desire)?” Manual on Advance Counselling for ICTC Counsellors Page 72 Self Monitoring: “Would you be willing to keep track of how you take your medications for a week? This will help us see any patterns that could indicate when you have trouble remembering your pills.” Past Successes: “What strategies have worked for you in the past?” “Tell me about the last time you were able to use a condom.” Optimism: “What’s different now that makes change possible?” Explore Extremes: “What’s the best/worst thing that might happen when you start using this plan? What is the likelihood it will happen?” Commitment: “Where do you stand on this issue, at least for today?” Decision Making: “Which of those ideas might you be ready to try?” “Do any of these ideas to decrease your drug use sound possible for you?” Autonomy: “You are in charge – no one is going to go home with you to check on your progress.” “You can decide whether you want to do this.” REDUCE barriers “What has worked best so far?” “How can you improve that idea?” “Here are some resources that will help you (plan nutritious meals, develop a schedule for taking your medication, etc).” “How can I help you get past this?” RESTRAIN excessive change “It’s better not to change too many things all at once. How can you take a small step in this direction?” “Where is the best place to start?” “What do you think you can do to improve your health this week?” V: When the client is in Maintenance stage Patients in the maintenance stage have succeeded in changing a behavior, and have sustained the change for at least 6 months. Your goals are to: Help the patient stay focused, and Reduce the chance of a relapse. PREDICT ups and downs “It is not unusual for people who have changed behaviour to occasionally move backwards. This is normal. If you know this can happen, you can be prepared to deal with it.” “A lapse is not a relapse.” Manual on Advance Counselling for ICTC Counsellors Page 73 ENLIST support “Is there anyone who can remind you to take your meds?” “What other activities can help you stay away from the bath house?” “Are you ready to share your success with others?” PLAN ahead “What situations do you think may make it hard to maintain your new behaviour? How do you think you will handle them?” Set a follow -up: “When can we meet again to see how things are going?” RELAPSE: Relapses are a normal and expected part of the process of change. When one occurs, you have an opportunity to help the patient step back and reassess personal goals, readiness, and the strategies used so far. Your goal is to help the patient avoid becoming discouraged and reengage in the change process. “Did something trigger your drug use this time?” “What affected your ability to take your medications?” “Tell me what happened. What do you make of this?” “It can be very helpful to know what didn’t work. What can you learn from this Relapse?” “What will you do differently next time?” “You have the skills to make this change; you’ve done it before and you can do it again.” “Where do we go from here?” “A relapse is not a collapse.” Source: (Paul F. Cook, PhD,Lucy Bradley‐Springer, PhD, RN, ACRN, FAAN,Marla A. Corwin, LCSW, CAC III, 2009) Manual on Advance Counselling for ICTC Counsellors Page 74 Annexure-6 FRAMES Miller and Sanchez (1994) reviewed interventions in the alcoholism field and derived six common motivational elements from empirically tested successful treatments, which they described with the acronym FRAMES (feedback, responsibility, advice, menu of options, empathy, and self-efficacy). These elements are: use of objective feedback, stressing of client responsibility, use of therapist objective advice, offering clients a menu of options, use of empathy, and fostering self-efficacy. (Jeffrey Foote, Alexander DeLuca, Stephen Magura, Ann Warner, Anne Grand, Andrew Rosenblum, and Susan Stahl,, 1999) F: Feedback Present feedback to the patient in a way that is respectful and has impact. This can include providing feedback about how unhealthy behaviors are harming the individual, but ensuring that your communication reflects the patient’s statements of concern. Feedback should be based from information gathered in patient interviews, reports, and objective measures. It can be helpful to present this data to the patient and elicit his or her opinions from this information. R: Responsibility Emphasize that the patient has the responsibility and freedom to make the choice to change. This is not a decision that can be made by anyone else, and it is really up to the patient to decide what decisions to make. A: Advice Provide clear and direct advice about the importance of making lifestyle changes and suggest different ways that this can be accomplished. Advice should reinforce that the patient makes the ultimate choice. M: Menu Offer different alternatives that the patient can choose from. For example, “There are different ways that people successfully change their lifestyle behaviors. Perhaps we can spend a few moments talking about this so that I can tell you some of these strategies, and you can tell me which of these might make the most sense for you.” Manual on Advance Counselling for ICTC Counsellors Page 75 E: Empathy It is important to listen to, and reflect the patient’s statements and feelings. This ensures that you understand the patient, and that the patient feels understood by you, both of which foster productive communication. Expressing empathy to your patient involves communication that is warm and supportive, and demonstrates that you are paying attention to the patient’s verbal and nonverbal communication. S: Self-efficacy Part of your goal in motivational interviewing is to help instill optimism and confidence in your patient that he/she can make meaningful behavior changes. You want to communicate to your patient that “you can change.” (Yale Rudd Center for Food Policy and Obesity, n.d.) Manual on Advance Counselling for ICTC Counsellors Page 76 Annexure-7 QUIZ: Questions with Answers: Q1- Jai is 20 years old MSM. He has relation with multiple partners with whom he has never used condom. He says in true relationship one should not use condom. Jai is in which stage as per Transtheoretical Modle? Ans: Pre-contemplation Q2-I will get myself tested for HIV this Monday. Which stage is this? Ans: Preparation Q3- Stimulus control is the technique used in which stage of Transtheoretical Modle? Ans: Maintenance Q4- Counsellor can use readiness & confidence ruler to measure how important client thinks it is to change behaviour. (True/False) Ans:True Q5- Rajesh is an IDU who is now thinking of leaving his habit of drug use but at the same time also thinks of withdrawal, pain and loss of peers. In which state of mind is he? Ans: Ambivalent Q6- The decision matrix helps in weighing the benefits & cost of the given behaviour. (True/False) Ans: True Q7- Four major principles of Motivational Interviewing are: Ans: 1) Express empathy 2) Develop discrepancy 3) Roll with resistance & 4) Support self-efficacy. Q-8 What does FRAMES stand for: Ans: FRAMES: (feedback, responsibility, advice, menu of options, empathy, and self-efficacy) Manual on Advance Counselling for ICTC Counsellors Page 77 Annexure-8 Optional Reflective Diary The Topic of the Session Example: Understanding Behaviour Change What did you learn? Example: Learned about different stages of behaviour change. Also understood that different techniques specific to each stage can be used by counsellor to move client from one stage of change to another Manual on Advance Counselling for ICTC Counsellors What difference will it make to your Practice? Example: Now I am confident enough to effectively practice the transtheorectical model of behaviour change. I used to have difficulty in moving client from one stage to another now when I have practiced all the techniques of behaviour change I feel more in control. Page 78 Practice of Counselling Skills across HIV/AIDS and Related Issues Session Overview: Segment 1 Role Play Preparation (15 min) Role Play Enactment (30 min) Feedback and Facilitator Debriefing (10 min) Self Reflection based on Feedback, Facilitator Debriefing and Video Replay (10 min) Presentation of Improvised version of role play (20min) Segment 2 Role Play Preparation (15 min) Role Play Enactment (30 min) Feedback and Facilitator Debriefing (10 min) Self Reflection based on Feedback, Facilitator Debriefing and Video Replay (10 min) Presentation of Improvised version of role play (20min) Take home messages from the session (10 min) Session Objectives: At the end of the session participants would be able to: Identify and prioritize counseling issues in different situations. Demonstrate the appropriate application of counseling skills. Time allowed: : 3 hours. Manual on Advance Counselling for ICTC Counsellors Page 79 Materials required: Time allowed: : Copies of the role plays for all the participants Copies of the debriefing with respect to each of the role plays for all the participants Video camera with tripod ( depending upon feasibility) Laptops for each of the sub groups with functional audio facility (depending upon feasibility) Two Facilitators are required for the session Method: Time allowed: Preparation prior to the Session: : Ensure that copies of role plays are available for all the participants. Two separate rooms for conducting the session should be arranged. Seating arrangement in both the rooms should be done according to the session’s requirements. Arrangements for video recording should be made ( if the facility is available) Laptops should be organized for each of the sub groups with functional audio facility ( based upon the feasibility and if video recording is being done) Discussion with the facilitators about the two segments that would be covered in the session. During the Session: Divide the participants into two groups (preferably not more than 12 to 13 counselors per group). One way of dividing the group could be on the basis of their fruit preferences. The group members could be asked as to whether they like an apple or an orange or any other seasonal fruit. Accordingly they could be divided into two groups naming them as the Apple and the Orange Group. Manual on Advance Counselling for ICTC Counsellors Page 80 And, I love an orange I love an apple One of the groups is asked to sit in the main training hall and the other group is asked to proceed to the next room. The facilitators and the training team would also divide themselves amongst the two rooms. Once the groups are settled in their respective rooms, inform them about the purpose of this session. Tell them that this session is about learning to apply the skills they have learnt in skill labs 1 and 2. It is a session that aims at deriving relevant content from previous sessions and applying to different counseling situations. Please tell the counselors to consciously apply the skills practiced in skill lab 1 during this role plays. The facilitators would now divide the group in each of the rooms into three sub groups. Each sub group may have three to four members depending upon the total number of participants. Since by this time, a decision has been taken about the two segments to be covered, assign one role play each from the first selected segment to each of the groups. Tell the participants that while a lot of issues could be covered in the role play, they would focus on the theme of the segment. For example, in the segment on partner notification, the participants would concentrate on issues related to disclosure; partner management and can use the sandwich technique, normalization etc in this scenario. Note for the trainer: The role play situations for each of the segments are included as part of Annexure 1. Three different situations have been provided in each of the segments. Tell each of the groups that they have to plan the role play before the actual demonstration. Give each of the groups a worksheet to plan the role play. Each group should be given 15 minutes to plan for the role play. Manual on Advance Counselling for ICTC Counsellors Page 81 Trigger Who are the individuals that you would talk to in the counseling sessions? In what order would you speak to each of them- who would you speak to first and who would you speak to later Response (List the individuals in the order that you would like to speak to them) What are the issues that you would discuss with each of these individuals Individual Issues to be discussed Which skills would you be using while talking to the clients Note for the facilitators: As an example one of the worksheets has been filled up and is included as Annexure 2. Facilitators should move around and assist each group in planning for the role play. The debriefing points provided with each of the role plays in Annexure 1 would help the facilitator in assisting the groups. Manual on Advance Counselling for ICTC Counsellors Planning may be done for two to three counseling sessions but only one of the sessions would be demonstrated in the training hall!!!! Page 82 Once the planning has been done, give each of the groups 10 minutes to enact the role play. Read out the role play situation for the entire group before the demonstration or you may ask a participant to do so The role plays could be video recorded if the facility is available After each sub-group has demonstrated the role play, ask the other members of the same sub-group to provide feedback in the light of the plan that had been made by them. After this provide an opportunity to the other group members to provide a feedback. The facilitators can then sum up the discussion and provide any additional inputs in terms of the areas to be covered and the skills used. (10minutes) A checklist of Counselling skills to be given to each of the participants. This is based on the earlier session. Facilitators: Do look up the debriefing points for each of the role plays in Annexure 1. Ask the participants to move back in their small groups. If a video recording of the role plays has been done, then it may be provided to each of the groups on a laptop. Tell the groups that they would now view the recording of their own role play and think of ways to improvise it based upon the feedback provided to them and the plan they had developed. In case if the facility for video recording is not available, then the team members may discuss amongst themselves ways to improve their role play based upon the feedback and plan developed by the group. (10 minutes) Finally ask one or two of the groups (based upon availability of time) to present an improvised version of their role play. Time permitting comments may also be invited from other groups. Since demonstration has been presented of only one counseling session in every case, the groups could be asked to share the plan that they had developed for the other sessions with the help of the worksheet that had been filled up by them. Manual on Advance Counselling for ICTC Counsellors Page 83 After summarizing the proceedings of this segment, the facilitator would announce the Announc ing entry into the Second Segmen t entry into the next segment. The procedure as outlined from point 7 to point 12 would be followed in this segment as well. The facilitator would tell the participants that the role of counselor would be taken on by a different member of the group in this segment. Further, the improvised version of the role play (as provided for in point no. 12) would be presented by a different sub group in this segment. To end the session, the counselors within their respective groups could be asked to reflect upon: What would they do differently in counselling after this training? How would they make counselling more clients centred in their respective facility? The groups could then be asked to share two to three points within their large group. In case if the facilitator is available and the training is residential in nature, the third segment may also be covered during the evening. This should however be based on the willingness of the participants. Note for Facilitator: Keep reminding the participants that the skills that they have learnt and revised in their previous sessions have to be kept in mind while enacting the role plays. The skills should be used based upon the specific needs of the session. Manual on Advance Counselling for ICTC Counsellors Page 84 Annexure 1: Segment 1: Partner notification Role plays and points of debriefing for the segment on partner notification or disclosure Situation 1 A pregnant woman of 30 years has come to the ICTC counselor for Antenatal HIV testing. This is her second pregnancy. She is tested HIV positive. Her husband is an embroidery worker and works in a different city. He comes home once in a month. She is scared The legal position with respect to partner that her husband and in-laws will throw notification is that HIV positive status of a client has to be disclosed to the partner or her out if they know her HIV status. From the prospective partner. (Mr. X vs. Hospital the pre-test counseling it has emerged that Z (1998) 8 SCC 296) the client is from a very low economical background. Debriefing: The tentative process that might be followed in cases of this nature to facilitate partner notification: The counselor would always attempt to support the infected partner to disclose their status to their partner or prospective partner on their own. However if this were not to happen then the counselor is duty bound to do it. Summarize the discussion from the previous session. Empathize with the client regarding the challenges and dilemmas of partner disclosure. Explore the thoughts and feelings of the client. Understand if the client is able to identify the reason behind these thoughts and feelings. Counsellor should state that this is a space where the client can feel free to share her thoughts and feelings. They would not be judged or labeled as being good or bad based upon their sharing. Confidentiality would be maintained. Enable the client to reflect upon the need for partner notification. Explore the pros and cons of partner notification in her case. Explore the hindrances that she perceives in the process of partner notification. Ask her about her current stay arrangement – whom is she currently residing with. Understand the nature of relationships that she has with the natal and matrimonial family (The attempt should be to understand the support structure). Explain the process of prevention of mother to child transmission. Discuss the possible strategies that she can use for disclosing her status to her spouse. Manual on Advance Counselling for ICTC Counsellors Page 85 Some of the strategies that have been suggested are: Directly explaining to the partner about the infection and the need for getting tested. Motivate and accompany the partner to the ICTC. Asking the partners to attend the ICTC without specifying the reasons. Providing a referral card to the partner(s) and ask him or her to attend the ICTC. (These strategies have been adapted from the Refresher Training Module for Counselors at the STI/RTI services, 2012). The counselor may also explore about situations in the past when the client has shared things with the spouse where she has felt fearful of the consequences. How did she manage to do so in the past? What were the consequences? How did she deal with them? Explain the importance of getting her first child also tested. Situation 2 Bony is 35 years old. He is married and lives with his wife and his two children. While he mentions that he has emotional attachment with his wife, he prefers sexual relationship with men only. He has had multiple sexual partners (male). Bony uses a different identity with his male sexual partners. He dresses up as a woman and uses a different name. His wife is not aware of his actual sexual preference and his multiple relationships. Recently, Bony found that he is HIV positive. Now he wants to inform his wife about his HIV status but is afraid that she might leave him when she becomes aware of the truth. Debriefing: The tentative process that might be followed in cases of this nature to facilitate partner notification: The counselor first needs to acknowledge his/her own thoughts and feelings associated with Bony’s life and behaviors. As a counselor, the first step would hence be to ensure that personal judgments do not come forth while interacting with the client. Begin by telling the client that as a counsellor you are able to understand the dilemma that he is facing – while on the one hand he wants to inform his wife about his status but on the other hand, he is not sure of what would be the reaction of his wife if she gets to know about his HIV status. Manual on Advance Counselling for ICTC Counsellors Page 86 Counsellor should assure the client about being non judgmental and respecting confidentiality. Help the client to reflect upon the pros and cons of sharing his status with his wife. This exercise may also be done through a paper and a pen. Ask the client about the factors which are preventing him from sharing his status with his wife. Proceed bit by bit to help the client to understand how valid these apprehensions are and how they could be addressed. Help the client to empathize with his wife. How would you feel if you were to be in the position of your wife? Tell the client that the negative feelings that might arise within the wife are justified if we were to look at things from her perspective. Help the client to formulate a plan of action based upon the discussions that the counselor has had with him. Equip the client to deal with the negative feelings that might arise in the wife on account of the disclosure. Restate that the wife has a right to take decisions concerning her life just as the client has. Discussion needs to happen on reducing risk to others: The counselor can inform about the possible ways of reducing risk for his wife as well as his other sexual partners. Situation 3 Kulsum, 25 years, is working in a call centre. She had come to the ICTC for receiving the report of her HIV test. She had been referred for HIV test on account of some health related complaints. She had come along with her parents to receive the report at the ICTC centre. Her parents were sitting outside the room of the counselor. The counselor began the session by exploring the life of Kulsum and in that process Kulsum informed the counselor that she was into a live-in relationship for the past two years. She also informed that her parents stayed out of station and were visiting Kulsum since she was not keeping good health. When the counselor informed Kulsum that her test results revealed that she was HIV positive, Kulsum broke down. She was inconsolable. She however requested the counselor not to reveal her status to her parents. Kulsum was also wary about how her live in partner would receive this information. She is keen on continuing the relationship but does not want the partner to know about her status. Kulsum wants to eventually get married to the boy and have children since she is so deeply involved in the relationship. She also expresses that life is suddenly falling apart for her. Debriefing: The tentative process that might be followed in cases of this nature: Begin by acknowledging the feelings that she is experiencing. Validate her feelings and practice normalization as well. Help her to look at life with HIV and how it could be managed. This could be done by first asking her to talk about her understanding with respect to HIV. Help her to discuss about her apprehensions regarding life with HIV. Manual on Advance Counselling for ICTC Counsellors Page 87 Discuss about what she would say to her parents if they were to ask her about the test result (since she does not want to disclose the test result to them). Explore how she would feel if she were to hide this information from her parents and how she would deal with those feelings. Explore the reasons behind her decision of not wanting to share the information with her live in partner. Help her to look at how valid those reasons are. Help her to look at the risks involved in not sharing this information with her live in partner. Tell her that she could take her time to decide upon how to share the information with her live in partner. Counsellor should assure her about her availability and inform her that she could return for any discussions that she would want to undertake with the counselor. Before departing discuss her journey back home and what would she be doing at home. Segment 2: Children and Adolescent Counselling Role plays and points of debriefing for the segment on children and adolescent counseling Situation 4 Roshan was 14 years old at the time of referral to the ICTC. She had been experiencing abdominal swelling for sometime due to which her father had brought her to the hospital. Despite being given medication, the abdominal swelling was not subsiding. She was then referred to the ICTC. She was referred for HIV testing and her test results were positive. She had come to the ICTC along with her father for post test counselling. Her father was asked to wait outside. During the pre test counseling Roshan had revealed that she had been sent to live with her father so that she could take care of him while he worked. Her biological mother had passed away as soon as she was born after which her father had remarried. Her step mother lived in the village along with her other siblings. Roshan was sitting on the edge during the session. Debriefing: The tentative process that might be followed in cases of this nature: Verbalize the feelings that Roshan is experiencing while sitting in the counseling session. For eg. It appears that you are extremely scared about what I might discuss with you. Empathize with the client. If not already explored then ask her to describe any usual day ( what happens from morning till night) Tell her that you would be talking about certain personal issues and seek her permission before doing so. Manual on Advance Counselling for ICTC Counsellors Page 88 Tell her about the physiological changes that happen in girls when they enter into the stage of adolescence. This may be done pictorially if IEC material is available in the ICTC. Ask the adolescent if she has also been through these changes. If she is unable to verbalize, she might be helped by the counselor by putting a finger on each of these changes and then asking her to nod if she has been through them. Explain to her about the process of ovulation, menstruation and conception using a diagram. Ask her if she has any queries with respect to it. Discuss with her about the symptoms of STIs/RTIs. On the basis of the above discussion, ask her if there are any specific vulnerabilities to which adolescents are exposed to or any specific risks which adolescents are faced with. While she is talking about it, the counselor may decide to list them down. Explore is there anything about her life which she would like to share which is exposing her to a higher degree of risk. Strategies for risk reduction need to be discussed with the client. Explain the support services that she might access if the need so arises. (Smiles that could be used to help children identify their emotions are included as Annexure 3) Note for Facilitators: Do remind the counselors that in cases of child sexual abuse including incest, they have to report such cases to the Medical Officer or District Supervisor or DAPCU supervisor. Under Section 19 of the Protection of Children from Sexual Offences Act, 2012, whoever has knowledge or apprehension about the commission of a sexual offence is required by law to report the case to the Special Juvenile Police Unit or to the local police and any person who fails to do so is liable for punishment under Section 21 of the above Act. Situation 5 Ravi, an 8 year old child was found on the footpath by an NGO in a very poor state of health. He was produced before the Child Welfare Committee where a medical examination was ordered. He was taken for a medical examination during which anal lesions were found and a HIV test was recommended. The NGO representative presented the recommendation before the Child Welfare Manual on Advance Counselling for ICTC Counsellors Page 89 Committee who authorized the NGO to provide consent on behalf of the child. At the ICTC Ravi mentioned that he was an orphan and had spent all his life on the streets. The HIV test results of the child revealed that he was HIV positive. During this process Ravi was living in the shelter home of the NGO as per the order of the Child Welfare Committee. Debriefing: The facilitator points out the tentative process that might be followed in cases of this nature: a. Given the age of the child and depending on the discussions that have taken place in the pretest counseling, the counselor may explore with the child the names of his closest friends. The counselor could also ask about what the child likes within his friends or what is it that makes him close to his friends. Since the child has been living on the streets, the friends may not always be children. This should be accepted by the counselor. b. The child could then be helped to draw his life on the street or a typical day on the streets or things that he liked or disliked on the street. A discussion could then be held with the child based upon the drawings. c. Alternatively drawings could be shown to the child in order to help the child to define his relationships with the people or friends on the street. This should however be done only after seeking permission from the boy if he would be comfortable with looking at the pictures. d. Explain to the child how these relationships might have affected his body and the precautions he now needs to take in order to protect his health. e. Explain that regular intake of medicines along with an improved life style in terms of routine, diet; purposefulness would help him to remain healthy. f. Explain that support is available to the child at ICTC . Remind the Counsellors: In case of children without parental support informed consent for HIV testing has to be obtained from the District Magistrate or the Child Welfare Committee. Situation 6 Nimreet has come to a counsellor with her 12 years old boy Sunny. Sunny is on ART. Every day he refuses to take medicines as no friend of his takes medicines on a regular basis. He keeps on asking his mom ‘why should I take medicines everyday’. Sunny suspects something is wrong with him as he has to take medicines daily. Nimreet is worried about him. Debriefing: The tentative process that might be followed in cases of this nature: Manual on Advance Counselling for ICTC Counsellors Page 90 a. Verbalise the feelings of Sunny. As an example the counselor might say, “I can see you are very angry with us and your mother since she is asking you to take medicines everyday”. b. Subsequently, the counselor might ask Sunny to simulate the situation that happens at home. He could be asked to role play a day in the family. The child would take on the roles of different members and actually enact the way they behave. c. Follow up the role play with a discussion on what he liked or disliked about the day. This would enable the counselor to understand the areas of discomfort for the child. The counselor may assess whether it would be helpful to have the caregiver (mother) sitting while the child is enacting the role play. d. Counsellor may call in the caregiver (mother) separately on another day when the child is at school. e. Explore the barriers that the caregiver is facing in disclosing the HIV status to the child. f. Discuss each of these barriers and acknowledge the anxiety that the caregiver is facing in disclosing the status to the child. g. Explain the advantages of disclosure or partial disclosure which would promote a greater degree of adherence. h. Discuss the options of disclosure with the caregiver – either the caregiver disclosing it to the child or the caregiver disclosing it to the child in the presence of the counselor or the counselor discussing with the child in the presence of the caregiver. Weigh the pros and cons of each of these options and facilitate the decision making process of the caregiver. i. Counsellor might use stories for explaining to the child or these could be given to the caregivers to disclose to the child. The book: Bam Bam Vishanu Ki Kahani developed by NACO could be used. Any other interesting booklet might also be used. The link for one such booklet (Zindagi Mile Dobara) brought out by UNESCO and Plan India is http://unesdoc.unesco.org/images/0021/002129/212949e.pdf. The booklet is also available in Hindi. Segment 3 – Counselling Marginalized Groups Role plays and points of debriefing for the segment on marginalized groups Situation 7 A 35 year old intravenous drug user came to ICT centre with pain in abdomen and diarrhoea. He does not want to kick the habit for fear of losing friends and acceptance in the group. His parents have been very hostile and have threatened to throw him out of the house. He is a motor mechanic. He is from a middle class family. Debriefing points: The tentative process that might be followed in cases of this nature: Manual on Advance Counselling for ICTC Counsellors Page 91 Assure the client about your non judgmental attitude. Seek the permission of the client to ask certain questions pertaining to his drug intake. After seeking permission ask questions about the type of drug being used, frequency of drug use, mode of drug use and time of last dose. Explore and Listen to the client about what all he has been experiencing since the time that he started taking drugs at the familial level, at the work place, in the neighborhood or larger society. Explore the sexual behavior of the client since ID Users stand the risk of HIV transmission through sexual mode when intoxicated. Explore reasons for this behavior and his understanding about risks involved Since the client is in the Precontemplation stage according to the BCC transtheoretical model, look at how the techniques could be used with the client. Engage the client in discussing about how injecting drug use is impacting his life and other persons in his environment. Through images or available material, let the client travel through the consequences of ID use. Enable the client to prepare a risk reduction plan. Situation 8 A 30 year old woman is into street based sex work. She has been in the profession for over 10 years and has used condoms occasionally saying that some customers don’t want to use condoms and are willing to give more money for that. She therefore feels that if she has to earn more she has to do sex without condoms. She was tested negative last month but has come to the counselor as her white discharge is not cured. She is married and has children and engages in this work purportedly without the knowledge of her family. The husband does not support the family economically and is an alcoholic. She belongs to a family from the lower economic strata and has practically received no education. Debriefing points: The tentative process that might be followed in cases of this nature: Show acceptance to the client despite the knowledge that the client is not practicing safe sex even though she has the knowledge with respect to it. Tell her that you understand that even though you understand the necessity to practice safe sex you are unable to do so. Explore the various health related issues that the client is facing – she is mentioning about white discharge but it is also important to explore if the discharge is smelly, is there a burning or itching in the vagina, are there any blisters or ulcers in the genital area, is she experiencing pain during intercourse. This would help to understand if there is a possibility of STI. Inform the client that STIs increase the chances of HIV infection. Alternatively since the client has come to the ICTC earlier as well, her understanding about the symptoms of STI might be explored. Tell her that you understand her dilemma about condom use since she needs to support her family Manual on Advance Counselling for ICTC Counsellors Page 92 Ask her about the advantages and disadvantages of condom use with her customers. Explore whether she understands the consequences of her behavior on herself and her immediate environment. Train her on condom negotiation skills. If she is comfortable do a role play where she is trying to negotiate with a client. As a debrief to this, discuss with her what her options were to protect herself and what could be the likely consequences of each of those options. Further ask her what else she could have done to protect herself. Assure her about your support and availability. Situation 9 A 22 years old (Kothi) walks in for HIV test with a peer educator in an NGO. His test confirms that he is HIV positive. On being asked by the counselor he shared that at the age of 16 he experimented with anal sex (passive) and he enjoyed it and continued this activity. He is currently unmarried and his family stays in the village whereas he stays in the city. Debriefing issues: The tentative process that might be followed in cases of this nature: Show acceptance through verbal and non verbal communication. Explore the reasons which had brought him to the centre. Explore his awareness about the symptoms of STIs in males. Depending upon the level of awareness inform the client about the common symptoms of STI/RTI in males – urethral discharge, pain during urination, frequent urination, genital itching, blisters or ulcers on the genitals, anus, mouth, lips, ano-rectal discharge, warts on genitals, anus or surrounding area. Seek permission to explore his sexual life. Ask about partners (single or multiple), nature of sexual activity that they engage in, how often does he use condom, problems with use of condom during sex. Explore his understanding about the risks that he is exposing himself and his sexual partners to. Discuss strategies for risk reduction. Discuss strategies for taking care of health and nutrition related requirements. Manual on Advance Counselling for ICTC Counsellors Page 93 Annexure 2: An Example of a filled up worksheet for planning the counseling session Situation 1 A pregnant woman of 30 years has come to the ICTC counselor for Antenatal HIV testing. This is her second pregnancy. She is tested HIV positive. Her husband is an embroidery worker and works in a different city. He comes home once in a month. She is scared that her husband and in-laws will throw her out if they know her HIV status. From the pre-test counseling it has emerged that the client is from a very low economical background. Trigger Response Who are the individuals that you would talk to? In what order would you speak to each of them- who would you speak to first and who would you speak to later (List the individuals in the order that you would like to speak to them) What are the issues that you would discuss with each of these individuals Party Client (Pregnant Woman) (1) Client (pregnant woman) (2) Husband of the Client Husband of pregnant woman Manual on Advance Counselling for ICTC Counsellors the Issues to be discussed (With the assumption that the disclosure of status has been done) Her immediate Concerns and Fears Support System Importance of Partner Notification Nature of Relationship with Spouse Strategies for Partner Notification and Possible Barriers Prevention of Mother to Child Transmission Testing of the First Child Nature of Care she needs to take of herself Nature of work being carried out by him Nature of living arrangements in the place of work General Health Condition Any illnesses which have been of concern (The discussion on the above points would help in rapport building as well as undertake risk assessment) Prior understanding about HIV Page 94 Which skills would you be using while talking to the clients Empathy, Active Listening, Summarizing, Paraphrasing, Normalization Manual on Advance Counselling for ICTC Counsellors Explanation about the progress of the infection Explanation about the importance of positive living Discussion regarding HIV status of wife Need for HIV testing of husband Prevention of mother to child transmission Myths and misconceptions regarding HIV Reflection, Use of Silence, Open Ended Questioning, Page 95 Annexure 3 Smileys that could be used with children to identify their emotions Figure 1 Anger Figure 2 Sadness Figure 3 Fear Manual on Advance Counselling for ICTC Counsellors Page 96 Annexure 4 (A checklist on counseling skills could be included which the participants could use while they are doing a reflection on the role play enacted by them) Manual on Advance Counselling for ICTC Counsellors Page 97 References National AIDS Control Organisation. 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