Counselling issues in people with HIV

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Counselling issues in people with HIV

• Fergus (Gus) Cairns
• Diploma, Body psychotherapy
• Diploma, humanistic counselling

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Contents

• Introductions
• Theoretical models I have found useful
• Issues for people with HIV
• Assessment and how to handle certain clients

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Introduction to course

• Aim of training
• To educate and inform participants about aspects
  of HIV and mental health
• To help you discuss own experiences of dealing
  with clients with mental health and emotional
  support issues
• To do some elementary experiential training to
  help volunteers deal with and relate to people
  with specific emotional support needs

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Introduction to people!

• Name
• Why are you a counsellor?
• Why you work in HIV
• One thing you like doing thats nothing to do
  with HIV

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Pair exercise

• My bad day, and what I did about it

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Part one some theoretical models I have found
useful

• Stress and stressors
• Fight, flight and freeze
• The Kübler-Ross adaptation model
• The Gestalt cycle
• Predispositions the Reichian character
  structures

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A side-journey into STRESS

• The state arising when the individual perceives
  that the demands placed on them exceed (or
  threaten to exceed) their capacity to cope, and
  therefore threaten their wellbeing.
• Stress is not mental illness
• Stress is a normal part of life
• Stress has physical effects
• The result of stress depends on what you do with
  these physical effects
• To energise you
• To give you ideas
• To make you angry
• To shut you up
• To make you depressed
• To make you ill
• Paul Martin The Sickening Mind Brain,
  Behaviour, Immunity and Disease. ISBN
  978-0006550228

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Stress scale top 10
Stress Event value
Death of spouse 100
Divorce 60
Menopause 60
Separation from living partner 60
Jail term or probation 60
Death of close family member other than spouse 60
Serious personal injury or illness 45
Marriage or establishing life partnership 45
Fired at work 45
Marital or relationship reconciliation 40
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Fight, flight or freeze

• Sympathetic and parasympathetic nervous systems
• React automatically to stress
• Sympathetic excitatory, parasympathetic
  inhibitory
• Usually the sympathetic nervous system responds
  to a stressor
• Adrenaline (epinephrine) mobilises the Fight or
  flight reaction
• When fight or flight is impossible the
  sympathetic and parasympathetic nervous systems
  both fire at once
• Acetylcholine (and NO) normally produces
  relaxation
• In the presence of sympathetic arousal it
  produces dissociation the Freeze reaction
  like an animal playing dead
• Dissociation lies behind many adjustment
  disorders and stuck states see below

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Adaptation to loss and change from On Death and
Dying by Elisabeth Kübler-Ross
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The Gestalt Cycle adaptation and moving on
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Four primary emotions

• Happiness
• Anger
• Fear
• Sadness
• Confusion

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Five primary emotions - stuck

• Happiness stuck ? manic defence, denial
• Anger stuck ? pathological rage, blame,
  self-harm, suicide
• Fear stuck ? anxiety disorder, panic attacks,
  phobias, PTSD, OCD
• Sadness stuck ? depression, dysthymia,
  irritability, physical symptoms
• Confusion stuck ? more confusion (compound
  dissociation, fugue, DID, amnesia)

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Predisposition the Reichian character
structuresDifferent structures vulnerable to
different stress

• Schizoid child hated or ignored
• Life means nothing unless I am in control
• Oral child loved inadequately (e.g. PND)
• Life means nothing unless I am loved
• Symbiotic child loved to exclusion of others
• Life means nothing unless we are in love
• Narcissistic child used to make parents feel
  good
• Life means nothing unless I am adored and
  special
• Masochistic child over-disciplined or
  controlled
• Life means nothing unless I do it myself
• Histrionic child used to create drama and
  fights
• Life means nothing unless it is (sexually,
  emotionally) exciting
• Rigid child brought up with rigid social
  expectations
• Life means nothing unless I am a success

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Issues for people with HIV

• HIV is a chronic stressor youre always aware
  of it
• It may at certain times also be an acute stressor
  risk encounter, HIV diagnosis, AIDS diagnosis,
  rejection (sexual or family), discrimination,
  stigma

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HIV-specific issues

• Physical HIV illness, dementia
• Drug side effects efavirenz, also possibly AZT
  etc
• New diagnosis
• Stigma and isolation
• Long term survivors Lazarus effect Im not
  special any more
• Work and career
• Loss and bereavement
• Sex, love, disclosure, rejection
• Body changes/image
• Life issues that may have led to HIV depression,
  addictions, abuse

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Why mental health is important in HIV
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How common I North Carolina
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How common II London 2002
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Assessment what do you notice?

• Appearance/behaviour unkempt, restless,
  eccentric
• Rapport are they with you? Eye contact?
• Speech slow, fast, easy, reluctant,
  comprehensible
• Mood euphoric, depressed, anxious, irritable,
  labile, blunted, incongruent
• Thought block, incoherence, delusion, obsession
• Cognition ability to understand and have
  concepts
• Body and perception dizzy, spaced-out, cold
  sweat, heart, headache, noise
• Insight self-awareness, including the awareness
  that something is wrong (if it is)
• And most important
• HOW ARE YOU FEELING ? (countertransference and
  embodied countertransference)

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What do you cover?

• Famous first words (and actions)
• Presenting problem
• Family history
• Relationships
• Family relationships
• Current life setting work, money, housing etc
• Psych. History/medication
• Medical history including HIV
• Drink/drug issues/dependency
• Any suicide history/ideation?
• Sex risks/dysfunction
• What are their hopes for counselling?
• What do they expect counselling to be like?
• Practical issues e.g. times/frequency/duration/fee
  s/contact
• If this worked, what would you be like?

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Depression and its risk factor, suicide

• A storyMr Pig
• Inner experience and meaning of depression
  shutdown
• Language to watch out for overt/sleep/going
  away/switch off/cant cope
• Depressed people are helpless, hopelessand
  annoying! Value their anger!
• How NOT to help a depressed person
• Dont reassure ?You dont understand
• Dont reason ?Yes, but
• Dont sympathise ? You see? Its hopeless
• Dont get angry ?You see? You hate me too
• Action and distraction work best

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Anxiety and its risk factor, panic

• A storyTim and my dog
• Inner meaning and experience of anxiety states
  the adrenalin trap
• Fight, flight and freeze
• How NOT to help anxious clients
• Do NOT reason with the fears
• Do NOT argue with the irrational
• Do NOT reassure
• Physical relaxation techniques usually dont
  work person spaces out
• Ask If you werent worrying about this, what
  would you be worrying about?

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Anger and its risk factor, violence

• A storyDave C.
• Inner meaning and experience frustration and
  isolation
• Language and behaviour to watch out for
• How to handle angry clients
• Stay calm
• Sit down
• Match them with energy but not with anger
• Make sure they can really see you they may be
  in Trauma an angry person is a frightened
  person
• Understand they need to be heard
• Pre-set limits if you can no violence/destruction
  /safe words

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Knowing who you cant work with

• A story I am a medical experiment
• Knowing when you cant work with someone is a
  very personal decision, based not only on your
  professional experience but your life issues
• Signs no contact/relationship, no insight,
  delusion, extreme countertransference, clients
  issues mirror ones you currently have, client
  triggers trauma/memories
• Strong reactions arent always bad!
• Dislike, boredom, annoyance, anxiety, sadness,
  attraction (especially sexual!), urge to touchif
  you feel these then a) You feel what others feel
  b) Youre probably feeling what theyre feeling
  (even if they dont know it).

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Bully/victim/rescuer

• The roles people play
• and the roles they try to get you to play
• Projective identification
• A story autistic Rob and his dreams
• His therapists always started as rescuers and
  ended as bullies

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Boundaries and confidentiality

• The client who wants to be your friend
• The client who tells you shocking things
• When to break confidentiality
• Imminent harm to self or others
• Always have a professional contact
• You are not there to suffer or be punished

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Groups and peer groups

• Isolation is the biggest single predisposing
  factor for mental illness
• If you are a group facilitator, many of the same
  issues will come up with individuals
  complicated by group dynamics
• Models directive, non-directive open, closed,
  slow open
• You are there to interpret the group process, not
  to counsel individuals. The group will do that

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Some workshops that could be adapted

• Prevention/safer sex Healthy Relationships.
• See
• www.cdc.gov/hiv/topics/research/prs/resources/fact
  sheets/healthy-relationship.htm
• Living with HIV The Positive Self Management
  Programme (the Living Well course).
• See www.livingwelluk.com/ and http//patienteducat
  ion.stanford.edu/programs/psmp.html
• Self-confidence and getting more from life The
  AIDS Mastery. See www.aidsmasteryokc.org/

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Any questions?