Counselling issues in people with HIV

1. www.ferguscairns.co.uk Counselling issues in people with HIV Fergus (Gus) Cairns Diploma, Body psychotherapy Diploma, humanistic counselling

2. Contents • Introductions • Theoretical models I have found useful • Issues for people with HIV • Assessment and how to handle certain clients www.ferguscairns.co.uk

3. 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 www.ferguscairns.co.uk

4. Introduction to people! • Name • Why are you a counsellor? • Why you work in HIV • One thing you like doing that’s nothing to do with HIV www.ferguscairns.co.uk

5. Pair exercise • “My bad day, and what I did about it” www.ferguscairns.co.uk

6. 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 www.ferguscairns.co.uk

7. 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 www.ferguscairns.co.uk

8. Stress scale top 10 www.ferguscairns.co.uk

9. 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 www.ferguscairns.co.uk

10. Adaptation to loss and change from On Death and Dying by Elisabeth Kübler-Ross www.ferguscairns.co.uk

11. The Gestalt Cycle:adaptation and moving on www.ferguscairns.co.uk

12. Four primary emotions • Happiness • Anger • Fear • Sadness • Confusion www.ferguscairns.co.uk

13. 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) www.ferguscairns.co.uk

14. 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” www.ferguscairns.co.uk

15. Issues for people with HIV • HIV is a chronic stressor – you’re 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 www.ferguscairns.co.uk

16. 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’: I’m 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 www.ferguscairns.co.uk

17. Why mental health is important in HIV www.ferguscairns.co.uk

18. How common I: North Carolina www.ferguscairns.co.uk

19. How common II: London 2002 www.ferguscairns.co.uk

20. 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) www.ferguscairns.co.uk

21. 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/fees/contact • “If this worked, what would you be like?” www.ferguscairns.co.uk

22. Depression and its risk factor, suicide • A story…Mr Pig • Inner experience and meaning of depression: shutdown • Language to watch out for: overt/sleep/going away/switch off/can’t cope • Depressed people are helpless, hopeless…and annoying! Value their anger! • How NOT to help a depressed person • Don’t reassure ⇒”You don’t understand” • Don’t reason ⇒”Yes, but…” • Don’t sympathise ⇒ “You see? It’s hopeless” • Don’t get angry ⇒”You see? You hate me too” • Action and distraction work best www.ferguscairns.co.uk

23. Anxiety and its risk factor, panic • A story…Tim 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 don’t work: person ‘spaces out’ • Ask: “If you weren’t worrying about this, what would you be worrying about?” www.ferguscairns.co.uk

24. Anger and its risk factor, violence • A story…Dave 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 www.ferguscairns.co.uk

25. Knowing who you can’t work with • A story: “I am a medical experiment” • Knowing when you can’t 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, client’s issues mirror ones you currently have, client triggers trauma/memories • Strong reactions aren’t always bad! • Dislike, boredom, annoyance, anxiety, sadness, attraction (especially sexual!), urge to touch…if you feel these then a) You feel what others feel b) You’re probably feeling what they’re feeling (even if they don’t know it). www.ferguscairns.co.uk

26. 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 www.ferguscairns.co.uk

27. 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… www.ferguscairns.co.uk

28. 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 www.ferguscairns.co.uk

29. Some workshops that could be adapted • Prevention/safer sex: Healthy Relationships. See; www.cdc.gov/hiv/topics/research/prs/resources/factsheets/healthy-relationship.htm • Living with HIV: The Positive Self Management Programme (the ‘Living Well’ course). See www.livingwelluk.com/ and http://patienteducation.stanford.edu/programs/psmp.html • Self-confidence and getting more from life: The AIDS Mastery.See www.aidsmasteryokc.org/ www.ferguscairns.co.uk

30. Any questions? www.ferguscairns.co.uk